Individual at Wakefield

Investigation into the circumstances surrounding
the death of a man in hospital whilst a prisoner at HMP
Wakefield in January 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2010
This is the report of an investigation into the death of a man. He was a prisoner at
HMP Wakefield and died at 12.57pm in January 2008 at hospital. He appears to
have taken an overdose of paracetamol three days before his death. He was 34
years old.
The loss of a loved one is always distressing and I extend my condolences to the
man’s family. I hope that my investigation helps them to better understand the
circumstances surrounding his death. I must also apologise for the delay in issuing
this report.
The investigation was carried out by my colleagues. A clinical review was
commissioned from the local Primary Care Trust and this was completed by a clinical
reviewer with the assistance of a pharmacist. I would like to thank them for their
observations and recommendations.
I am also grateful to the then Governor of HMP Wakefield and her staff for their co-
operation and assistance during this investigation. Particular thanks go to the most
efficient liaison officer.
The man was a troubled young man who, 15 years into a life sentence, was still
having difficulty coming to terms with the enormity of his offence. In my reports, I do
not usually go into great detail about the offences leading to imprisonment.
However, in this case his offence and his reaction to it was relevant to his state of
mind at the time of his death. He had also recently been told that he had multiple
sclerosis, a progressively debilitating illness that would make him increasingly
dependent on others. His mobility and general physical health was deteriorating and
he had taken the decision to give up a job he loved.
I make five recommendations to the Governor, the majority of which relate to the
assessment and support given to prisoners who might be at increased risk of self-
harm. I have also commented on the support given to disabled prisoners at HMP
Wakefield. Most significantly, the report draws attention to Wakefield’s former
practice of allowing prisoners up to eight paracetamol tablets at a time, without
keeping any record. This practice was reversed during the course of the
investigation. Given the evident dangers of even modest quantities of paracetamol
and the capacity for stockpiling, it is to be hoped that this practice is not in place in
any other jail.
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.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2010
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CONTENTS
Summary
The investigation process
HMP Wakefield
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man died in hospital at 12.57pm in January 2008. He had told staff at HMP
Wakefield at 9.44pm on 4 January that he had taken an overdose of 40 paracetamol
tablets 24 hours earlier. He was 34 years old.
In 1991, when the man was 18 years old, he was sentenced to life imprisonment.
He had no previous convictions. He was categorised as a category A prisoner (a
prisoner who would be highly dangerous to the public, police or national security if
they were to escape) and remained so until his death.
The man was a quiet man who found social situations difficult. He did not mix with
many other prisoners and had a small group of friends. He was assessed as being
unable to deal with negative emotions, and found it very difficult to come to terms
with his offence. He did agree to attend an offence related treatment programme in
1998, but had difficulty in demonstrating any empathy with his victims. During the
course, he also disclosed new information about his offending and was assessed as
being at a higher risk of offending at the end of the course (which he was advised to
repeat). This assessment marked a turning point for him. He refused to participate
in the sentence planning process thereafter, in the belief that he would never be
released from prison.
Throughout his time in custody, the man had periodic bouts of depression. This was
particularly so in the winter months, when he would engage in non life-threatening
self-harm. He was prescribed anti-depressant medication to help control his mood
swings.
The man had worked in the Braille Unit at Wakefield for approximately ten years and
was very highly thought of by the instructional staff. He loved this work and was
committed to the unit. He trained others, and had designed a bespoke computer
programme to improve the transcribing process.
In October 2000, the man started to complain of pins and needles in his legs, but the
sensation soon stopped and was put down to a muscle strain. In November 2002,
he complained of paraesthesia (an unusual tingling or burning sensation on the skin)
down his leg, muscle numbness and problems with his eyesight. He was referred for
tests but refused to attend external hospital appointments. An X-ray showed no
abnormality.
He continued to complain periodically of paraesthesia and problems with his vision.
He was diagnosed with a vitamin B12 deficiency in September 2006 and prescribed
injections which seemed to help his sight. He continued to refuse to attend hospital
appointments until he saw a Consultant Neurologist in May 2007 when the possibility
of multiple sclerosis was first discussed. He then realised that he needed to accept
medical help, and in July 2007 agreed to attend appointments and take all
prescribed medication.
