Individual at Styal

Investigation into the circumstances surrounding the
death of a woman at HMP Styal in June 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2009
This is the report of an investigation into the circumstances of the death of a woman,
who died in June 2007 whilst in the custody of HMP Styal. She had been found
hanging in her cell less than two days after her arrival.
I would like to offer my sincere condolences to the woman’s family and all those
touched by her death.
Immediately after the woman’s death, the police investigated the care she received
whilst she was in prison custody. The police commissioned a former prison service
governor to assist them. A number of issues were raised, but the Crown
Prosecution Service (CPS) decided that criminal charges would not be brought.
My investigation was delayed by over 14 months and only began after the police and
CPS completed their work. I apologise for any additional distress the delay may
have caused to the woman’s family.
The investigation was conducted by two of my colleagues. Both they and I would
like to thank the Governor of Styal and the Liaison Officer, for their co-operation
during the course of our inquiries. Undoubtedly, it was difficult for staff to be
investigated by my office so soon after being investigated by the police, and I
appreciate their helpfulness.
The woman had arrived at Styal on 1 June 2007, charged with the murder of her 19
year old son. She had been prescribed medication by her local doctor for anxiety
following his death. After her arrest and whilst in police custody, she admitted to
harming herself and was placed on suicide watch. This was the first time she had
come into prison.
During the woman’s brief time in prison (approximately 41 hours), staff did not
identify any specific concerns in respect of suicide or self harm tendencies. She was
a high profile prisoner and her case had featured in the local media. Staff were
aware that she had been charged with the murder of her own son, was in custody for
the first time and could be vulnerable. She herself appeared adamant that she did
not have any suicidal or intention of harming herself. As a result the prison’s suicide
and self harm monitoring was not put into place. Due to the seriousness of the
charge she faced, the woman was referred to the Mental Health In-Reach Team and
was waiting for a mental health assessment when she died.
Having played some part in assisting Baroness Corston during her year-long review
of women with particular vulnerabilities in the criminal justice system, I am all to well
aware of the damaged and vulnerable women who arrive in prison. The woman,
unfortunately, was all too representative of them.
I also acknowledge the population pressures faced at Styal. The Prison Service has
to remember that prisoners are at their most vulnerable in the days that immediately
follow their arrival at a prison. It is vital that any risk of self-harm or suicide is
identified at an early stage, and appropriate care and support plans are drawn up,
implemented and monitored. This is of even greater importance given that the
incidence of self-injury among women is much higher proportionately than for the
rest of the prison population.
2
I make eight recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman May 2009
3
CONTENTS
Summary 6
The Investigation Process 8
Background
HMP Styal 11
Key Findings
Prior to the woman arriving at HMP Styal 15
The woman’s arrival at Styal on Friday 1 June 16
Events on Saturday 2 June 23
Events of Sunday 3 June 25
Events following the woman’s death 27
Post Mortem 27
Issues Raised in the Investigation 28
Conclusion 33
Recommendations 34
1. Wing history sheet
2. Cell Sharing Risk Assessment
3. First Reception Heath screen document
4. Post mortem report
5. Death in custody contingency plans
6. Prison incident log
7. Staff incident statements
8. Governors Hot Debrief meeting note
9. Transcript Note of telephone conversation between the woman and her
daughter
10. Police statements
11. Police submission report to Crown Prosecution Service
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SUMMARY
The woman was arrested by the police on Wednesday 30 May 2007, on suspicion of
murdering her 19 year old son, who had been found dead two days earlier in the
family home. Whilst in police custody, she told staff that she had been prescribed
diazepam (commonly used to treat anxiety and agitation) by her doctor for her
nerves following the death of her son. Due to the nature of the alleged offence, the
police decided to conduct 30 minute observation reviews of her.
The woman was examined by a police doctor who authorised the continued use of
her medication. Later that evening, she told staff that she was depressed. When
asked if she had ever harmed herself, she responded by nodding her head. As a
result of her demeanor and response, the police increased the level of supervision to
constant.
The following day (Thursday), the woman was escorted to court, charged with the
murder of her son and informed that she would have to return to the court the next
day. She returned to police custody and the constant supervision resumed until the
following morning.
On Friday morning, the woman was prescribed diazepam by the police doctor at her
request. Shortly afterwards, she was transferred into the custody of Global
Solutions Limited (GSL) escorting staff and taken to court. GSL were informed of
her potential suicide risk and details of her medication were listed in the documents
handed over to them.
GSL staff arrived at the Magistrates’ Court at 8.45am. After reviewing the
information about the woman’s state of mind, staff opened a prison document called
a Suicide and Self Harm Warning Form. The form was opened around 9.00am and
staff made observations and comments about her until 2.25pm while she waited to
appear before the magistrates.
The form highlighted that the woman had a history of harming herself by cutting and
described her as being a vulnerable prisoner. She was checked approximately
every ten minutes whilst in the court holding cells. She appeared before the
magistrates and was charged with murder. Bail was refused and told that she would
be remanded into prison custody.
GSL subsequently transferred the woman to HMP Styal, arriving at the prison
reception area at 5.48pm. They informed prison staff of all the concerns and passed
the documentation to the reception staff.
There had been significant media interest in the woman because of her alleged
offence and some staff were aware of her imminent arrival at the prison. After she
was booked in at reception, she was immediately spoken to in private by two senior
prison officers. During their lengthy meeting, neither officer referred to the police or
court documentation, and no record was made of the conversation. In spite of the
Suicide and Self Warning Form included in her paperwork, she was not considered
by the reception staff to be at risk of harming herself. The prison’s suicide and self
harm monitoring procedures were not opened.
5
After the routine reception screening was completed, the woman was escorted to the
First Night Centre (FNC) and handed over to the staff on duty. She arrived at the
FNC at around 8.30pm where she was interviewed by an FNC officer and a
Healthcare Assistant (HCA). Afterwards, she was allocated to a single room on the
first floor. No immediate concerns were noted in respect of her mental or physical
health.
The following day (Saturday), the woman received a routine second health
screening around 12.30pm. She was assessed by a Registered General Nurse
(RGN) and the prison doctor. It was recorded in the notes that she was tearful, but
had no thoughts of harming herself. Aware that she had been prescribed diazepam
for her anxiety by her own doctor, the prison doctor authorised its continued use.
At 7.00pm that evening, the woman made a telephone call to her daughter using the
prison PIN phone. The conversation related to her son’s death and both she and
her daughter became distressed. When checked by staff later that evening, she
said she was fine.
The following morning (Sunday 3 June) the woman was unlocked at 8.00am and
proceeded to collect and eat her breakfast. An officer on duty spoke with her briefly
and her demeanor caused him no concern.
At 11.20am, the prison lifer officer arrived at the FNC to interview the woman and
was directed by FNC staff to her room. The room appeared to be empty and the
door was locked. When the officer looked through the observation panel, he could
see her sitting behind the privacy screen which had a ligature tied to it. He
immediately unlocked the door and tried to go inside but found it barricaded by
furniture. The officer shouted for assistance and used his radio to announce an
emergency call. He then began kicking and pushing the cell door until he was able
to enter the room. He received assistance from other staff very quickly.
The woman was suspended by a ligature (made from a pillow case) from the privacy
screen. Staff cut the ligature and requested an ambulance. Healthcare staff and
two prison doctors went to her room and began cardio pulmonary resuscitation
(CPR) to try to revive her. Unfortunately, she was pronounced dead at 11.54am.
This woman’s was the second death in custody at Styal since April 2004 when my
office became responsible for investigating deaths in prison custody. Since her
death, a further four women have died. Of these, two were apparently self inflicted
with the cause of death being hanging.
