Individual at Wakefield

Investigation into the circumstances surrounding the
death of a man at HMP Wakefield
in July 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2008
This is a report into the death of a man, a life sentence prisoner at HMP Wakefield,
in July 2007, who died having taken an overdose of prescribed medication. He was
aged 41.
I would like to offer my sincere condolences to the man’s family and friends for their
loss. I most also apologise for the delay in issuing this report.
Two of my colleagues conducted the investigation. I would like to thank the
Governor of Wakefield for making my investigators welcome and for arranging the
necessary facilities to enable them to carry out their work. I am also grateful to the
prison’s liaison officer who gathered all the relevant documentation.
As part of the investigation process, Wakefield Primary Care Trust conducted a
clinical review of the man’s care. I am grateful for his invaluable contribution. Those
are extended to the pharmacist who contributed to the review.
One of my Family Liaison Officers contacted the man’s next of kin to inform them of
my investigation and to offer the opportunity to raise any concerns. I hope this report
answers any questions they may have about the circumstances surrounding his
death.
The man had a history of violent behaviour. He also frequently spoke to prison staff
about his intention to take his own life, and was subject to the Prison Service’s
monitoring and support procedures (ACCT) for those believed at risk of self harm
and suicide for the two years before his death. He was regularly prescribed
medication for various physical ailments. He held these medicines in his own
possession as no risks had been recognised. A week before his death, he was
mistakenly prescribed double the amount of one of his regular medications.
On the morning of 12 July 2007, the man’s ACCT document was closed after being
open continuously for two years. Within 24 hours, he was found unconscious and
was later pronounced dead by paramedics. A large quantity of medication was
discovered in his cell and more was missing. A suicide letter was also in his cell.
According to the post mortem examination, the cause of death was ischaemic heart
disease combined with a drug overdose.
I make five recommendations, one of which concerns the involvement of mental
health staff with new receptions that I have made previously. I also comment on the
closure of the man’s ACCT document by a single member of staff. Although there
were some mitigating circumstances, and while I do not criticise the decision itself,
this was wholly contrary to the ACCT guidelines.
Not surprisingly given the circumstances, the clinical reviewer has commented on
medication management. I have been pleased to learn that some new systems have
now been implemented.
This report has been anonymised for publication on the website of the Prisons and
Probation Ombudsman.
2
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2008
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CONTENTS
Summary 5
The investigation process 6
Background
HMP Wakefield 8
Key findings 12
Issues considered in the investigation 30
Conclusions 32
Recommendations 34
4
SUMMARY
The man who is the subject of this report was 41 years old when he died. He was
serving a life sentence at HMP Wakefield, having transferred from HMP Manchester.
An ACCT plan (a system for managing, monitoring and supporting prisoners in
distress who might pose a danger to themselves) had been opened by Manchester
in 2005. It remained open for the next two years because of his repeated threats to
commit suicide.
During the majority of the time the man spent in custody, he rarely agreed to
healthcare intervention other than for his physical ailments. His medication included
diltiazem (for angina) and gabapentin. He was not assessed as at risk when holding
this medication in his own possession. A week before his death, he was mistakenly
prescribed a double dosage of gabapentin.
Mental health assessments had been carried out on the man, but he was considered
to have a personality disorder rather than a mental health problem. It appeared to
staff that his threats to take his own life were not meant seriously.
Several ACCT reviews had considered closing his ACCT plan and the observation
levels were reduced. The ACCT document was eventually closed on 12 July 2007
by the man’s case manager. Neither the man nor anyone else was present.
No concerns were raised about the man’s wellbeing during that day and several staff
spoke to him. He was last seen alive at around 8.00pm and gave no cause for
concern. However, when his cell was unlocked the next morning, he was discovered
to have died. Resuscitation was not attempted as rigor mortis had already set in.
The paramedics formally pronounced his death.
The police retrieved large amounts of medication from the man’s cell, including a
number of empty blister packets. A suicide letter addressed to a friend was also
discovered. This intimated that the man had taken a drug overdose.
A post mortem examination found that the man had ischaemic heart disease that,
coupled with a mixed drug overdose of diltiazem, gabapentin and paracetamol,
caused his death. There was no evidence to suggest third party involvement.
Although the process was flawed, I do not criticise the decision to close the ACCT
form on the day before the man’s death. It had been discussed over the previous
two months and staff had no grounds for thinking he was at particular risk. It is
possible that the pure chance that he had been provided with surplus medication
presented itself as an opportunity for him to take his own life. However, as he had
long been in receipt of medication without proper risk checks, he could have taken
his life at any point. I also judge that he was unlikely to be aware of the extent of his
heart disease.
5
THE INVESTIGATION PROCESS
1. The investigation was formally opened on 18 July 2007 by one of my
investigators. My investigator met the Governor, Deputy Governor, Prison
Family Liaison Officer, Prison Liaison Officer, Vice Chair and the Head of
Healthcare at Wakefield. My investigator was briefed about the circumstances
leading to the man’s death and a number of relevant files and records were
examined. My investigator also met a member of the local Prison Officers’
Association (POA) and the Independent Monitoring Board (IMB) to brief them
about the investigation process. They were informed that they could speak with
him at any time during the course of the investigation should they have any
relevant information.
2. My investigator visited the wing where the man died. He also visited all other
parts of the prison. My investigators subsequently interviewed a number of
prison staff and four prisoners. Due to a number of staff being unavailable for
interview, this investigation report has been delayed.
3. The Wakefield Primary Care Trust conducted a clinical review of the man’s
clinical care and treatment whilst at Wakefield. The clinical reviewer also took
the opportunity to assist my investigator with some of the interviews. As
pharmaceutical issues were raised during the investigation, a pharmacist kindly
assisted the clinical reviewer in his review. The clinical review and
recommendations will be shared with Wakefield PCT upon completion of the
investigation.
4. The man’s next of kin was listed as a friend. The man was also in regular
contact with another friend. The prison contacted both men to inform them of
the man’s death. One of my Family Liaison Officers (FLOs) tried to contact
them shortly after the investigation was opened but only one responded. She
explained the role of the PPO and provided information about the investigation
process. Although he was not listed as next of kin, the man’s friend was given
the opportunity to raise any concerns he had relating to the death.
5. A short while afterwards, the prison informed my investigators that they had
managed to contact the man’s aunt and uncle. My FLO contacted them to offer
the opportunity of a meeting to discuss any issues or concerns. The family has
said they would like to see a copy of the report once the investigation had been
concluded.
6. The man’s friend and his family had the following concerns:
(cid:127) Could the man have been monitored more closely?
(cid:127) Was he allowed to keep his medication in his own possession?
(cid:127) They believe that the man had made it very clear that he was going to take his
life. This included writing to other prisoners to inform them. How did the
prison react to this?
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(cid:127) The man had lost his step-father before he went into prison and then his
mother died shortly afterwards. This, along with receiving a life sentence, had
caused him to feel hopeless.
7. My investigators wrote to HM Coroner to inform him of the nature and scope of
my investigation and to request a copy of the post mortem report. Upon
completion, this report will be sent to the Coroner to assist in his enquiries into
the man’s death.
8. Since my office took responsibility for investigating deaths in prison custody,
there have been five previous deaths at Wakefield, four from natural causes
and one that was apparently self-inflicted.
7
HMP WAKEFIELD
9. There has been a prison on the site of HMP Wakefield since 1595. In its
current form, it dates back to 1845. The prison’s healthcare centre is separate
from the main residential areas. All the cells have integral sanitation and the
prison has recently undergone refurbishment.
10. Wakefield is a male prison for those serving four years or over as well as life
sentence prisoners. It forms part of the high security estate housing prisoners
who potentially pose the greatest risk to the public or state. It specialises in the
treatment of serious sex offenders.
