Individual at Swansea

Investigation into the circumstances surrounding the
death of a man
at HMP Swansea in May 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
This is the report of an investigation into the circumstances of the death of a man
who died at HMP Swansea in May 2009. The man was found hanging in his cell
approximately nine hours after arriving at the prison. He was 21 years old. I would
like to offer my personal condolences to the man’s family and to all of those touched
by his death.
The investigation was undertaken by two of my colleagues. Both they and I would
like to thank the management and staff at Swansea prison for their cooperation
during the course of our inquiries. I am also grateful to the Healthcare Inspectorate
of Wales for the review of the man’s medical care whilst he was in prison.
The consultation period was extended to allow the man’s family time to consider the
draft report and provide their comments. These have been incorporated into this
final report. It has taken longer than normal to issue this final report, for which I
apologise.
The man who is the subject of this report had been in police custody prior to his
arrival at Swansea. Whilst there he had torn strips from a bed sheet, and tried to
strangle himself. This information was not passed onto prison staff save for ticks on
the PER, and this matter has been subject to a separate investigation by the
Independent Police Complaints Commission (IPCC).
Despite his behaviour in the police station, the man did not appear to be at risk of
harming himself while at Swansea. I believe that, had staff been aware of the man’s
actions, his time at Swansea could well have been managed very differently. I am
concerned that the first night health screening process was not completed
satisfactorily and that the man, in the opinion of the clinical reviewer, should have
been offered assistance to manage his withdrawal from drugs during his first night. I
make eight recommendations in total.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman September 2010
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CONTENTS
Summary
The Investigation Process
HMP Swansea
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The man who died was arrested by South Wales Police on Friday 8 May 2009. The
man was charged with a number of offences, and was held in police custody over
the weekend of 9 and 10 May. He was initially taken to hospital as he was
withdrawing from drugs. The man admitted a number of offences, some of which
were more serious than those for which he was arrested.
The man attempted to strangle himself whilst he was in the police station and the
Independent Police Complaints Commission (IPCC) is investigating the period the
man spent in police custody. This act was not noted on the paperwork designed to
inform those responsible for the man as he was transferred from police to prison
custody. On the eve of the man’s death, he was remanded into custody and
transferred to Swansea Prison. Staff at the prison were not aware that the man had
harmed himself at the police station. The man had been in Swansea prison for a
short time earlier in the year.
Reception and first night centre staff at Swansea prison talked to the man. His
demeanour, overall behaviour and willingness to talk to both staff and other
prisoners led staff to believe that the man was settling in well and did not pose a risk
to himself. The man was put into a single cell as he expressed unhappiness to staff
at the prospect of sharing a cell with another prisoner. No concerns (other than an
enquiry about medication) were raised by the man until he was found hanging in his
cell at 1.40am. Staff arrived quickly and cardio pulmonary resuscitation (CPR) was
attempted. However, the man was declared dead at 2.12am.
I make eight recommendations. They include the need for staff to ask escort staff for
further information, the requirement for documentation to be correctly completed, the
need for substance withdrawal to be appropriately managed and for prison and
healthcare staff to undertake refresher training in resuscitation techniques.
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THE INVESTIGATION PROCESS
1. My colleague led the investigation assisted by a further colleague of mine. On
their initial visit to the prison, my colleagues met the Deputy Governor and
representatives of the Independent Monitoring Board. My colleagues were
shown the induction wing and the man’s cell. Notices had already been
issued to prisoners and staff to alert them to the investigation. No-one came
forward in response to the notices.
2. My colleague wrote to Healthcare Inspectorate Wales to request a clinical
review of the care the man received while in prison custody. A clinical
reviewer conducted the clinical review. The clinical reviewer was provided
with all of the relevant documentation and transcripts of the interviews in order
to assist in her report. The clinical reviewer left her post with NHS Wales in
September 2009 and responsibility for finishing the man’s review was passed
to the Inspections Manager at Healthcare Inspectorate Wales.
3. My colleague and one of the Ombudsman’s family liaison officers visited the
man’s family to discuss the investigation and any issues or concerns they had.
The family were concerned as to whether the man had been identified as
being at risk and, if he had, what monitoring he was subject to. The family
also wanted to know why the man had been checked at 1.40am, how he was
found and what position he was found in. These points are answered in the
report. The man’s family’s legal representatives later wrote to the office to
raise further issues relating to the investigation.
4. The Independent Police Complaints Commission (IPCC) provided a copy of
the statement given to them by an officer from Reliance Custody Services (a
private company responsible for escorting prisoners) who, in turn, gave
permission for his statement to be referred to in this report. The
Ombudsman’s investigators also reviewed the man’s records from his
previous sentence at Swansea.
5. The investigators conducted interviews with prison staff and prisoners on 14
and 15 July. Following these interviews, they requested further information
from the prison on a number of occasions in order to answer questions raised
by the man’s family.
6. The draft report took longer to publish than we would have liked, and I regret
the delay. Some of this was due to the complexity of the investigation, and
some of it was caused by the investigators ensuring that they answered the
issues raised by the man’s family. The consultation period following the draft
report was extended to allow the man’s family further time to consider their
comments. Their comments have been answered in this report, or replied to
separately. There was a further delay in finalising this report and I apologise
for any inconvenience.
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HMP SWANSEA
7. The prison was built in 1861. It is a category B prison that holds both
convicted and unconvicted men aged 21 and over. In the first quarter 2009-10
National Offender Management Service quarterly performance review
Swansea prison is assessed as achieving good performance.
8. The prison has an operational capacity of 422 prisoners. Swansea started the
Samaritan trained prisoner Listener scheme in the early 1980’s, which has
gone on to become a national initiative across the prison estate.
9. B wing is the induction wing where prisoners live for the initial period of their
custody.
HM Chief Inspector of Prisons
10. HM Chief Inspector of Prisons last conducted a full inspection of Swansea in
April 2005. There was also an unannounced follow-up inspection in February
2008. In her 2008 report she considered Swansea to be a generally safe
prison which had made noticeable improvements in managing activities
despite its limited space.
