Individual at Reading

Investigation into the circumstances surrounding the death of
a young man at HM Young Offender Institution Reading in July
2005
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2006
This is the report of an investigation into the death of a young man at HM Young
Offender Institution (YOI) Reading in July 2005. He was 18 years of age and was
found hanging in his cell from a ligature attached to the light fitting. He had been
remanded into custody facing sentence for offences of dangerous driving, taking a
vehicle without consent, possession of drugs and breach of a supervision order.
My colleagues and I offer sincere condolences to his family and friends in their sad
loss.
The investigation was led by one of my colleagues. I am grateful for all the
assistance that the investigation team received from the Governor of Reading and
her staff, including the Deputy Governor, who acted as the establishment’s Liaison
Officer. I regret the delay in completing this report.
A key objective of all my investigations is to ensure that the bereaved family has the
opportunity to raise any concerns and contribute to my inquiries. I am grateful to the
young man’s mother for agreeing to meet with the investigators at what must have
been a hugely difficult and distressing time.
The deceased was a troubled young man, who took his prescribed medication only
fitfully, and whose potential for self-harm had been identified by the police, the court
and prison staff. However, he was also perceived as a threat to other prisoners,
making it more difficult for him to share a cell as he wanted. I have identified a
number of occasions when Reading failed to follow up on actions that had been
agreed in support of this young man. However, I do not underestimate the challenge
of caring for prisoners who could present a risk both to themselves and to others.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN DECEMBER 2006
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CONTENTS
SUMMARY
CONDUCT OF THE INVESTIGATION
HMP and YOI READING
THE MAN’S TIME AT READING
EVENTS ON 3 JULY 2005
CLINICAL REVIEW
CONCERNS RAISED BY THE MAN’S FAMILY
CONSIDERATION AND CONCLUSIONS
RECOMMENDATIONS AND GOOD PRACTICE
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SUMMARY
1. The young man was remanded into custody at HM Young Offender
Institution (YOI) Reading on 16 April 2005, awaiting sentence. He had a
history of offending between 2000 and 2005 and was known to misuse
illegal substances, particularly heroin. In a pre-sentence report completed
for a hearing on 29 July 2004, his Youth Offending Team (YOT)
Supervisor expressed concerns that the man would not cope well with a
custodial sentence and would pose a ‘significant risk of attempted suicide.’
2. The young man was estranged from his family and he was concerned that
his girlfriend, who was expecting his child, was not keeping in touch with
him. She did visit him while he was in Reading on 18 May, 1 June, 21
June and 22 June. The man’s mother said that she was not aware of his
drug use before this period in custody. The young man also had a history
of deliberate self harm, at home and when in custody.
3. Before arriving at Reading, he was held in police custody between 14 and
15 April 2005. Concerns were expressed about his fitness to be detained.
The young man saw a doctor once on 14 April and three times on 15 April.
He was put on a constant watch whilst at the police station.
4. On 16 April, at the Magistrates’ Court the man headbutted his cell door,
and generally tried to self harm. He said he did not want to go to prison
and wanted to eat people. He claimed that he hated white people. A
suicide and self harm warning form was opened and the young man was
checked by staff through regular intermittent checks every couple of
minutes.
5. When he arrived at Reading, a First Reception Healthscreen was
undertaken, taking into account the concerns from the police station and
the suicide/self harm warning form from court. The young man was placed
on an F2052SH ‘Self Harm At Risk Form’ on the basis of that information.
He said during the reception healthscreen that he had taken heroin two
days previously, and that he also took cocaine. He said he had never
been treated for mental illness before, but had tried to harm himself when
previously in prison. The man saw the doctor immediately afterwards for
an assessment of his physical health. He told the doctor that he had
previously made numerous attempts at deliberate self harm, and had tried
to hang himself three months previously. The young man was seen to be
in good general physical health and was prescribed medication to ease the
symptoms of drug withdrawal. But during his time at Reading he
consistently refused to take the medication, despite encouragement from
staff. He said he had been prescribed treatment for depression by his GP
but had not had anything for the last year. No efforts were made to follow
up this information.
6. The young man exhibited some bizarre behaviour, such as barking like a
dog, covering his cell spy hole and covering his bed with a blanket so he
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could not be seen. He shared a cell on two occasions and was content for
a period of time. Then for no apparent reason, he assaulted one of his
cellmates. He also smashed his TV and video link equipment.
7. The young man remained on the original F2052SH until 11 May 2005.
Another form was opened on 13 May and closed on 13 June. On 22 June,
he had a visit from his probation officer who recommended that he should
be put back on an F2052SH. There is no evidence that any action was
taken in light of this recommendation.
8. The young man made several court appearances between 20 April and 24
June, some via video link. The Prisoner Escort Record forms completed
for those hearings note his risk of self harm and his drug problem. On 24
June, he was visited at the Magistrates’ Court by his YOT Supervisor who
expressed concern to custody staff that the man might self harm. This
was not specifically noted in his escort record by custody staff.
9. Throughout his time at Reading, the young man was reported to be an
angry, frustrated, manipulative and impulsive young man. On two
occasions he was moved from shared to single cells after fighting with
cellmates and he often changed his mind about whether he wanted to be
located in a single or shared cell. The Consultant Psychiatrist
recommended that he should be located in a single cell due to his risk to
others.
10. The young man did not comply with medication prescribed for him and he
was often reluctant to engage with healthcare staff. His medical record
confirms that he gave differing accounts of how he felt to different
members of staff.
11. Healthcare staff were of the opinion that the young man needed useful
occupation to help him cope with custody. However there is little evidence
that this was followed up by staff. It took eight weeks for his gym
application to be considered, despite several requests being made to staff
to progress his application. However, when he completed his gym
induction he refused to go to the gym. He only went to the gym once. The
man mentioned to healthcare and discipline staff that he felt lonely and
was upset as he felt that his pregnant girlfriend was not keeping in touch
with him and that he had little contact with his mother.
12. The young man saw a Consultant Psychiatrist on several occasions. The
Consultant Psychiatrist concluded that each of his self harm attempts was
as a result of recent events rather than longstanding issues.
13. The young man was not referred to the Community Mental Health Team
(CMHT) until 6 June, when they were approached to attend a Care
Programme Approach (CPA) meeting for the man. A CPA meeting is
usually arranged for those who have severe and enduring mental illness.