The diagnosis of multiple sclerosis was confirmed in August, by which time the man
was already having problems with walking. He was described by Wakefield’s
Disability Liaison Officer as being “frail and unsteady on his feet”.
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At the end of June 2007, the man was moved from C wing to D wing as a result of a
hole being discovered in his cell. He was also put onto the Escape list which meant
increased security precautions whenever he left the wing. He found this change very
unsettling and he initially struggled to make new friends.
During the second half of 2007, his health deteriorated and he was provided with the
use of a wheelchair to get to work. The use of the wheelchair caused considerable
confrontation and upset with staff. He tried to commandeer the chair for his sole
use, but it was eventually withdrawn in December on medical advice.
Also in December, the man decided that he was physically unable to carry on
working in the Braille Unit. He requested and was given medical retirement. Staff
and prisoners who knew him, including his psychiatrist, all said that he gave no
indication of any intention to take his own life.
On the evening of 4 January 2008, the man pushed a note under his door and rang
his cell bell. The note said that he had taken 40 paracetamol tablets 24 hours
previously, was in a lot of abdominal pain, and had been sick.
The night officer immediately summoned assistance and the man was assessed by a
nurse. The nurse took advice from the 24 hour helpline at the Poisons Unit. They
said that the prescribed medication that he was taking would heighten the effect of
the paracetamol, and that the vomiting could be a sign of liver failure. An ambulance
was called and he was very quickly escorted to hospital. He slipped into a coma the
next day and died. His family saw him before he went into the coma and were with
him when he died.
The toxicology report says that the level of paracetamol in the man’s blood was 16.4
mg which, if not treated within 24 hours, is potentially a fatal overdose.
I make five recommendations and recognise the quick and professional response of
the nurse. I also comment on Wakefield’s then policy that wing staff could give
prisoners eight paracetamol tablets at a time on request, with no record being kept.
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THE INVESTIGATION PROCESS
1. Two investigators carried out this investigation on my behalf. The first
investigator made initial contact with the then Governor of HMP Wakefield and
formally opened the investigation on 15 January 2008. She met the Governor
and the then Chair of the Independent Monitoring Board and a representative of
the local branch of the Prison Officers’ Association. She also visited the man’s
cell on D wing and the healthcare centre.
2. All available documents likely to be required for the investigation were collected
or requested at this time. During the course of the investigation, the investigator
kept the incoming Governor informed of progress.
3. Notices were issued to staff and prisoners. The notices announced the
investigation and invited anyone who had information about the man’s death to
make themselves known to either investigator.
4. My investigators visited the prison on 1, 2 and 3 April. They conducted six
interviews with relevant prison staff and three with prisoners who knew the man.
This report is based on these interviews and a review of all relevant paperwork
including the man’s clinical records.
5. The incoming Chair of the Independent Monitoring Board (IMB) asked to be
interviewed. During the interview, he raised concerns regarding the procedure
for secondary dispensing at Wakefield. My investigators considered his
evidence. However, as it concerned the dispensing of prescribed medication, it
was considered to be outside the terms of reference for this investigation and
therefore not included in my report.
6. The clinical reviewer and his assistant were nominated by the local Primary Care
Trust to conduct a clinical review of the medical care the man received whilst in
custody. The review team interviewed the nurse at Wakefield on 16 April. They
shared their initial findings with senior members of the healthcare team at
Wakefield on 22 May 2008.
7. My investigator contacted HM Coroner to inform him of the nature and scope of
this investigation and to request a copy of the post mortem report. Upon
completion, a copy of this report will be sent to the Coroner to assist in his
enquiries.
8. One of my Family Liaison Officers contacted the man’s mother and father to
inform them of my investigation and offer them the opportunity to raise any
concerns that they wished us to address. The man’s father raised two matters.
The first concerned the issue of medication. The second was whether the
stomach pain the man complained of could have been a symptom of a problem
with his arteries (the post mortem report identified severe clogging of the
arteries). The issue of medication is addressed within my report. The post
mortem report clearly records that the cause of the man’s death was paracetamol
poisoning, and therefore the cause of stomach pain falls outside the scope of this
investigation.