11. The report described the prison as clean but overcrowded with shared single
cells, having unscreened toilets and insufficient showers. It also commented
on good prisoner-staff relations and, whilst positive interactions were
commented on, the report also noted weaknesses in the oversight of bullying
and suicide prevention.
12. Although the prison has no dedicated detoxification wing, drug use was
described as relatively low for a local prison. The report also commented on
the introduction of courses aimed specifically at drug users such as the Short
Duration Programme.
Independent Monitoring Board
13. Each prison in England and Wales has an Independent Monitoring Board
(IMB). The Board consists of members of the local community who have full
access to prisoners and all areas of the prison. IMB members undertake a
variety of activities in prison including the consideration of complaints made by
prisoners, visits to individual prisoners, reporting on the condition of the prison
and examining the treatment prisoners receive in healthcare. Each IMB
produces an annual report. The last available report on Swansea was
published in 2008.
14. The report commented on Swansea’s “true community feel … where respect
for individuals is paramount and relationships between staff and prisoners are
at the heart of this”.
15. The IMB commented on the healthcare department’s objectives which include
the delivery of timely comprehensive assessment and evidence based
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practice and the promotion of effective links with health related services in the
community, to ensure continuity of care as appropriate. Reference is also
made to the intention to deliver “more holistic substance misuse services”.
Assessment, Care in custody and Teamwork (ACCT)
16. Assessment, Care in Custody and Treatment (ACCT) is a care planning tool
used by the Prison Service to help support and monitor those prisoners
identified as being at risk of suicide or self harm. The ACCT process
encourages staff to work together to provide individual care to prisoners in
distress and help to diffuse circumstances where self harm or suicide may
occur.
17. The investigators asked prison staff about the training provided in ACCT.
They were told by an officer that it is provided yearly to staff. A further officer
said that he was a tutor in ACCT procedures. He explained that in the autumn
of 2008 he had updated all of the reception and induction unit on ACCT
training.
Prisoner Escort Record
18. The Prisoner Escort Record (PER) is a document which is individual to each
prisoner held in custody by the police, escort services and the prison service.
It is a standard form agreed by all the agencies involved in the management of
the transfer of prisoners. It is a record of the external movements of each
individual prisoner between these different agencies. In this man’s case, the
PER recorded his movements between South Wales Police, Reliance custody
services and Swansea prison.
Previous deaths at Swansea
19. Since this office assumed responsibility for the investigation of deaths in
prisons in 2004, Swansea has experienced four other self-inflicted deaths. A
colleague’s investigation into the death of a man in 2007, also by hanging,
highlighted some similarities to this man’s case. He also died shortly after
arriving at Swansea. In particular one recommendation from that report is
relevant:
The Governor should ensure adequate systems are in place to ensure
important information from the PER form is communicated to staff
responsible for the prisoner concerned, in particular healthcare staff.
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KEY FINDINGS
20. The man who is the subject of this report was born in August 1987. He told a
probation officer in 2006 that he had been taking heroin since he was 15 and
had continued to use heroin, cocaine and Valium since then. The man’s
remand in May was his second experience of Swansea prison in 2009. He
had served a short prison sentence there between February and March. He
did not harm himself during that sentence, and was not subject to ACCT
procedures.
21. The man’s father said that, although he was involved in drugs, there were
times when his son had tried very hard to get well. The investigators were
also told that, despite the problems he faced, the man maintained close family
contact and was described as having a good sense of humour and “not an
ounce of aggression in him”. He was a keen Swansea City football supporter.
22. The man’s family told the family liaison officer that they would often be
relieved when he went into prison because they knew where he was. They
felt that he would be safe in prison and would look much better upon release.
The man’s family said that they had hoped that he would receive treatment for
his drug addiction problems, as he had during his previous time at HMP
Swansea.
23. The man was arrested by South Wales Police in the afternoon of 8 May 2009.
He was taken to Swansea Police Station where officers became concerned for
him as he appeared drowsy. The man told officers he had used a ”£10 bag”
of heroin just before being arrested. This prompted them to seek medical
advice and he was taken to hospital. He was kept under observation for
approximately six hours, following which he was deemed to be fit for detention
and taken back to the police station.
24. The man was charged with Going Equipped for Theft. He also admitted to a
number of other offences.
25. Due to the time spent in hospital, it was too late for the man to attend a
magistrates’ court that day. He was held at Swansea Police Custody suite
throughout the weekend of 9 and 10 of May.
26. On the evening of 9 May, the man was recorded on CCTV tearing strips from
his bed sheet and wrapping them around his neck. He then attempted to
strangle himself. Custody staff entered the cell and intervened. He was
prescribed codeine (a pain-killer), amitriptyline (an anti-depressant) and
temazepam (to help him sleep).
27. On the front page of the Prisoner Escort Record (PER) it was written that the
man was received into the custody of Reliance Custody Services (RCS) at
7.30am on the eve of the man’s death. This information is in fact incorrect.
Page two of the PER shows that the man was actually received into RCS
custody at approximately 10.25am by a different officer. I understand that the
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delay in handover was caused by conversations the police were having with
the Crown Prosecution Service.
28. No records were provided to RCS that mentioned the man’s attempt to
strangle himself whilst in police custody, other than a tick in the suicide/self-
harm tick-box on the PER. The officer from RCS also noted that he was not
told anything about the man’s actions. In his statement, the officer
commented:
“The Prisoner Escort Record (PER) form that accompanies the
prisoner from police custody to the courts can often be misleading as
regards the warning marker tick boxes. If the suicide/self harm or other
marker boxes are ticked, these can often refer to incidents that have
happened a long time ago. If there had been an incident that had
occurred recently … I would expect there to be more information on the
PER form.”