It is used to bring services together for those vulnerable prisoners who
may suddenly be released, to ensure continuity of care. Although he was
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not considered to have a severe and enduring mental illness, it was
thought he would benefit from a CPA meeting.
14. The CPA meeting took place on 1 July. The young man was said to be
angry and upset after the meeting, but this information was not passed on
to other staff by the member of healthcare who attended the meeting. In
fact, there is no mention in his medical record or core (landing) record that
this meeting ever took place and the man is recorded to be settled on that
day.
15. At 8.05am on 3 July, the duty officer and the wing Senior Officer (SO)
found him hanging in his cell. Staff responded promptly. No
cardiopulmonary resuscitation (CPR) was undertaken because the clinical
assessment of the wing nurse was that rigor mortis was well established.
The young man’s death was pronounced by a Police Surgeon soon after.
16. The young man’s family was initially told of his death by the Police. The
Deputy Governor contacted the man’s mother shortly after the police
contact.
17. My report makes three recommendations in areas where improvements in
practice have been identified.
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CONDUCT OF THE INVESTIGATION
18. The lead investigator for the Prisons and Probation Ombudsman was
assisted by one of her colleagues.
19. During the course of initial inquiries, the investigation team was shown
around Reading and visited the cell where the man died. They reviewed
all the relevant documentation and established a chronology of events.
Notices were issued to staff and prisoners telling them of the investigation
and offering them the opportunity of contributing. There were no
responses to these notices.
20. One of my Family Liaison Officers contacted the young man’s mother and
offered her the opportunity to contribute to the investigation. The
investigation team met with the man’s mother on 26 July 2005. His mother
raised a number of concerns mainly relating to her son’s medical treatment
and assessment during custody, and what was done to monitor and help
him with any physical and mental health problems he had while he was
there. These concerns are examined further in this report.
21. The investigation team met a representative of the local branch of the
Prison Officers’ Association (POA) and a representative of the
Independent Monitoring Board (IMB) to tell them about the investigation
process. Five members of staff were interviewed during the course of the
investigation. They were all offered the opportunity of being accompanied
by a work colleague or Trade Union official.
22. The investigation team met with the young man’s Youth Offending Team
(YOT) Supervisor on 16 September. They also spoke to the young man’s
solicitor.
23. The investigation team contacted Her Majesty’s Coroner to tell him of the
nature and scope of the investigation. The Coroner provided a copy of the
post mortem report of 7 July and toxicology report of 8 July. The post
mortem report recorded the cause of death as ‘hanging (self suspension)’.
The toxicology report did not suggest the man had taken excessive
amounts of illicit or prescribed drugs.
24. The Director of Quality, Standards and Workforce, Reading Primary Care
Trust, organised a clinical review of the healthcare provided to the man
while at Reading.
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HM YOI READING
25. Reading is a remand centre and young offender institution, holding young
adults between 18 and 21 years. The jail was built in 1844 on the site of a
former prison. It was designated as a local prison in 1973 and was re-
roled as a remand centre and young offender institution in 1992. The
operational area it covers includes Thames Valley, Hampshire and the Isle
of Wight. The certified normal accommodation, without overcrowding, is
196 and Reading has an operational capacity of 289. The accommodation
consists of three main wings, a segregation unit and a separated prisoners
unit (SPU) on E Wing. There is also a 20-bed resettlement unit, Kennet
House, which forms part of the resettlement estate for young offenders. C
Wing houses young adults on induction on two landings. The third landing
is mainly for young adults who work around the prison. B Wing is also
mainly for workers while A Wing is a general wing holding both remanded
and convicted prisoners.
26. The last full inspection by Her Majesty’s Chief Inspector of Prisons took
place in August 2004. This concluded that Reading was an improving
establishment, but still had a significant task to continue progressing. The
report noted, ‘a number of key building blocks are in place, particularly with
regard to safety, staff-prisoner relations and resettlement. But there is still
much to do, including a radical overhaul of catering, delivery of much more
equitable provision of time out of cells and improved and expanded
purposeful activity to occupy this time.’
27. The local strategies for the care of prisoners at risk of self-harm at
Reading are in accord with national policy. The local policy for the
prevention of suicide is published within the prison and is available to both
staff and prisoners.
28. The Deputy Governor confirmed that, between September 2004 and
September 2005, suicide awareness training had been delivered to 14
newly appointed prison officers, 24 existing uniformed staff (officer support
grades, prison officers etc), 6 contracted staff and 2 members of the
Independent Monitoring Board (IMB). Reading will soon be introducing a
new system for suicide prevention, the assessment, care in custody and
teamwork programme (ACCT).
29. This was the second self inflicted death in custody at Reading in 2005
investigated by my office. There are some common issues, particularly
relating to healthcare, between the man’s case and the other investigation,
to which I shall refer later.
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THE YOUNG MAN’S TIME AT READING
30. The young man was remanded into custody at Reading on 16 April 2005
from the Magistrates’ Court. He had been detained in police custody on
14 April. The Custody Officer assessed his fitness to be detained and a
doctor was called. On 14 April, the doctor’s assessment read, ‘Morose
young man. Needs 15 minute checks. Denies he will self harm.’ On 15
April, a doctor was again called to assess him, and at 4pm he noted,
‘Declined medical attention, been vomiting and probably heroin
withdrawal. Needs cell watch.’ At 5.30pm, the doctor noted, ‘Now
accepts meds. May be able to remove cell watch when he settles. May
need doctor to see him.’ At 10.42pm, the young man was again seen by
the doctor who prescribed medication for his nausea. The doctor said
‘declines meds at present but offer at times anyway, continued cell watch
in view of the threat of self harm.’ He remained on a constant watch at
the police station.
31. On 16 April, a suicide and self harm warning form was opened for the
young man at the Magistrates’ Court by a Senior Custody Officer. It said,
‘Headbutting cell door, generally trying to self harm. Doesn’t want to go to
prison. Says he wants to eat people and claims he hates white people.’
The man was checked by staff through regular intermittent checks every
couple of minutes.
32. The young man was remanded to Reading later that day and all the above
information was available for the First Reception Healthcare Screen. The
First Reception Healthscreen was undertaken by a Registered General
Nurse (RGN)/Registered Mental Health Nurse (RMN). He wrote, ‘Heroin
and Crack cocaine/refer to doctor re physical health/drug abuse. Epilepsy,
only fits when in custody. Last time was in police custody. Has had fits for
years. Never sought medical attention.’ The young man told the RMN
that he had not previously received treatment from a psychiatrist outside
prison or medication for any mental health problems. He said that he had
tried to harm himself when in prison before and stated he currently felt like
harming himself. An F2052SH (suicide and self harm form) was
immediately opened for him by the RMN. There is a note that has been
added to the warning form from the court, written by the nurse, ‘Denies
allegation that he hates white people, states he was beaten by a white boy
previously in the cell.’ The young man was placed on level 1 observation.