11. The prison provides workshops and an education department offering both full
and part time education. The programmes department offers a range of
offending behaviour courses including FOCUS (drug programme), Personal
Development (PDC), Sex Offender Treatment Programme (SOTP) and the
Enhanced Thinking Skills (ETS) programme.
12. The most recent report by HM Chief Inspector of Prisons, Ms Anne Owers, was
published in 2005 following an unannounced follow up inspection. The report
says:
“Overall, Wakefield was clearly a prison on the move. But there was a
great deal of movement still required in order to make it a fully effective
prison, able to engage properly with the serious and difficult offenders
that it holds.”
Healthcare
13. HMP Wakefield provides 24-hour nursing care for prisoners and has a 20-bed
inpatient facility. A mental health in-reach team is provided by South West
Yorkshire Mental Health Trust. The team comprises one on-site Community
Psychiatric Nurse (CPN) supported by three visiting consultant Forensic
Psychiatrists providing three sessions a week.
14. The prison has developed a First Contact nurse-led clinic. The clinical reviewer
comments that it provides a new way of working for both nurses and prisoners
alike. It has enabled the nurses to develop a service that has been well
received by the prisoners, and has helped the nurses develop their skills and
confidence in first contact care within the areas of acute care, disease
management and health promotion. It has changed the terminology from ‘Sick
Parade’ to ‘First Contact’, implying a modernisation of the service on offer to
prisoners.
15. A permanent pharmacist, employed by Wakefield District Primary Care Trust, is
now in post. The pharmacist is supported by pharmacy technicians and
between them they deliver a full range of pharmaceutical services to the
prisoner population.
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16. A report by the prison’s Independent Monitoring Board (IMB) in August 2004
praised the healthcare department which was about to undergo the transition to
the local Primary Care Trust.
17. In 2005 the Chief Inspector of Prisons’ report said of healthcare:
“There had been little change in healthcare facilities since the last
report. Wakefield provided 24 hour care for prisoners and had a 20
bed inpatient facility. Staff were enthusiastic and committed to
improving services but there appeared to be a lack of strong clinical
leadership particularly in primary care area.”
18. The clinical reviewer reports that since the Chief Inspector’s inspection, efforts
had been made to strengthen staffing. A recent initiative had been to train
Discipline Officers to NVQ Level 3 and recruit further nursing grades.
Medication management in prison
19. The clinical reviewer has also commented on medication management at
Wakefield. The Government has said it is committed to providing a health
service to prisoners that is equivalent in quality and range to that in the wider
community. Under Prison Service Instruction 028/2003 (“A Pharmacy Service
for Prisoners”), medicines in use, together with associated monitoring and
administration devices, should normally, as a matter of principle, be held in the
possession of prisoners. Each prison should have a policy and risk
assessment criteria for determining on an individual basis when medicines may
not be held in the possession of a prisoner. Although the risk assessment tool
was in use at Wakefield, the clinical reviewer has found flaws in the way it
operated.
Reception
20. On arrival at HMP Wakefield, all paperwork for prisoners is checked before they
are taken off the escort vehicle. Staff check warrants to ensure they have the
correct prisoners in custody, and then set up the necessary records. The
prisoner is taken from the vehicle and booked in by the senior officer on the
front reception desk. Personal and offence details are taken, together with any
known or identified concerns.
21. All prisoners see the first night in prison officer, reception officers and the nurse
on duty. During this process, staff obtain address and next of kin details.
Prisoners are strip searched, their property is logged, and they are health
screened, before being placed in a holding cell ready for locating staff to take
them to a wing.
Emergency alarm codes
22. The alarm system used in Wakefield is a two tone system. If a member of staff
presses an alarm bell, it is transmitted over the hand-held radios. A code red or
blue system is used for emergency response.
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Insiders and Listeners
23. As is common with most prisons, Wakefield uses experienced prisoners to
operate as Insiders and Listeners. Insiders welcome new prisoners, highlight
any concerns and explain the processes the newcomers will encounter in the
early days of custody. Listeners assist those prisoners who require additional
support at any time in their period in custody. They are provided with training
from the Samaritans to support them in this role.
Roll Check
24. The roll check is the physical count of the number of prisoners on each wing
within a prison. Roll checks occur on a number of specified occasions during
the day and night, and staff must sign that the roll is correct.
Safer cells
25. Wakefield has a number of ‘safer cells’, which are specially designed to contain
as few ligature points as possible. They are used for prisoners assessed to be
at risk of harming themselves.
Cell Sharing Risk Assessment (CSRA)
26. In order to make sure that unsuitable prisoners do not share cells (e.g. a racist
prisoner and one from a visible ethnic minority or a mentally disturbed prisoner
with a violent one), a cell sharing risk assessment form should be completed by
reception when a prisoner is first admitted.
Assessment, Care in Custody and Teamwork (ACCT)
27. As at all prisons, ACCT has been introduced at HMP Wakefield 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.
28. Each prisoner is assessed within 24 hours (ACCT assessment) and then
reviewed further at intervals decided on an individual basis. The ACCT
guidance says that, to be effective, the review should involve the people who
know the person at risk or are involved in their care. The key questions for
each review are listed as:
(cid:127) have the problems that caused the ACCT plan to be opened now been
resolved?
(cid:127) if not, what needs to be done to resolve them?
(cid:127) have any further problems arisen that are now causing distress and more
risk?
(cid:127) if so, what action can be taken to address these?
10
(cid:127) is the person at risk now in contact with friends, family or other support?
(cid:127) does the person at risk now have something in their lives that they feel good
about?
(cid:127) if not, how can this be improved?
29. Over time, the reviews should also consider other factors such as:
(cid:127) distress – has anything changed to make the person at risk more or less
desperate?
(cid:127) resources – has anything changed that makes the person at risk now feel
more or less alone?
(cid:127) previous suicidal behaviour – has anything changed that makes suicide more
familiar or more acceptable to the person at risk?
(cid:127) suicide intention or plan – has anything changed to show that the person at
risk is more or less prepared to kill themselves?
(cid:127) pattern of self harm – is self harm becoming more or less frequent?
30. Amongst other things, the ACCT guidance states that prisoners should be
cared for in a safe environment. It is for the case review team to decide the
most appropriate place to locate an individual prisoner.
31. HM Chief Inspector of Prisons’ report found that levels of self-harm were low
but it was difficult to establish any trends from the records. Between October
2004 and March 2005, 17 prisoners at Wakefield had self-harmed, eight of
whom did so regularly. Twelve prisoners were currently on open F2052SHs
(ACCTs).
Multi-Agency Public Protection Arrangements (MAPPA)
32. The MAPPA is a formal partnership between police, probation, prisons and
other statutory and non-statutory agencies that assesses and manages
offenders in order to minimise the risk of serious harm they may pose to the
public.
33. Offenders who come within the MAPPA remit are classified according to the
nature of the risk and its management. The higher the risk, the higher the level
at which they are managed. Level one offenders are managed by one agency,
usually the police or probation service. Level two offenders are managed jointly
by all the MAPPA agencies and level three offenders are managed by the Multi-
Agency Public Protection Panel (MAPPP) made up of senior managers from
the MAPPA agencies.
Licence/Recall
34. Once released, a prisoner can be recalled to prison if they breach the
conditions of their licence. The Parole Board will consider the details of the
breach and make a recommendation to the Secretary of State with whom the
final decision rests.
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Incentives and Earned Privileges Scheme (IEPS)
35. The IEPS was introduced to encourage and reward good behaviour in prisons.
There are three levels - Basic, Standard and Enhanced. Incentives include
access to in-cell television, more private cash to spend, wearing own clothes,
more time out of cell, and community visits.