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9. A copy of the draft report, including the clinical review, will be sent to the family
once completed. I hope that my investigation has helped them to better
understand the circumstances leading up to the man’s death.
7
HMP WAKEFIELD
10. HMP Wakefield is a high security prison for men. It is one of eight high security
prisons in England and Wales and has a centre for life sentenced prisoners. In
its current form, the prison dates back to 1845 and the wings are arranged in the
Victorian-style radial system. The prison can accommodate approximately 700
prisoners, including a maximum of 100 category A prisoners (prisoners who
would be highly dangerous to the public, police or national security if they were to
escape) and ten high risk category A prisoners.
11. There are four accommodation wings, A, B, C and D, all built on four levels. All
cells are single occupancy, each wing has shower and cooking facilities for the
prisoners and there are snooker and pool tables for recreation. D wing has 183
cells over the four levels. At the time of the man’s death, there were 25 category
A prisoners living on the wing. Each landing has three officers during the day
and each wing has one officer during the night time.
12. HMP Wakefield provides 24 hour nursing care and has a 20 bed inpatient facility.
Primary care is provided by the local Primary Care Trust and a mental health in
reach service is contracted to the Mental Health Trust.
13. The prison’s Independent Monitoring Board’s report for 2007/2008
“acknowledges the good work being done in all departments of the prison.” In
particular, it refers to the improvements being made in the healthcare
department. It highlights a number of areas of concern, none of which is relevant
to the man’s death.
14. HM Chief Inspector of Prisons carried out an unannounced inspection of
Wakefield in 2005. She concluded that:
“Overall, Wakefield was clearly a prison on the move.”
15. There were five deaths in custody at Wakefield in the eight months preceding the
man’s death. Four were as a result of natural causes and one was apparently
self-inflicted.
8
KEY FINDINGS
16. The man was sentenced to two life sentences on 25 October 1992. He had been
convicted of the murder of a woman known to him and the murder and rape of a
child. He was given a tariff of 25 years. (A tariff is the minimum period a life
sentence prisoner has to serve in custody.) This was reduced to 20 years in
2000. His first parole review was due in March 2008. He was classified as a
category A prisoner and remained so throughout his time in prison.
17. The man was 18 years old when he first entered custody, and had no previous
convictions. A Social Enquiry Report (now known as a Pre Sentence Report)
prepared by the Probation Service described him as quiet, withdrawn and leading
a chaotic lifestyle. He was prone to violent outbursts and had problems
communicating, made worse by a speech impediment. The early documentation
also records that he took an overdose while in the police cells shortly after his
arrest. However, interviews with forensic psychiatrists at the time of his
conviction did not identify any mental illness.
18. His prison records document a second self-harm attempt by the man in 1991. He
was noted as being withdrawn and uncommunicative, but had shown some
improvement by the time he was transferred to HMP Wakefield in December
1994 when he was 21. There were further recorded instances of superficial self-
harm in 1994, 1998, March and May 2005, and in January 2006.
19. It is clear from prison records that the man was not a problem for prison staff.
Although he was quiet, he would challenge decisions that he thought were wrong
but did so politely and usually following the complaints procedure. He did not mix
with many other prisoners, keeping himself to himself and having a small group of
friends. He would not volunteer information to staff but would answer questions if
asked. His mother and father kept in regular contact with him and offered
considerable support.
20. The man started work in the Braille Unit in December 1997 and excelled as a
transcriber, often teaching new prisoners the required skills. He worked within
this unit until he retired on medical grounds in 2007. His work was highly praised
by the officer who runs the unit.
21. Early in his sentence, the man had been assessed as needing to attend the Sex
Offender Treatment Programme (SOTP). SOTP is a cognitive behavioural
programme made up of 210 hours of group work, designed to identify and
address distortions in the thinking process. Prisoners are risk assessed at the
beginning and the end of the programme to measure any change in their risk of
re-offending. He completed the programme in August 1998 but had some
difficulties in addressing some of the victim awareness issues and in
demonstrating empathy towards his victims. He also disclosed new information
with regard to his offending. As a result, the tutors assessed his risk of re-
offending to have increased at the end of the programme and recommended that
he should repeat it.