33. According to Reading’s local policy statement on suicide prevention, level
1 observation is when a prisoner is on an open F2052SH, in a shared or
single cell, and an intermittent watch is required, a minimum of five times
an hour, at irregular intervals. Level 2 observation is when a prisoner is
on an open F2052SH in a single cell and requires intermittent watch at all
times. Level 3 observation is when a prisoner is on an open F2052SH in
a shared cell, and an intermittent watch is required if the cellmate leaves
the cell for any reason and the prisoner on the F2052SH is left alone.
Level 4 observation is required when an F2052SH is opened and the
prisoner is actively suicidal and unable to be managed on normal location.
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The prisoner would be located in the Care Suite in a safer cell, on a level
of observation considered appropriate, in consultation with a Medical
Officer.
34. After the First Reception Healthscreen, the young man was immediately
referred to a doctor for a secondary assessment. The prison doctor noted
that the man admitted heroin abuse and said that he had used heroin two
days previously. It was also noted that he had been on medication from
his GP for depression but had not taken that medication for a year. The
young man’s GP records were not obtained. The young man also said
that he had made numerous attempts at deliberate self harm, the last time
being three months previously, when he attempted to hang himself. His
mother had apparently called the police and he ran away before the police
arrived as he was on an outstanding warrant. The doctor noted superficial
scars on his arms and referred him to the Outreach team. (The Outreach
team are healthcare staff with specialist skills, such as dealing with mental
health issues.)
35. The RMN gave the young man the medication to help with his withdrawal
symptoms, but he spat it out. He refused to take any medication. A full
explanation of withdrawal was given to him. The young man consistently
refused to take his medication, as detailed throughout this report. This
information was not relayed by senior nursing staff to medical staff and
alternatives do not appear to have been offered to him.
36. A cell sharing risk assessment was undertaken by a prison officer who
recommended that the young man remain in a single cell. On the
assessment form, the RMN noted that the young man had reactive
depression and had previous self harm history and used heroin. The
young man was assessed as a medium risk of sharing a cell with others.
(That is, there was no immediate risk if he shared a cell, but the situation
would have to be reviewed regularly.)
37. The young man received a full induction and was located in a single cell
on the induction wing. On 17 April, the duty senior officer (SO) and the
wing officer undertook another cell sharing risk assessment for him.
Following this, the young man was located in a shared cell. He still
refused to take his withdrawal medication.
38. On 18 April, the young man was seen by a substance misuse nurse. He
was still refusing to take his medication despite the obvious withdrawal
symptoms from which he was suffering. The young man was also seen
by the staff nurse (an Outreach Worker) who noted that he appeared to be
low in mood and said that he was feeling suicidal. The young man had
lost his glasses and was referred to an optician, but there is no evidence
that he ever saw an optician.
39. On 19 April, the young man had an F2052SH review and was to continue
on Level 1 observation. He was said to be angry and still refused to take
his medication. However, he saw the substance misuse nurse again and
10
agreed to take his medication. He was reported not to want his family to
be informed of his whereabouts or for them to visit him.
40. On 20 April, the young man appeared at the Magistrates’ Court and is
reported to have exhibited bizarre behaviour, howling like a dog. He was
sentenced to 28 days imprisonment for failure to surrender to bail on 12
May 2004 and 20 November 2004. He was remanded to appear again at
Court, via video link, on 29 April on some of the outstanding charges. The
remainder of the outstanding charges were to be dealt with by the Crown
Court. On return to Reading, he was seen for another health check. It is
unclear who saw him. No changes in his condition were reported. He was
later seen by the staff nurse who noted that he was much more settled and
getting on well with his cellmate.
41. On 26 April, the young man was seen for an F2052SH review. He was still
refusing to take his medication. He was low in mood and was finding it
hard to engage with others. He did, however, agree to be referred to the
mental health team. Level 1 observations were to be continued until 28
April when he was due to appear at the Crown Court.
42. On 27 April, the young man was again seen by the staff nurse who noted
that he seemed brighter. He told her that he could not contact his family,
as he did not have any of their phone numbers. It was also noted that he
had applied to join the gym and to attend education. The gym facilities are
open to all prisoners once they have successfully completed their
induction. The usual waiting time is seven days- the end of induction
week- if the prisoner applies at the onset of the induction programme.
43. The young man attended the Crown Court on 28 April. The wing nurse
saw him before his court appearance and said he looked tired and made
very little eye contact. He returned to Reading on remand later that day.
44. On 29 April, the young man appeared at the Magistrates’ Court by video
link. He was again remanded in custody until 20 May. Later that day, he
was moved to the Segregation Unit after he threw a television at officers.
He also damaged video link equipment beyond use. The wing nurse saw
him in the Segregation Unit. The young man was later found making a
noose with his t-shirt and was seen by the senior healthcare officer. He
was moved to a reduced risk cell with fire retardant clothing. (Reduced
risk cells at Reading are cells specially designed with reduced ligature
points. Modifications include moulded furniture and bed to reduce ligature
points, flush taps and safer design windows and recessed light fitting. The
build was to Safer Custody Specification of the time, carried out by
external contractors.)
45. On 30 April, the young man was assessed as fit for adjudication in relation
to the incident the previous day. He spoke to his mother, and during their
conversation made several threats to self harm. He said that he would like
to be in a shared cell and was moved to a shared cell later in the
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afternoon. The young man was assessed as fit for adjudication, although
the entry is not signed.
46. On 1 May, the young man went outside on exercise and later attended the
chapel. On 2 May, he joined in the association period. He saw the staff
nurse and told her that he was angry at being remanded again, but had no
thoughts of self harm. He agreed to see a psychiatrist. On 3 May, the
young man saw a Consultant Psychiatrist. She concluded that the young
man was at risk of self harm or suicide and that he should not be moved to
a single cell, although that was what he now wanted. He was having
difficulties sleeping and was not eating. He was upset that he had not
heard from his girlfriend. The psychiatrist was of the opinion that the
man’s self harm attempts were as a result of something that had
happened within the previous day or two, and that he was a risk to others
and probably to himself. She recommended that the young man should
have increased daytime activities and relaxation or acupuncture. There is
no evidence that the relaxation or acupuncture were followed up.