Personal officer
36. All prisoners at Wakefield are assigned a personal officer. Their role is to meet
with the prisoner on a regular basis and to discuss any issues or concerns the
prisoner may have.
Canteen
37. Prisoners can obtain various foodstuffs and other items as ‘canteen’ from the
prison shop. They also have access to a water boiler and are provided with a
weekly tea pack, bread and other food items.
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KEY EVENTS
Prior to Friday 13 July 2007
38. On 3 May 2005, the man who is the subject of this report was released on
licence from HMP Acklington on what was considered a robust Risk
Management Plan. He was a MAPPA level 3 offender. As part of his licence
conditions, he was to wear an electronic tag and reside at an approved
premises (a probation hostel). His licence was due to expire in 2011.
39. The man was arrested again on 10 July and charged with a total of 11 offences.
He appeared at the Magistrates’ Court in July 2005 and was subsequently
recalled back to prison because he had breached the conditions of his licence.
The man later pleaded guilty to the offences at court, and would return at a later
date to be sentenced. He was transferred to HMP Forest Bank.
40. When he arrived at Forest Bank, the man was interviewed as part of the normal
prison reception screening process. This included an examination by a
member of the healthcare team. The man asked to be separated from the main
prison population because of the nature of the offences he had committed. He
was located in the segregation unit.
41. Two days later, on 14 July, the man disclosed to staff that he would kill himself
because he was having difficulty in sleeping. As he had admitted to possible
self-harm, the self-harm document FS2052SH (the form used prior to ACCT)
was opened by staff, and he was monitored frequently.
42. On 17 July, the man was interviewed by healthcare staff. His mood was
described as okay, but he was angry. He said he was unhappy in prison,
wanted to hurt others, kill himself and felt that there was no point in living.
43. At the beginning of August 2005, the man again told staff that he intended to kill
himself and refused to eat any food. On 24 August, he wrote to a fellow
prisoner in another prison saying he intended to take his own life. Still on an
open F2052SH, he continued to be monitored and offered support by staff.
Despite these offers, he declined to take advantage of any of the support that
was offered.
44. The following month, staff recorded in the man’s wing history sheet that he had
calmed down over the last week and was apologetic for his angry behaviour
towards them. However, he still maintained that he wanted to take his life.
The man’s transfer to HMP Manchester
45. The man was transferred to HMP Manchester on 27 September 2005, having
spent around five months at Forest Bank. He again went through the normal
induction screening interviews. He was interviewed by the prison doctor who
identified that his mood was low and he was depressed. The man’s response
was that he did not want to be around and wanted to harm himself.
13
46. Given his mood, the man was immediately admitted into the healthcare unit.
He was located in a single cell and placed on constant medical and psychiatric
observation. The doctor prescribed medication of tildiem (for diabetes), aspirin,
omeprazole (for stomach ulcer condition), citalopram (an anti-depressant), and
salbutamol inhaler. The man was also taking medication for angina.
47. As part of an ongoing risk assessment to gauge the level of risk he posed to
others, a cell sharing risk assessment (CSRA) was conducted. He was
assessed as a high risk to others. Following further assessments throughout
his entire time in prison, he remained at this level.
48. Manchester had by this time moved from using the F2052SH to using ACCT.
Because of the man’s continuing threats of self harm, the ACCT plan remained
open and he was again offered support and monitored by staff.
49. On the morning of 28 September 2005, the mental healthcare nurse attempted
to speak to the man. He was verbally abusive and refused to engage in
conversation. He told the nurse that he would refuse any medication and
intended to kill himself within two weeks. He also declared that he did not
intend to eat any prison food. This behaviour was repeated for the next few
months with the man saying that, once he had spoken to his solicitor, he would
take his life.
50. At the beginning of December 2005, the man was told that his mother was
terminally ill. He was allowed to ring the hospital ward to speak to staff. His
mother subsequently died and her funeral (cremation) was scheduled to take
place on 7 December.
51. On 6 December, the prison doctor ceased prescribing the man with medication
for his depression and sleeping problem. The man was very angry about this
and in protest said he would refuse to take his angina medication. Again he
said he wanted to die. He made violent threats against the doctor and said he
needed the medication because his mother had recently died. He was not
happy that his mother was being cremated and said that the prison staff were to
blame for arranging this.
52. The following day, although the man displayed no anger towards other
healthcare staff, he again made threats to harm the doctor. Staff tried to
persuade him to take his angina spray with him when he went to his mother’s
funeral, but he adamantly refused to do so. His ACCT monitoring continued.
53. On the night of 12 December, healthcare staff were called to the wing because
the man complained of dental and chest pain. He was given paracetomol and
ibuprofen for the pain. A few hours later, he was experiencing severe pain, had
ripped his bed sheets and was threatening to kill himself. He was relocated to a
cell on B wing that contained CCTV, and given tramadol to help with the pain.
The following day, he was diagnosed as having a tooth infection.
54. The man continued to reiterate his intention to take his own life in January
2006. He continued to be monitored under the ACCT procedures but continued
14
to refuse help or support for his suicidal thoughts. The prognosis made by the
prison doctor was that the man had displayed no evidence of mental illness,
depression, self-harm or suicidal intention. It was felt that he had a borderline
personality disorder. As there had been no attempt at self-harm or suicide,
intermittent observation of him was to cease.
55. The man was informed on 1 February that he was fit for ordinary location and
would be moved from the healthcare unit. Not happy about this decision, he
refused to move and applied to be located in the vulnerable prisoners unit
(VPU) unit because of his offence.
56. Still being monitored under the ACCT procedures, the man was subsequently
relocated to E wing VPU. He was visited on a regular basis by the mental
healthcare nurse. His mood was still hostile and he continued to refuse food.
Around two weeks later, however, staff noted that the man obtained water and
snacks from his canteen. He remained in his cell most of the time and did not
socialise with others.
57. On 6 March, the security department informed wing staff that the man had
written to a prisoner in another prison intimating he was going to kill himself.
He said he had nothing in his life and knew when and how he intended to end
it. He refused to engage with wing staff or members of the mental healthcare
team, and was subsequently returned to the healthcare unit.
58. The man was assessed on 10 March 2006 by the prison doctor and two mental
healthcare nurses. He had not made an active attempt to harm himself since
his admission to the healthcare unit. The doctor again noted that he showed no
evidence of depression or mental illness, but had a ‘antisocial/borderline
personality disorder with manipulative behaviour using his suicidal threats to
achieve his aim’. The man was prescribed medication, and he was observed to
see what effects it would have.
59. When the man was examined again by the doctor on 16 and 17 March, he was
relaxed and cooperative. He disclosed that his mother’s death had left him
feeling upset and angry. He was prescribed medication to control his anger
and his impulsive behaviour. His level of observations was reduced to
intermittent watch. Preparation was also made for his return to ordinary
location.
60. The intermittent observations ceased on 30 March. The man had complied
with his medication and shown no evidence of depression or self-harm. This
pattern of behaviour was replicated throughout April.
61. The man’s ACCT plan was reviewed twice in May. On each occasion staff from
healthcare, the wing and the man attended. His mood was low which he
attributed to the anniversary of his step-father’s death. He was still having
thoughts of self-harm, although he believed he could manage them and said
that he would tell staff if the need for support arose. His ACCT document
remained open, and his level of risk was considered to be ‘Low’.
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62. Security information was received on 29 May 2006 about the man from HMP
Acklington. He had written to a prisoner there that he intended to kill himself
within the next two weeks. At the ACCT review meeting a week later, he
disclosed that his low mood was due to the death of his mother earlier in the
year and the forthcoming anniversary of her birthday. Staff offered support, and
the man said he would utilise this if necessary. As his mood was low, his ACCT
risk level was increased to ‘Raised’.