29. Once in the custody of RCS, the man was searched and given refreshments.
He was checked by RCS staff prior to seeing his solicitor and was taken
before the magistrates at 12.33pm. He was remanded into custody to crown
court and his next appearance was scheduled for 8 June.
30. The PER shows that the man arrived at HMP Swansea at 4.35pm. While
waiting to be formally inducted into the prison, the man was heard by other
prisoners to say that he had harmed himself whilst in police custody. He told
the prisoners that this was done in an attempt to get more medication. Staff at
Swansea were not told of this conversation by prisoners before the man died.
31. The man was allocated his prison number and had a jovial exchange with an
Operational Support Grade (OSG) regarding the man’s Swansea City football
shirt. The OSG recalled the man as being in good spirits.
32. The cell sharing risk assessment (CSRA) was started as part of the normal
reception process. An officer told the investigators that the man was in a
buoyant mood when interviewed, and raised no concerns other than his drug
problem. When the investigators read the CSRA during the investigation it
contained notes stating: “PER warning; suicidal and drug and alcohol issues”
and “abuse all drugs” although the comments were undated. Section two of
the CSRA also confirmed that the man abused drugs and was dependant on
drugs or alcohol.
33. The man was seen by a nurse for the medical section of the CSRA and for his
initial health screen. The nurse told the investigators that he had met the man
before and he remembered him from his previous prison sentence. The nurse
remembered asking the man directly if he had any thoughts or intentions of
self harm. He confirmed that the man had replied ‘no’ to this question. The
nurse told the investigators that the suicide warning was not on the CSRA
when he completed his section. He also said that he had not seen the PER.
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34. The nurse said that a drugs test was completed on the man’s urine which
tested positive for Subutex (a controlled drug prescribed to counter the effects
of opiate withdrawal), opiates and benzodiazepines. He said that the man had
seemed fine and did not appear to be withdrawing from drugs. The nurse
spent “quite a bit of time with him” undertaking the assessment, although the
initial health screen form was not fully completed. The disclosure consent
form and healthcare medication compact were also not completed.
35. The nurse described the man as:
“talkative … with good eye contact … good communication was
maintained throughout the interview … he was in a good mood; he
was, you know … talking properly.”
36. The nurse said that the man asked “will I have anything?” referring to
medication. The nurse responded by offering metoclopramide (an anti-
nausea treatment) and quinine (an anti-cramping medication). In his
statement the nurse said that the man declined the offer of this medication
stating that he was fine and did not need anything at the time. The nurse went
on to say that there were nurses on night duty who could respond to the man
if he felt he needed the medication.
37. The nurse also clarified to the investigators that no doctors were available in
the prison overnight, however there was an emergency out of hours service.
He went to say that there was a GP service available during the day.
Although the health screen document is incomplete, the nurse said that the
man would have seen the doctor the next day. The doctor would then assess
him and consider the need for any further treatment. This could include the
prescription of a detoxification regime.
38. Following his health screen interview, the man went to the induction unit on B
wing at approximately 6.45pm. The man was provided with a first night pack
containing basic toiletries, including a Bic safety razor.
39. Further work on the induction process was carried out by the officer who
completed the induction paperwork, who noted that the man was familiar with
Swansea prison having served a short custodial sentence there in February
and March. He remembered the man from that sentence and told my
colleagues that he was “jovial and relaxed” and “we shared a [football] joke
about the Swans and Cardiff making play-offs”. The officer said that he had
not at that point seen the PER but was aware of the self-harm/suicide
references on the CSRA. He also confirmed that the CSRA warning would
ensure that he would seriously address self harm and suicide with all
prisoners whose documentation carried this warning. He said that the man
showed him where he had injected into his arms and he had also looked for
evidence of self-harm scars but could see none.
40. The officer said that whilst he was completing the induction paperwork he
addressed the issue of self-harm directly with the man. The officer said that
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he referred to the CSRA form, which had the reference to the PER suicide
warning on it. He told the investigators:
“I asked him about suicide, he said he didn’t know anything about it.
And I asked him had he attempted self-harm or suicide of any note and
he categorically said no and his words to me were ‘no boss, never
have and I never will.”
41. The officer summarised on the form: “has previous experience of Swansea.
Has severe drug problem. No self harm issues. Should settle quickly once
over his drug issues”.
42. The man was initially allocated a double cell with another prisoner. The officer
who is a tutor in ACCT procedures told the investigators that, once the man
became aware of who he was going to share a cell with, he specifically
requested not to share with that particular prisoner. The man had told the
officer who had completed the induction paperwork that the prisoner was “a bit
of a tramp”. The officer replied “that’s fine; we will have a look now and see
what spaces we’ve got”. My colleagues were told that there were no other
double cells available. The officer who had completed the induction
paperwork said that he asked the man directly if he would be alright on his
own to which he replied “Yes, fine boss”. During his interview, the officer who
is a tutor in ACCT procedures said that he repeated the same question of the
man and the man gave the same response, “Yes that’s fine boss”. The man
was allocated single cell B3-2.
43. The man took part in the association period and was seen playing pool and
talking to other prisoners. During association, the officer who had completed
the induction paperwork allowed the man to make a telephone call from the
wing office to let his partner know that he was in custody. The officer who is a
tutor in ACCT procedures told the investigators that, during this telephone call,
he heard the man ask his partner to visit him and send in some money. There
was nothing in the telephone call that concerned the officer about the man’s
welfare.
44. The officer who is a tutor in ACCT procedures told the investigators that the
man approached him at the end of association, ”asking about some
medication that the nurse in reception told him he would sort out”. The officer
telephoned the nurse who saw the man for the medical section of the CSRA to
ask about the medication. The nurse told the investigators that the officer
asked him if the man was able to have Valium (Diazepam). The nurse said
that in his opinion Valium was not required. The nurse confirmed to my
colleagues that, had the man asked for the metoclopramide and quinine, this
could have been provided.