47. On 4 May, the adjudication hearings for both incidents on 29 April were
concluded. The young man pleaded guilty to both charges. Punishment
relating to attempting to throw the TV at staff was suspended for a month
and the charge relating to the video link equipment was dismissed.
48. On 5 May, the young man’s F2052SH was reviewed and he was said to
appear more settled and was spending more time out of his cell. He
maintained good eye contact and understood why he could not have a
single cell. He was feeling more comfortable sharing with his cellmate.
He wanted the F2052SH to be closed. The observation level was reduced
from Level 1 to Level 3. On 6 May, the young man refused association.
He said he was still having difficulty sleeping.
49. On 7 May, the young man was seen by the RMN. There was no change in
his condition. Later that evening, the young man assaulted his cellmate by
throwing tea at him. The young man was subsequently found in a struggle
with his cellmate and his cellmate tried to restrain him. The young man
continued to struggle and tried ‘to headbutt’ his cellmate, sustaining minor
injuries. He was moved to the Segregation Unit to prevent a fight
escalating. Later, the young man was found making a noose with bedding
by the second wing officer. The young man told him that he had nothing
left to live for and his cellmate had ruined his life. The Level 3
observations were increased to Level 1. He was located in a reduced risk
cell overnight.
50. On the evening of 8 May, the young man was moved to a single cell in the
segregation unit and was said to be pleased to be out of the reduced risk
cell. However, he was vomiting and was referred to see a doctor. The
wing nurse also questioned whether he should be referred back for further
mental health assessment by the consultant psychiatrist. Meantime, Level
1 observations were to be continued.
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51. On 9 May, the young man was seen by the prison doctor. He was no
longer vomiting and was assessed as fit for adjudication. The Adjudication
Record shows that he pleaded guilty and the charge of fighting was
proved. The young man was to be removed from normal location and to
remain in the segregation unit for a further three days. He said he would
try to get along with his cellmates in the future. Although he said he had
no suicidal thoughts at that time, Level 1 observations continued.
52. The man attended the Crown Court on 10 May. A bail application was
refused and he returned to Reading. He was seen by the wing nurse
before and after the court appearance. He told her that he did not want to
be seen by a psychiatrist again. He said he was fine. He returned to the
Segregation Unit when he came back from court.
53. On 11 May, the young man was moved from the Segregation Unit to
normal location on C Wing. He had an F2052SH review and the
document was closed by a review panel of the duty principal officer (PO),
the wing PO, the wing officer and the staff nurse. The review summary
said that, “apart from an impulsive incident whilst segregated there has
been little concern over his intentions to self harm. He has stated that he
is so happy to be out of the Segregation Unit and has no intentions of
harming himself. Induction staff have no concerns other than preferring
him to share a cell with a compatible person.” This was agreed by the
man, who said he would talk to staff if he had a problem. He also agreed
that he would see staff if he felt he needed medication. The F2052SH was
closed with a note that continued support was needed from staff and
healthcare and a compatible cellmate would be helpful. There is no
evidence that any action was taken to locate him with a compatible
cellmate at this stage.
54. On 13 May, the F2052SH was re-opened by the wing nurse. In view of the
incident on 7 May with his cellmate and later when he had been
discovered making a ligature, she was concerned that the man still had
thoughts of killing himself and felt that the F2052SH had been closed
prematurely. She noted that he had seen the psychiatrist on 3 May, but
was still refusing to take his medication. Level 1 observation was again
started and the wing nurse put a comprehensive care plan in place for him.
The young man was to be monitored closely by healthcare staff, to
establish a trusting therapeutic relationship with staff and his food and fluid
intake were to be monitored. The wing nurse recommended that he should
see a psychiatrist again to reassess and monitor his mental state. Staff
were to encourage him to become more active, as he was spending a lot
of time sleeping in his cell. The investigation found no evidence that staff
followed the care plan.
55. On 14 May, the young man’s F2052SH was reviewed and Level 1
observations were to continue. The prison doctor recorded that the man
was feeling low and fed up. She concluded in her assessment that he
seemed immature, had poor coping skills and was reluctant to accept help
(Samaritans and buddies). The young man agreed to take medication and
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was prescribed amitryptilline to help him sleep. The doctor noted that the
man had previously taken anti-depressants which had not helped.
56. On 16 May, the young man’s F2052SH was further reviewed and Level 1
observations continued. The young man was later found making another
ligature from sheets. He was seen by the duty nurse who advised him to
seek occupation as he got bored easily. He said that he had not been
making a ligature, it was a washing line. He also said that he had no
intentions of self harm, but was fed up and bored as he did not have any
visitors. He was upset as he had not had contact from his girlfriend and
could not get in touch with his mother. However, it was noted that he had
made contact with his mother on 30 April prior to his adjudication, so he
had apparently located her telephone number.
57. On 17 May, the young man told the wing nurse that he did not have any
thoughts of self harm. She noted that he spent most of the day sleeping
and then could not sleep at night. He covered his ‘spy hole’ and refused to
remove the covering until staff entered the cell.
58. On 18 May, the young man was seen by the staff nurse in his cell. He told
her he was tired. She spoke to officers about his gym application, which
had apparently been made two weeks previously. They said they were
chasing it up for him. The young man said he had no thoughts of self
harm. On 19 May, he was seen by the wing nurse. He said he was ‘low’
as his pregnant girlfriend had not been in touch, and he had not heard
from her since early May. However, prison records indicate that he had a
visit from his girlfriend on 18 May. On 20 May, the young man appeared
at the Magistrates’ Court via video link. He was again remanded in
custody until 3 June, to appear again via video link for sentencing. During
20 May, he barricaded himself in his cell and threatened to kill himself.
Staff found ligatures in his cell and he was moved to the Segregation Unit
and placed in a reduced risk cell. He was spoken to by a member of
healthcare about the importance of taking his medicine.
59. On 21 May, the young man attended an adjudication hearing about
barricading himself in his cell the previous day. The Adjudication Record
shows that he pleaded guilty and the charge was proven. The punishment
was removal from the wing for seven days. Although the punishment was
suspended for two months, the young man was already in the Segregation
Unit. He was seen by the wing nurse. He again told her that he was fed
up, as he had not heard from his girlfriend. He had not been taking his
medication. He persuaded the wing nurse to move him out of the reduced
risk cell, but he was to remain on Level 1 observation. During the previous
night, staff had noted that he had exhibited bizarre behaviour, screaming
and barking like a dog, which he denied. The wing nurse recommended
that he should be seen by a psychiatrist on 27 May and should be
encouraged to take his medication. He agreed to see the psychiatrist.