63. In June 2006, the man was escorted to the Crown Court where he was
sentenced to life imprisonment with a minimum term of 12 years before
eligibility for release on licence.
64. He later returned to Manchester where he was assessed again by the doctor
and nurse in reception. He displayed no evidence of psychosis and appeared
physically and mentally stable. Aware that he had now been sentenced, he
was offered support, admitted back to a safer cell in the healthcare unit, and
placed on intermittent observations. Again, he told staff that he intended to kill
himself.
65. For the next two days, the man remained in his cell, refusing to talk to staff or to
be examined by the doctor and mental healthcare nurse. Attempts were made
to talk to him about his personal hygiene, but he ignored them and reiterated
his intention to kill himself rather than serve his sentence. However, the ACCT
review decided that intermittent observations could be reduced.
66. The man was told on 27 June he would be located to ordinary location to which
he agreed. Since receiving his life sentence he had made no attempts to self-
harm. His ACCT monitoring continued and his level of risk remained ‘Low’.
67. The following day, the security department passed on information to wing staff
indicating that the man had a ligature hidden in his cell. He was questioned by
staff, became argumentative and repeated that he intended to kill himself. Staff
carried out a full cell search. A ligature was found along with a suicide letter
and some other documents relating to the man’s offence.
68. Following the ligature find, an immediate case conference was convened to
discuss the man’s future location and treatment. The review was chaired by a
Governor and attended by two senior officers and a healthcare nurse. The
review concluded that, although it was considered that the man was being
manipulative to gain a move back to healthcare, this was probably the best
place for him at the present time. The decision was taken that he would soon
be transferred to another prison.
69. The next ACCT plan review was held on 3 July. Four members of staff as well
as the man attended. He displayed no obvious signs of depression or
psychosis and simply laughed and joked throughout, whilst reminding the staff
of his suicidal intention.
The man’s transfer to HMP Wakefield
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70. The man had spent approximately ten months at Manchester before being
transferred to Wakefield on 4 July 2006. He arrived and went through the
normal prison reception screening process. His ACCT plan, as well as his
assessment as a high risk to others, was passed on to Wakefield.
71. A Senior Officer (SO) interviewed the man in reception. The man was calm
and disclosed the anger he felt towards other prisoners. He also talked about
the recent death of his mother. The SO updated the man’s wing history sheet
and CSRA form, and noted that he gave no indication that the transfer to
Wakefield was of any concern to him.
72. Immediately after this interview, the man was examined by a healthcare nurse.
He disclosed to the nurse that he had seen a doctor in the past few months
because of suicidal thoughts. He said he suffered from angina and was
currently taking tildiem and simvastatin (a cholesterol-lowering angina spray).
He was noted as allergic to penicillin. The man said that he had only ever
harmed himself once, 20 years previously, when he had taken an overdose of
tablets.
73. The nurse noted that the man’s current mood and behaviour was appropriate to
his situation. His mood did not appear to be low, but he said he intended to kill
himself and that depression had always been a factor in his life. Aware that he
was already being monitored under the ACCT procedures, the nurse made a
referral for him to be seen by the doctor the following morning.
74. Later that evening, the man was located to A wing. He was placed in a single
cell, the norm for all prisoners at Wakefield. A possible risk to female members
of staff was also recorded.
75. The next morning, the man was examined by the doctor. He disclosed his
medical history and said he had no present thought of suicide. The doctor
assessed that he was fit for normal location and should be observed on the
wing for any mood changes. He had no concern about the man’s mental
health. Over the next couple of days, the man received his prison induction.
76. On the morning of 7 July 2006, an ACCT assessor conducted a care
assessment interview with the man. This was normal practice for a prisoner
who had transferred into the establishment on an open ACCT plan.
77. At interview, the man disclosed that in the last 13 months some four members
of his family had died - including his mother. He said he felt more relaxed at
Wakefield than at Manchester, although boredom made him feel stressed.
Depression had also been a factor in his life for some time. He said that
although he had previously self-harmed, this was something he was not
interested in now.
78. With regard to his life sentence, the man said he was not worried as he had
nothing to live for, and had every intention of killing himself soon. He indicated
that he would do this once his mother’s estate was settled and would not tell
anyone of his plans. The outcome of the review was that he remained on
17
ACCT. He would be reviewed regularly and encouraged to engage with staff
and prisoners. He would also be encouraged to undertake a bereavement
counselling course and to engage in some of the prison activities, such as
education classes and workshops.
79. Later that afternoon, the man attended his first ACCT plan review at Wakefield.
The ACCT assessor, two SO’s (one of whom was the man’s ACCT case
manager) and the man all attended. At interview with my investigators, the
man’s ACCT case manager said that he chaired the reviews and, as far as
possible, invited other interested parties, including the man. Interested parties
could include a prisoner’s personal officer, the chaplain or a member of staff
from the wing or healthcare.
80. During the review meeting, the man reiterated his intention of wanting to kill
himself. He had been making this statement now since he was first placed in
prison custody, but was always vague about how he intended to do it. He said
that he had no contact with any family members and intended to commit suicide
as soon as his deceased mother’s estate was settled. This information, as well
as other dates such as specific anniversary dates, had already been recorded
as trigger points on his ACCT plan. This served to alert staff to possible times
and events that might cause a change in his behaviour.
81. The man’s risk level was assessed as ‘Raised’, and staff were instructed to
monitor and interact with him. He was initially placed on three observations
during the day when staff would have to interact to gauge, monitor and
document his mood. During the night, he would be observed on five separate
occasions that would be documented at the end of the shift. Night staff would
visit his cell at five random times throughout the night and look through the cell
observation panel to confirm he was okay. Should the man’s risk of self-harm
change, his level of observations could be increased or decreased.
82. The man’s second ACCT plan review took place on 17 July. The case
manager, another SO and the man were all in attendance. The case manager
noted that the man remained upbeat about his induction, but said he was still
determined to kill himself when his mother’s estate was settled. He had already
started the legal process by enquiring about legal aid and solicitors. The case
manager referred the man to the prison chaplaincy to consider attending a
bereavement course. His level of risk was reduced to ‘Low’.
83. Over the forthcoming weeks, the man settled into life at Wakefield without any
problems. However, staff did have to remind him about the cleanliness of his
cell. He was still located on A wing, a normal residential wing. He was
socialising with others, but remained quiet and engaged in limited conversation
with staff. The man had gained employment in the textiles workshop number
eight which made clothing items. This was an area of work he had experienced
in other prisons.
84. On 31 July 2006, an ACCT review meeting took place. The man attended
along with the SO who had attended the review meeting on 7 July 2006 and an
officer. It was noted that the man was associating on the wing and had made a
18
few friends. He was told that he could attend the next bereavement course
which was due soon. The man once more disclosed that he was intent on
taking his own life in the near future. The ACCT plan remained open and his
level of risk was again recorded as ‘Low’.
85. Three ACCT review meetings took place in August. At least two members of
staff were present at each meeting and the man attended two of them. They
noted that there was no change to his mood or behaviour, and he was still
adamant that he would take his own life soon. He further added that he did not
wish to engage with any probation or psychology staff. His level of risk
remained ‘Low’.
86. The SO who had attended reviews on 7 and 31 July carried out an ad-hoc
ACCT review on 19 September. Security information had been received
indicating that the man was planning to escape from prison. At the meeting, he
was immediately placed on what is called the E-list. He was given E-list
clothing (highly visible clothing) to wear at all times and was not allowed to
leave his cell unless he was wearing it. The man denied that he had planned to
escape and was upset at the prison’s action. His ACCT document remained
open. His monitoring level was changed to frequent and irregular observations,
the risk level remaining ‘Low’.