45. However, the officer who is a tutor in ACCT procedures remembered the
conversation differently. He said that he discussed with the nurse medication
the man had been given by a police doctor and that the nurse said he could
not offer anything else. Despite this uncertainty, the two members of staff
agree that the man was not given any further medication.
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46. The officer who is a tutor in ACCT procedures went back to the man who was
in his cell and told him that the nurse who saw the man for the medical section
of the CSRA was unable to give him anything until he saw the doctor in the
morning. The officer told my colleagues that the man’s response was “Ok,
[officer] that’s fine, thank you very much”. The man showed no signs of
distress at this decision.
47. The officers on night duty were responsible for a roll check at the start and
end of their shift. They were required to look in each cell and verify the
numbers of prisoners on their wing(s). They were also required to undertake
‘pegging’ which involved walking to certain pegging points each hour. It
should be noted that pegging does not require the staff to look in any cells or
check on any prisoners. The man was not receiving Assessment, Care in
Custody and Teamwork (ACCT) monitoring checks, and so would not have
been checked anymore than any other prisoners. Prisoners on the induction
wing do not receive more checks than those on regular wings.
48. At 9.05pm, an officer undertook the roll check. He noticed that the lights were
on in the man’s cell and, on reaching the cell, saw him writing at his desk.
49. At 9.50pm, staff noticed a discrepancy with the roll check numbers. During
interview, the officer who undertook the roll check at 9.05 pm told the
investigators that he and a fellow officer immediately checked the cells again.
On the wing cell occupancy printout the man’s cell had two prisoners recorded
as being present and this caused the anomaly in the numbers. Having
checked the cells, the officers clarified that the man was the only occupant of
cell B3-2. The officer who undertook the roll check at 9.05 pm looked into the
cell and told the investigators that, although the lights were off, the television
was on and he saw the man moving.
50. At approximately 1.40am the fellow officer noticed a light on in the man’s cell.
He opened the cell flap and saw the man hanging from the cell window. The
officer saw that the man had tied a green sheet to the bars on the window and
“made a noose around his neck”. He also said that the man’s feet were
obscured by the toilet seat. It appears that there was some blood on the floor
of the cell, apparently caused by cuts the man had made to his arm. Police
later removed a broken razor blade from the cell.
51. The officer who had opened the cell flap and saw the man hanging
immediately radioed and called for help. He was joined by the Night Orderly
Officer, Senior Officer (SO) and a further officer. This happened very quickly
as the Night Orderly Officer described himself as “within sort of yards” to the
officer who had opened the cell flap and saw the man hanging. He explained
the process of opening the cell door to my colleagues:
“[The officer] was attempting to open his sealed pack to open the door
but I said get out of the way because it was quicker, I had the bunch [of
keys] in my hand, and I opened the cell straightaway because
obviously time is of the essence.”
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52. Once the cell door was open the Nightly Orderly Officer lifted the man up to
take the weight off the ligature. The officer who had opened the cell flap and
saw the man hanging cut the ligature using his anti-ligature knife and started
cardio pulmonary resuscitation (CPR). A staff nurse arrived at the cell.
During interview, the staff nurse said that she moved a chair out the cell and
instructed the Night Orderly Officer to call for an ambulance. She then began
CPR. (Although there was a defibrillator close by, it was not brought to the
cell. A defibrillator is a device that can restart the heart by giving it an electric
shock. It cannot always be used and can only provide a shock if there is
sufficient electrical activity in the heart.)
53. The paramedics arrived at 1.55am. They took over CPR and used their
defibrillator on the man. The staff nurse told the investigators that she thought
that it was used to shock the man. Despite these efforts, the man was
pronounced dead at 2.12am.
54. Following the man’s death, the police attended the prison in accordance with
usual protocol. There was some confusion amongst the prison staff about
who was to break the news to the man’s family. Although the deputy governor
was keen for the usual prison contingency plan to be put into action, the news
of the man’s death was broken to his family by South Wales Police. Swansea
prison appointed a principal officer as the Family Liaison Officer. The family
were visited by the Governor and the prison chaplain on the day of the man’s
death.
55. Three letters were found in the man’s cell. One was addressed to his mother.
The man started the letter referring to his arrest and time at Swansea police
station. He wrote “my life is not worth anything … no respect for myself and
no one has respect for me”. The man also wrote that he was depressed and
“I might as well get it over with but I’m afraid you would do the same”. Later in
the letter, the man started to make some plans for the future by asking his
mother for some money and finished the letter by saying he had put his
mother’s name on the visiting order he had sent to his girlfriend. The
remaining letters were written to his girlfriend and to a friend. He asked for
some money to be sent in to him as well as some photographs. There was
also a note, possibly addressed to his girlfriend, in which the man wrote “its
not that I can’t cope with jail it’s my life” and “I’ll watch over you”.
56. Prisoners located on the man’s wing learned of his death from officers. One
prisoner who was situated in an adjacent cell was interviewed by the
investigators. This prisoner, who was subject to ACCT monitoring procedures
at the time of the man’s death, praised Swansea prison staff for their caring
approach to him at a time when he was particularly vulnerable. I was pleased
to hear of this.
57. The Deputy Governor and Governor both came into the prison immediately
following the man’s death and supported the staff. Although there was no
formal debrief in the hours following the man’s death, it is clear that staff who
attended to the man were supported as a group and individually. A
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notification was placed in the staff entrance to the prison to alert officers to the
man’s death reporting for duty the next day. On 26 May, the National
Offender Management Service (NOMS) employee support team organised a
formal debrief at the prison.
14
ISSUES
Deciding whether to open an ACCT plan
58. Annexe 3B of Prison Service Order 2700 (Suicide Prevention and Self-Harm
Management) says:
“If prisoner has self-harmed whilst under escort supervision, at court, in
transit, or while in Police or other custody, then the reception
healthcare screener (or nearest reception staff equivalent if no
Healthcare presence) will open an ACCT Plan.”