9
22. The man reacted with anger and extreme frustration to this recommendation, and
from 1999 refused to discuss his offence or engage in the sentence planning
process at all. (Sentence planning is the process by which relevant staff across
the prison and the external probation officer meet with prisoners to agree targets
to reduce the risk of re-offending.) He refused to attend these meetings or any
meetings with staff to discuss his progress.
23. According to prison records, the man converted to Buddhism in September 2000.
No reason is documented for this conversion but it was formally approved by the
chaplaincy.
24. At a Life Sentence Planning Board in December 2001, the man’s external
probation officer suggested that he had come to the conclusion that he would
never be released and therefore did not need to undertake any offending
behaviour work. This view was documented by the man himself in a letter to
another probation officer in 2000 and again in a complaint form in 2005.
25. In 2003, a trainee forensic psychologist reviewed the man’s assessment reports.
She concluded that he needed help in problem-solving and dealing with negative
emotions, in particular those that would result from addressing the issues around
his offending. She recommended that he attend a Stress Management course
and the Enhanced Thinking Skills programme.
26. The man maintained regular contact with his mother and father until 2005, when
he decided that he did not want any external contact at all. He also self-harmed
on two occasions during this year, burning his arm with a cigarette and scratching
“nonce” and “retard” into his arm. He was placed for a week on monitoring under
the provisions of a F2052SH self-harm document to ensure closer observation
and support from staff. (The F2052SH process has since been replaced by the
Assessment, Care in Custody and Teamwork (ACCT) procedures.)
27. He refused to participate in the sentence planning process until 2006, when he
attended the Stress Management Course. However, he still refused to attend the
sentence planning meetings. He then agreed to be assessed by a second
trainee forensic psychologist. Following this interview, the man wrote to her
complaining of a breach of confidentiality and said that he would not
communicate with the Care Management Team in future.
28. In the past, the man had been reluctant to seek mental health support but had
admitted to low moods during the winter for which he had been prescribed
Sertraline, an anti-depressant. He sought further help with his condition and was
assessed by a nurse from the mental health in-reach team on 10 October 2006.
A Threshold Assessment Grid (a way of assessing the severity of a person’s
mental health problems) was completed. His score did not give cause for
concern. However, he was referred to a Consultant Forensic Psychiatrist, at his
request, for support in coping with a possible seasonal affective disorder (low
mood in winter months).
29. The Consultant Forensic Psychiatrist first saw the man six days later and he
remained under his care until the time of his death. The psychiatrist noted that
10
during the time he worked with him, “His mood was stable and I had no major
concerns about his mental state … He never gave any signs of suicidal intent.”
30. The man first complained of pins and needles in the back of his legs on 16
October 2000. This was thought to be the result of a strain doing yoga exercises
and the sensation was recorded as having cleared at a follow up appointment a
week later. He next complained of paraesthesia (an unusual tingling or burning
sensation on the skin) down his leg, muscle numbness, and problems with his
eyesight, in November 2002. He was referred for X-rays and to an optician. The
X-rays showed no abnormality and he refused to attend the eye clinic or go to
any outside hospital appointments.
31. The next recorded mention of paraesthesia was in November 2005. X-rays and
blood tests were normal, but the man continued to experience sensations in his
legs and he was referred to a neurologist on 30 March 2006. He was diagnosed
with a vitamin B12 deficiency - which can cause pins and needles and problems
with vision - for which he was prescribed vitamin B12 injections. Six months
later, his medical notes record an improvement in his vision.
32. A consultant neurologist examined the man in November 2006 and requested an
MRI scan. He again refused to attend hospital for appointments until 22 May
2007. He then had an appointment with the neurologist, who first raised the
possibility of him having multiple sclerosis (MS) and requested further tests. The
man was recorded as saying that he did not want to discuss any diagnosis until it
had been confirmed. However, he appears to have realised that he now needed
to accept medical help. On 3 July, he wrote a letter to say that he would no
longer refuse hospital appointments as he had in the past and would take all
prescribed medication. Six days later, he wrote another letter detailing his
symptoms. Neither of these letters has an addressee, and it is not possible to
say which, if any, staff read them.