6
THE INVESTIGATION PROCESS
1. The investigation into the woman’s death was opened by one of my
investigators, on 6 June 2007 when he visited HMP Styal. He met the
Governor and some of his staff. Notices of the investigation and terms of
reference had already been sent to the prison to invite anyone with any
information to contact my investigators. No prisoners came forward to be
interviewed.
2. My investigator also met representatives of the Prison Officers’ Association and
the Head of Healthcare. He visited the reception and first night centre (FNC),
where the woman lived during her short time in custody.
3. My investigator was due to return at a later date to conduct interviews
accompanied by his colleague. However my investigation was suspended as a
result of the police enquiries. The police were concerned about the level of
care given to the woman throughout her time in prison. They believed that
prison staff had not acted upon the suicide warning information provided to
them on her arrival at prison. As a result, the police seized all prison
documentation and interviewed a number of staff under caution. Their
investigation included commissioning a former prison governor to assist them
and assess their findings. The police willingly shared key documentation
including staff witness interview statements, with my investigators.
4. Following submission of the police report to the Crown Prosecution Service, it
was decided that criminal charges would not be brought against any individual
within the prison. This process took approximately 14 months. The Governor
of Styal was informed of the findings of the police investigation. Once my office
was informed of the CPS decision, my investigators were able to resume their
investigation.
5. My investigator informed the prison once again of the Ombudsman’s
investigation. Staff and prisoners were informed to contact him with any
information they felt might be relevant to the investigation. There was no
prisoner response to this. My investigator however conducted several
interviews with staff accompanied by his colleague and fellow investigator.
6. My investigator fed back the findings of this report to the Governor following the
interviewing of staff. A number of these findings had already been documented
by the police investigation.
7. I also commissioned a clinical review from the local Primary Care Trust (PCT)
to assess the woman’s medical care. I am grateful to the clinical reviewer for
his report.
8. One of my family liaison officers (FLOs) contacted the woman’s daughter and
informed her of my investigation. Her concerns about her mother’s death are
listed below. I hope that my report goes some way to addressing them.
7
(cid:127) The woman’s daughter believed her mother was clearly disturbed and
mentally unstable – she had killed her own son and as the Prison Service
knew the information, it is hard to understand why she was not on a
suicide watch.
(cid:127) A year after the woman’s death, her personal belongings had yet to be
returned to her family and this had caused them some concern. (The
matter was followed up by my investigators and the belongings were
subsequently returned to her family in December 2008.)
(cid:127) Following receipt of my report, the woman’s daughter told my FLO that her
Aunt and Uncle said they had telephoned the police and the prison
(although it was not known who they spoke to) before her mother died, to
warn them that she had tried to commit suicide in the past and was at risk
of doing so again. My FLO informed the woman’s daughter that no
evidence of this had come to light from the police or my investigation.
(cid:127) The woman’s daughter also said she was pleased to see that Styal had
made a number of changes to improve procedures since her mother’s
death, although she was disappointed these changes had not been in
place earlier and it took such a tragedy for such improvements to be
made.
9. The woman’s daughter told my FLO that she believed that her mother was
depressed and had been for some time. However, instead of seeking help, she
had used alcohol as a way of self-medicating to cope with her depression.
8
HMP STYAL
10. HMP Styal began life as a children’s home in 1898. It was then used to house
refugees, before finally opening as a women’s prison in 1962. In April 1999,
Styal’s population increased in size by 60 per cent following the change of role
from a training prison to a local prison, and the closure of the women’s wing at
HMP Risley. Today, Styal has an operational capacity of 460 prisoners.
11. Styal is the only local prison for women from the North West and North Wales.
It holds mainly short term sentenced prisoners and those on remand awaiting
trial. The prison also has a small number of women serving indeterminate
sentences. Approximately 3,000 women are received through its gates every
year.
12. Styal is essentially two prisons within one perimeter. The accommodation is
divided into 16 Victorian houses or villas on one side, and the conventional
prison block (Waite wing) on the other. The houses provide shared
accommodation for sentenced prisoners and are self contained. Waite wing
takes prisoners on remand. The Keller unit is for women who are prolific self-
harmers or have serious mental illness. The prison has a separate Care
Support and Reintegration Unit (CSRU), which provides temporary
accommodation for prisoners who need to be segregated or are considered too
vulnerable to remain in the main prison. There is also a mother and baby unit
and Willow unit which houses young women from 17 to around 25. The woman
was located in the First Night Centre (FNC), Oak House, which accommodates
25 prisoners. Styal does not have any safer cells in the establishment.
13. Between August 2002 - 03, there were six self inflicted deaths at Styal. All six
women had histories of drug misuse. Five of the women were located on Waite
wing, and one woman was in the CSRU. All died within one month of arriving
at Styal.
14. Since those events, Styal has made considerable investment in reception, first
night in custody and induction procedures. There is no longer an inpatient
facility in healthcare and the original mental health facility, the Reeman Unit,
has closed. A new mental health strategy has been put in place.
15. According to the prison service, women in prison tend to commit less crime and
their offences are generally less serious. In 2006, 33% of sentenced women
had committed drugs offences; 19% were convicted of violence against the
person; 12% for theft & handling and 9% for robbery. Women tend to have a
different type of drug use from men with higher levels of hard drug use. They
are also normally the primary carers for elderly relatives and children. Up to
80% of women in prison have diagnosable mental health problems, with 66%
having symptoms of neurotic disorders (anxiety, poor sleeping). The
comparable figure in the community is less than 20%. Up to 50% of women in
prison report having experienced physical, emotional or sexual abuse.
9
16. After a full announced inspection of the prison in September 2008, HM Chief
Inspector of Prisons published a report which contained the following
observations amongst her findings:
“Styal is one of the largest women’s prisons. All women’s prisons hold a
disturbed and challenging population, but at Styal the needs of a heavily
substance-dependent population were extreme, complex and growing.
On arrival at Styal, over a third of women said they had felt depressed or
suicidal, over 40% said they had health problems, over half drug
problems, and nearly 40% alcohol problems. The last was significantly
higher than the 9% at comparator prisons, or the 10% on our last
inspection three years ago.
“Reception and first night arrangements were mostly good, but induction
needed improvement. Anti-bullying procedures were not robust. The
level of self-harm was very high and procedures to support women at
risk were inadequate.”
“A number of interventions were delivered through the resource centre
staffed by healthcare that aimed to support women who had been
abused, raped or experienced domestic violence.”
“The level of need and vulnerability of the women at Styal, even by the
standards of women’s prisons, was extremely high. Incidents of self
harm occur on a daily basis. Between January and July 2008, there
were 1,335 recorded incidents of self-harm with on average 190
incidents each month.”
Recommendations made in the inspection report included:
(cid:127) “Prisoners should wait in reception for as short a time as possible.
(cid:127) The first night centre should be staff by dedicated and experienced
officers who interact with and support new arrivals.
(cid:127) New arrivals should receive essential fist night procedures irrespective
of their time of arrival.”
Assessment, Care in Custody and Teamwork (ACCT)
17. As at all prisons, ACCT has been introduced at Styal to monitor and support
prisoners assessed as at risk of suicide or self harm. (The previous system
was known as the F2052SH procedure.) Once placed on ACCT, the prisoner is
observed at pre-determined intervals according to the perceived level of risk.
At ACCT plan review meetings, a prisoner’s level of risk can be reviewed and
noted as either ‘Low, Raised or High’ depending on the level of concern staff
have about an individual.
18. Each prisoner is assessed within 24 hours (ACCT assessment) and then
reviewed further at intervals decided on an individual basis. The ACCT
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guidance says that, to be effective, the review should involve the people who
know the person at risk or are involved in their care.
Counselling, Assessment, Referral, Advice and Throughcare (CARATS)
19. Organisations specialising in the treatment of substance abuse have drugs
workers based in most prisons. CARATS workers run programmes, offer
counselling, support and referral to rehabilitation centres to prisoners and on
release. Access to CARATS is voluntary, by application of the prisoner.