87. On 21 September, the man refused to wear his E-list clothing and eat his
meals. The next day, he met the mental healthcare nurse. At interview with my
investigators, the nurse said that the man was not happy having to wear E-list
clothing, and as a result said he would refuse food until the restriction was
lifted. The nurse attempted to assess the man, but he refused to cooperate.
He was abrupt and obstructive to any help and support offered.
88. The man was again seen by the healthcare nurse on 24 September. He still
refused to eat and had begun to experience chest pains. He was advised that
he needed to go to the Accident and Emergency Department at the local
hospital. The man refused despite being advised strongly that he was putting
himself at risk of a possible coronary attack.
89. Until 25 September, the man refused to wear the E-list clothing, but then
decided to conform to the instruction to do so. On the afternoon of the following
day, the man’s personal officer introduced himself. The man disclosed that he
was not eating prison food in protest at having to wear the E-list clothing. He
said this was also why he had refused to attend hospital recently, although he
did say he was eating his canteen.
90. The Independent Monitoring Board (IMB) regularly meets prisoners who are
reported as giving concern. As the man was refusing food, the information was
passed to the IMB. At interview with my investigators, an IMB member said she
interviewed the man on 26 and 27 September. On both occasions he explained
his reasons for refusing food. He said he had no intention of escaping, had no
one to escape to, and for this reason refused to wear the clothing. He was not
feeling weak and was not bothered if he died. After the second meeting, the
man said he had no reason to meet with the IMB again.
19
91. A further ACCT review took place on 28 September. It was chaired by the SO
who had carried out reviews on 7 and 31 July and 19 September, with a mental
health nurse and the man in attendance. It was noted that the man still refused
to eat his meals. He was offered bereavement counselling and medical
interventions but refused. He again disclosed his intention to kill himself.
During the review, he became abusive and obstructive, and was returned to his
cell. Staff felt the man was still at risk of self-harm and the ACCT document
remained open with frequent and irregular observations. In spite of the man
saying on numerous occasions that he would take his life, so far he had not
attempted to do this.
92. On 5 October, staff reported that the man spent most of his time in his cell.
This became a frequent occurrence and he still refused food although
occasionally ate his canteen.
93. On 18 October, the man was referred to the mental health team because of his
continued refusal to eat food, and his expressed suicidal intention. He was
interviewed and assessed by a nurse. The man told the nurse that he was
depressed, was not sleeping well, did not feel mentally well and that these
symptoms were possibly due to his living conditions. He was not participating
in work or education and had few friends on the wing. He had also stopped
taking the medication for his angina. He told the nurse that he was a diabetic,
although this illness was yet to be confirmed. The man disclosed that he
intended to sort out some business with his solicitor during the week, and then
he would join his mother in heaven.
94. The nurse noted that the man presented as calm and co-operative during the
examination. He displayed no symptoms of psychosis or neurosis, and said
that taking his own life was a logical decision he had made. He reiterated that
he did not wish to be offered any support for how he was feeling.
95. An ACCT review took place on 24 October with an SO, an officer and the man
in attendance. The man still spent a lot of time in his cell. At the meeting he
maintained that he would kill himself, saying he would do so between 27
November 2006 and the New Year. However, he had now ended his food
refusal and his personal and cell hygiene had improved. He was still not
interacting with other prisoners and, despite being offered the services of
Listeners and the chaplain, still refused all support. His level of risk remained
‘Low’.
96. As the man appeared to pose no risk of escape, he was taken off the E-list on 7
November. He had showered and seemed in much better spirits than
previously, although was still interacting with only a few prisoners. However, he
was now having regular and polite conversations with staff. The man had also
resumed working in the workshop. He said the workshop was something that
made him happy.
97. The ACCT case manager chaired the next ACCT plan review, held on 27
November, with an SO who had attended the review on 17 July. Just before
20
the meeting, the case manager spoke to the man who refused to attend. It was
noted that he was still enjoying the workshop. The anniversary of his mother’s
death was approaching on 1 December and that of his grandmother on 8
December. Given these factors and possible triggers to self-harm, his ACCT
document was to remain open.
98. A Risk Assessment Board was convened on 30 November. The Board
consists of a multi-disciplinary team and the purpose is to look at a prisoner’s
sentence planning targets. (These might include the prisoner maintaining
settled behaviour on the wing, or being assessed for offending behaviour
programmes.) The man refused to engage.
99. On the night of 1 December, and aware that it was the anniversary of the man’s
mother’s death, an officer spoke with him to check that he was alright. She told
my investigators at interview that the man seemed fine and his mood was
upbeat.
100. No concerns were recorded during the next fortnight. On 15 December, an
officer introduced himself to the man as his new personal officer. At interview,
the officer told my investigators that when he first took on this role the man was
having problems with toothache but was talkative and in good spirits. He
described him as someone who did not interact with many prisoners or staff.
As his personal officer, the officer said he tried to speak with the man on a
regular basis. Although the man spent lots of time in his cell, he did engage in
conversation.
101. Following the death of a prisoner in another part of the prison, an additional
ACCT case review was held with the man on 18 December 2006. The SO who
had attended reviews on 17 July and 27 October conducted the review and was
accompanied by an officer (who had previously attended the man’s review on
31 July), the Safer Custody Officer. The man said he was not aware of the
other prisoner and his death had had no impact on how he was feeling.
102. The man’s scheduled ACCT review was carried out four days later on 22
December. The case manager chaired the review with an officer and the man
in attendance. Consideration was given to closing the ACCT document. The
case manager noted that the man had good and bad days, but was working
well and interacting with staff and other prisoners. The man said he wanted the
Christmas period to pass before the ACCT was closed. It was agreed that it
would remain open for a further two weeks.
103. On the morning of 12 January 2007, the mental health nurse interviewed the
man following a request from wing staff who were concerned about him. His
physical appearance had deteriorated and he was not taking his medication.
Despite the nurse offering support, the man refused to see a psychiatrist and
refused to take any medication. He said he was still adamant that at some
point he would take his life, would never be admitted to healthcare, and did not
want any help from the mental healthcare team.
21
104. An ACCT review was carried by the case manager during the morning.
Another officer and the man were present. The man said that, now his mother’s
estate was being dealt with by solicitors, he felt the time was near for him to
end his life. His ACCT document therefore remained open, with an observation
level of hourly throughout the night and intermittently during the day.
105. On 23 January, the man’s personal officer had a long chat with him whilst he
was working in the textile workshop. The man was polite throughout their
conversation and said he enjoyed working in the workshop. He was
experiencing some back pain but refused to take any medication to relieve it.
He also said it was only a matter of time before he killed himself. He was not
upset when he said this and just mentioned it in the conversation with his
personal officer. Despite his personal officer trying to persuade the man not to
take his own life, he said he was intent on doing so.
106. The personal officer met the man again on 14 February for a general chat to
discuss his wellbeing. His personal and cell hygiene were still considered poor
and, although the personal officer told him it could result in his IEP level being
reduced to basic, the man was unconcerned. He still only associated with a
few other prisoners and, despite still enjoying the workshop, he continued to
reiterate his intention to take his life soon.
107. A week later, the security department were alerted to a letter the man had
written to a prisoner in another prison. In the letter, he said he was suffering
from clinical depression and no longer took any of his medication. He said he
was weakening and getting closer to his goal. He had planned to die that day
but had made a promise to finish some work in the workshop. He would keep
his word to complete this before he pulled “the plug”.
108. At their meeting on 26 February, the personal officer reported no problems
raised by the man. There was still no change in his behaviour: the man’s
association with others was still limited to a select few and the threats of killing
himself continued.