59. An ACCT was not opened for this man. It is, therefore, essential to consider
why the Swansea prison staff did not undertake this task, and whether this
was reasonable. As I have said, the man did harm himself whilst he was in
police custody, but regrettably the information was not described on his PER
although the self-harm/suicide box was ticked.
The response to the ticked box on the PER
60. PSO 2700 states:
“When receiving a prisoner with a Suicide/Self-Harm Warning Form, an
open ACCT Plan, or a Prisoner Escort Record with the suicide/self-
harm warning box ticked, if the reasons for the concern are not clearly
documented the Reception Officer should be asking for a verbal
handover (i.e. a further explanation).”
61. It is not clear if any of the reception staff asked the RCS escort staff about the
tick on the PER. However, as has become clear, even if they had done so
they would not have received any information from the RCS staff about the
man’s actions in police custody. Since the escort staff had not been given any
information (written or verbal) from the police, they would not have had any to
pass to reception staff. An officer from RCS who received the man into
custody explained in his statement that, as he was not given any information
from the police, he deemed the tick to relate to historical information. PSO
2700 says:
“When receiving a prisoner with a Suicide/Self-Harm Warning Form, an
open ACCT Plan, or a Prisoner Escort Record with the suicide/self-
harm warning box ticked, if the reasons for the concern are not clearly
documented the Reception Officer should be asking for a verbal
handover (i.e. a further explanation).”
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62. It requires staff to request a verbal handover from the escorting staff but does
not mention asking the other services involved, such as the police, for such
information. It is the responsibility of the police to share such information, and
their failure to do so is subject to a separate investigation. However, it would
clearly be good practice for staff to contact other agencies in such situations,
and should be encouraged where possible. Therefore, with reference to PSO
2700, I recommend:
The Governor should remind reception staff of the requirement to ask
escort staff about any ticks relating to risks on the Prisoner Escort
Record.
63. Although, it is clear that RCS gave Swansea no further information, reception
staff still had a responsibility to further consider the implication of the tick.
Prison Service Order 1025 (Communicating information about risks on escort
or transfer - The prisoner escort record) instructs escort and prison staff:
“If a prisoner is received from the police with this box [suicide/self-
harm] ticked staff must establish whether the risk is current or past.”
64. The PER that arrived at Swansea prison did have the ‘suicide/self-harm’ box
ticked, but no further information was provided. The investigators were told by
prison staff that a tick by the self-harm/suicide box with no additional
information would not necessarily be assumed to be a current risk. The officer
who completed the man’s induction paperwork said that such warnings can be
“old markers … sometimes they [prisoners] don’t know anything about it”.
However, as the PSO makes clear, staff had to ascertain whether the risk was
current.
65. Swansea staff did explore self harm and suicide issues with the man as a
result of the information on the PER. His presentation and demeanour in
interview with prison staff was such that he was assessed not to be at risk of
suicide or self-harm. The officer who completed the man’s induction
paperwork stated to the investigator:
“I asked him about the suicide [tick], he said he didn’t know anything
about it. And I asked him had he attempted self-harm or suicide of any
note and he categorically said no and his words to me were ‘no boss,
never have and I never will’.”
66. Swansea staff attempted to find out from the man whether the risk was current
or past, he assured them that he had never thought of suicide or self harm
and never would. As noted earlier, it would have been good practice for staff
to have sought further information on this tick from the police.
Other information omitted from the PER
67. Another factor related to the judgment about the risk is the lack of further
information provided on the PER. PSO 1025 states that those ticking the
boxes on the PER are required to provide further information:
16
“Any warning boxes that are ticked in Section 4 must be supported by
further information in this section unless an additional report is
attached. This box should also be used to indicate any special care to
be taken by receiving authorities, including the need for further
attention by professional medical staff.”
68. No further information was written on the PER by the police and no verbal
information was passed to the escort service. When the man arrived at
Swansea, the tick was the only reference to suicide and self-harm on the form.
69. The Ombudsman’s investigators were told that when the suicide/self harm box
is ticked and no further explanation is recorded, this will often be interpreted
as historical information. Staff told the investigators consistently that, if a
serious attempt at self-harm had recently occurred in police custody, they
would have expected further information on the PER. The officer who is a
tutor in ACCT procedures stated:
“I’d definitely expected that to be explaining more than a tick box on the
PER from the escorting staff that had brought him in … If something
happens whilst he’s in custody, and he’s made an attempt in custody,
that should definitely be highlighted in Section 5 of the PER.”
70. The lack of any further information, and the responses and attitude of the
man, meant that the tick was deemed not to refer to a current risk.
71. PSO 1025 also states:
“Staff should note that it is now a requirement to indicate both a current
risk of suicide or self-harm and any known past risk. It is now however
only a requirement that an F2052SH1 is opened if there is a current
risk.”
72. The responses given by the man, and the lack of other information, show why
staff did not deem the tick to be related to a current risk, and therefore explain
why ACCT procedures were not begun. It is clearly highly regrettable that the
police did not pass on specific information related to the self-harm the man
committed while in their custody. However, it is not in the Ombudsman’s remit
to investigate the actions of the police, and I understand that the IPCC have
conducted their own investigation into this.
73. I believe that prison staff took the tick seriously. Although some of the staff
recalled the man from his previous sentence, it does not appear that their
actions were overtly influenced by their memories of him. A note referring to
the tick was written on the Cell Sharing Risk Assessment and all staff who
came into contact with the man sought to establish the relevance of the tick.
The man was consistently denied any knowledge of the reason for the tick,
1
The F2052SH system was formerly the Prison Service’s procedures for dealing with prisoners at risk of self-
harm or suicide. It has now been replaced by the ACCT process.
17
and appeared to be stable, in relatively good spirits and not visibly suffering
from drug withdrawal. He had a conversation on the telephone to his girlfriend
which included reference to events and issues in the forthcoming days. If staff
had been aware of such a recent and serious self harm had occurred so
recently, it is reasonable to have expected the likely outcome to be that the
man be placed under the ACCT monitoring procedures. The officer who
completed the man’s induction paperwork told the investigators:
“ … if it was marked up that he’d attempted suicide or self-harmed then
an ACCT would have been opened.”