During the night he made another noose and was moved back to a
reduced risk cell.
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60. On 22 May, the wing nurse saw the young man again. The young man
was still refusing to take his medication and now told her that he did not
want to see a psychiatrist again. He was agitated and angry towards staff.
On 23 May, the man had an F2052SH review. It was decided to maintain
Level 1 observations. He was taken to healthcare and saw the staff nurse
and a Community Psychiatric Nurse (CPN). He told them that he was still
waiting for a response to his gym application and wanted to be on normal
location in a shared cell. He was then located in a reduced risk cell which
he flooded.
61. On 24 May, the young man was seen in healthcare by several members of
the healthcare team, including the CPN. He said that he did not have any
thoughts of self harm. He was returned to normal location.
62. On 26 May, he appeared more calm and relaxed and agreed with the wing
nurse that he would see a psychiatrist. An appointment was made for him
on 27 May, but this did not go ahead although the reason why is unclear.
Another appointment was made and he saw the psychiatrist on 31 May.
The young man said he had no thoughts of deliberate self harm, and was
encouraged by staff to spend more time out of his cell.
63. On 30 May, the staff nurse visited the young man during association and
spoke to him about taking his medication. He told her that he felt bored in
his cell alone. A note was made that officers should pursue his gym
application, which had been made for the third time the previous week.
The staff nurse in fact pursued the gym application and encouraged him to
occupy himself. He told her that he was worried about his girlfriend and
had not had any contact with his mother. Wing staff advised him to call his
mother and sisters and to re-apply for a shared cell which they would
follow up. There is a note in the F2052SH that observations were reduced
from Level 1 to Level 3. However, the young man was in a cell on his own
and Level 3 observations are for those occupying shared cells. The staff
nurse recommended that a cell sharing risk assessment should be
completed to decide whether the young man could share with his cousin
who had recently been located in Reading. There is no evidence that this
ever happened.
64. On 31 May, the psychiatrist undertook a psychiatric review. She
concluded that the young man needed more activities and was still a
suicide risk. Observations were again increased to Level 1. The young
man said he wanted to share with his previous cellmate, but this was not
considered appropriate. The psychiatrist prescribed medication for him
and was to review him in two weeks, but that did not happen. The doctor
noted that the young man needed a Care Programme Approach meeting
(CPA). A CPA meeting is usually arranged for those who have a severe
and enduring mental illness. It is used in prisons to bring services together
for those vulnerable prisoners who may suddenly be released. The young
man did not have a severe and enduring mental illness, but it appears that
the psychiatrist considered that a CPA meeting would be useful. The man
15
finally went on his gym induction on 31 May, eight weeks after being
located in Reading.
65. On 1 June, the young man seemed brighter, according to the wing nurse,
and said that he had no ideas of suicide or self harm. He was concerned
about his court appearance the next day. He also had a visit from his
girlfriend which apparently went well.
66. On 2 June, the young man appeared at the Crown Court, and was
remanded back to Reading. On 3 June, he appeared at the Magistrates’
Court via video link. He was remanded in custody until 17 June.
67. Between 2 June and 5 June, the young man continued to refuse to take
his medication and spent most of his time in his cell, refusing to go to
association. It is unclear what action staff took in relation to this. On 4
June, he asked to speak to the Samaritans but later changed his mind.
68. On 6 June, the CPN contacted the local Community Mental Health Team
(CMHT) and an officer from SMART, part of the CMHT, to invite them to a
CPA meeting on 1 July. The young man had an F2052SH review, and the
conclusion was that the form should remain open. There is a note in his
medical record that his gym application was still outstanding and he was
bored. However, records show that the man had his gym induction on 31
May and his F2052SH notes that he refused to go to the gym on 6 June.
The man’s F2052SH remained open.
69. On 7 June, the young man was seen by the CPN. He was said to be low
in mood, but not suicidal. He complained that he did not get enough
money to pay for tobacco to last him a week and asked for money to buy
more tobacco. That request was refused. He also said he wanted to go
into a shared cell with somebody he could get on with and that he hated
being in Reading. The CPN noted that the care plan for him was that he
should stay in a single cell, that the CPA date of 1 July should be changed
as it clashed with a court appearance, and finally that outreach should
monitor him.
70. On 8 June, the young man attended the gym. Between 8 June and 12
June, he was seen by various healthcare staff. He said he was not
suicidal, but he still refused to take his medication and would not talk about
it. He was still on an F2052SH which he wanted closed. He said he
wanted a job, enhanced status and to share a cell. He refused to go to the
gym on 11 June.
71. On 13 June, the prison doctor saw the young man and he complained of a
chalazion (meibomian cyst), a swelling in the eyelid which is usually easily
treated without the need for any surgery. The doctor referred him to the
optician. However, he never saw the optician. The young man also spoke
to the staff nurse and told her he wanted to apply for an art and design
course which she said she would support. He told her that he did not have
any thoughts of suicide and still wanted to share a cell.
16
72. The F2052SH was closed following a review by an officer, an SO, a PO
and the duty nurse. The review team concluded that, ‘The man is once
again using his support mechanism to get attention, he states he has no
thoughts of self harm and what he says to staff is taken the wrong way.
He wants to stay at Reading when he gets sentenced and we asked him
that he needs to start investing time in improving his employment
prospects.’ The PO, the SO and the officer told my investigation team that
they were content to close the F2052SH at that stage. They explained
that the young man told them during the review that he was definitely not
feeling suicidal and said that he was using the system as a way to stay at
Reading, as he did not want to be transferred to another prison.
73. The SO, the PO and the officer said that they had spoken to the young
man before the review and tried to encourage him to engage in more
purposeful activity within the prison. They reinforced this and further
encouraged him to occupy himself constructively. The SO said that he
spoke to the education department during the review and arranged for the
young man to undertake an assessment with them. My investigation team
was unable to speak to the wing nurse as she no longer works at Reading.
74. Also on 13 June, the young man saw his solicitor. She told the
investigation team that she saw him while he was in custody at the Police
Station and later at the Magistrates’ Court before he arrived at Reading.
