Individual at Shrewsbury

Investigation into the circumstances surrounding
the death of a man
at HMP Shrewsbury on 22 August 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2010
This is a report into the circumstances surrounding the death by hanging of a man
who was a licence recall prisoner at HMP Shrewsbury, on 22 August 2009. The man
was 34 years old. Suicide monitoring procedures were in place until three days
before he died.
I offer my sincere sympathy and condolences to the man’s family and friends for their
loss. I apologise for the delay in issuing this report and any distress this may have
caused.
The investigation was carried out on my behalf by one of my colleagues. A clinical
review of the man’s healthcare at Shrewsbury was undertaken by Mr A on behalf of
Shropshire County Primary Care Trust (PCT). I am grateful for the review. I would
also like to thank the Governor of Shrewsbury, Mr B, and the Director of Dovegate,
Mr C and their staff for their co-operation and assistance with this investigation.
Particular thanks go to Ms A, who was a very efficient liaison officer.
Throughout his sentence, the man remained troubled by his crime and presented
prison staff with a number of challenges. He became addicted to drugs in prison
seemingly as a way of coping with his guilt about his offence. Several attempts at
detoxification were unsuccessful. He had been recalled to Shrewsbury only hours
after being released into the community on licence. Although staff at his previous
prison had helped the man to prepare for his release, he nevertheless faced it with
trepidation. Also, he had been unable to take part in some offending behaviour
courses because of his personality disorder and social phobia. Consequently, he
was unable to demonstrate that his risk to the public had reduced.
I am satisfied that the man was well supported by staff at both prisons. However, I
make three recommendations, covering recording refusal to take medication; timely
risk assessments for prisoners with significant mental health conditions and noting
the reasons for moving prisoners at risk of suicide or self-harm to single cells. All
three recommendations were accepted.
I have copied this report to the Director of Dovegate and the West Mercia Probation
Trust.
Jane Webb
Acting Prisons and Probation Ombudsman October 2010
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CONTENTS
Summary 4
The investigation process 6
HMP Dovegate and HMP Shrewsbury 7
Key findings 11
Issues 27
Conclusion 33
Recommendations 34
Annexes
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SUMMARY
The man was born in 1975 and died on 22 August 2009 in his cell at HMP
Shrewsbury. He was 34 years old. He had been recalled to prison five weeks
earlier after breaking the terms of his licence. He had been in Shrewsbury several
times before and many of the staff knew him.
In 2002, the man was sentenced to ten years imprisonment for the manslaughter of
his mother’s partner. A psychiatric report prepared for the court indicated that he
had a personality disorder and social phobia. He therefore found it difficult to
undertake the group work element of offending behaviour courses. As a
consequence, he was not eligible for early release as he could not demonstrate that
his level of risk had reduced. The man began using drugs in prison as a way of
coping with the crime he had committed and became addicted to opiates.
The man was due to be released from prison on licence in July 2009. In April 2009,
he told staff that he had suicidal thoughts as he was worried about being released as
well as remaining addicted to drugs on release. Staff placed him on the suicide and
self-harm prevention monitoring procedures and continued this additional support
until he left prison on 17 July. The man initially disputed the condition of his licence
which forbade alcohol and threatened to get drunk, not report to the hostel and to
harm himself. However, staff calmed him and he eventually accepted the conditions.
On the day of his release, the man made his way to his home town, where he went
to a pub and got drunk. At around 11.15pm that night, he went to the police station.
He told the police he had been released from prison earlier that day and had
contravened his licence conditions. Consequently, the Probation Service issued a
licence recall. The police arrested him and took him to Shrewsbury prison the
following day. Staff at Shrewsbury immediately placed him under the suicide and
self-harm provisions, but they ended the following day as plans were put in place to
address his issues. The man was again subject to these measures between 2 and
19 August, following his claim to have taken an overdose of his prescription drug,
fluoxetine. During his time at Shrewsbury, the man also engaged with drug workers.
He attempted to stop taking drugs by moving to a wing with minimal drug use.
However, after a while he returned to a general wing, reportedly because of the
greater availability of drugs.
Three days after the suicide monitoring ended, on 22 August, the man was found
hanging in his cell by officers conducting the morning count of prisoners. As he
appeared to have been dead for some time, they did not attempt resuscitation. The
paramedics subsequently certified him dead at 6.17am. Support was provided for
both prisoners and staff. The prison asked the police to contact the man’s family as
they held no next of kin details. Thereafter, the prison kept in touch with the family
and was represented at the man’s funeral.
The investigation has found that the man’s refusal of medication was not recorded in
his clinical record and therefore not communicated to relevant staff. Also, given he
had been assessed as having complex needs, a detailed risk assessment should
have been conducted as a priority. The man moved to a single cell while subject to
self-harm monitoring, but the reasons were not recorded. I make three
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recommendations regarding these matters.
5
THE INVESTIGATION PROCESS
1. The man died on 22 August 2009. Notices were issued to staff and prisoners
at the prison to inform them of the investigation process and give them the
opportunity to speak with the investigator. No one responded.
2. My investigator visited the prison to open the investigation four days later.
During the visit, she met the Governor, a representative of the Prison Officers’
Association and the Independent Monitoring Board. She also visited A wing
and looked at the man’s cell. The prison provided the man’s prison records
for examination as well as his medical record. My investigator later returned
twice to interview staff and a prisoner.
3. In the early part of the investigation it became clear that the investigator
needed to interview staff at HMP Dovegate. The Director appointed a liaison
officer who arranged for my investigator and a colleague to speak to the staff.
4. One of my family liaison officers, contacted the man’s family and gave them
the opportunity to raise their concerns. The family appreciated the efforts of
prison staff who were respectful and welcoming towards them when they
visited. However, they also raised a number of issues:
(cid:127) How was the man able to take an overdose in prison?
(cid:127) Why was he allowed to be in a single cell?
(cid:127) What mental health assessments were carried out?
(cid:127) The length of time before the man was found.
(cid:127) How long was the man at the approved premises?
(cid:127) His family was not told of his whereabouts, or his release to an
approved premises.
(cid:127) What were the conditions of his release on licence and which did he
breach?
(cid:127) Did the prison help him to deal with his guilt about the offence?
(cid:127) How was the ligature attached to the window bars?
I hope that this report and additional correspondence from the investigator
goes some way towards addressing the family’s concerns.
5. Mr A undertook a clinical review of the man’s healthcare at Shrewsbury on
behalf of Shropshire County PCT. He reviewed the man’s clinical record and
the transcripts of the interviews with staff. He and colleagues met as a panel
to discuss the issues and their findings. His review is at annex 2.
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HMP DOVEGATE AND HMP SHREWSBURY
HMP Dovegate
6. Opened in 2001, Dovegate is a category B prison for adult male prisoners
sentenced to over four years and local remand prisoners. New prisoners are
risk assessed and given a category based on their offence and the risk that
they pose to the public should they escape. There are four categories: A, B,
C and D, with category A prisoners being the most dangerous. Category B
are prisoners for whom the highest security conditions are not necessary but
for whom escape must be made very difficult.
7. Dovegate is managed by Serco under contract to the National Offender
Management Service (NOMS). It currently holds up to 1,146 prisoners.
There are 946 in the main prison and 200 in the therapeutic community (TC).
(TCs provide a long term, residential, offending behaviour intervention for
prisoners who have a range of offending behaviour risk areas, including
emotional and psychological needs.) Healthcare services in Dovegate are
provided by Serco Health.
8. The former Chief Inspector of Prisons last reported on Dovegate following an
announced inspection in October 2008. She said:
“On our last two visits to the main prison, we noted serious
weaknesses in safety and control and a lack of progress between
inspections. To the credit of the Director and his staff, this full
announced inspection found a safer and more controlled prison with
reasonable purposeful activity, although resettlement remained weak.