109. On 14 March, the personal officer noted that the man was polite, in good spirits
and still enjoyed the workshop. His personal and cell hygiene remained
unacceptable. With regard to self-harm, the man told his personal officer that
he wished the ACCT document to remain open.
110. Two weeks later, the man spoke to his personal officer to ask if he knew why
he was no longer required in the workshop. His personal officer was unaware
and said he would make enquiries, and that the man should remain optimistic.
He said it was not uncommon for the work to be limited every now and again.
111. The ACCT case manager held an ACCT case review on 1 April, with only the
man in attendance. He was still not required in the workshop. He was
interacting with other prisoners on association but still reiterated his intention to
take his own life. The case manager spoke with the man again about the
support networks available to him.
22
112. Throughout April, the personal officer noted no concerns with the man. He
remained polite and continued to socialise with a few prisoners. His cell and
personal hygiene had improved slightly. Later in the month, the personal officer
was reassigned to other duties and no longer had the responsibility of being the
man’s personal officer. He told my investigating officers that, in his contact with
the man, he never had any concern that he would take his life. This was
despite his repeated statements of his intention to do so.
113. From 9 May, the man resumed working in the workshop. Three days later, the
ACCT case manager carried out an ACCT case review. No other members of
staff were present and the man also refused to attend. There was no change
from the last review.
114. Having attended the treatment clinic for abdominal pains the previous month,
the man was diagnosed on 15 May as suffering from diabetes and prescribed
metformin by the doctor. He had raised glucose levels and increased
complaints of thirst. The appointment was followed up by a specialist nurse at
the prison’s diabetic clinic.
115. At the next scheduled ACCT review on 12 June, the man refused again to
attend or speak with staff. An SO chaired the review (in the absence of the
case manager) alongside Safer Custody Officer Brown. The SO noted that the
man had been more settled recently and was interacting well with staff and
prisoners. It was agreed that his observations and interactions could be
lowered with a view to closing the ACCT document at the next review. His level
of risk remained ‘Low’.
116. Two days later, an additional review was conducted because of a further death
of a prisoner in the prison. The man again said that he was not affected. He
had recently taken his medication and had experienced a bad night’s sleep,
although he was feeling much better now.
117. On the night of 15 June, the man disclosed to staff that he was a little
depressed as it was a day before the anniversary of his mother’s birthday. He
talked to the night officer and later appeared to be in a better mood.
118. A further ACCT plan review took place on 16 June, the anniversary of the
man’s mother’s birthday. The review was chaired by the SO who had chaired
the review on 12 June with an officer. The man attended on this occasion but
refused to talk about his mother, saying it made him feel depressed. He had
taken some medication that had helped his mood, but again said that he
intended to take his own life at some point and staff could not change his mind.
The man said he liked the current night staff, so would not take his life on their
shift. He was once more reminded of the support mechanisms that were
available to him. He again declined the offer.
119. At interview with my investigators, The ACCT case manager said that the staff
had discussed closing the man’s ACCT plan for at least a month before it was
finally closed. The man had a period of more settled behaviour. It was agreed
that the observations and interactions by staff should be lowered, with a view to
23
closing the document at the next review. The case manager told my
investigators that the man’s observations were eventually lowered to one
observation during the day, and one during the night.
120. On 27 June, an officer noted in the man’s wing history book after a
conversation with him. The man was going to work regularly and was still
enjoying the workshop. Despite his cell and personal hygiene being poor, the
officer had no concerns about his wellbeing. The next day, the man attended
the diabetes clinic to be assessed by the specialist nurse who also referred him
to the optician.
121. The man was seen by the one of the prison doctors on 2 July. He had long
been in receipt of regular monthly repeat prescriptions for his physical ailments
and his low moods. He was prescribed his usual medication (set out below),
which included gabapentin for his diabetes:
(cid:127) 84 gabapentin capsules
(cid:127) metformin 500mg tablets
(cid:127) 28 simvastatin 40mg tablets
(cid:127) 28 diltiazem (Tildiem) LA 200mg capsules
(cid:127) 28 aspirin 75mg dispersible tablets
(cid:127) 1 beclometasone 100 Inhaler
122. The medication was dispensed to the man the following day by the pharmacist.
None of the medication was listed as unsuitable for IP under prison policy.
Neither healthcare nor wing staff had raised any concern about any risk
associated with him being responsible for his own medication. As noted, he
had always kept his medication in his possession.
123. For some months now, the man had given staff no general cause for concern.
Often, he was reported as being pleasant and in a good mood. His attendance
at workshops was regular and he continued to enjoy his work. He socialised on
the wing, ate regularly and was regularly observed playing his PlayStation
game, sometimes until the early hours of the morning.
124. On 10 July, the man was seen by a different doctor. On this occasion he was
prescribed the medication erythromycin (an antibiotic) 250mg tablets and 168
gabapentin 300mg capsules (one month’s supply). Both were, as usual,
dispensed to him by the pharmacy the next day.
125. My investigators liaised with the police and clinician regarding the man’s receipt
of this quantity of gabapentin in such a short period of time. It appears that an
entry was missing on his medical records when the second doctor saw him on
10 July. (This entry then subsequently appears out of chronological order.)
The doctor was therefore not aware that the man had been prescribed
gabapentin only a week earlier.
126. Gabapentin is not on the prison’s list as a high risk drug. No further risk checks
were carried out, therefore, when it was prescribed. The pharmacist is also not
routinely informed of prisoners who are on an open ACCT. Prisoner officers
24
escort prisoners to the medication hatch to collect medication, but are not
involved in the actual transaction, respecting an individual’s right to medical
confidentiality.
Events on Thursday 12 July
127. On the morning of 12 July, the ACCT case manager spoke with the man at
breakfast time. An ACCT review was scheduled to take place and, as usual,
the case manager invited the man to attend. He said he was busy at the
workshop and unable to be present. When asked how he was feeling, he
expressed no concerns. The case manager told him that he intended to close
his ACCT plan. The man shrugged his shoulders, said fine and walked away.
128. The case manager held the ACCT review meeting at 9.00am. No other
members of staff were in attendance. On closure of the ACCT plan, the case
manager noted the following:
“The man did not attend this review but expressed his feeling saying he
was feeling fine and ok with himself. Since he arrived at HMP
Wakefield he has not self-harmed and has had many trigger points. I
currently have no areas of concern with him. He is aware of the help
available and support.”
129. The case manager told my investigators that he had discussed the closing of
the man’s ACCT document at the beginning of the week with two SOs who had
been present at other of the man’s ACCT review meetings. All were in
agreement that the document could be closed at the next review on 12 July.
This was a decision that the SOs believed could have been taken months ago.
The man had given the staff no reason for concern, despite his continual
statements that he intended to take his life.
130. A prisoner on the man’s wing, told the investigation that he recalled that the
man had his dinner that evening and seemed fine. The prisoner told my
investigators that he was aware that the man had at times bought drugs off
other prisoners for recreational purposes. He said that two or three days prior
to his death, the man told him that he had received double his medication (by
accident). The prisoner said he did not believe the man intended to take his
life.
131. A second prisoner also confirmed that he was aware of the man being
prescribed double medication. In previous conversations, the man had talked a
lot about suicide and feeling depressed, and had written a number of suicide
notes before disposing of them in the bin. At interview with my investigators,
the prisoner said that at around 6.40pm that evening, the man had told him he
had stomach pains. At no point, however, did he mention taking his own life.
132. The officer on duty on A wing began his duty around 7.50pm. He had worked
on A wing for some time and was familiar with the prisoners. On reading
through the wing paperwork, he discovered that there was no ACCT plan for
the man, and it was recorded in the wing sheet that the ACCT had been closed
25
that morning. At interview with my investigating officers, the officer said he had
previously been informed that the man’s ACCT plan was to be closed.