Cell Sharing Risk Assessment (CSRA)
20. In order to make sure that unsuitable prisoners do not share cells (for example
to prevent the location of a known racist prisoner with someone of the targeted
group or a prisoner with disturbed behaviour or mental illness from cell sharing
inappropriately), a cell sharing risk assessment form is completed by reception
when a prisoner is first admitted and is a live document which can be reviewed
at any point and follows the prisoner on transfer to another establishment.
First Night Centre (FNC)
21. All prisoners who come into custody at Styal are initially located in the First
Night Centre (FNC). On arrival from reception, the prisoner is interviewed by a
FNC officer, a doctor and a nurse. After an induction period, usually of two to
three days, women are allocated to the normal prison wings (known as houses)
according to their needs. The FNC holds around 25 women consisting of a
mixture of single and double rooms and a four bed dormitory room. All rooms
have a safe for the storing of valuables. There are no designated “safer” cells
in the FNC. Whilst on the FNC prisoners do not work or attend any education
classes, but are allowed periods of association (time out of their rooms).
Induction
22. Induction is the process of introducing new prisoners or newly sentenced
prisoners into custody. It is designed to explain the immediate consequences
of being in custody, to explain the routines of the prison, rules and regulations
they must observe, the procedures governing certain processes such as
obtaining visits and to offer practical advice on obtaining goods and services as
well as helping them to understand how to navigate their way around issues of
imprisonment. The induction period includes sessions with various agencies
such as Mental Health In-Reach Team, the chaplain, probation and CARATS.
Staff check that prisoners understand what is going to happen to them and
attempt to deal with any immediate problems.
Listeners
23. Listeners are selected prisoners trained by the Samaritans to provide a
listening ear by a peer. Like Samaritans, they do not offer counselling but are
there to offer support particularly for prisoners at risk of self harm. The support
which they provide is confidential.
11
Mental Health In-Reach Team
24. Community Psychiatric Nurses (CPN) within the In-Reach team assess
prisoners following concerns about their mental health being identified.
Prisoner Escort Record (PER)
25. The PER form accompanies each prisoner on all journeys between police,
courts and prison, as well as any other journeys. It is compiled by the escort
staff and gives a chronological record of the journey, for example that meals
were served or the time that a journey started. It includes a section which
records whether a prisoner poses any risks to themselves or others.
Prison Service Order 2700
26. The Prison Service has a duty of care for all prisoners and staff. This Prison
Service Order (PSO) provides the Service with instructions on identifying
prisoners at risk of suicide and self-harm, and on providing the subsequent care
and support for such prisoners and support for the staff who care for them.
Reception
27. Prisoners are handed over to the prison reception staff and their paperwork is
handed over by the escorting contractor. The prisoner is then booked in by
prison staff at the front desk. Prisoner details are checked against the
documentation received and relevant files are opened. Prisoners wait in a
waiting room and are processed individually by staff. This includes being
searched, providing information about prison, providing prison clothes,
checking their property and answering any initial questions. After this process,
prisoners are escorted to the First Night Centre. Dependant on a prisoners
time of arrival, they are also allowed to make a telephone call on their day of
arrival.
Women in custody
28. The number of women in prison custody in January 2008 was approximately
4,189. Prison Service states that women tend to commit less crime and their
offences are generally less serious. In 2006, 33 per cent of sentenced women
had committed drugs offences, 19 per cent were convicted of violence against
the person, 12 per cent for theft and handling and 9 per cent for robbery.
However this should not be overshadowed by the fact that the level of need and
vulnerability of the women at Styal, even by the standards of women’s prisons,
is extremely high.
.
12
KEY FINDINGS
Prior to the woman arriving at HMP Styal
29. The woman was arrested by the police at 8.15am on Wednesday 30 May 2007,
on suspicion of murdering her 19 year old son. He had lived with his mother
and had been discovered dead at their home the previous day.
30. Whilst in police custody, the woman told staff that she had been prescribed
diazepam by her doctor for her nerves following her son’s death. Due to the
nature of her alleged offence, the police decided to conduct 30 minute
observation reviews. She was examined by a police doctor who identified a
scratch with bruising on her left wrist as well as bruises to the back of her legs
and both arms. The doctor authorised the continued use of diazepam,
describing her as being well in herself and not suffering from any current mental
illness.
31. At around 9.00pm later that evening, whilst a review of the woman’s detention
was taking place, she informed the police officer that she was depressed. The
officer asked her if she had ever harmed herself to which she responded by
nodding her head, although she gave no further details. Her risk of self harm
was raised and she was placed under constant supervision. This meant her
cell door remained open and a member of the police custody staff remained
outside the cell monitoring her.
32. The following day, Thursday 31 May at 5.05pm, the woman was escorted to
court and charged with murder. The court took the decision that she should be
remanded into police custody in order to appear before the Magistrates’ Court
the following morning, Friday 1 June. She was therefore returned to the police
custody where she remained under constant supervision.
33. On 1 June, at around 8.40am, the police medical doctor authorised that the
woman could be given three diazepam a day, at her request. She was then
transferred to the custody of GSL escorting staff who were made aware of her
potential suicide risk and details of her medication. Both were listed in the PER
Part A and B escort documents and handed over to staff with other documents.
In respect of the risk she was thought to pose to herself, the following
information was recorded on the PER Part A document:
“Charged with murder of her son. Intelligence has been received that the
DP [detained prisoner] may self harm. She has a small cut to her wrist
and has been kept on const s/v [constant supervision] whilst in police
custody.”
34. The escorting GSL staff arrived with the woman at the Magistrates’ Court
around 8.45am. The information they were given about her state of mind
caused them to open a document called the Suicide and Self Harm Warning
Form. She told the GSL escorting officer that she had other family to care for
and would not do anything “silly”. Nevertheless the form was opened shortly
before 9.00am and staff made observations and comments about her until
13
around 2.25pm, whilst she waited to appear before the magistrates. The
following was written about the woman:
“DP [detained prisoner] states she does not self harm at this time she has
not come to terms with the offence of which she has been charged
[murder of her son]. DP has had lunch and seems to have come to terms
with being remanded she is chirpy and enquiring about facilities at HMP
Styal.”
35. The form also highlighted that the woman had history of harming herself by
cutting, and she was described as a vulnerable prisoner. She was checked
approximately every ten minutes whilst in the court holding cells. During this
time, it was recorded that she was given two of the three recommended doses
of diazepam. The first was issued to her by GSL staff at 9.45am and the
second at 12.35pm.
36. The woman appeared before the magistrates and was charged with murder.
Bail was refused and she was remanded into prison custody. She was to
return to Preston Crown Court for a hearing on 14 June.
The woman’s arrival at Styal
37. The woman was subsequently transferred to HMP Styal by GSL, arriving at the
prison reception area at 5.48pm. All the documents mentioned were
transferred with her and presented by the GSL staff to the prison reception
staff.
38. From her police statement, the GSL escort officer said that they arrived at Styal
at 5.35pm and she asked to speak with the prison senior officer (SO) in charge
of reception. All the prisoners at this point remained on the van. Although the
GSL escort officer could not recall the SO’s name (she did recall that it was a
female member of staff), she said that she had informed her that the woman
had been the subject of suicide watch whist in police custody. She told the SO
that, as a result, GSL had also placed her on four irregular checks each hour.
The GSL escort officer said that the SO’s response was that the woman should
be removed from the escorting vehicle first and be risk assessed.
39. One of the concerns raised by the GSL escort officer with the SO, was that the
woman had not come to terms with the offence she had been charged with.
She also passed over the police PER Part A and B document which had been
updated to show all the checks completed whilst she was in transit. The last
entry on the GSL log sheet was shown as made at 5.48pm, when a member of
the Styal reception staff received her into custody. The PER Part B form and
the Suicide and Self Harm Warning Form were handed over to prison staff,
together with her belongings.