“The establishment was now much better ordered and considerable
efforts had been made to tackle bullying. A strong emphasis had been
placed on security, and this was not disproportionately affecting the
regime for prisoners. Staff appeared more confident and there had
been a substantial reduction in the use of force.”
9. Regarding the healthcare services at Dovegate, the Chief Inspector made the
following comment:
“Primary health services were reasonable, but were compromised by
shortages of staff and accommodation, which needed a substantial
increase in funding for healthcare to move forward. …Mental health
services were good and developing, and prisoners were well supported
by the primary and secondary services.”
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10. The Independent Monitoring Board (IMB) comprises lay people from the
community who monitor the day-to-day life in their local prison and ensure
that proper standards of care and decency are maintained. The IMB Annual
Report, for the period 2007-08, made the following comments regarding
healthcare services:
“Serco Healthcare has a contract to provide healthcare at HMP
Dovegate. Unlike Home Office prisons the local Primary Care Trust is
not responsible for delivering healthcare at HMP Dovegate, but does
provide support for clinical guidance.
“There has always been a high turnover of staff in healthcare, nurses
and GPs, as well as managers. This unit needs some stability
particularly at this time. As part of the ongoing extensions to HMP
Dovegate the healthcare unit is to be increased in size, extra facilities
and more single rooms are to be provided.”
HMP Shrewsbury
11. Shrewsbury is one of the oldest prisons in England and there has been a jail
on the site since 1793. The present prison was built in 1877. In January
2010 it became a Category C training prison. (Category C prisoners cannot
be trusted in open prison conditions but would not have the ability or
resources to make a determined escape.) However, at the time of the man’s
death, it held both sentenced and unconvicted men from the courts in
Shrewsbury, Mid Wales and Stoke-on-Trent. The information below
describes the prison as it was when the man was there.
12. The prison has an operational capacity of 340 adult male prisoners who
occupied mainly double cells within two wings, ‘C’ and ‘A’ wing. ‘A’ wing cells
are located on four galleried landings, known as A1 (ground floor), A2, A3 and
A4 landings.
13. The local Primary Care Trust is responsible for healthcare provision within the
prison. The Primary Care Centre is staffed by a multi-disciplinary team under
the management of a doctor and a healthcare manager. It is currently open
from 7.30am to 9.00pm daily and provides primary healthcare as well as a
number of services - substance misuse, dental, psychiatric, optical, chiropody
and counselling. In addition, there are clinics for sexually transmitted infection
(STI), blood borne virus (BBV), Well Man, asthma and diabetes. A Mental
Health In-reach Team provides services for prisoners with mental health
issues.
14. The prison's drug strategy links the initiatives of both the National Offender
Management Service and the Government to combat the illicit use of drugs
and offer treatment to those using drugs. Rehabilitation is offered to those
requiring detoxification using a Subutex based treatment programme.
(Subutex prevents withdrawal symptoms.) Subsequent treatment
programmes cover a wide range of issues, including drug awareness and
education, individual and group counselling.
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15. There is a system of emergency radio calls in place to ensure that staff are
aware of the type of healthcare emergency. ‘Code blue’ is a local procedure
used to alert the communications room staff that someone is experiencing
breathing difficulty. The radio operator in turn alerts healthcare staff, who can
then bring the correct emergency equipment.
Previous deaths at Shrewsbury
16. There have been six deaths at HMP Shrewsbury since April 2004, when the
Prisons and Probation Ombudsman was given responsibility for investigating
deaths in prison custody. There are several themes running through them
that link with the man’s’ death. Several recommendations have covered
suicide and self-harm monitoring procedures, which I again address in this
report.
Her Majesty’s Inspectorate of Prisons
17. The former Chief Inspector of Prisons made a full announced inspection of
Shrewsbury in June 2006. In the report of the inspection, the former Chief
Inspector said, “Communication and joint working between healthcare and the
prison regime were good, and healthcare was well supported by Shropshire
Primary Care Trust”. She also judged that healthcare services had improved
over the previous two years.
18. The former Chief Inspector of Prisons said the quality of ACCT entries and the
Care Map actions were good. (The ACCT procedure provides additional
monitoring and personalised support for prisoners considered to be at risk of
harming themselves or suicide.) The quality of staff/prisoner relationships at
Shrewsbury was higher than average. The former Chief Inspector of Prisons
said:
“Many prisoners were well known to staff and a degree of familiarity
and mutual tolerance had developed. In an overcrowded and relatively
impoverished environment … there was evidence of real care and
thought for and about prisoners.”
Independent Monitoring Board (IMB) report
19. Each prison is monitored by an Independent Monitoring Board, members of
which are volunteers drawn from the local community. They have full access
to prisoners and every part of the establishment. In its latest annual report,
for the year ending 30 April 2009, Shrewsbury’s IMB concluded:
“The Board feels it essential that prisoners are provided with
surroundings that are at all times safe and humane and appreciate that
this is being achieved to a high level by all concerned.”
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20. The report also highlighted a recent survey of prisoners being released from
Shrewsbury which found that it:
“… did not throw up any negative criticisms of the prison. Health Care;
treatment by staff; food; all rated highly but the most significant item to
come out of the survey was that they all felt safe while in the prison.”
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KEY FINDINGS
21. The man was remanded into custody on 7 November 2002 and taken to HMP
Blakenhurst. This was not his first time in prison. On 2 October 2003, he was
sentenced to ten years imprisonment for the manslaughter of his mother’s
partner. After serving the early part of his sentence in HMP Blakenhurst and
Shrewsbury, he moved to Dovegate on 12 January 2004.
Dovegate
22. Throughout his sentence, the man refused to take part in offending behaviour
courses. The psychiatric report prepared for the court before sentencing had
concluded that the man suffered from a personality disorder and a social
phobia. Staff tried to persuade him to complete courses, such as Enhanced
Thinking Skills. However, the courses all involved group work and his social
phobia meant he was very uncomfortable in groups. As the man could not
show that his level of risk to the public had reduced, he was not released on
parole or Home Detention Curfew (HDC). (HDC allows certain prisoners early
release from prison to serve the remainder of their custodial sentence in the
community wearing an electronic tag, which must not be removed, while
subject to a curfew.)
23. The man settled into life in prison and was employed in the workshops. Staff
described him to the investigator as, “a hard worker … he would work like
mad.” When he was not at work, he spent a lot of time in his cell. Prison
Custody Officer (PCO) A told the investigator:
“He tended to spend a lot of time on his own or with a select couple of
prisoners on the wing. Most of the time though, he was a fairly quiet
guy.”
24. Whilst at Dovegate, the man began using drugs and other prisoners’
medication, becoming addicted to opiates. He told staff in 2005 that he had
been using heroin for 18 months. For the next two years he was prescribed a
number of detox programmes using Subutex, an opiate substitute that lessens
the effects of withdrawal. However, at other times, he was prescribed
methadone, a substitute for heroin, as part of a maintenance programme.
From 2005, the man was prescribed fluoxetine, an anti-depressant.
25. Mr D, a prisoner in Shrewsbury who was an old friend, said that the man
spoke to him of his life in Dovegate. The man told Mr D that he had started
using drugs:
“... to get all the bad things he had done in his life, he wanted to forget
them all. But where most people will talk to Samaritans or officers or
In-reach [staff], he didn’t want that … He didn’t want to be a burden to
anybody.”
Mr D described the man’s daily life at Dovegate as, “… doing a bit of work,
come back, take a bit of heroin, go to sleep.” The man told Mr D that he was
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“so remorseful for what he did”. G wing Unit Manager, Ms A, told my
investigator that the man had spoken to her about his offence. She said,
“He struggled to cope with what he’d done, that was his biggest [issue]
… He was worried about being released, facing his mother and coping
with what he’d done.”