She said he was struggling with withdrawing from drugs and that she was
concerned for his wellbeing, as he expressed thoughts of committing
suicide. She thought that those taking care of him were aware. She saw
him twice at Reading. The young man cancelled a third meeting. She felt
that he had psychiatric problems and would have trouble completing a
prison sentence. When the solicitor saw him for the last time on 13 June,
he made eye contact with her and she felt he had ‘turned a corner’. She
said that he seemed much better. He did not mention any issues with how
he was being treated in Reading. She explained that the man pleaded
guilty to the charges and did not lodge an appeal.
75. On 15 June, the young man saw the staff nurse again and told her he was
fine. Wing staff noted that he had been asking to share a cell. This was
not considered appropriate as the psychiatrist had recommended a single
cell as the young man had assaulted a cellmate. However, there is a note
that healthcare should ask the doctor if that could be reassessed. There is
no evidence that this happened.
76. The young man had been advised, on 20 April, during the induction
process that he should attend education and foundation classes were
recommended as his basic skills score was low. At that time the
foundation classes were full, so he was put on a waiting list to attend. He
was allocated a place starting on 20 June. He attended his first class on
the afternoon of 20 June. He attended further classes on 21 June, 23
June, 24 June, 28, 29 and 30 June. He had a visit on 22 June so could
17
not attend, there was no class on 27 June and he refused to attend on 1
July.
77. On 21 June, after a meeting with the young man, his Probation Officer
suggested that he should be put back on an F2052SH. As a result, on 22
June, the SO and a governor noted that the man should be reassessed by
healthcare. There is no evidence that this happened.
78. On 24 June, the young man appeared at the Magistrates’ Court. The
man’s previous YOT worker told the investigation team that he visited the
young man in custody at the court, following a telephone call from the
Probation Court team about the outstanding breach of supervision orders.
He said there was no statutory obligation on him to visit the young man at
that time, as he was no longer the responsibility of the Youth Offending
Team. He said he visited the young man as he had not heard from him
since November 2004 and he thought he might have been able to offer
him support. He described him as being ‘low’ at that time, but said that the
man seemed pleased to see him. He said he was honest when talking to
the man about what was going to happen and about the possibility of a
long sentence. The YOT supervisor explained that he told custody staff the
young man had mental health problems and a history of self harm and
depression and that he thought that he was likely to self harm. He could
not recall whether custody staff made a written note of his concerns. The
relevant Prisoner Escort Record notes that the young man had a visit from
the YOT supervisor at 12.53pm, but does not note the concerns which the
supervisor said he expressed for the man. When the young man returned
to Reading, he had a further reception health check which noted no
change in his condition and recorded that the man stated he was fit and
well. It is not clear who undertook that health check.
79. On 27 June, the young man saw the prison doctor as he was complaining
of a headache. He asked the doctor if he could share a cell. The doctor
recommended that the Outreach team liaise with landing staff about this.
There is no evidence that a shared cell was ever considered at this stage.
The young man denied any thoughts of deliberate self harm or depression,
and was spending more time out of his cell at work.
80. On 1 July, a CPA meeting went ahead, with the young man, the CPN and
the officer from SMART. There are no records of this meeting. The CPN
told the clinical review team that the young man was angry and frustrated
after it. She said that during the meeting the man had been angry, but
objective to a point about his future. The young man had not been able to
engage with the CPA for more than a short time. She said he walked out
of the meeting after 15-20 minutes and was accompanied back to the
wing. She recollected she had been concerned that the young man had
been angry and asked the returning officer to keep an eye on him. She
also recalled she had been unable to complete the CPA forms as she had
been called away for an emergency after the meeting. There is no note in
the young man’s medical record or his core record (landing record) that
18
the meeting ever took place. The young man’s medical record says that
he had no problems that day.
EVENTS ON 3 JULY 2005
81. On 3 July, the duty officer checked the F2052SH forms on A1 landing,
where the young man was located in a cell on his own. As he came to the
young man’s cell at approximately 8.05am, the officer noticed that the
observation hatch of the young man’s cell was covered with paper. He
spoke to the SO on duty about the situation and they both went back to the
young man’s cell. The SO called through the door to the man and
knocked on the door several times, but there was no reply. The SO
shouted for assistance from landing officer 1 and landing officer 2. As the
SO opened the door she saw the young man hanging by a ligature, made
from torn bedding and attached in a figure of eight format around the light
fitting. She entered the cell and felt the young man’s face which was cold.
The SO and landing officer 1 lifted the young man’s legs. Landing officer 2
and landing officer 3 removed the ligature. Landing officer 3 had followed
the other two landing officers to the cell. The third wing officer also arrived
around the same time. The young man was placed on the top bunk and
the SO and the third wing officer checked for a pulse but were unable to
find one.
82. At around 8.15am, the wing nurse arrived from healthcare and found the
young man’s skin was cold to touch and there were no signs of life. The
nurse brought resuscitation equipment with her to the cell, but no attempt
was made at resuscitation as, in her opinion, rigor mortis appeared to be
well established.
83. The SO had radioed the control room for an ambulance at 8.13am and the
paramedics arrived shortly after at 8.20am and confirmed the young man’s
death. The local Police were contacted at 8.40am to notify the young
man’s next of kin. At 8.40am, the Deputy Governor held a ‘hot’ debrief for
all the staff directly involved and obtained initial statements from them.
The Chaplain provided support to staff involved and the local care team
were notified and attended later in the morning.
19
84. The Deputy Governor issued a notice to staff and all prisoners, which gave
details of what had happened. The IMB and the Samaritans were notified
and two Samaritans attended during the morning and afternoon to provide
support to staff and prisoners. All prisoners on open F2052SH forms had
case reviews.
85. Police attended with scenes of crime officers. The young man’s death was
pronounced by a Police Surgeon at 11.45am and the body was taken to
the hospital mortuary at around 12.30pm. By this time the Deputy
Governor had made initial contact by telephone with the young man’s next
of kin, his mother, following the Police notifying her of the young man’s
death.
86. The Deputy Governor told the investigation team that initial contact was
made by the Police, and not the prison, primarily because he was duty
governor on the morning of 3 July and, as it was the weekend, there was a
minimum number of staff on duty. The Deputy Governor had to manage
the aftermath of the young man’s death and did not feel that there was
anybody else on duty with the appropriate specialist skills to break the sad
news to the young man’s family.