40. The GSL escort officer’s statement to the police concludes by saying that the
woman was escorted from the GSL vehicle into the reception area and
introduced to the officer who was on the reception front desk. The GSL escort
officer said she handed over all the paperwork relating to the woman. The GSL
14
staff then took the remaining three prisoners off the vehicle one by one and
booked them into the prison reception.
41. At interview with my investigators, the reception officer said that she could not
recall any details about the woman’s arrival. She confirmed that GSL would
normally give the PER forms containing the warrant, property and other
documents to the prison reception booking-in officer to check. She could not
remember whether she was taken off the GSL van first, but said that generally
prisoners would be escorted into the reception area one at a time. The
reception officer said she would then ask standard questions to confirm the
prisoner’s identity, address and religion, check their property and details of their
offence and then provide information about the reception process.
42. The reception officer confirmed that she received the woman’s PER Part A and
B documents from GSL. Contained within them were other documents and
information about her. Although the GSL escort officer said she handed over
the Suicide Self Harm Warning Form to prison reception staff, the reception
officer said she did not receive such a document for the woman. The reception
officer said that she would only check the warrant documentation, which she
did whilst going through the standard questions with the woman. The other
documents contained in the PER forms would be read by the officers who
would interview her afterwards. The reception officer said that the woman
expressed no concerns whilst she was being questioned by her. She was not
aware of any medication that she was currently taking and she did not bring it
to her attention.
43. At interview with my investigators, an SO said that she was in charge of the
reception area on the day the man arrived, which was the first time she had
carried out this duty. The SO said that when she arrived for duty on Friday
morning, she checked the staff and the First Night Centre (FNC) and there
were no concerns.
44. The SO said that she learnt of the woman’s case from the Principal Officer
(PO). That morning, the PO had seen the high level of interest the woman’s
case had generated in the local news and was aware that she had been
remanded into prison custody. As Styal was the only women’s prison in the
North West, she knew that she would be located there. The PO, who was the
Oscar 1 (duty officer in charge of the prison), also confirmed this at interview
with my investigators. The PO told staff to inform the SO as soon as the
woman arrived at Styal, as she wanted to speak with her to check on her well
being. (It should be noted that an interview with senior staff is not part of the
routine reception procedures.) The PO had seen the woman on the television
news and believed that she was coming into prison under extremely stressful
circumstances given the nature of the alleged offence.
45. When the woman arrived at Styal, neither the PO nor the SO were in reception.
Staff contacted both officers who arrived in the reception area simultaneously.
They said that the woman had not yet been processed by reception staff and
was standing at the front desk with a member of staff from GSL. The PO told
my investigators that she recognised her from the news and immediately
15
escorted her into a side interview room. Both officers confirmed that they did
not speak to the GSL staff about her. None of her paperwork was shown to
them, and neither asked the reception officer for the woman’s documentation
before speaking to her. My investigators confirmed that both senior officers
were trained in the Prison Service’s ACCT procedures for assisting prisoners at
risk of suicide and self harm.
46. The PO introduced herself and the SO to the woman and offered her a drink.
They then engaged in an informal conversation with her and talked about a
number of issues including the events surrounding the death of her son. The
PO said that the woman talked about her offence, saying that her family were
all supportive and she had a good network around her. The PO asked her
about self harm issues and whether she had “thought of harming herself” in any
way. She gave no indication and did not speak of any concerns. The PO then
left the room leaving the SO to continue her talk with her and to put her at ease.
Not having any of the escort paperwork, both officers were unaware that the
police and GSL had monitored her in accordance with their suicide and self
harm monitoring procedures.
47. The SO said that the purpose of taking the woman into a private room was not
to interview her but solely to have an informal chat with her and see if she was
okay. This was something the SO said she would do for anyone who arrived at
the prison with “any difficulties or any stresses”, or if it was their “first time in
custody and they needed that comforting time”. The SO described the
conversation as quite lengthy and relaxed, and included taking her outside to
show her the prison courtyard. The SO said that the woman had been very
convincing that she was coping with things. When she talked to the SO about
her alleged offence, she said it was an act of self defence and that she was not
the main aggressor in the incident that had occurred. The SO told my
investigator that the nature of the woman’s offence would not immediately raise
her risk level and that she was “just another woman for a serious offence”.
48. Neither the PO or the SO were aware that the woman had arrived with a
Suicide and Self Harm Warning Form. The SO said that she had not seen any
of the woman’s documentation, nor did she ask to see any of it, during or
following her lengthy chat with her. Neither was any record made on her prison
file regarding the lengthy conversation with the two officers.
49. After their conversation ended, the SO returned her to the reception waiting
area. She told my investigators that she had no concerns about her so was to
be processed in the normal way. No formal handover was provided to the
officer who was asked to interview the woman.
50. The woman was fully searched according to the normal procedure. This meant
that she would have to remove all her clothing with prison staff conducting the
search in two halves. She would remove clothing above the waist, then
dresses again before removing clothing below the waist. Whether or not staff
(only female staff search prisoners) noticed the marks on her wrist, arms and
legs (which were identified whilst she was in police custody) is not known, as
no record of them was made.
16
51. At interview with my investigators, the interviewing officer said that there are
usually five members of staff in reception. The Operational Support Grade
(OSG) stays behind the desk, the SO moves between the FNC and the
reception, and three officers share the general work of interviewing and booking
in prisoners.
52. When the woman arrived, the interviewing officer noticed that she was taken
immediately to a holding room where she remained for a considerable amount
of time in the company of the SO and PO. Following this conversation, she
was searched in one of the interview rooms. The interviewing officer said that it
was not unusual for senior staff to speak with a prisoner on arrival, if that
prisoner was charged with a serious offence. She said that the reason was to
identify any issues that the prisoner wished to bring to their attention. Although
Styal had received individuals in the past who were charged with murder, the
officer said that the arrival of a prisoner charged with the murder of their child
was less common.
53. The interviewing officer said that she read the woman’s paperwork, including
the warrant and both parts of the PER form. My investigators found some
confusion when they spoke to the interviewing officer as to whether she had
read the Suicide and Self Harm Warning Form completed by the GSL staff. In
her police statement, she said she did see it but in interview with my
investigators she was unsure. The interviewing officer said that there was a
general problem when receiving documents in reception. GSL handed over all
paperwork stapled together and staff would have to unclip, separate and then
sort them out. There was sometimes confusion with the large amounts of
paperwork for each prisoner and it was possible that some pieces were filed
incorrectly.
54. The interviewing officer proceeded to ask the woman questions whilst
completing the cell sharing risk assessment (CSRA). She knew that it was her
first time in prison. She told the interviewing officer that she had never abused
drugs or alcohol. There is a section on the CSRA form which asks if there is
any evidence of the prisoner being on a previous F2052SH (later replaced by
ACCT document). As she had never been in prison before, the interviewing
officer ticked the ‘No’ box, and made no reference to the Suicide and Self Harm
Warning Form completed by GSL.
55. The PER Part A and B document stated that the woman had a medical
condition and had received diazepam. The interviewing officer was not aware
of, nor did she ask her about any medication she was currently receiving. She
told my investigators that she was not medically trained and therefore this was
an issue for the nursing staff.
56. The interviewing officer said that medication which arrived with a prisoner,
which was handed over by GSL staff, would be stored behind the counter in
reception. It would be taken over with the prisoner to the First Night Centre
(FNC) and given to the nurse. Prior to this arrangement, problems had
sometimes occurred as GSL often put all of a woman’s property into one big
17
bag, including their medication, which was supposed to be kept in a separate
bag. The interviewing officer checked the woman’s property bags and signed
for it. She told my investigators that she did not recall seeing any medication.