26. During his time at Dovegate, the man sometimes became very low in mood
and occasionally he harmed himself. A PCO said that when he did so, he
usually told the staff. He cut himself, used ligatures and, on one occasion,
stockpiled his medication and then took an overdose. Staff opened ACCT
plans to give him additional support while he worked through his problems.
Other prisoners with whom he was friendly also looked after him. Custody
Officer A said that the prisoners used to tell staff how the man was feeling and
sometimes advised them to “keep an eye on” him.
27. The man had a re-categorisation board in January 2008. Staff prepared
reports about his behaviour and readiness (or otherwise) to move to a lower
category of prison to assist him progress through his sentence. The board’s
decision was to change the man to category C to enable him to move to a
training prison where the necessary offending behaviour courses were
available. The man should then have applied to transfer to a category C
prison but he did not do so. His offender supervisor, Custody Officer B, noted
in her records,
“Received his cat C. Seems happy at the moment. Not bothered
about a transfer. Happy here”.
Staff considered that to force the man to move prisons against his will would
be counter-productive and so they did not insist that he had to transfer.
February 2009
28. In February 2009, staff from various departments at Dovegate began
preparing for the man’s release. As mentioned earlier, he was not eligible for
parole or HDC, and so his release date was the ‘non-parole date’. This date
is when the person has served three-quarters of their sentence which, in the
man’s case, was after seven and a half years. The person is then released
from prison ‘on licence’ for a further period. The licence sets out certain
conditions that the person must observe, otherwise they can be recalled to
custody. The person must be released from prison on their non-parole date.
29. Custody Officer C was the man’s resettlement officer, and responsible for
“liaising with [prisoners] to gain accommodation, employment, education,
training and any other needs they might have”. She told the investigator that
she first met the man on 10 February and assessed his needs using the
‘seven resettlement pathways’ guide. This is a set of areas that might be
problematic for a person leaving prison and covers accommodation, work,
education, attitudes, thinking and behaviour, finance and debt, substance
misuse and health.
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30. The man’s main issue was accommodation and his worry that he would have
to sleep rough on release. Custody Officer C told my investigator that she
contacted various housing agencies but none could accommodate him at the
time of his release.
31. On 16 April, Custody Officer A opened an ACCT plan to provide additional
monitoring as the man said that he had suicidal thoughts because he was so
concerned about his forthcoming release. He was also worried about being
addicted to drugs when leaving prison. Staff noticed that his mood had
changed and he was not eating or socialising with other prisoners.
32. The following day, an ACCT assessor interviewed the man to ask about his
thoughts of self-harm, the reasons for his actions and possible coping
mechanisms. She and the man discussed his drug use and the man said that
he felt it would be helpful to detoxify before release. Unit Manager, Ms A,
then completed the Care Map section of the ACCT. It lists the prisoner’s
problems and identifies actions to resolve them. In relation to his drugs
problem, Ms A wrote that the man would contact the Counselling,
Assessment, Referral, Advice and Throughcare service (CARATs) team.
(CARATs workers are based in prisons and specialise in the treatment of
substance abuse. They run programs, offer counselling, support and referral
to rehabilitation centres to prisoners and on release.) Given his worries about
being released, Ms A advised him to work with his offender supervisor and
offender manager to plan his release. She also encouraged him to contact
his mother before leaving prison as the man had said that he was worried
about how to re-establish his relationship with her.
33. Later that day, Ms A held an ACCT case review meeting, attended by staff
and the man. A member of the CARATs team was present, together with the
legal services officer, Custody Officer B and a G wing officer who knew the
man well. (ACCT case reviews are supposed to be multi disciplinary
meetings but this is not always the case. I am pleased that staff of different
disciplines who knew the man were at the meeting.) The man was concerned
about being unsupported on release. The staff noted that he now appeared
more positive and was less withdrawn. They discussed starting a detox
programme to deal with his drug addiction.
34. The next review was held a week later, when staff described the man as
“despondent”. He was unhappy because his drugs treatment had not started
immediately. However, he told them that he had no intention of harming
himself.
35. The clinical reviewer notes that rather than a detox programme:
“Following a case conference in April it was decided that stabilisation
for opiate use was necessary prior to his release, due to chaotic drug
use. There is no account of drug use in the IMR [medical record], we
would presume that he was purchasing illicitly. Naltrexone was
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discussed but the decision was to retoxify with methadone. This was
administered in increasing doses.”
36. On 30 April, the man attended an Offender Assessment System (OASys)
review board, chaired by Ms B, his offender manager, with Custody Officer C,
Custody Officer B and two other members of staff. (OASys is a sentence
planning tool to inform decisions on release and interventions.) They
discussed the man’s recent months and set targets for the next three months
to stay out of trouble on the wing and continue his education.
37. Custody Officer B noted in the Supervision and Sentence Plan, “To complete
victim awareness and to engage with CARATs workers.” The man had
applied for a victim awareness course in 2007 but had not completed it
because he was on the Vulnerable Prisoners Unit (VPU). (The VPU
accommodates prisoners who ask to be segregated, for example if they are
vulnerable to bullying or have committed an offence of which other prisoners
disapprove. Prisoners within the unit can mix with other vulnerable prisoners.)
The man also agreed to complete an Enhanced Thinking Skills (ETS) course
after release if he could do it in a one-to-one setting rather than in a group.
He had been allocated a place on a course during his time at Dovegate but
had refused to participate. He also considered working part-time while
attending college to gain some qualifications that would improve his
employment prospects. (He had gained a level 2 NVQ in Performing
Manufacturing and Operations and level 1 literacy and numeracy certificates
at Dovegate.)
38. Custody Officer B also wrote:
“The man seems scared of leaving his comfort zone, which is the
prison. He has been in a very low mood lately and because of this he
has not been engaging with the CARAT team, RMN [registered mental
health nurse] etc”.
In the section on relationships, Custody Officer B noted that the man was in
contact with his mother by letter but was worried about meeting her. He
hoped to have contact with his sisters through his mother.
39. On the same day, there was an ACCT case review meeting. Ms A wrote:
“Very positive as there are now measures in place for his release. Had
a visit today from his outside probation and is having a phone call
tomorrow via OMU (Offender Management Unit) regarding housing.”
40. In May, unit managers held five ACCT case reviews. During the first, on 6
May, the man was noted to be:
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“low in mood, poor eye contact, became irate at times due to he thinks
H/care [healthcare] are playing God with him. However, he again
denied any thoughts of harming himself”.
41. The next review was three days later. The man refused to talk to the staff.
He became upset and told them that he would kill himself that night. Ms A
raised the frequency of ACCT observations to five per hour and scheduled the
next review for three days’ time. However, a review was held the next day.
The man said he felt much better and staff noted that he interacted well with
them. The man told them that he was finding the very frequent ACCT
observations “somewhat agitating”. He said that he was not thinking about
harming himself and would talk to staff if he needed to. The case manager
reduced the observations to four per hour and warned that, if the man did not
interact with staff, it could mean that his risk was rising.
42. At the review on 11 May, the man spoke about the methadone maintenance
programme he had started. Staff recorded that he was “chatty” and “in good
spirits not 100% though”. The notes of the review held a week later stated
that he was going to work and eating regularly. The manager reduced the
observations to two per hour.
43. Because of the seriousness of his offence, the man was managed by the
Multi-Agency Public Protection Arrangements (MAPPA) panel. This is the
process through which the Police, Probation and Prison Services work
together with other agencies to manage the risks posed by violent and sexual
offenders living in the community in order to protect the public.