87. The young man’s mother agreed to visit Reading later in the day. She
arrived at Reading at around 5pm, with the young man’s father, and met
with the Governor, the Deputy Governor and the Chaplain. Initial
questions from the family were answered and the investigation procedure
was explained. The mother did not want any member of the Prison Service
to attend the young man’s funeral.
88. Reading has paid the cost of the funeral. They have also agreed, in
principle, to pay the stonemason’s bill for the headstone but the bill has not
been sent to them yet. A proposal has been sent to the Prison Service’s
Director of Operations to approve a generous payment towards the
headstone.
20
CLINICAL REVIEW
89. The investigation team advised Reading Primary Care Trust (PCT) of the
young man’s death on 5 July 2005. The PCT then arranged to undertake
a clinical review of the healthcare provided to the man while at Reading, in
accordance with the agreement between the Department of Health and the
Prisons and Probation Ombudsman. A multi-disciplinary panel was
convened to undertake the review. This consisted of the lead reviewer
(Director of Nursing and Clinical Services Bracknell Forest PCT), a GP
and Professional Executive Member, Reading PCT), a RMN (Locality
Manager Community Mental Health Team, Reading PCT) and the Head of
Adult Services, Reading PCT.
90. The clinical review has highlighted a number of issues relating to
healthcare within Reading and, as in the investigation of the previous
death in Reading, has made a number of far reaching recommendations
which will need to be considered jointly by Reading PCT, Reading’s
Healthcare Manager and the Governor. The recommendations cover
many of the same issues identified in the earlier investigation.
91. The investigation has also been provided with an update of the clinical
review, dated October 2005, which clearly demonstrates the commitment
of the Primary Care Trust and the prison to learn from the findings of the
clinical review to try and prevent any future deaths in custody.
.
21
CONCERNS RAISED BY THE MAN’S FAMILY
92. The young man’s mother raised concern about her son’s treatment from
the time of his arrest and location in police custody until his death at
Reading. She asked particularly what steps were taken to deal with her
son’s apparent mental health problems and his threats to self harm during
his time in custody.
93. The mother also raised specific questions about who visited her son,
whether he had any personal letters in his cell and who telephoned the
man while he was in Reading. Prison records show that since his
reception on 16 April, the only person the young man had personal visits
from was his girlfriend, on 18 May, 1 June, 21 June and 22 June. He had
legal visits on 25 April (a WPC and PC), 10 June (WPC and PC), 13 June
(Solicitor) and 21 June (Probation Officer).
94. No personal letters were found in the young man’s cell, the only incoming
letters were from his legal advisor, and were left with the man’s property.
Only one outgoing letter was found in his cell, addressed to his girlfriend.
The Police have the original letter.
95. There is a pin phone print out of all the calls the young man made, but it is
a series of telephone numbers which are not allocated to a particular
named person and would be difficult to decipher.
22
CONSIDERATION AND CONCLUSIONS
96. The young man was a complex character and he clearly had a troubled
time before and during his remand at Reading. He was known to the
Youth Offending Team and had served a previous term of prison custody.
During his custody at the police station between 14 April and 16 April 2005
there were concerns for his wellbeing and he was placed on a constant
watch. He also exhibited erratic behaviour when in custody at the
Magistrates’ Court on 16 April, where a suicide and self harm awareness
form was opened and he was on constant watch. This information was
available when he arrived at Reading where a further suicide and self
harm awareness form (F2052SH) was opened immediately after he
arrived. Although this was closed on 11 May, there were still concerns
about his wellbeing, so another F2052SH was opened between 13 May
and 13 June. The young man’s behaviour continued to give cause for
concern as he made nooses or ligatures on at least five occasions,
exhibited bizarre behaviour and covered his observation hole on
occasions.
97. The young man was moved several times while he was at Reading and
there was an ongoing issue about whether to locate him in a single or
shared cell. Decisions were based upon the need to balance the risk of
the young man harming himself, with the risk he posed to others. On 30
April, the young man asked to share a cell and on the same day he was
placed in a cell with another prisoner. However, by 3 May, the young man
had changed his mind, wanting to be in a single cell, although the
psychiatrist decided the risk of self-harm or suicide was too great for this to
be allowed. On 7 May, the young man assaulted his cellmate and he was
moved to a reduced risk cell in the Segregation Unit, where his behaviour
remained unpredictable and erratic. Nevertheless, four days later, on 11
May, the F2052SH review stated that a compatible cellmate would be
helpful for him. The investigators found no evidence to indicate that this
was followed up.
98. On 30 May, the staff nurse recommended that a cell-sharing risk
assessment should be carried out to decide whether the young man
should be allowed to share with his cousin who had recently been located
in Reading. Once again there is no evidence that this happened. On 7, 8,
and 13 June the man asked to share a cell but this did not happen. There
is also a note in his record that healthcare should ask the psychiatrist if his
decision could be reassessed. Again, there is no evidence that this
occurred. On 27 June, when the young man saw the prison doctor about
a headache he again asked if he could share a cell. The doctor
recommended that the Outreach team should liaise with landing staff
about this. There is no evidence that any such liaison happened, although
it was noted that the young man denied any thoughts of deliberate self
harm or depression, and was spending more time out of his cell engaged
in purposeful activity.
23
99. As a consequence of his behaviour and concerns about the risk to others,
the majority of his time at Reading was spent in a single cell and he spent
some time in a reduced risk cell following self harm threats. It seems clear
that recommendations made on at least four occasions that the cell
sharing risk assessment should be re-assessed were not acted upon.
100. I recommend that auditable systems and procedures are put in place
for the care of more vulnerable prisoners. This should include
documented liaison between healthcare staff and discipline staff to
ensure that the prisoner is placed in the most appropriate location
and any action in this respect is carried through in a timely manner
and that staff caring for the prisoner are aware of circumstances that
may escalate thoughts of self harm or suicide.
101. The young man had F2052SH forms opened on two occasions. There did
not appear to be a clear system of risk assessment for opening or closing
these forms and information was not shared between disciplines. In
particular, the role of healthcare in the process did not appear to be clear.
The young man saw the psychiatrist on 3 May and she considered that he
was a risk of self harm. However, on 30 May the F2052SH level was
reduced to Level 3, despite the fact that he was due to see the psychiatrist
on 31 May. When the psychiatrist did see him, she considered that the
risk remained high and requested that the level be raised to level 1.