57. Due to the nature of the woman’s offence, the publicity it had attracted and this
being her first time in prison custody, the interviewing officer deemed her
vulnerable but not at risk of harm to herself. The officer identified her as “High
Risk” in respect of sharing a cell with another prisoner, which meant that she
would have a single room in the FNC. The CSRA document was duly
completed with this information.
58. The interviewing officer said that she asked the woman a number of times if
she had any thoughts of harming herself. She repeatedly said that she did not
and also did not declare a history of self harm. The interviewing officer had
seen comments made on the PER Part A document about a small cut on the
woman’s wrist and asked her about them, to be told that they were not an
attempt to harm herself.
59. A number of core prison records (an Offender Management record, CSRA and
two wing files) were opened for the woman by the interviewing officer during
their interview, which lasted around 35 minutes. She then escorted her to the
FNC and said she handed these documents to the staff there.
The woman’s arrival in the First Night Centre (FNC)
60. The woman was introduced to an officer in the FNC at around 8.30pm, about
two and a half hours after arriving at Styal. The interviewing officer said that
she gave the officer in the FNC a verbal handover and also brought to her
attention the comments she had made about the woman in the wing file. They
provided the information about her which had been collected from their
interview.
61. At interview with my investigators, the officer in the FNC explained that prison
staff had been talking about the woman before her arrival because of her
alleged offence. The officer in the FNC was however unaware of any further
information about her until she was brought over to the FNC. Neither the PER
Part A and B or the Suicide and Self Harm Warning Form were included in the
handover papers she received from the interviewing officer.
62. The officer in the FNC said that Fridays were generally quite busy in reception
and it could sometimes take a couple of hours for a prisoner to arrive at the
FNC. Although she was unable to say how many prisoners had come in that
evening, they were still waiting for two or three more women to be brought
across after the woman’s arrival.
63. The officer in the FNC interviewed the woman for approximately 15 minutes.
The conversation took place in the dining room because there was nowhere
else available. The officer carried out an initial induction to the FNC and
recorded details about her. She was offered a shower and an immediate needs
assessment was conducted. The officer recorded that the woman was worried
18
about the security of her home and mortgage payments. She said she had no
thoughts of harming herself or suicide at present. She was given something to
eat whilst the officer in the FNC spoke with her, went through the Offender
Management file and asked a number of questions. The woman told her that
Styal seemed a nice place and everybody had so far treated her okay. The
officer wondered if the woman could be in shock, but she denied it.
64. The officer in the FNC issued the woman with an Induction booklet. She also
explained a number of prison practices and procedures which included the
violence reduction policy, smoking policy, personal officer scheme, emergency
cell bell procedure and the Listeners and Samaritans scheme.
65. The duty Governor that evening, having been informed by the PO that a woman
charged with murder was in their custody, she made her way to the FNC to see
her. The duty governor told my investigators that her purpose was to see if
things were satisfactory with the prisoner. When she arrived, she was being
interviewed by the officer in the FNC and the duty governor joined them. The
duty governor spoke briefly to the woman to ensure that she was well and let
her know that she should ask if she needed anything. She responded that she
was fine. The duty governor then left the officer in the FNC to continue with the
interview. After the officer had completed the interview, the woman was taken
to be interviewed in the healthcare suite in the FNC by a member of the
healthcare team.
The woman’s contact with healthcare staff
66. The head of healthcare described their role as crucial and complex. At
interview with my investigators, she explained that on arrival many women
need observation and treatment for drug or alcohol withdrawal. Some women
become depressed and exhibit signs of having mental health problems. Many
also have physical problems and may not have engaged with clinical services
outside of prison. The head of healthcare said that the key challenge for staff is
to identify the problems, and put plans in place quickly, as the average stay for
women at Styal is only about six weeks.
67. The healthcare assistant (HCA) told my investigators that she interviewed the
woman after the officer in the FNC. The HCA had been at Styal for about 15
months and she was not a qualified nurse. Her training consisted of working
alongside and assisting qualified nurses and undertaking first aid training. If
she had particular concerns about a prisoner, she would speak to the qualified
nurse on duty, who was located in the room next door with the prison doctor.
At the time, the HCA was not ACCT trained. She said, however, that if she
thought that an individual was at risk, she would be able to open one. In her
police statement, she said that she had opened an ACCT document before for
other prisoners, but had done so under the guidance of a qualified nurse.
68. The role of the HCA is to conduct an initial screening of the prisoner using a
national healthcare screening document. The screening identifies a prisoner’s
immediate physical and mental health needs, drug addiction and suicide or self-
harm issues. The screening is not an assessment but to collect information. It
19
is described as a quick screening process to immediately identify what issues a
prisoner may have on that particular evening. If necessary the doctor would
then prescribe the appropriate treatment. Women who do not see the nurse or
doctor on their first evening will see them the following day, at the second
health screening.
69. A verbal handover was not given by the officer in the FNC to the HCA, who
collected the woman’s paperwork from the desk in the FNC. The only
document the HCA said she received for the woman was the CSRA, which did
not contain any medical information. She was interviewed in a private room,
next door to the nurse and doctor. The HCA said that she used the new
electronic medical information system (EMIS) to record a prisoner’s data, which
had only recently come into operation within the prison.
70. The HCA did not consider that the woman appeared upset and her mood raised
no concerns. From her responses, the HCA noted that she did not use drugs
and was not alcohol dependent, although she had consumed 20 units of
alcohol in the week preceding her custody. The HCA also noted that she had
been charged with murder and was on remand.
71. My investigators found that no information was recorded by the HCA on EMIS
referring to the woman being prescribed any medication. However reference to
her medication was hand written in her medical record.
72. Section three of the CSRA form is completed by the Healthcare Team, and was
signed by the HCA. She noted that the woman had “No current thoughts of self
harm” and her risk of harm to others was reduced to “Medium Risk”.
73. The HCA told my investigators that she was aware that there were some other
prisoners who had been identified as being drug users who also arrived at the
prison that evening. As is usual in the FNC, they have to prioritise anyone with
a medical history of substance misuse issues. The doctor’s shift was due to
end very soon (9.30pm) and so the HCA asked the nurse on duty if she would
want to see the woman, who appeared to be drug and alcohol dependent free
that evening or the following morning. The nurse said that she would see her
the following morning because she had to prioritise treatment for those women
who needed alcohol and drugs detoxification.
74. The HCA subsequently made a referral for the woman to be seen by a member
of the Mental Health In-Reach team on Monday. (The team did not work at
weekends at the time of her arrival.) She made the referral because of the
offence the woman had allegedly committed and the long length of sentence
that she might receive.
75. The woman was then returned to the wing staff to be located in her room for the
night. She was allocated room three, which is a single room on the first floor.
The head of healthcare confirmed that if any concerns had been raised about
her, or any other prisoner during the night, there was a qualified nurse on duty
who could deal with them.
20
76. The officer in the FNC said that at around 9.15pm she was in the FNC
checking and locking the women into their rooms, when she came across the
woman waiting in the corridor. She said that she was waiting to see the doctor.
The officer presumed that the woman had seen a nurse already. She was
aware of an incident elsewhere in the prison which the nurses were called to
attend, and informed her that it was unlikely that she would be seen by the
doctor that evening. She was therefore escorted to her room.
77. The duty governor said it was normal procedure for her to review the CSRA
form for prisoners who are assessed as “High” risk. Later that evening she
reviewed the woman’s CSRA paperwork and agreed that she was a “High
Risk”. This simply meant that she could be of risk to others if placed in a cell
with another prisoner. The assessment would be reviewed after seven days.
No concerns were relayed to the duty governor about the woman’s well being.
In interview the duty governor said that she was not told staff that there was
any record from the police or GSL that she was at risk of harming herself. She
would rely upon the judgement of staff as to whether the opening of an ACCT
document was necessary. The duty governor said that staff described the
woman as positive.