44. A MAPPA meeting took place on 23 May to manage the risk the man
presented to the community. The panel members decided on a number of
actions, one of which was to arrange to transfer the man to Shrewsbury
prison. This was considered to be beneficial as the man would be closer to
his home. Ms B and staff at Dovegate organised the transfer. However, the
man refused to move and staff did not pursue the matter. The MAPPA co-
ordinator agreed to contact the Community Mental Health Team (CMHT) to
ensure that the man’s mental health needs would be met after his release.
45. At the ACCT case review on 10 June, the man told staff that he was looking
forward to his release, although he was still “a little worried” about it. Ms A set
the date for the next review as 1 July and made a note to invite staff from the
offender management unit (OMU), the CARATs team and the psychology
department.
46. On 23 June, the MAPPA panel met again and the members discussed the
licence conditions that the man would have to abide by in the community.
They decided that he had to work with the CMHT and live in an approved
premises (formerly probation hostel). As well as the normal morning and
evening curfews, the man would have to report to approved premises staff at
midday. The minutes noted:
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“Concerns are expressed about the length of time that NT [the man]
has spent in a therapeutic community, apparently without engaging
with any group work or therapy. He is known to be self-harming and
his resistance to the prison move suggests that the transition from
prison to the community will be even more stark.”
47. The panel members agreed that, on his release, the man should be escorted
from the prison to the hostel. They also arranged to transfer the man to the
Worcester MAPPA panel which was where he would be living. When Custody
Officer C told the man that he would be escorted to the approved premises,
he refused to accept being accompanied.
48. On 1 July, the man did not attend the ACCT review because he had earache.
The panel noted a continuing improvement in his outlook but, because of his
impending release, decided to maintain the ACCT monitoring. The entries in
the On-going Record of the ACCT plan show that the man began to spend a
lot of time walking around the landing. When asked why he was doing this,
he said that he was trying to get additional exercise to prepare himself for
leaving prison. Often when he spoke to officers, he told them the number of
days left until his release and the PCOs noted his excitement.
49. During the weeks leading up to his release, Custody Officer C, Custody
Officer B, and Ms B, worked closely together to arrange accommodation for
the man. On July 6, Custody Officer C learned that the approved premises in
Worcester had agreed to take the man and she gave him the news. She told
the investigator that he was very pleased that he now had somewhere to stay
on his release. Custody Officer C also arranged an interview at Birmingham
College for the week after his release, to discuss numeracy and literacy
courses. The man had originally considered looking for a job but decided that
collecting his methadone several times a day would be difficult to fit into a
working day. Methadone had been prescribed as a way of stabilising the
man’s chaotic drug use.
50. At the ACCT case review on 9 July, the man was “in very good spirits, good
sense of humour”. The next review was set for 15 July, two days before his
release.
51. On 13 July, the man asked to leave work early. Custody Officer D noted:
“He said he feels paranoid and irritated. He says people are watching
him. Really is not himself this afternoon … He did say he would not
self-harm, but in a very low mood.”
52. Later that afternoon, the man spoke to one of the CARATs workers. A PCO
noted that he was restless and during association he walked around the
landing. However, when a member of the night staff spoke to him, he said
he was “fine”. (Association is when prisoners are out of their cells and are
able to associate with and speak to each other.)
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53. The following afternoon, Custody Officer C and a colleague met the man.
They asked if he would like an appointment with a counsellor in the
community and he replied that he would. They then discussed his licence
conditions. When told that one of the conditions was that he could not drink
alcohol without permission, the man was upset and walked out of the office.
Wing staff contacted Custody Officer B who spoke to the man and they
discussed the licence conditions. Custody Officer B wrote in the ACCT plan:
"The man seemed overly cheerful and stated that he will not go to the
hostel when released but will go to Bognor Regis [and] spend his
money on drink and drugs … The man then stated that after a couple
of nights when he is beginning to ‘settle’, he will get very drunk and kill
himself. The man doesn’t seem to want to listen to reason over this
licence condition.”
Custody Officer B told the investigators that, when he said this, he was very
matter-of-fact and calm. She had no doubt that he was capable of doing
what he said, that is taking his life.
54. The man repeated this assertion to one of the wing staff the following day. At
4.00pm, he attended an ACCT case review where the licence conditions were
discussed. Ms B took part in the review by telephone. The man became very
angry about the condition that he could not drink alcohol without permission.
He said that he would get drunk and jump from a tall building in Telford. He
would not report to the hostel or take his methadone.
55. The review meeting was suspended while staff tried to discuss the issue and
calm him. After speaking to CARATs and resettlement staff and being told it
was a normal licence condition, the man agreed to accept it. The review
meeting discussed all the support networks that were in place for the man on
his release. He told staff that he was looking forward to leaving prison,
although he was a little nervous.
56. The entries in the ACCT plan on 16 July show that the man had a quiet day.
One PCO wrote that he was in a very good mood and hopeful about the
future, another noted that he “was joking on the wing”.
Release from Dovegate on 17 July
57. The final ACCT case review was held in reception on the morning of the
man’s release. The reception duty manager chaired the review and Custody
Officer B, Custody Officer C and a member of CARATs were there. Because
the man was about to leave prison, the ACCT plan was closed. However,
Custody Officer C had liaised with the approved premises staff and they had a
self-harm care plan ready to put into place for him, which would include hourly
observations and a care coordinator who would act as a mentor. They had
also arranged twice-weekly appointments with a nurse from the CMHT.
Custody Officer C had requested that during his journey to Worcester National
Rail staff at each station would meet the man to assist him in get the correct
train.
17
58. Mr D, the man’s friend in Shrewsbury prison, told my investigator that the man
had spoken to him about how he felt and what he did during the short time he
was in the community. The man was unhappy at having to share a room in
the hostel and because so many of the other residents were sex offenders.
(Prisoners have an unofficial hierarchy based on their offence. Sex offenders
are at the bottom and many serve their sentences in Vulnerable Prisoners
Units.)
59. The man did not report to the approved premises. Instead he travelled from
Worcester to Telford, his home town, intending to meet some of his friends
there. However, he could not find any of his friends and so went to a pub in
the town centre. He spent several hours drinking alcohol, in contravention of
his licence conditions. At some point, he obtained drugs which he took. He
told Mr D that he thought about harming himself (as he had told Dovegate
staff he would) but did not do so.
60. At about 11.15pm, the man went to the nearby police station and gave an
officer his name. He said that he had been released from prison that morning
and had broken his licence conditions by drinking alcohol and missing the
hostel’s evening curfew. He sat in the reception area of the police station for
about 90 minutes while the police checked his information. Once they
confirmed that probation staff had taken the appropriate action to recall him to
prison, they arrested him and took him to the cells and, the following day, to
Shrewsbury.
HMP Shrewsbury
61. In reception at Shrewsbury on 18 July, the man told Officer E that he had cut
both his wrists about a month earlier in Dovegate. He said that he now felt
“low in mood” because his licence had been revoked. Officer E opened the
ACCT suicide and self-harm prevention procedures to support him. The
senior officer in reception, Senior Officer A interviewed the man, who said that
he would not try to harm himself. Senior Officer A then completed the
Immediate Action Plan, setting out the ways staff would help him over the
following 24 hours.
62. The man had previously spent time in Shrewsbury. He asked for
accommodation on the Vulnerable Prisoners Unit on C wing because of
“trouble with people in the Dana (Shrewsbury prison) connected to drug
dealers” and this was agreed. However, until a cell became available on C
wing, he would be in a cell close to the wing office on A wing. Senior Officer
A decided that, whilst subject to ACCT monitoring, the man would share a cell
with another vulnerable prisoner. Staff were to observe him each hour and
have a “meaningful conversation” with him several times a day.