74. However, the nurse who saw the man for the medical section of the CSRA
said that, had he seen the PER when undertaking his conversation with the
man,
“I would have opened an ACCT straightaway.”
75. This opinion of the nurse reflects the importance the judgement of staff plays
in the protection of prisoners. Had the nurse seen the PER, he may have
asked further questions of the man, and he might have decided to begin
ACCT procedures. In a previous report on the death of a prisoner at
Swansea, a recommendation was made regarding the importance of
healthcare staff seeing information on the PER prior to the initial healthscreen
interview. As this is the second time information sharing has been involved in
a death in custody at Swansea, I would encourage the Governor to review
their response to that recommendation.
76. While in hindsight, his stated decision to begin ACCT procedures would have
been appropriate, I do not think that his colleagues acted unreasonably on the
basis of the information they had at that time. An Annexe to PSO 2700
(Suicide Prevention and Self-Harm Management) includes the sentence:
“In the event of any incident of self-harm, or whenever a member of
staff believes a prisoner is at risk of suicide or self-harm, they must
(where there is not one open already) open an ACCT Plan.”
77. If ACCT monitoring procedures had been started staff would have decided
how often he should be checked which could range from constant observation
to three in 24 hours. The assessment interview which provides much of the
information for the ACCT is required to be carried out within 24 hours. It
should also be remembered that, unfortunately, although ACCT procedures
are a huge asset in the effort to safeguard prisoners, they are not a guarantee
of safety. The Ombudsman’s office has, sadly, investigated the deaths of
many prisoners who killed themselves while subject to ACCT monitoring
procedures.
78. It is clear to me that the staff involved with this man’s care did not believe him
to be, at that time, at risk of suicide or self-harm. The limits of my remit
prevent me from making a recommendation, but I would expect all of the
agencies involved to ensure that crucial information such as this is always
18
shared in a timely and appropriate manner. The Governor will wish to discuss
the report with the Chief Constable of Police.
The initial health screen
79. The man had a lengthy interview with the nurse who saw the man for the
medical section of the CSRA, during reception. During his interview with the
investigators, the nurse confirmed he had met the man before and
remembered him from his previous sentence served in February and March.
80. When asked about why the health screen document was only half-completed,
the nurse said that he began to interview the man with a new document but
also requested the man’s medical notes from his previous sentence. When
they arrived, the nurse used the previous file as the basis for his interview. In
doing so the nurse believed he had completed the right documents. When
asked if it was possible that he had mixed the two sets of medical notes up he
said:
“That could be possible. I could have turned back to his old notes,
gone through the questions and thought I’d ticked them … that’s a
possibility. I’ll be honest with you; that could be a possibility. When I’ve
opened up his notes … carried on with the interview process and
thought I’d ticked the boxes.”
81. The clinical reviewer commented that the result of the document being
incomplete was that “we are not clear about his mental state or any risk
assessments that might have been needed”. It is clearly not acceptable for
the initial health screen document to be partially completed. The initial health
screen meeting is vital in ascertaining the immediate and ongoing health
needs of a new prisoner. It was good practice that the nurse remembered the
man, and requested the former documents from the healthcare unit.
However, this was undermined by his apparent inability to complete the health
screen document or the disclosure consent form and healthcare medication
compact. This lapse is frustrating as the nurse appeared to have a useful and
open conversation with the man. By not recording it in its entirety, he lost
much of the intelligence gained from it. I therefore endorse the
recommendation made by the clinical reviewer:
Healthcare staff must complete the First Reception Health Screen Form
completely, in case a prisoners’ circumstances have changed and new
risk assessments are indicated.
82. The actions put in place following the first reception health screen are vital for
all prisoners entering prison with a substance misuse problem.
83. PSI 46/2005 states:
“Prisoners identified via the first reception healthcare screen to have a
current substance misuse problem are referred on for a clinical
substance misuse assessment. This assessment informs any need for
19
medicated management of withdrawal symptoms on the first night of
custody.”
84. The nurse’s failure to complete the health screen meant that these referrals
were not made. Therefore, had the man been alive the following morning, it is
not clear that he would have been referred to the doctor and for a substance
misuse assessment.
85. I therefore endorse the recommendation made by the Inspections Manager at
Healthcare Inspectorate Wales:
Healthcare staff should refer prisoners who admit or are suspected of
being substance misusers for a full substance misuse assessment.
Treating the man’s drug problem
86. PSO 2700 states:
“There is a significant relationship between drug and/or alcohol
withdrawal and suicide, the risk of which may be significantly reduced if
people are assessed on reception and provided with effective needs
based treatment commenced on the day of reception.”
87. Prison Service Instruction (PSI) 46/2005 (Drug Treatment and Self-Harm)
explains the reasons why the link is significant:
“Drug treatment is by nature demanding. Participants often feel under
great pressure, especially early on:
(cid:127) Coming off drugs can be an emotional roller coaster – emotions
dulled for many years by drug misuse may be unblocked;
(cid:127) Facing the underlying causes of addiction can be traumatic; and
(cid:127) Facing the damage caused by addiction, for example, to loved ones,
can be stressful.”
88. During the health screen interview, the man was assessed by the nurse who
saw the man for the medical section of the CSRA who did not consider him to
be showing signs of drug withdrawal symptoms. He described him as:
“And like I say he maintained good eye contact, good communication,
he was sat back in the chair, quite relaxed and in a good mood.
Obviously talking about you know when he’d come back in and he’d
been silly again and what he’d been brought back in for. But from that
point of view no and then from my observations obviously through that
as well I deemed he didn’t require any further medication.”
89. On the basis of how he presented and spoke the nurse did not believe that the
man warranted Diazepam. Information from the man’s time in police custody
was not available to the nurse, and he would not have been aware of any
medication provided to the man. The nurse did offer the man some
20
medication, which the man refused, namely quinine for leg cramps and
metoclopramide, an anti-sickness treatment.