78. During the night period, no concerns were reported about the woman, who was
checked every hour by the night duty officer. (This is standard practice for all
new arrivals at Styal during their first night in custody.)
Saturday 2 June
79. The following morning, Saturday 2 June, the woman left her cell soon after
8.00am to collect her breakfast. The SO was in the FNC where she saw her
briefly and asked her if she had been given a telephone call yet. She said she
had not. The SO told her that she would sort this out and spoke to the officer in
the FNC to arrange it.
80. From evidence gathered during the police investigation, another prisoner saw
the woman in her room crying shortly after breakfast. The woman told the other
prisoner that she was fed up with other prisoners “scrounging her sweets”.
Staff interviewed by my investigators were unaware of the incident.
81. Later that afternoon, the woman’s induction routine continued. She was
medically assessed by a registered general nurse (RGN) and her RGN
colleague. (At the time of my investigation, the RGN was no longer employed
at HMP Styal.) The HCA’s notes from the previous evening were referred to.
in the RGN’s police statement, she said that having logged onto the EMIS
system that afternoon, she had noticed that the woman had arrived the
previous night and had not had a urine test or seen the doctor. During her
assessment, the nurses took her blood pressure, weight and a urine sample
which were recorded on EMIS.
82. The RGN noted that the woman said that she had no thoughts of deliberate self
harm. She told the RGN that she had been taking the diazepam prescribed by
her doctor. She subsequently tested positive for benzodiapines and was
21
referred to the prison doctor. The RGN further noted that the woman was to be
referred to the Mental Health In-Reach Team and was fit for normal prison
location and work. Again, there is no reference to the Suicide and Self Harm
Warning Form that had been completed by GSL.
83. A GP worked at Styal two days a week (at the time of my investigation, he too
no longer worked at Styal) and examined the woman soon after she had seen
the nurse. His entry on the EMIS system for her was made in the RGN’s name
as he was unable to log on for himself.
84. The GP noted that the woman had “anxiety with depression”. He recorded that
the recent death of her son had been very traumatic for her. She had been
prescribed diazepam (2mg) and some other medication (no information was
recorded as to what this was) by her doctor to help her through this period. The
GP prescribed the continued use of diazepam for her anxiety and ranitidine for
gastro-oesophageal reflux (leakage of stomach acids), a problem which she
had had for many years. The GP said that the woman was tearful, said she
had no thoughts of self harm and was to be referred to the Mental Health In-
reach Team. It was also noted that she drank excessively at times but not
every day. In his interview with the police, the GP said that he was not aware
of the PER documents or the Suicide and Self Harm Warning Forms for her,
and neither was he ACCT trained.
85. When interviewed by my investigators, the RGN colleague’s recollection of
events relating to the woman was very vague. The nurse said that she had
come for her second health screening and seemed fine when she arrived. No
concerns were noted on her wing history after this.
86. Later that afternoon, the prison chaplain spoke with the woman. He told my
investigators that it was part of his normal duties to see new prisoners who had
never been in prison before. The chaplain said that he spoke with the woman
in a room on the landing. He did not judge that she was at high risk and he did
not notice anything worrying about her demeanour. She told him that she was
anxious about her family but did not go into any detail. Their meeting ended
with the chaplain reminding her that he was available should she ever need to
talk to anyone.
87. According to the woman’s medication prescription chart, she received her first
dose of diazepam at 6.50pm. There is nothing noted on her medical file which
highlighted any concerns about her when it was issued.
88. At 7.00pm on Saturday evening, the woman made a telephone call to her
daughter using the prison PIN phone. The telephone was located on the
ground floor. At interview with my investigators, a second SO explained that
she had been asked earlier that day to facilitate a telephone call for the woman
to her family as she had not made one since her arrival at the prison. As is
normal procedure for a prisoner’s first telephone call, the second SO entered a
pin number and dialled the number she wished to ring. Once the telephone
started to ring, she passed the telephone over to her and left her to talk in
private to the recipient of the call.
22
89. The call was not monitored by prison staff. From prison records made available
after the woman’s death, my investigators found that her conversation was with
her daughter and they talked about the death of her son. Both she and her
daughter were distressed throughout the call. The call was terminated after
three minutes in mid conversation because the maximum call time had been
reached.
90. After making the telephone call the woman returned to her room. From the
police investigation and from a statement given to my investigators from a
fellow prisoner, it appears that she had confided in another woman that a pair
of her earrings and some sweets had gone missing from her room. She also
said that she had made a telephone call that had left her feeling down and
upset. It appears that no staff were aware of the concerns she expressed to
the other prisoner.
91. The second SO said she saw the woman soon after she had made her
telephone call (between 7.15pm and 7.30pm), when she was locking prisoners
into their rooms for the night. She had gone specifically to check her and
ensure that she was okay and there were no concerns about her.
92. This was the woman’s second night in custody. She was not subject to ACCT
monitoring and night staff were not required to conduct hourly observations.
Sunday 3 June
93. An officer had worked the previous day, Saturday, when he met the woman.
He had no concerns about her from their first meeting. On Sunday morning,
the women’s rooms were unlocked at 8.00am. The officer recalled seeing her
in the queue waiting on the ground floor to collect her breakfast pack, eat it and
wash her cutlery afterwards at around 10.00am. She was polite when he spoke
to her and had said good morning to staff.
94. A short while afterwards, the officer had cause to visit the woman’s room whilst
carrying out the accommodation and fabric checks (AFC). (This is a daily
check to ensure that the fabric of all the rooms is in good working order and
that there is no damage.) When he arrived at her room, she was not there.
The officer assumed that she was in the television room on the ground floor
and so continued with his check of her room.
95. The lifer manager went to the FNC at around 11.20am to interview the woman.
All prisoners who are serving a life (or potential life) sentence are assigned a
lifer manager to assist them with concerns and administrative matters at all
stages of their sentence.
96. The lifer manager told my investigators that the woman’s case had a high
profile in the media. He was directed to her room by two officers. Both officers
told the lifer manager that the woman appeared to be okay, had not displayed
any adverse behaviour, and, although she kept herself to herself, was polite to
staff.
23
97. When the lifer manager arrived at the woman’s room, the door was locked. He
looked through the door observation panel and saw her sitting behind the cell
privacy screen with a ligature tied to it. He unlocked the door but found that it
was barricaded with room furniture. The lifer manager then quickly shouted for
assistance and used his radio (recorded as occurring at 11.25am) to announce
a Code Blue emergency over the net. (A Code Blue emergency call means
that a prisoner is not breathing or is suspended.) He then began kicking and
pushing the door until he was able to go inside.
98. Once inside, the lifer manager found the woman suspended by a ligature
(made from a pillow case) from the privacy screen. The two officers who had
previously directed him, responded to the shout for assistance along with the
officer in the FNC. They arrived at her room just as the lifer manager had got
inside. The lifer manager believed that from the woman’s appearance she was
dead, her face was cold and her eyes and lips were deep purple.
99. The lifer manager cut the ligature away from the woman’s neck with his
standard issue ligature knife, and requested an ambulance over his radio
(recorded by Communications as being called at 11.32am). Along with one of
the officer’s, he placed her in the recovery position. Whilst the lifer managerl
was clearing her airway, healthcare staff arrived and took over. The officers left
the room.
100. The RGN colleague was carrying out the medication round on the FNC with the
an officer, who was monitoring the prisoner medication queue. She was alerted
by an officer at the medication hatch who said medical assistance was required
immediately upstairs as someone was having a “fit”. The HCA was also in the
medication room and locked the medication cupboards whilst the RGN
colleague grabbed the emergency bag which contained resuscitation
equipment. She too made her way to the woman’s room.