63. Senior Officer A explained how to use the telephone to call friends and family
and the special handset to talk to the Samaritans. He also spoke about the
Listeners. (Listeners are trained, selected and supported by Samaritans to
offer confidential emotional support, 24 hours a day, to fellow prisoners in
18
distress.) Finally, he referred the man to the Mental Health In-reach Team
(MHIT).
64. For the first 90 minutes, until a cellmate was found, staff kept the man on
constant supervision, meaning that a member of staff was always with him.
At 4.15pm, about two hours after arriving at Shrewsbury, he went to the
healthcare centre where the doctor prescribed an opiate detoxification
programme. On returning to the wing, another prisoner had moved into the
man’s cell, so the staff observations were reduced to hourly. During the
evening, staff checked on the man and noted in the ACCT plan that he was
“getting on with his cellmate”.
65. The following morning, Senior Officer B interviewed the man and completed
the ACCT assessment. He told the investigator that the man sounded quite
positive and denied any wish to harm himself. He said:
“His concern was that he had come out of prison with an addiction and
he still had it and he stated he wanted to change basically, he needed
help to change his life around. … He wanted to be drug free and to
give himself a fighting chance when he got back out into the
community.”
66. The man told Senior Officer B that he had been released from Dovegate with
a drugs habit and “had problems at the hostel he was sent to”. Also, that he
had “got drunk” on the day of his release and had been recalled the same
evening. He said that he no longer felt miserable, had slept well and his
appetite was good. He had a further appointment with the detoxification staff
later that day.
67. An ACCT case review meeting was held immediately after the assessment
interview. Senior Officer C, the duty wing manager, joined the man and
Senior Officer B. They discussed the man’s issues and the way they were
being resolved. All three decided there was no reason to keep the ACCT plan
open,and so it was closed. After an ACCT plan is closed, a post-closure
interview must be held to assess how well the person is coping without the
extra support of the ACCT process. The man’s review was set for 24 July.
68. On 24 July, Senior Officer B interviewed the man during the ACCT post-
closure review. The man said he had no thoughts of self-harm or suicide and
that he was “feeling okay”. He was waiting to learn how long he would remain
in prison before being released again. Meanwhile, the probation staff in the
prison were trying to arrange accommodation for him in the community. He
told Senior Officer B that he would speak to staff if he had any further
problems.
Suspected overdose
69. On 2 August some time after 10.00pm, the man pressed his cell bell. (Each
cell has a bell to be used if the prisoner requires urgent assistance.) The
officer on night duty went to his cell. The man asked what would happen if he
19
“ … had taken an overdose of his medication”. The officer telephoned Nurse
A in the healthcare centre and asked her for an answer.
70. Nurse A went to the wing and the officer opened the man’s cell door. They
stood at the door and spoke to him. The nurse asked him why he wanted the
information. She told the investigator:
“His intention was that he wanted to die. He didn’t want anybody to be
involved or blamed and he said it had nothing to do with anybody within
the prison and it was a decision he had made himself.”
71. The man said that he had written to his family saying that he wanted to die
and showed the notes to Nurse A. When she questioned him further, he said
he did not wish to die and was not going to harm himself. However, he then
told Nurse A that he had taken 31 fluoxetine (Prozac) tablets after stockpiling
them for a number of days.
72. Nurse A returned to the healthcare centre and telephoned the out-of-hours
doctor to ask about the urgency of the situation. Acting on his advice, she told
the senior officer on duty in the prison to send the man to the accident and
emergency department at the local hospital. The hospital carried out blood
tests and admitted him for observation.
73. At 8.30 am the following day, 3 August, the man returned to prison. The
discharge letter from the hospital said that he had shown no symptoms of
having taken the medication and asked the healthcare staff to arrange
“psychiatric follow up as appropriate”. After telling the duty nurse that he was,
“ok no problems”, the man was referred to the Mental Health In-Reach Team
(MHIT) and returned to A wing.
74. Senior Officer B, one of the safer custody staff, opened an ACCT plan to give
the man support. He completed the Immediate Action Plan that sets out the
various means of help that were available straight away. He decided that staff
should check on the man five times each hour and have at least one
conversation with him each shift.
75. At 10.00am, Nurse C from the MHIT and Nurse D, a community psychiatric
nurse (CPN) from the community forensic (mental health) team, visited the
man in his cell. The visit had been arranged prior to the man saying that he
had taken an overdose. The man had worked with Nurse D before and was
described as comfortable talking to her. He said that he had taken the
overdose to highlight that he felt he was still suffering the effects of
detoxification. He told her that he felt the detoxification “had been too quick
and that he is struggling”. He was also feeling “low” after learning that he
might have to remain in prison much longer than he had expected.
76. Nurse D said that she would contact the man’s offender manager to clarify
how long he would have to serve. He agreed to work with the prison MHIT
and, on his release, with the community forensic team. Nurse C also
encouraged him to work with the CARATs team as he had not yet done so.
20
However, the man said that he did not like the attitude of the CARATs staff.
Nurse C put the man on the list of patients to be discussed at the team
meeting the following day.
77. Just over an hour later, a nurse from the healthcare team discussed the man’s
detoxification with him. The man said that when it had ended he continued to
withdraw from drugs, but he had not told staff this. He felt that the
detoxification had not helped as he was restless and his legs were twitching.
The nurse referred him to the CARATs team and arranged to discuss further
treatment with the doctor. At 2.00pm, the doctor prescribed a lofexidine
detoxification (to reduce the symptoms of withdrawal from opiate addiction) for
the man. The nurse who gave him the first medication at 8.00pm, noted that
he was “pleased and calm”.
78. However, at 7.45am the following morning, the man collapsed whilst queuing
for his medication. He was not injured and a nurse visited him in his cell. She
measured his blood pressure, which was low. She decided that staff should
monitor his blood pressure before giving the lofexidine and discontinue it if the
readings were too low.
79. Senior Officer B interviewed the man in his office to complete the ACCT
assessment interview at 8.30am. When asked what his problems were, the
man said that he was finding the detoxification process difficult. Also, after
serving a ten year sentence, he had been recalled to prison just over 15 hours
after being released and did not know how long he would have to serve. He
continued to feel guilty about his offence.
80. Having discussed the problems, Senior Officer B completed the ACCT Care
Map, setting out ways of tackling each problem. (Over the next few days, the
actions Senior Officer B set out in the Care Map were completed. The man’s
medication was reviewed and he started another detoxification. Senior Officer
B contacted the OMU to ask about the recall process and release plan. The
man also applied for an interview with CARATs staff.)
81. Senior Officer B and the man were then joined by the duty wing manager and
a healthcare nurse for the first case review meeting. The man told the staff
that he did not intend to harm himself, although he felt “low”. Staff again
checked that he knew what help was available if and when he needed it.
They decided to continue the same level of observations but supervise him
constantly when he was alone in his cell. The next review was scheduled for
two days later, 6 August. By the end of the meeting, the man was feeling
unwell and asked to return to his cell.
82. The man collapsed for the second time that day at 5.30pm, but again was
unhurt. Healthcare staff informed the prison doctor, who told them to stop the
lofexidine detoxification. At 9.05pm, the duty nurse visited the man in his cell.
He refused his anti-depressant medication but accepted paracetamol as he
had a temperature.
21
83. Nurses continued to monitor the man throughout the following day (5 August).
At 4.00pm, a nurse told him that, although he could not have lofexidine, he
would be able to have other medication to ease the withdrawal symptoms.
The doctor examined him the following day and reviewed the medications
listed as alternatives to lofexidine. The doctor again prescribed fluoxetine,
having stopped it after the alleged overdose. However, from then on, the man
refused fluoxetine, although he accepted his other medication. (There is no
record that staff took any action over his refusal of the anti-depressant.)