133. The officer explained that, if a prisoner is not on an ACCT and not a category A
prisoner, staff would only check on them at the beginning and end of their
nightshift. However, if an officer had concerns about a prisoner, they would
carry out periodic checks to make sure they were okay.
134. At around 8.00pm, with all prisoners already locked in their cells, the officer
carried out his roll check. On looking through the observation panel of the
man’s cell door, he observed he was awake playing on his PlayStation. He
asked him how he was, and received the response ‘I’m okay boss’ followed by
a comment about the game he was playing.
135. After the officer completed the wing roll check, he attended the centre office to
sign off the figures in the log book. This was at approximately 8.30pm. As he
approached the centre, he noticed paramedics headed towards C wing as a
prisoner had attempted suicide. After completing the log book, the officer went
to assist on C wing. Soon afterwards, he was required to escort the prisoner to
outside hospital and so did not return to A wing until the following night.
136. Another officer relieved the A wing officer of his duties. He carried out the night
checking procedures as normal and checked any prisoners on an ACCT, as
well as those that were category A. At the end of his shift, the relief officer
carried out a full roll check count. On checking the man’s cell, he saw him in
bed. He appeared to be asleep.
Events on Friday 13 July
137. On the morning of Friday 13 July 2007, a wing officer arrived on A wing at
7.30am to start her shift. She attended the usual morning briefing meeting in
the wing office. Staff were told that the man and another prisoner had had their
ACCT documents closed the previous day. They were also told, however, to
keep a watchful eye on the two men.
138. Around 8.00am, the officer made her way up to the third landing where the man
was located. The general call was given for all prisoners to be unlocked and,
along with another officer, she unlocked the cells on the third landing. On
arriving at the man’s cell, the officer unlocked it and continued to unlock other
cells along the landing (the officers would then return to make sure that all
prisoners were awake). When the officer completed the unlock, and conscious
that the man’s ACCT document had recently been closed, she returned to his
cell to check on him.
139. The officer pushed the man’s cell door open and thought that everything looked
normal. She told my investigation that the man was lying in bed on his back as
usual, was half dressed and his legs were spread apart. He appeared to be
asleep and so she called to him to wake up. There was no response. For
safety reasons as a woman officer, the officer called her male colleague to the
26
cell to try and wake the man up. The female officer in the cell remained at the
cell door whilst the male officer went in.
140. The male officer told my investigators that he walked up to the side of the bed
and tried to wake the man. Having received first aid training, he checked him
for signs of life. There was no response. The female officer heard the male
officer say that something was wrong, and so called to two other officers on the
landing. One of those officers came into the cell and pinched the man’s leg to
see if he could get a reaction. His leg was cold and there was no response. As
not all officers carry radios, the female officer was told to call the Principal
Officer (PO) and healthcare staff. She proceeded to the wing office to do so.
141. At interview, the PO told my investigators that he was in close proximity to the
man’s cell when he noticed the female officer looking distressed. He recalled
her saying that she thought the man was dead, and saw her make her way
down to the wing office. As the PO was a wing manager, he used his radio to
contact the Communication Control Unit to request a member of healthcare
staff attend the wing immediately. He then proceeded to the man’s cell where
he was directed in by other staff. On entering, the PO touched the man’s wrist
and arm. Both were cold and stiff and he believed that the man was dead. The
healthcare nurse then arrived at the cell and took charge.
142. At interview with my investigators, another nurse said she was on duty on the
morning of 13 July. She had been rostered to be ‘Hotel 5’, which is the
emergency response for healthcare. A code blue alarm on A wing came
through over the radio at 8.06am. The nurse was aware that her colleague, the
first nurse to arrive at the cell, was working in the centre treatment room which
was next door to A wing. So that the alarm could be responded to quickly, she
telephoned and asked him to attend the emergency on A wing. The emergency
response nurse made her way to the healthcare treatments room to collect the
emergency bag, and then went on to A wing.
143. As the first nurse to arrive at the cell was not available to be interviewed during
the investigation period, his prison incident report was reviewed by the clinical
reviewer and my investigators. It shows that he arrived at the cell within two
minutes. He asked for an update of the situation and whether anyone had
attempted cardio pulmonary resuscitation (CPR) on the man. Staff had not yet
begun CPR so the nurse asked for the man to be laid flat on the floor so that he
could conduct further assessments with a view to starting resuscitation. Once
the nurse examined the man and observed that rigor mortis had set in, he
formed the opinion that the man had been dead for some time. Resuscitation
was therefore not carried out.
144. The emergency response nurse arrived at the man’s cell to find her colleague
dealing with the situation. As the first nurse on the scene said that he did not
require any further nursing assistance, the emergency response nurse
continued with the rest of her normal duties.
145. At interview with my investigators, one of the SOs present at the ACCT closure
meeting said that the female wing officer arrived in the wing office about two
27
minutes after the wing unlock call had been given. She had said that staff were
having difficulty waking the man, and she thought he was dead. The SO
immediately used his radio to notify the healthcare unit, and the two members
of staff made their way back to the man’s cell. On arriving, the healthcare
nurse was already in attendance. The female officer remained outside the cell.
146. An ambulance had been called and paramedics arrived at the prison at 8.12am.
Following their examination, they declared that rigor mortis had begun and that
the man displayed no signs of life.
147. The Governor told my investigators at interview that he was in the control room
when he heard the emergency call, code blue, on A wing come through
between 8.00am and 8.05am. He quickly made his way towards the main
prison. En route, a call was made over his radio for Victor 1 (the was a request
for the duty governor to attend A wing immediately). He arrived at the man’s
cell within ten minutes. Staff explained that the man had been found
unconscious and the PO was keeping a log. The man’s death was confirmed at
8.35am by the paramedics.
After the man’s death
148. The Governor ensured that the prison’s death in custody contingency plan was
followed and the control room contacted all the necessary parties including the
man’s next of kin and the police. He arranged a hot debrief later that day with
the staff involved and ensured staff completed incident reports. The Staff Care
and Welfare Team was deployed to support staff, especially the officers who
had had found the man. They were given the opportunity to be relieved of their
duties for the day.
149. All prisoners on a current ACCT document, or one that had been recently
closed, were reviewed. The Governor asked staff to be aware of any changes
in prisoners’ behaviour and moods.
150. The man’s cell was sealed. When the police later arrived, copious amounts of
different medications were found in a cabinet on the wall. Numerous blister
packets were also found in the wastepaper bin. A handwritten letter was found
within an envelope and this was addressed to one of the man’s friends. The
letter indicated that the man had taken an overdose of his medication.
151. The following medication was recovered from the man’s wall cabinet:
(cid:127) Simvastatin 40mg
(cid:127) Gabapentin 300mg
(cid:127) Salamol inhaler
(cid:127) Tildiem
(cid:127) Metformin 500mg
(cid:127) Aspirin 75mg
(cid:127) Beclometasone Inhaler
(cid:127) Nitromin spray 400mg
(cid:127) Glyceryl TNT spray 400mg
28
(cid:127) Empty unlabelled bottle
(cid:127) Empty bottle of gabapentin (issued 3/7/07 - should have contained 84
capsules)
(cid:127) Salbutamol inhaler
(cid:127) Tube of ibruprofen pain gel cream
(cid:127) Saccharin 12.5mg
152. The following empty blister packets were found in the wastepaper bin:
(cid:127) Four empty packets of tildiem (diltiazem) 200mg which should have
contained 14 tablets each
(cid:127) Six empty blister packets of gabapentin 300mg capsules - each packet
should have contained 10 capsules
153. A total of 56 tildiem 200mg and 60 gabapentin 300mg capsules was missing.
Post Mortem
154. The post mortem results found that the man had ischaemic heart disease. It
was this, coupled with a mixed drug overdose of diltiazem, gabapentin and
paracetamol, that caused his death.