90. The officers who later saw the man also remarked that he did not appear to be
suffering from withdrawal symptoms. Later, the man did ask wing staff to
contact the nurse who saw the man for the medical section of the CSRA
regarding his medication. The nurse told the investigators:
“I remember the phone call asking whether he could have anything and
I remember asking the officer what does he want and he asked for
Valium. And my opinion was that he didn’t require it at the time
because he showed no forms or signs of withdrawing from any
medication.”
91. The nurse who saw the man for the medical section of the CSRA also told my
investigators that, had the man asked for the symptomatic relief, this could
have been provided for him. There was no doctor in the prison at the time of
the man’s health assessment. The GP system at Swansea was described to
the investigators by the nurse as:
“I have to go through an emergency doctor which would be then
contacted in the out of hours services. … It’s an SOS doctor which we
can contact. We phone up an out of hours service, give the relevant
information over the phone, the doctor then can come back to us.”
92. The nurse did not contact the on-call GP to discuss further treatment for the
man as he did not consider him to be withdrawing from drugs. However, the
clinical reviewer commented:
“However, we do not consider staff to have appropriately managed [the
man’s] withdrawal from drugs and alcohol when he was readmitted in
May 2009. It is clear from the initial health screen that he [(the man)]
reported to [the nurse] that he had been taking heroin daily,
benzodiazepine daily and cocaine daily. As [the man] confirmed that
he last took cocaine, heroin and benzodiazepine on 7 May 2009, he
should have been prescribed Diazepam.”
93. The oversight identified by the clinical reviewer is a serious one, due to the
reasons outlined at the start of the section. It is clear that the timely and
appropriate care for prisoners suffering from substance misuse problems is a
vital part of the prison’s responsibility to care for the person in custody. In light
of the findings of the clinical reviewer, I would suggest that this part of the
man’s time in custody is closely reviewed by the PCT and Head of Healthcare.
Location in a single cell
94. The man was initially allocated a double cell sharing with another prisoner.
He approached the wing officers and asked not to share with the other
prisoner, to which officers replied that they would see what spaces they had.
The officer who is a tutor in ACCT procedures and the officer who completed
21
the man’s induction paperwork said in interview that they both asked the man
if he would be alright on his own and he replied that he would be fine. The
man was then allocated his own cell. This decision was underpinned by the
induction assessments which judged that the man presented no risk to himself
or others.
95. PSO 2700 discusses the potential location for prisoners deemed to be at risk.
“The type of accommodation required for at-risk prisoners cannot be
prescriptive, as much will depend on the facilities available in
establishments. … The doubling-up of an at-risk prisoner with a
cellmate can help to reduce feelings of loneliness and provide both with
someone to talk to.”
96. Although the man may well have benefited from sharing a double cell, the
decision where to locate him was predicated on the assessments of his risk.
As these assessments concluded that the man was not at risk of harming
himself staff sought to meet his request and I do not think it unreasonable for
them to take this step. It should also be noted that ‘doubling-up’ prisoners is
not a fail-safe. I have, unfortunately, investigated many deaths where the
deceased shared a cell.
Giving the man a razor
97. The man had attempted to cut his arms while in his cell at Swansea. The
post-mortem report makes reference to two cuts on the left arm and a slight
cut on the right arm. Following the man’s death, the police removed a broken
razor blade from the cell. Staff would not routinely remove objects from
prisoners unless they had a specific reason to do so. Despite the tick on the
PER form, the man was not deemed to be at risk of harming himself by staff
who had interacted with him and so he was allowed to have the razor.
98. However, even if staff had considered the man to be at risk of harming himself
the razor may still have been provided to him. PSO 2700 states:
“However, removing personal belongings from a person who is feeling
hopeless and depressed … can increase feelings of distress and
therefore increase the risk of suicide, self-harm or a higher risk method
of self-harm. Where possible, prisoners at risk should be allowed to
retain their belongings unless it is clearly unsafe to do so.”
Discovering the man hanging
99. The man was discovered hanging by a ligature by an officer at 1.40am. Staff
and paramedics responded quickly but the man was declared dead at 2.12am.
100. The clinical reviewer commented:
“From the information made available to us it would appear that staff
acted quickly to resuscitate [the man] upon finding him in his cell on
22
12 May. However our review has highlighted that staff used a
resuscitation rate of 15:1. The Resuscitation Council (UK)
Resuscitation Guidelines 2005 state that “a ratio of compressions to
Ventilations of 30:2 is to be used for all adult victims of sudden cardiac
arrest and for a victim the initial two rescue breaths are omitted and 30
compressions given immediately after cardiac arrest is established.”
101. The clinical reviewer recommended:
All staff should undertake update training in CPR as a matter of
priority to ensure compliance with the Resuscitation Council
(UK) Resuscitation Guidelines 2005.
102. A defibrillator was not taken to the man’s cell by the nurse although one was
located nearby. Swansea prison operates a “first responders” system
regarding the defibrillator. Staff on the first responder list are trained to use
the defibrillator, and they are the ones designated to use it in the event of an
emergency. On the night of the man’s death there were no first responders on
duty. The staff interviewed implied to the investigators that, in such a
situation, the nurses on duty would not be expected to use a defibrillator. The
clinical reviewer referred the investigators to the Resuscitation Council (UK)
view that it is inappropriate to display notices to the effect that only trained
personnel should use the devices and that it is against the interests of victims
of cardiac arrest to restrict the use of defibrillators. She provided the
investigators with the views of the Resuscitation Council (UK):
“While it is highly desirable that those who may be called upon to use
an AED [automated external defibrillator] should be trained in their use,
and keep their skills up to date, circumstances can dictate that no
trained operator (or a trained operator whose certificate of training has
expired) is present at the site of an emergency. Under these
circumstances no inhibitions should be placed on any person willing to
use an AED. It is the view of the Resuscitation Council (UK) that the
use of AEDs should NOT be restricted to trained personnel.