84. The second ACCT case review was held on 6 August. The man told staff that
he was embarrassed at “his recent behaviour” and he now “wants to live more
than he wants to die”. He was getting on well with his cellmate and was due
to start work the following day. The staff and the man decided to reduce the
observations to hourly and scheduled the next review for 13 August.
85. Throughout this time, officers regularly spoke to the man about how he was
feeling and his plans for the future, both short-term and long-term. On 12
August, the man spoke to Officer F about transferring back to Dovegate
where he “felt safer”. He said the same thing to a member of the chaplaincy
team about an hour later. He also spoke about the events surrounding his
recall to prison. The chaplain wrote in the ACCT document:
“He stated that he was not prepared to do 3½ years simply having a
drink whilst on probation. I questioned what he meant and he said ‘he
will take his life, rather than do this’.”
That evening, the man told an officer that he was hoping that the ACCT
would be closed at the next case review meeting as “he was not suicidal”.
86. The third case review took place on 13 August. The man told staff that he
wanted to move back to Dovegate as he thought that it was easier to obtain
drugs there. Everyone discussed this and noted that the man was waiting for
an appointment with the CARATs team. They also noted that arrangements
were in place for the man and his cellmate to move to C wing shortly. The
level of observations was left at the same level and the next review scheduled
for 19 August. Senior Officer B, who chaired the review, told the investigator
that the man would not have been transferred to Dovegate after admitting his
reason was to obtain drugs.
87. After the meeting ended, the man asked to speak to a Listener. He spent
some time in the interventions suite talking to the prisoner who was the duty
Listener. (As Listeners are bound by the same confidentiality code as the
Samaritans, I do not know what they discussed.)
88. Mr F, one of the drugs workers from the CARATs team, interviewed the man
in the afternoon. The man said that he wanted to move to a prison with a
methadone maintenance programme as he was finding it “difficult at the
moment being without drugs”.
22
89. After the meeting ended, he and his cellmate moved to C wing. An officer
noted in the ACCT document that the man was “very cheerful and happy”.
The entries for the next days noted that he continued to be “happy” and
“content”. He began working in the C wing workshop and mixed well with the
other prisoners during exercise and association.
90. However, on 17 August, the man asked for his vulnerable status to be
removed and to return to A wing as a normal prisoner. This surprised the C
wing officers who had thought him settled. Mr D, who was a prisoner on A
wing and a friend of the man’s both in and out of prison, told my investigator
that the move was because drugs were more readily available on A wing. He
said:
“He went VP because he didn’t want to be … back on the heroin and
on C wing, you know, the kind of people that are on C wing, there’s
hardly anything like that on C wing.”
Mr D also explained that a prisoner (whom he was unwilling to name)
persuaded the man to move.
91. The man returned to A wing and told Officer G that he was pleased to be
back. He took part in association and said he was looking forward to getting a
job on the wing. The following day, he moved to cell A1-07, a single cell. The
investigator asked who made the decision to give the man, who was still
subject to ACCT monitoring, a single cell and why, but did not discover the
answer. Despite changing wing, an ACCT review was not called. These
issues are discussed later in my report.
92. The man appeared to settle well into the A wing routine. He told a member of
the chaplaincy that he was “on an up” and appreciated having a single cell.
He began working as a cleaner and took part in association.
93. On the evening of 18 or 19 August, Nurse A was on A wing and passed the
man’s cell. He was talking to an officer at the door and, as she passed, asked
her for “his subbies” (Subutex pills). He was smiling as he said this and Nurse
A laughed as she pointed out that he was not prescribed that medication.
She told the investigator that he had, “laughed quite a hearty laugh and
seemed in very good spirits and in a very good mood”.
94. The final ACCT case review took place on the morning of 19 August. Senior
Officer B was on annual leave, and so Senior Officer D chaired the meeting.
He went through the Care Plan and checked that all the actions were
complete, noting in the ACCT plan:
“[Nenad] stated that he was happier and more settled now off VP and
on A wing. Employed as a landing cleaner which is keeping him
occupied. Medication is now stable with no issues. Pleased about the
support he has had and now wants to come off the book. No thoughts
or indications of self-harm.”
23
95. Two members of the MHIT spoke to the man on 20 August. The man told
them that he had just had a legal visit that went well and was waiting for a
decision about his licence recall and length of sentence. He said that he was
happy with his new job as a cleaner but had applied to return to C wing. They
discussed his drug taking and detoxification and the man said he had no
thoughts of harming himself. A follow-up appointment was arranged for the
following week.
22 August
96. At 8.30pm, the officers on night shift came on duty and at 10.00pm the prison
went into night patrol state. Senior Officer E was the night orderly officer
(radio call sign Oscar1), the most senior officer on duty in the prison. (At
night, all prisoners are locked in their cells and the number of staff in the
establishment is much lower than during the day. The night orderly officer is
in overall charge of the prison.) Senior Officer E had an assistant night
orderly officer (Oscar 2). The wings were patrolled by officers and officer
support grade (OSG) staff, as usual.
97. During night patrol state, only the senior officer in charge of the prison carries
a full set of keys to unlock all gates and cells. His assistant has keys that
allow movement through the prison. Wing staff and nurses do not have keys
allowing them free access around the prison and they have to be escorted.
The officers and OSGs are each issued with a cell key in a sealed pouch for
use in emergencies. The staff instructions are that during the night patrol
state, a cell may only be unlocked by a single member of staff where there is,
or appears to be, immediate danger to life.
98. There were three officers on duty on A wing that night, Officer H, Officer J and
Officer K. Officer H carried out the evening roll count, checking that all the
prisoners were locked in their cells. Several prisoners were on open ACCT
plans and the officers checked on them throughout the night. As the man was
no longer on an ACCT plan, staff did not look into his cell. It is normal for
prisoners who are not on ACCT or any other monitoring not to be checked by
staff between the evening and morning roll counts.
99. Officer H began the morning roll count at 5.30am. He started on the level four
landing and worked down to level one. He reached the man’s cell just before
6.00am, opened the observation hatch and looked inside. He saw the man at
the back of the cell, under the window, and realised that he was hanging from
the window bars. Officer H called for assistance on his radio, telling staff it
was a “code blue” emergency (indicating breathing difficulties). Then he
broke the seal on his emergency key pouch so that he could unlock the cell
door.
100. Officer J and Officer K heard the radio call and went to the cell. Senior Officer
E was on the A wing landing very close to the door through to the healthcare
centre. He unlocked the door to allow Nurse A access to the prison. She had
already collected the bag of emergency equipment, oxygen tank and
defibrillator. (A defibrillator is a portable electronic device which measures
24
electrical activity in the body and advises on action to be taken.) Senior
Officer E helped her carry the equipment to the cell, arriving just as Officer H
opened the cell door. Officer H switched the light on and went into the cell
while Senior Officer E used his radio to request an ambulance. They went to
the man and supported his weight. Custody Officer J jumped onto the top
bunk to reach and cut the strip of bed sheet that was tied to the window bars.
101. The officers lowered the man on to the floor and cut the sheet from his neck.
They then stood back to give Nurse A room to examine him. She noted that
his body was very cold and rigor mortis had begun to stiffen his arms. She
saw blood on his chest, which she thought was because he had bitten his
tongue. Nurse A established that the man was not breathing, had no pulse
and the pupils of his eyes were fixed and dilated. Nurse A told the
investigator that, in her opinion, the man had been dead for some time. She
attached the defibrillator to him and the machine confirmed that he had no
heartbeat.
102. Two paramedics arrived at 6.10am and used their equipment to examine the
man. They agreed that he had died and that no treatment was possible. Five
minutes later, a third paramedic arrived and he certified the man’s death at
6.17am.