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ISSUES CONSIDERED IN THE INVESTIGATION
Mental healthcare
155. The man remained on an ACCT plan for a long time, but never actually harmed
himself. But even before he was transferred to Wakefield in July 2006, he had
made his intention to take his life very clear. He reiterated this intention to the
nurse during his reception screening on arrival at Wakefield. Despite this
admission, and the fact that – as the clinical review shows – the man fitted the
referral criteria, a referral was not made to the mental health in-reach team.
156. It was not until October 2006 that the man was assessed by a mental health
nurse (he presented no signs of mental illness). After this, the in-reach team
attempted to assess and support him on numerous occasions, but on most
occasions he was resistant. However, he did accept healthcare attention to his
physical needs.
It is recommended that consideration be given to all new receptions
receiving oversight from a Registered Mental Nurse. (This
recommendation was also made in a previous clinical review carried out
by this reviewer in June 2007.)
In the interim, all nurses and the doctors should receive an urgent update
upon the implementation of referral protocols to Mental Health In-Reach.
Stockpiling of medication
157. No risks had been associated with the medication the man had in possession
or indeed his IP status. At interview with my investigating officers, wing staff
said that during routine cell searches they would not normally question
medication found in a prisoner’s cell, so long as it was clearly labelled as
belonging to them. Staff were also not necessarily aware of what medication a
prisoner was taking. This was described as the responsibility of the healthcare
team.
158. Given the profile of its population, security is a prime consideration at
Wakefield. The most recent IMB report (2007) said that the establishment had
seen in increase in the number of wing (cell) searches and searches carried out
in the workshops. Staff told my investigators that routine cell searches are
carried out approximately every six weeks. The man’s cell was last searched
on 22 June 2007 when it was recorded that ‘Nil’ was found. This search made
no note of the large quantity of IP medication the man obviously should have
had in his possession.
159. The clinical reviewer comments that he found there can be a different
nurse/healthcare officer present in the treatment room each day giving out
medication to prisoners, and that they rely on prison officers updating them on
the ACCT status of an individual. The prison pharmacy confirmed that they
were not made aware of prisoners on an open ACCT.
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160. When the man received a duplicate prescription, it resulted in him receiving a
total of 252 gabapentin capsules in possession over a period of nine days. The
original 84 supplied to him on 3 July were never reclaimed, presumably
because the pharmacist/healthcare staff were unaware of the error.
161. Since the man’s death, Wakefield PCT has taken steps to improve
communication and record keeping by running workshops for staff. A new
system has also now been implemented and the pharmacy receives a daily
record of every prisoner who is subject to an ACCT plan.
It is recommended that a procedure should be put in place to retrieve
medication that has been changed or stopped before the new supply is
given to the patient to prevent excess medication being held in
possession.
162. The post mortem report highlighted that paracetamol was one of the drugs on
which the man had overdosed. According to his medical record, he was last
issued with eight paracetamol tablets on 13 December 2006. Where he
obtained the additional paracetamol (assuming he had not stored it from 2006
or earlier) is unknown. Other prisoners suggested that the man tried to buy
medication for recreational purposes, but there is no further evidence to support
this. It is quite possible that having obtained paracetamol, he took it to alleviate
the stomach pain he was reported as having the evening before his death.
163. I believe staff should be more vigilant when carrying out cell searches in
checking medication.
The Governor should remind staff that, should they discover large
excesses of IP medication, advice should be sought from a member of the
healthcare team.
Medication risk assessment
164. The clinical review lists a number of recommendations. It was known by all on
the wing that the man received regular medication and was deemed suitable to
hold it himself. However, despite his repeated spoken intention to take his own
life, a risk assessment had not been completed in relation to the medication he
was taking. This was despite his admission, at the reception screening
interview, that he had once tried to commit suicide by taking an overdose.
165. The risk assessment tool is a multi-disciplinary document involving input from
the healthcare nurse, the pharmacist and the doctor. The outcome would have
decided if the man should be allowed in possession medication and, if so, for
how long. Had this occurred, it might not have prevented his death but staff
would have been able to review the amount of medication he was in possession
of at any one time.
166. I am pleased to report that since the man’s death the risk assessment
document has been reviewed and amended in respect of its use. The
medication gabapentin has also been reviewed and had now been added to the
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high risk column of drugs. Although I make no formal recommendation, it would
be sensible for this new process to be fully documented.
Closure of the ACCT document
167. The ACCT guidelines state that reviews should include the key people who
know the person at risk or are involved in their care. However, the man’s
persistent refusal of mental health intervention meant that there was an
absence of multi-disciplinary input at a number of his ACCT reviews.
Furthermore, when the ACCT document was closed, there was still no
reference to any input from the in-reach or healthcare team.
168. The guidelines also say that a ‘case review team’ should be present to close
the ACCT document. Staff had previously discussed and agreed the man’s
monitoring would cease so it was of no surprise when it eventually was. It was,
however, closed by only one member of staff (the case manager). Given that
the closure of the ACCT document had been discussed for some time, I think
there were mitigating circumstances. However, the case manager told my
investigators that he was unaware that a team had to be present when closing
the ACCT document. The man who died’s review was not the only one
conducted with a single member of staff.
169. I agree with the clinical reviewer’s comments that the closing of the ACCT
document may not on this occasion have been influenced by the lack of
healthcare input. I also appreciate that there can be restraints on staff
availability to attend reviews. However, the quality of decision-making is self-
evidently weakened if a range of staff and disciplines are not involved. It was
for exactly this reason that the ACCT system was introduced.
170. I am pleased to say that, since the death of the man, the Governor has
reissued a notice to all staff reminding them that ACCT reviews should not be
conducted single-handedly. My recommendation is simply to confirm the
importance that I attach to this.
The Governor should remind staff that all ACCT reviews should be
attended by a multi-disciplinary panel.
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CONCLUSIONS
171. The man who is the subject of this report was a damaged man who had
threatened to take his own life over a period of years. However, while he had
experienced some significant bereavements, he seemed to show an
improvement in his general wellbeing in the time he was at HMP Wakefield.
The fact that he had never actually attempted to self harm during two years led
staff to believe he was using his suicidal threats to manipulate them. Although
the process was flawed, I do not think the decision to close the ACCT form on
the day before his death can be criticised. I do not think that staff had any
reasonable grounds for thinking he was at particular risk.
172. This investigation has shown that staff consistently offered support to the man
throughout his time in custody.
173. It is possible that the chance event that he had been provided with surplus
medication presented itself as an opportunity for the man to take his own life. It
was further chance that this coincided with closure of the ACCT document.
However, as he was in receipt of regular medication without proper risk checks,
he could have taken his life at any earlier point. And while he suffered from
angina, there is no reason to suppose that he was aware of the extent of his
heart disease.
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RECOMMENDATIONS
1. It is recommended that consideration be given to all new receptions
receiving oversight from a Registered Mental Nurse. (This
recommendation was also made in a previous clinical review carried out
by this reviewer in June 2007.)
2. In the interim, all nurses and the doctors should receive an urgent update
upon the implementation of referral protocols to Mental Health In-Reach.
3. It is recommended that a procedure should be put in place to retrieve
medication that has been changed or stopped before the new supply is
given to the patient to prevent excess medication being held in
possession.
4. The Governor should remind staff that, should they discover large
excesses of IP medication, advice should be sought from a member of the
healthcare team.
5. The Governor should remind staff that all ACCT reviews should be
attended by a multi-disciplinary panel.
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