101. It took less than a minute for the RGN colleague to arrive at the woman’s room.
She saw her lying in the recovery position on her side. She told my
investigators that she looked blue and was unresponsive. The nurse placed
the oxygen mask on her and, whilst turning her onto her back, noticed a ligature
mark on her neck. She could not find a pulse.
102. Another nurse also arrived at the woman’s room within moments of the
emergency call and together they commenced cardiopulmonary resuscitation
(CPR). The RGN colleague administered cardiac compressions at the rate of
30 compressions to two breaths whilst the nurse controlled the ambu-bag (air
compression bag). The HCA also arrived and was asked to collect the
defibrillator from the wing and the prison doctors who were in the healthcare
unit. During this time other staff attended to assist.
103. The HCA returned with the defibrillator (a machine which delivers a therapeutic
dose of electrical energy to the affected heart), which was used by the nurses
to assess the woman’s heart activity. The defibrillator stated that there was no
“shockable” rhythm and that CPR should continue. Two doctors arrived at her
24
room (recorded as 11.30am) and assisted with CPR. One of the doctors noted
that there was no response from the woman and he believed that she had been
dead for at least 30 minutes. He administered adrenalin into her arm but she
still failed to respond to their resuscitation attempts.
104. The ambulance paramedics arrived at the woman’s room at 11.47am. They
carried out tests on her and, with the doctors, agreed that CPR should cease.
She was pronounced dead at 11.54am.
Events following the woman’s death
105. The prison’s Death in Custody Contingency Plan was immediately activated by
the Duty Governor. The Governing Governor and the necessary agencies were
contacted, including the police. The police were at the prison for most of the
afternoon. Notices regarding the woman’s death were also displayed around
the prison for staff and prisoners. All prisoners on the FNC were informed of
the morning’s events and offered support from Listeners and Samaritans. The
prison care team were informed of the woman’s death and attended to offer
support to staff the on duty.
106. The Governor held a hot debrief meeting at 1.25pm. All staff who had had
some involvement with the woman attended to explain their contact with her
from the day of her arrival.
Contact with the woman’s family
107. A governor was appointed as the prison family liaison officer and attended the
hot debrief meeting. She left the prison with the Governing Governor after the
meeting to inform the woman’s family of her death. When they met with the
family, they explained what had occurred and provided them with the contact
numbers for the prison, undertakers and offered financial assistance with the
funeral expenses.
108. Although arrangements were made for the return of the woman’s personal
belongings, they were not actually given back to her family. Her daughter
raised the issue when she spoke to my family liaison officer in November 2008
and they have since been returned.
Post Mortem
109. A post mortem was conducted on 4 June 2007. The pathologist noted that over
the front of the woman’s left arm were a series of very shallow interrupted
abrasions which were consistent with healing recent self inflicted injuries
(probably several days old).
110. The woman’s cause of death was compression of the neck, caused by hanging.
The toxicology examination found that she had consumed diazepam a
considerable time before her death. There were no traces of any alcohol,
commonly encountered drugs of abuse (except diazepam) or prescription and
non prescription medicines.
25
ISSUES RAISED IN THE INVESTIGATION
Information sharing in reception
111. The clinical reviewer makes a number of recommendations which will be
shared with the Primary Care Trust. Of his recommendations, I concentrate on
those which I believe are the most pertinent to the circumstances of the
woman’s death.
112. The first relates to the sharing and recording of information between the
escorting contractor, GSL, and prison reception staff. What is clear from my
investigation is the fact that all the staff in the reception area failed to recognise
the importance of the documentation provided by GSL. The clinical reviewer
recommends that the information flow into the prison from agencies such as
police and GSL should be reviewed and improved and I endorse his
recommendation. My investigator found no evidence in the woman’s prison
records that, when she arrived, reception staff questioned the escorting staff
about their document or indeed her current risk of harming herself. It is
therefore of concern to me that the Suicide and Self Harm Warning Form was
not acted upon.
The Governor should ensure that all staff in reception and the FNC are
aware of their responsibility to read any significant information relating to
risks to a prisoner.
113. The woman arrived at Styal accompanied by clear documentation which said
that she had been on suicide watch for the previous two days and that she was
receiving prescription medication for anxiety following her son’s death. GSL
staff maintain that the medication and the records were given to reception staff.
However, staff in reception said they had no recollection of receiving the
medication, and there is no record that any was received.
114. Either way, the medication was listed on the woman’s documentation. I find it
incomprehensible that staff did not question, note or check to confirm whether
or not she was actually in possession of medication. There are both health and
security implications with such an oversight. The Head of Healthcare told my
investigator that although a procedure existed relating to the receipt, recording
and transfer of medication to the FNC, the procedure was not written down.
The Governor and Head of Healthcare should formalise a procedure for
the receipt of medication when prisoners arrive in reception.
115. The woman spent around two hours and 40 minutes in the reception area
before being escorted to the FNC. The officer who escorted her failed to
ensure that the warning forms which related to her were taken to the FNC with
her. The omission affected the ability of other prison and healthcare staff to
assess her appropriately. The CSRA document was the only relevant
document which contained any information about the woman’s present level of
risk. The risk that others, that is the police and GSL, believed she may have
26
posed to herself was therefore not known when she was seen by the
healthcare assistant (HCA). That said, there is no guarantee that the presence
of the other documents would have influenced the HCA’s decision making.
116. Furthermore, the HCA is not a qualified nurse. In this instance, the HCA was
also not ACCT trained despite having contact with prisoners on their first day in
custody, when they are most vulnerable. ACCT is the fundamental tool used
by the Prison Service to help identify and care for prisoners at risk of suicide or
self-harm. It is imperative that all staff conducting health screenings are
appropriately trained, and most notably are aware of, and alert to, a prisoner’s
vulnerability.
The Governor and Head of Healthcare should ensure that all staff in
regular contact with prisoners are trained in the ACCT procedures.
117. It was noted that the woman had no immediate health needs, and she was
referred to see a qualified nurse and doctor the next day. Her second health
screen was postponed so that other new prisoners deemed to have more
immediate needs, such as detoxification, could be seen first. The HCA said
that she confirmed the arrangement with the nurse on duty but it is not recorded
in any of the woman’s medical records.
118. My investigators found interpreting the chronological order of the entries made
in the woman’s medical records very difficult and worrying. Most notably, the
HCA had made entries and comments for actions that she did not carry out
herself and it could not be identified who had done so. The records also
caused the RGN colleague some confusion during her interview. The EMIS
printout provided to my investigators appeared to show more logical entries
made by the HCA and the RGN. Asked about the discrepancies, the HCA told
my investigators that at around this time, the EMIS computer system had
suffered from a lot of teething problems. My investigators were informed during
the investigation that all healthcare staff are now fully trained to use EMIS.
All clinical staff should be reminded of their obligations in record keeping
as set out in the relevant Nursing and Midwifery Council Guidelines.
Time spent in reception
119. The late arrival of prisoners into reception is a known problem across the prison
service. Styal is no different, with late arrivals with self harm and drug or
alcohol problems being assessed in reception during the evening.
120. Nonetheless, I believe that the time the woman spent in reception was unduly
delayed by senior staff who spoke to her for over an hour. They did not have
the benefit of studying the records transferred from the police and escort
company. From their conversation, they concluded that she was of no cause
for concern. Unfortunately, no details of their conversation were recorded
anywhere. I do not doubt their good intentions of offering support to her, but I
do wonder if their curiosity got the better of them given the media attention she
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had attracted. I fail to understand why a significant contact with a prisoner was
not recorded, especially one who was vulnerable by her alleged offence.
121. It is imperative that all staff record significant contact and any concerns about
an individual, especially when they arrive late from court. This will assist FNC
and healthcare staff if a quick assessment has to be carried out on a prisoner
due to time constraints. I have mentioned many times in previous reports the
importance of good and clear record keeping, and how invaluable it can be.
Staff should be reminded of this.