103. After a death, prison managers must hold a “hot debrief”. This is a meeting of
all the staff who were involved in finding and attempting to resuscitate the
prisoner. The meeting should focus on information sharing and how staff can
support each other. The duty governor held a debrief immediately afterwards
and offered staff the opportunity to briefly discuss what had happened. He
then offered practical support and the Care Team were on duty to provide
emotional support.
104. The chaplain went round the cells and broke the news to the prisoners. He
and the chaplaincy team were available for prisoners who needed to talk to
them, as were the Listeners. The prisoners who were on ACCT plans had
case reviews later that day to check whether they had been affected by the
man’s death. Prisoners later collected £154, which the man’s family donated
to charity.
105. The prison had no contact details for the man’s next of kin and therefore
asked the police to investigate. The police subsequently broke the news to
his mother and then his father. Deputy Governor, Mr G, who is also the
prison’s family liaison officer, was on leave at the time of the death. However,
Reverend A was appointed to deputise in his absence. On his return to work,
Mr G visited both parents on several occasions and invited them to the prison.
The man’s father visited and went to see his son’s cell. The funeral was held
on 4 February. Mr G and Reverend A attended and the prison met the
expenses.
25
ISSUES
The man’s health
106. For most of his time in prison, the man was prescribed medication for anxiety
and depression. In early 2005, he spent several weeks as an in-patient in the
healthcare centre at Dovegate after an assessment concluded that he was
“low in mood and suicidal”. From around this time onwards, he was
prescribed the anti-depressant fluoxetine (Prozac). He harmed himself on
several occasions. Mr A, the clinical reviewer, notes,
“During this period his mood was frequently low, and he frequently
refused input from the Mental Health Inreach team, and other health
professionals.”
107. In 2009, as the date of his release approached, the man again appeared to
suffer from a low mood. Staff referred him to the MHIT but he refused to
attend appointments. A consultant psychiatrist assessed the man and
concluded that he “had capacity to decline involvement with [the Mental
Health In-reach] team”, meaning that he was capable of taking decisions
about his treatment.
108. The man’s refusals also extended to his medication. The clinical reviewer, Mr
A, discusses his refusal to take fluoxetine from 7 to 22 August. He notes that
the refusal:
“… is recorded in the Prescription chart but is not mentioned in the
CCR [Continuous Clinical Record] and was not communicated to
Prison In-Reach. There is no evidence that it was discussed by the
healthcare team, or was considered in the ACCT reviews.”
109. He concludes,
“It is not possible to ascertain whether this had any influence on the
event, [that is taking his life] but should have been considered when
assessing risks following the initial self harm event.”
The Primary Care Trust should ensure that when a prisoner refuses
medication it is recorded in the Continuous Clinical Record, as well as
the prescription chart and that relevant staff are informed of the refusal.
Mental health
110. The clinical review noted that, although the officer in reception referred the
man to the MHIT, staff did not see him before his alleged overdose. However,
after his return from hospital:
“ … Prison In-Reach were contacted and responded quickly seeing him
on the day of return to the prison. He was assessed as having
complex needs but not presenting any immediate risk. He was seen
26
again on the 20 August by two members of staff, noted no signs of
mental distress and a further visit planned for the 26 August.”
111. Mr A notes that it is not clear what stage the referral for the man was at. He
concludes that had the referral been actioned, “this would have led to a
comprehensive risk assessment, although this would not necessarily have
identified any further risk”. He recommends that:
“Where a prisoner is identified as having significant problems these
discussions should take place earlier, rather than letting the referral
process take its natural course. The need for comprehensive risk
assessment should be established involving all appropriate staff.”
The Primary Care Trust should ensure that a prisoner who has
significant mental health problems should have a comprehensive risk
assessment as soon as possible.
The man’s use of drugs
112. Many men arrive in prison addicted to drugs but the man was not one of them.
Tragically, his use began during his imprisonment. Whilst in prison, the man
took opiates (heroin) regularly and became addicted to them. In 2005, he told
staff at Dovegate that he had been using opiates for 18 months. He was
prescribed detoxification programmes several times but always resumed
using drugs.
113. Staff told the investigator that the man would use whatever drugs he could
obtain, including other prisoners’ medication. He was open about his use
and, as his release approached, grew concerned about leaving prison
addicted to heroin. Staff arranged for him to be prescribed a detoxification
regime. However, because of what the clinical reviewer describes as the
man’s “chaotic drug use”, staff decided to retoxify him by prescribing
methadone. It was hoped that this would have made it easier for him to
detoxify permanently in the community.
114. The man told a friend in Shrewsbury prison that he took drugs to block out
memories of his offence. I know that staff in many prisons try to stop the flow
of drugs into the prison, using a variety of methods. In spite of their efforts,
drugs do slip through the net and are available to prisoners who want them.
115. The man tried to stop using drugs several times at Dovegate, going through
detoxification programmes. However, he always returned to using drugs. In
Shrewsbury, he asked to be accommodated on the Vulnerable Prisoners Unit
on C wing. His friend, Mr D, told the investigator that vulnerable prisoners
generally do not use drugs, and it would have been more difficult to obtain
drugs on C wing. Although the man appeared to settle well there, he soon
asked to return to A wing.
116. Mr D also told the investigator that he spoke to the man on the night before
his death. The man said that he owed two prisoners several hundred pounds
27
for drugs that he had bought since his return to A wing. The sum involved
would suggest heavy use of drugs in the five days before his death. However,
the toxicology report provided by HM Coroner found that analysis of a blood
sample,
“ … excluded the presence of alcohol and common illicit drugs. A trace
of the anti-depressant fluoxetine and a low concentration of
Paracetamol were detected”.
117. At interview with the investigator, Senior Officer B said that he never saw any
signs that the man was using drugs. Similarly, Senior Officer E and Officer G
never saw him under the influence of drugs. During an ACCT review a few
days before his death, the man openly admitted that he wanted to transfer to
Dovegate as he considered that it was easier to obtain drugs there. Whatever
the truth about the man’s drug use, I am satisfied that the prison took
appropriate steps to restrict supplies.
The apparent overdose
118. On 2 August, the man told Nurse A that he had taken an overdose of his
fluoxetine medication. She took the appropriate step and contacted the
emergency doctor who advised her to send him to hospital. The man spent
the night in a local hospital before returning to Shrewsbury the following
morning. The prison staff, very correctly, acted on the assumption that the
man had taken an overdose. However, the discharge letter from the hospital
said that there was no evidence that he had done so.
119. The man maintained that he had taken an overdose but there is no
information about why he said this. However, from the letters he handed to
Nurse A, he would appear to have been thinking of his past life and
contemplating his death.
120. Whilst the man was at Dovegate, staff suspected that he might be attempting
to stockpile his medication. Custody Officer A told the investigator that nurses
who dispensed the medication alerted wing staff to their suspicion that the
man was trying to leave the medication hatch without swallowing his pills.
Staff were extra vigilant to ensure he was not able to keep the pills in his
mouth until he could hide them in his cell.
The man’s refusal to cooperate with his resettlement plans
121. Staff who spoke to the investigator described the man as an intelligent man
who was very clear about what he would and would not do. This can be seen
very clearly in his refusal to participate in offending behaviour courses. Partly,
this was due to his social phobia. Many of the courses use group work, which
the man would have found difficult. However, the phobia did not prevent him
taking part in education and completing a number of classes.
122. Staff tried to persuade the man to undertake offending behaviour work and
arranged for him start courses. However, he found reasons not to do them.
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Similarly, when managers at Dovegate changed the man’s classification from
category B to category C, he refused to request a transfer to a category C
prison. So, his objection to the suggestion that, prior to his release, he should
move to Shrewsbury, was completely in keeping with his previous refusals.