Furthermore, the Resuscitation Council (UK) considers that it is
inappropriate to display notices to the effect that only trained personnel
should use the devices, or to restrict their use in other ways. Such
restrictions are against the interests of victims of cardiac arrest, and
discourage the greater use of AEDs by members of the public who may
be able to preserve life and assist victims of cardiac arrest.”
103. Therefore I recommend that:
The Governor should ensure that a defibrillator is taken to all identified
or possible cardiac arrests.
The Governor should ensure that there are sufficient staff trained in
defibrillator use to cover the prison 24 hours a day.
23
Liaison with the man’s family
104. Contrary to the prison’s wishes, the police informed the man’s family of his
death. It also took over two hours for the news to be broken. This was
unfortunate as, in most circumstances, the prison is better placed to advise
the family of the circumstances of a prisoner’s death and is a symbol of how
seriously the prison regards the matter and the feelings of the family. An
annexe to PSO 2710 (Follow-up to deaths in custody) says:
“There are opposing views across the Prison Service and outside
consultees but the vast majority believe that the first contact must be
made directly by the establishment so that the family recognise that the
death is a matter of great concern to the establishment.”
105. The prison had detailed knowledge of the man’s time at prison and would
have been able to answer more of the family’s questions. The prison also has
a system of family liaison officers when liaising with newly bereaved families
that could have undertaken the role. I was pleased to hear that the prison
Governor and chaplain visited the family the following day.
The Governor should ensure that a suitable protocol concerning
informing relatives of prisoners who die at Swansea prison is agreed
with the Chief Constable of South Wales Police.
106. I understand that the man’s father has written to the prison chaplain thanking
him for his compassion and kindness in dealing with the family during a visit to
the family home. The man’s father also thanked the chaplain for holding
services in the chapel in memory of his son.
Support for staff and prisoners
107. The prison management’s response to the man’s death was quick and well
organised. The Governor and Deputy Governor arrived at the prison following
the man’s death and supported the staff. I understand that staff were
appreciative of this, and am glad to highlight their efforts. The prison held a
critical incident debrief on 26 May organised by the National Offender
Management Service employee support office. Feedback from the staff who
could attend was generally positive. However it was noted that some staff
were unable to attend for various reasons such as distance from their home to
the prison, or absent from work due to sickness. It is unfortunate that some
staff were unable to attend.
The Governor should ensure that all staff involved in fatal incidents are
offered the opportunity to attend critical incident debriefing.
24
CONCLUSION
108. The man entered police custody with a significant substance misuse problem,
and faced a number of charges. While there he harmed himself. It is very
disappointing that this information was not passed to either the escort or
prison staff beyond a tick in a box. Prison staff at Swansea did not contact the
police directly for further information, but they did ask the man repeatedly
about the indication of suicide and self harm. I believe that his care in prison
custody would have been substantially different had staff been aware of his
earlier behaviour.
109. There were problems relating to the medical care received by the man at
Swansea. The PER was not provided to the nurse, and the healthcare
documents were not correctly completed. He was not provided with
medication for drug withdrawal, as he should have been.
110. Although ACCT procedures could have been opened without knowing that he
had harmed himself at the police station, his denial of suicidal ideas and his
positive attitude meant that staff judged that he was not at risk. With the
available information they had, I do not think that this was an unreasonable
judgment. However, I have reminded staff of the need to seek as much
information as possible and hope that improved procedures from all relevant
agencies prevent a repetition of these circumstances.
25
RECOMMENDATIONS
1. The Governor should remind reception staff of the requirement to ask escort
staff about any ticks relating to risks on the Prisoner Escort Record.
The National Offender Management Service accepted this recommendation
and said:
“With the introduction of the redesigned PER all information regarding
risks should have remarks to support. A notice to staff with relevance to
reception staff highlighting this requirement has been published.”
2. Healthcare staff must complete the First Reception Health Screen Form
completely as prisoners circumstances from any previous reception may have
changed and new risk assessment may be required.
The National Offender Management Service accepted this recommendation
and said:
“This requirement has been reinforced by the Head of Healthcare and
is now carried out for every new reception.”
3. Healthcare staff should refer prisoners who admit or are suspected of being
substance misusers for a full substance misuse assessment.
The National Offender Management Service accepted this recommendation
and said:
“This is now fully compliant - prisoners who fit this criteria are referred.”
4. The Governor should ensure staff undertake update training in CPR as a
matter of priority to ensure compliance with the Resuscitation Council (UK)
Resuscitation Guidelines 2005.
The National Offender Management Service accepted this recommendation
and said:
“This recommendation has been accepted but will involve a rolling
training programme - all staff who have been trained since 2005
undertake the resuscitation requirements.”
5. The Governor should ensure that a defibrillator is taken to all identified or
possible cardiac arrests.
The National Offender Management Service accepted this recommendation
and said:
“Achieved and in place - The establishment has a team of trained first
responders who are immediately called to any identified situation - the
resuscitation equipment is taken with them at all times. There are two
26
full resuscitation units paced at strategic points within the
establishment.
6. The Governor should ensure that there are sufficient staff trained in
defibrillator use to cover the prison 24 hours a day.
The National Offender Management Service accepted this recommendation
and said:
“Achieved and in place - the two dedicated night staff are now fully
trained in resuscitation and the equipment.”
7. The Governor should ensure that a suitable protocol concerning informing the
relatives of prisoners who die at Swansea prison should be agreed with the
Chief Constable of South Wales.
The National Offender Management Service accepted this recommendation
and said:
“The protocol will be explored with the relevant personnel.”
8. The Governor should ensure that all staff involved in fatal incidents are
offered the opportunity to attend critical incident briefing.
The National Offender Management Service accepted this recommendation
and said:
“In place - this is already custom and practice - the Prison Chaplain
takes the lead in this area.”
27