The Governor should remind staff of the importance of record keeping.
122. Senior staff should also have been aware of the time pressures faced by
reception and FNC staff when they are processing prisoners who arrive in the
evening. That the woman spent this amount of time in reception reduced the
opportunity for her to be assessed by a qualified nurse and doctor. However I
am pleased to report that since this death, the doctor’s hours have been
extended until 10.00pm.
The Governor should review the reception procedures and ensure that
prisoners’ waiting time in reception is as short as possible.
Opening an ACCT document
123. The woman was seen by various members of staff, and had the opportunity to
express any concerns about her wellbeing. She did not do so and the staff
judged that opening an ACCT was unnecessary. However their judgements
were reached without any knowledge of her history of harming herself.
Whether their opinions would have been different had they had access to the
information is unclear. Their decisions were also made without noticing that
she had recently harmed herself as the records had not been read and the
search had not identified her injuries.
124. The lifer officer told my investigators that he was surprised that the woman had
not been on an ACCT document when she arrived at Styal because of the
alleged offence she had committed. He believed that this must have been a
traumatic experience for her and thus would have made her a vulnerable
prisoner. My interviews with other staff do not suggest that the charges faced
by the woman formed part of their judgements. I am aware that prisoners
charged with offences of violence are at greater risk of harming themselves and
I believe that the staff at Styal should be aware too.
125. I understand why staff, who only considered the way in which the woman spoke
and presented herself, failed to identify that she would attempt to take her own
life. When they asked her, she gave no suggestion that she intended to harm
herself. However, if only from the nature of her offence, and that it was her first
time in custody, I believe that opening an ACCT was justified.
126. PSO 2700 (issued in 2003 and in force when the woman arrived at Styal) states
that reception and first night staff should, when receiving prisoners with
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F2052SHs (the document used prior to the ACCT document), talk to the
prisoner and to the escort staff, to check whether their risk is current or
historical. It is obvious that the woman would not have had a previous
F2052SH because she had never been in prison before. However this
document, like the ACCT document, fundamentally relates to the well being
and concerns about risk of self harm. This was exactly the type of information
which was detailed in the Suicide and Self Harm Warning Form handed to the
prison staff by GSL.
127. I have already mentioned the need to improve the information flow from
agencies such as police and GSL into the prison. My investigators also found
discrepancies with documentation handling in the prison reception area,
meaning that useful information was not necessarily being passed on to those
individuals who were assessing prisoners’ risks.
128. In his response to the police investigation, the Governor acknowledged that,
given the way the reception process was working at the time, relevant and
important information was not always being passed onto staff whose role it was
to assess prisoners on arrival. Since the woman’s death, a new procedure has
been implemented within the reception area. Primarily, documents are no
longer separated or detached from each other whilst a prisoner is going through
the reception and FNC process. This should ensure that necessary information
is passed on quickly to staff making assessments.
129. The introduction of the new procedures is of course welcome, but it does not
detract from the issue, that staff still need to read and acknowledge information
on warning forms received and to clearly document such information.
130. In conclusion on this matter, since the woman’s death, a new safer custody
Prison Service Order (PSO 2700 October 2007) was issued which provided
guidelines for prisoners charged with homicide against a partner or family
member and which describes them as an exceptionally high risk of suicide.
The PSO states:
“Establishments must make provision for additional risk assessments and
care to keep safe prisoners who have been charged with domestic
violence and/or domestic murder/murder of a family member. Such
provision must include ensuring a record is maintained to show what
action has been undertaken.”
I am pleased to learn that the duty governor has confirmed that all staff are
aware of the PSO and so make no recommendation here.
Availability of Mental Health In-Reach over the weekend period
131. At the time of the woman’s death, the In-Reach team did not work over the
weekend, so, despite a referral being made, she would not have had an
appointment until at least Monday. Had she been seen by In-Reach, they
might have provided vital intervention with regards to her mental health. I am
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pleased to note that since her death, members of the In-Reach team are now
available over the weekend.
Staff response to the emergency
132. Staff responded quickly to the emergency call in the woman’s room. The nurse
on duty however said that she was informed that emergency was an individual
having a “fit”. Although this in no way affected the nurse’s promptness to deal
with the situation when she arrived at the woman’s room, it is imperative that
clear and accurate information is relayed to healthcare staff about what kind of
incident they are attending.
The Governor should remind staff to use the correct terminology and
emergency code calls when requesting emergency assistance.
Return of the woman’s personal belongings
133. I am greatly concerned that it took approximately 18 months for the prison to
return the woman’s personal belongings to her family and that the matter was
only resolved at the instigation of my office. I cannot underestimate the impact
this could have had. It is of paramount importance that, following a death in
custody, a prisoner’s personal belongings are returned to the next of kin as
soon as possible.
The Governor should ensure that, following a death in custody, the family
liaison officer immediately arranges for the return of prisoner’s personal
belongings to their next of kin.
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CONCLUSION
134. I have no doubt that the incident which caused the woman’s imprisonment was
very traumatic for her. To face the charge of killing one’s child must be
amongst the most extreme. She had been prescribed medication for anxiety as
a result and was already deemed to be at risk of harming herself before she
arrived at Styal. She had marks on her left forearm which were caused by
harming herself. This information was all documented whilst she was in the
custody of the police and the escorting contractor.
135. Tragically when the woman arrived at Styal, the concerns about her well being
were overlooked by the staff who assessed her in reception. Unusually two
senior staff came to speak to her to supplement the routine procedures. They
too failed to read about her history, failed to recognise the additional risk from
the charges she faced and failed to notice anything untoward.
136. Much of the information gathered at reception was not recorded or passed onto
those who subsequently assessed the woman in the First Night Centre. I think
that staff in both reception and the FNC focused on what she told them herself
about her risk rather than considering those identified by other agencies with
the most recent and accurate knowledge. Ignoring this information is even
more pertinent than ignoring the significance of her alleged offence.
137. Time and time again I report that a prisoner does not declare that they intend to
harm themselves. In some investigations, it appears that the thought of taking
their life is an act which has come about instantaneously. It is impossible to
judge for the woman. By virtue of her alleged offence, she was a vulnerable
woman. I have no doubt that the level of support she may or may not have
expected from her family would have added to her anxiety.
138. Although in my view these circumstances should have triggered the immediate
opening of the ACCT procedures, I am not convinced that it would have
diminished the woman’s thoughts of taking her life. There is no doubt that she
had a lot of contact with staff at the prison, but an open ACCT would have
provided additional support. Increased monitoring and observations might have
helped to keep her safe from harm.
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RECOMMENDATIONS
1. The Governor should ensure that all staff in reception and the FNC are aware
of their responsibility to read any significant information relating to risks to a
prisoner.
The Prison Service have accepted this recommendation.
2. The Governor and Head of Healthcare should formalise a procedure for the
receipt of medication
3. n when prisoners arrive in reception.
The Prison Service have accepted this recommendation.
4. The Governor and Head of Healthcare to ensure that all staff in regular contact
with prisoners are trained in ACCT procedures.
The Prison Service have accepted this recommendation.
5. All clinical staff should be reminded of their obligations in record keeping as set
out in the relevant Nursing and Midwifery Council Guidelines.
The Prison Service have accepted this recommendation.
6. The Governor should remind staff of the importance of record keeping.
The Prison Service have accepted this recommendation.
7. The Governor should review the reception procedures and to ensure that
prisoners’ waiting time in reception is as short as possible.
The Prison Service have accepted this recommendation.
8. The Governor should remind staff to use the correct terminology and
emergency code calls when requesting emergency assistance.
The Prison Service have accepted this recommendation.
9. The Governor should ensure that following a death in custody, the family liaison
officer immediately arranges for the return of prisoner’s personal belongings to
their next of kin.
The Prison Service have accepted this recommendation.
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