123. Given that the man’s refusals were very clear, staff decided not to force him to
comply. It would have been possible for them to arrange courses and
transfers to other prisons. However, I am satisfied that such actions may very
well have been counter-productive as the man’s sentence progression
depended on his co-operation.
124. Staff at Dovegate spent several months making arrangements for the man’s
release. Custody Officer C and Custody Officer B worked closely with the
man to ensure that he had support in the community. Ms B liaised with the
MAPPA panel and the approved premises in Worcester to arrange
accommodation for him. The clinical reviewer sums up the support that staff
prepared for his release:
“Because of his chaotic drug use it was decided to retoxify him prior to
release. A multi agency approach was taken to his release with Prison
In-Reach, the Probation Service, Forensic Service and local mental
health services. It was recognised that he was anxious about his
release and was vulnerable to self harm.”
125. The man spoke to staff of his hopes and anxieties about renewing
relationships after his release. However, as an adult, it was for the man to
decide to tell his family about his release plans, if he wished. Custody Officer
B and Ms A both encouraged him to re-establish contact with his family before
his release.
Monitoring under the suicide and self-harm prevention measures
126. Throughout the man’s imprisonment, staff opened a number of ACCT plans to
monitor and support him through difficult times. For the three months before
his release, staff at Dovegate used the ACCT plan as well as the resettlement
process to try to address his worries about re-integrating into the community
and re-establishing links with his family.
127. I judge that the Care Map and case reviews were well focussed on trying to
meet his needs. Many of the entries are detailed and show a good knowledge
of the man. The ACCT plan remained open until the man was about to leave
Dovegate. An equivalent support plan was waiting for him at the approved
premises. Both the ACCT plan and the planned continuity of care are
commendable. (I will share my report with the Director at Dovegate and West
Mercia Probation Trust.)
128. At Shrewsbury, the reception officer opened an ACCT plan for the man after
he said that he was feeling “low” because of his recall. The following day, at
the case review meeting after the assessment, the staff and the man agreed
to close the plan. They made the decision because they believed that his
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issues were being addressed. While I do not disagree with the decision, I
point out that in my experience prisoners who have been recalled to custody
can be at increased risk of self-harm. The shock of being back in prison and
the uncertainty about their future are additional to any other problems they
may have. The Governor may wish to remind his staff of this fact.
129. After the man returned from hospital on 3 August, Senior Officer B opened
another ACCT plan and completed the Immediate Action Plan. The following
day, he completed the assessment and Care Map, setting out ways to
address the man’s problems. Having the same senior officer carry out both
parts of the ACCT process provided good continuity of care. The Care Map
actions were focussed and designed to meet the man’s need. In a report on a
previous death at Shrewsbury, I criticised a Care Map for being sub-standard.
I am pleased to note that the plan for the man was both precise and practical.
130. It would have been preferable for a further ACCT review to have taken place
when the man moved from C to A wing. However, before Senior Officer D
closed the ACCT plan, he checked that actions to resolve the issues were
complete. The man said that he was happy to be back on A wing and with his
job as a cleaner. He also said that he had no thoughts of self-harm. Again,
everyone agreed and the ACCT plan was closed.
131. However, as already noted, the staff were unaware that the man had been
refusing his anti-depressant medication. Senior Officer D noted in the
summary, “Medication is now stable with no issues.” The nurses who gave
out the medication knew of his refusal but, as the fact was not recorded
anywhere, the information was not available to the rest of healthcare staff, let
alone wing staff. I have commented earlier that ACCT reviews should be
multi-disciplinary and, unfortunately, on this occasion no healthcare staff were
present.
Placement in single cell
132. After returning to A wing, the man obtained a job as a wing cleaner. Officer G
told my investigator that it meant that he was occupied for some of the time.
The man also moved to a single cell, even though his ACCT plan was still in
place. For many people on an ACCT plan, the company of a cellmate is
beneficial. The man had got on well with his original cellmate and they moved
together to C wing. However, when the man returned to A wing, his cellmate
did not.
133. The investigator asked why the man moved to a single cell and who had
made the decision. Staff told her that such decisions were made by wing
managers. Sometimes a prison doctor will ask for a prisoner to be given a
single cell for medical reasons but there is no evidence of this in the man’s
records. The Deputy Governor, Mr G, told the investigator that there is a
computer record of why staff move a prisoner to a single cell. However, in
August 2009, the record was only kept for a month and was then deleted. By
the time the investigator spoke to Mr G, the record of the man’s move was no
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longer available. I am pleased that Mr G has now ensured that the monthly
records are archived in a computer file, rather than being deleted.
134. Given the absence of information about the reason for the move, I cannot
comment on the decision. However, a change of cell can be a significant
event for a prisoner on an ACCT plan. As such, it would be helpful for the
decision and the reasons for it, to be recorded in the plan.
The Governor should ensure that if a prisoner subject to ACCT
monitoring is moved to a single cell, the move and the reasons for it are
reviewed and recorded in the ACCT document.
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CONCLUSION
135. The man had been in prison for almost seven years when he took his life. He
had been diagnosed with a personality disorder and social phobia which
prevented him from taking part in offender behaviour courses. In addition, he
struggled with coming to terms with the crime had committed and, during his
imprisonment, turned to drugs, as a way of coping with his guilt. He was
anxious about the prospect of facing his mother. The man tried many times to
overcome his addiction, but invariably returned to drug-taking.
136. Throughout the man’s initial sentence at Dovegate and then at Shrewsbury,
where he was held after his recall to prison, I have found that staff put in place
appropriate support to manage his various needs. He was subject to support
and monitoring under the suicide and self-harm procedures at both prisons,
having admitted to thoughts of harming himself. On one occasion, he claimed
to have taken an overdose of drugs. He also sought and received support
from the CARATs drug service and mental health team. (Unfortunately, a
referral for a more detailed mental health risk assessment had not been acted
on by the time of the man’s death.)
137. The clinical reviewer concludes that prison staff responded to the man’s
needs. I too am satisfied that his care and management during his
imprisonment was relevant to his needs and that, when he was found hanging
in his cell, staff acted quickly and appropriately, albeit too late to save his life.
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RECOMMENDATIONS
All the recommendations were accepted.
1. The Primary Care Trust should ensure that when a prisoner refuses medication it
is recorded in the Continuous Clinical Record, as well as the prescription chart
and that relevant staff are informed of the refusal.
The response was:
“To put in place a procedure for clinical staff to follow when prisoners ‘do not
attend’ for treatment continuously for 3 days or refuse to take medication and
document in prisoners clinical record.
Regular monthly audits of prescription sheets and clinical records will take
place.
“Discussions with staff have taken place to inform them that prisoners that
have not attended for medication for three days or longer must be seen by a
nurse to ascertain why. This must be documented in the prisoner’s clinical
record. Guidelines as to the appropriate action to take will be written and
shared with staff and the next staff meeting.”
2. The Primary Care Trust should ensure that a prisoner who has significant mental
health problems should have a comprehensive risk assessment as soon as
possible.
The response was:
“There is now in place a new system of referral TAG. All referrals are now
time lined to the urgency of referral to Primary and secondary mental health
services. This will be audited quarterly.”
3. The Governor should ensure that if a prisoner subject to ACCT monitoring is
moved to a single cell, the move and the reasons for it are reviewed and
recorded in the ACCT document.
The response was:
“The Governor will ensure that if a prisoner subject to ACCT monitoring is
moved to a single cell, the move and the reasons for it are reviewed and
recorded in the ACCT document.
The single cell data base should also be updated by the Orderly Officer giving
the reasons why the person has been placed in a single cell.”
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