102. The F2052SH remained open and, on 6 June, the young man’s behaviour
was said to be unpredictable and he was still considered to be at risk of
self harm. However, a week later, with no further medical assessment, it
was noted that the young man was considered to be ‘manipulating’ the
system and the F2052SH was closed. I consider that there was a lack of
clarity over the roles of healthcare and discipline staff in the process of
opening and closing self harm risk forms and that the actual risks were not
fully considered.
103. I am pleased to record that the Prison Service has implemented a new
system of assessment, Assessment Care in Custody Teamwork (ACCT)
that is being rolled out to all prisons. At Reading, ACCT training is well
underway with an expected implementation date of 19 June 2006. All
residential and resettlement staff will be trained in the use of the new
system which is designed to assess and manage risk more effectively with
a greater input from the prisoner and other members of the multi-
disciplinary team.
104. During his secondary healthscreen at Reading, the young man told the
prison doctor that he had been on medication from his GP for depression
but had not taken that medication for a year. The young man’s GP
records were not obtained or efforts made to follow up the information
given to healthcare staff.
105. I recommend that Reading PCT, in partnership with the Governor,
should be asked to develop a policy for ensuring a prisoner’s past
24
medical history is obtained in a timely manner.
106. The young man refused to take his medication during his time in Reading,
but this was not relayed by senior nursing staff to other medical staff and
alternatives do not appear to have been offered to him. There is evidence
that on a number of occasions follow up action for his care was delayed, or
not undertaken at all. The referral to the Community Mental Health Team
was not undertaken until 6 June and the recommendation that he should
attend relaxation or acupuncture was not followed up. The young man
saw the psychiatrist on 31 May. He was due to see her again two weeks
after that date, but this did not happen.
107. The young man’s probation officer expressed concerns about him to staff
on 22 June and told them that she felt that he should be put back on an
F2052SH. There is a note that discipline staff made healthcare aware of
these concerns, but no action appears to have been taken as a result. I
am also concerned that the CPA meeting held on 1 July was not
documented and, more importantly, the result of that meeting was not
communicated to healthcare or discipline staff.
108. I recommend that the Governor and Healthcare Manager issue
guidelines for healthcare and specialist staff to communicate
important information about prisoners to each other and that follow-
up action, including referrals to specialist services, is taken as soon
as possible.
109. Nevertheless, it is clear that both healthcare and discipline staff thought
that the young man could benefit from increased daytime activity. He was
referred to Education after his F2052SH was closed on 13 June and he
attended an assessment on 20 June. There are indications in the records
that staff encouraged him to come out of his cell and engage in useful
activity. Although there was a delay in processing his gym application, he
only attended once after he completed the gym induction and there is
evidence that he refused to go on other occasions. The gym issue aside,
the evidence is that staff had concern for his welfare and did all they could
to ensure that he engaged in purposeful activity. Unfortunately, he was
either unwilling or unable to benefit from these efforts.
110. The YOT supervisor visited him at the Magistrates’ Court on 24 June and
during that visit was concerned about his wellbeing. He said that he told
custody staff that the young man had mental health problems, and a
history of self harm and depression, and that he thought that the young
man was likely to self harm. He could not recall whether custody staff
made a written note of his concerns. The relevant Prisoner Escort Record
does not note the concerns which the YOT supervisor said he expressed
for the young man. When the man returned to Reading, he had a further
reception health check which noted that he was fit and well.
111. The local police delivered the news of the young man’s death to his
mother. The Deputy Governor then telephoned the mother and arranged
25
for her to visit the prison. My strong preference is that, wherever possible,
a senior manager from the prison where a prisoner has died should break
the news to the family. Where this is not possible (such as when the
family live a long distance from the prison), then consideration should be
given to asking a senior manager from a prison in the nearby area to visit
the family and break the news. The Prison Service’s newly revised
guidance Liaison with Bereaved Families Following a Death in Custody
(Prison Service Order 2710) explores these issues. It recommends that
the news is broken to a family as soon as possible after the death, face to
face, by a dedicated Family Liaison Officer, along with the chaplain,
Governor or most senior individual available. I note that at the time of the
young man’s death this new PSO would not have been available to staff.
112. The Deputy Governor explained that he was managing events at the
prison on a weekend, with a minimum number of staff on duty. He said
that he did not feel he had any other member of staff on duty with the
appropriate specialist skills to deliver the news in an appropriate manner.
In view of this, I consider that the decision taken was a reasonable one.
113. The clinical review makes a number of recommendations which I endorse.
As noted in the investigation for the other self inflicted death at Reading on
26 June, I am aware that Reading PCT has developed one action plan in
light of the recommendations from both clinical reviews.
26
RECOMMENDATIONS:
OPERATIONAL
1 I recommend that auditable systems and procedures are put in place for
the care of more vulnerable prisoners. This should include documented
liaison between healthcare staff and discipline staff to ensure that the
prisoner is placed in the most appropriate location and any action in this
respect is carried through in a timely manner and that staff caring for
the prisoner are aware of circumstances that may escalate thoughts of
self harm or suicide.
2 I recommend that the Governor and Healthcare Manager issue
guidelines for healthcare and specialist staff to communicate important
information about prisoners to each other and that follow-up action,
including referrals to specialist services, is taken as soon as possible.
HEALTHCARE
3 I recommend that Reading PCT, in partnership with the Governor,
should be asked to develop a policy for ensuring a prisoner’s past
medical history is obtained in a timely manner.
OBSERVATION OF GOOD PRACTICE:
4 The records kept by the wing nurse were comprehensive and
demonstrated her knowledge of the man and her concern for him as
demonstrated particularly by her care plan of 13 May.
5 The referral made by the CPN to the local CMHT was comprehensive.
27
There are no comments on the draft report from the man’s family.
The Prison Service has accepted most of the recommendations, including
those of the clinical review. However they do not accept the recommendation
that ‘a formal risk assessment and score should be produced for the opening,
review and closure of the F2052SH. Care plans should be laid out and the
review of elements of these recorded at each review.’ They explain that staff
complete a recorded Case Review in accordance with National Guidelines
and procedures, which includes a Care Plan. No scoring is included in this
process as it is not part of the 2052SH procedure. ACCT does have risk
indicators, but again is not scored.
The Prison Service partially accepts the recommendation that, ‘Key events
that affect an inmate’s behaviour or attitude should be communicated as a
matter of urgency. This should be written as well as oral form.’ They explain
that internal factors relating to a prisoner’s behaviour will be recorded in the
wing file, observation book and 2052SH/ACCT, if applicable. External matters
will be actioned, providing the prison is notified of these.
28