33. The diagnosis of MS was confirmed on 17 August by the Specialist Registrar in
Neurology following the results of a lumbar puncture. The man had another
appointment at hospital on 1 October 2007 to discuss options for steroids and
disease-modifying drugs. At this appointment he also raised a problem with
urinary incontinence.
34. Prison records show that staff started to notice a deterioration in the man’s
physical health around June 2007. He was having trouble walking and requested
help in collecting his meals. An entry by the Disability Liaison Officer describes
him as “frail and unsteady on his feet”.
35. On 26 June 2007, during a routine search, staff discovered a hole in the wall of
the man’s cell around the sink area. It was decided to place him on the Escape
list (E list) and move him from C to D wing. As an E list prisoner, he was required
to wear distinctive clothing whenever he left his wing and he was subject to
greater staff supervision.
36. The man’s friend on C wing told my investigator that the man had denied any
thoughts of escape. He claimed that the hole was a result of recent
11
refurbishment, and that a number of other cells on the wing had the same holes.
As someone who found making friends difficult, the man was very upset by the
change to his routine and location. He was removed from the E list on 15 August
2007 but remained on D wing.
37. A disability file was opened for him but the date was not recorded. A Senior
Officer was responsible for overseeing support for disabled prisoners. In early
July, she told him that he could use a wheelchair if he needed to go any distance
off the wing, particularly to his job in the Braille Unit. Prison Service Order 2855
“Prisoners with Disabilities”, paragraph 6.8, says:
“Any form of aid to mobility (or to sensory perception) including
wheelchairs, whether specially adapted or not, crutches, sticks etc
need to be retained in possession, unless there is a good (and
defensible) reason not to. If Reception staff are concerned that there
may be a security risk involved, a risk assessment needs to be carried
out and a suitable alternative provided.”
The PSO also requires in paragraph 6.31:
“All prisons will normally have in place contingency plans for dealing
with fires that take account of persons with individual/special needs.
(Taken from Standard 18 Fire Safety). The PEEP (Personal
Emergency Evacuation Plan) should be drawn up for every prisoner
who may need assistance in the event of an evacuation. Wing and
activities staff should be aware of any prisoner who might need
assistance in the case of an emergency.”
The PEEP in the man’s file has not been completed.
38. The use of the wheelchair appears to have caused considerable conflict between
the man and wing staff. He was waiting to be measured for his own chair. In the
meantime, the wheelchair was a wing resource to be used by any prisoner who
needed it. However, he took possession of the chair, taking it into his cell and
even making a laminated sign for it stating that it was his property. Over the next
few months, he made little effort to walk at all and was becoming reliant on the
wheelchair.
39. The man wrote to the then Governor in September 2007 outlining the problems
he was experiencing in collecting his meals, cleaning his cell and using the
laundry. This letter was referred to the SO for a response. She went to see him
to give him information about the Disability Liaison Officer (DLO) on his wing.
The entry by her does not deal specifically with the practical issues raised by him
nor does it authorise a carer to assist him. (A carer is a prisoner who is paid to
help a disabled prisoner.) During interview, another category A prisoner said that
he took on this role from July 2007, but my investigator was unable to establish
when this had been formally sanctioned.
40. The man’s solicitors wrote on his behalf to the Governor on 26 November 2007,
seeking clarification on whether prisoners could keep wheelchairs in their cells on
12
D wing. The Governor wrote in reply, “I am informed that the man has no
difficulty in accessing any part of the wing regime. He is able to collect his meals
and associates freely on the wing”.
41. In late December, after a number of confrontations, the DLO withdrew the
wheelchair from the man, advising him that he needed to use his legs as much as
possible to keep them active. This action was taken on the advice of the
Consultant Neurologist. The man was also told it was unwise to “borrow”
equipment that had been measured for someone else. However, he could still
use the wheelchair for longer distances.
42. At the same time, the man requested and was granted medical retirement from
the Braille Unit. His health was deteriorating and he was no longer able to type
with both hands due to numbness in his fingers and dizziness. The Braille Unit
officer tried to dissuade him, advising that they could find him alternative work to
keep him occupied. He recognised that the man had loved his job in the Braille
Unit and thought that he was likely to deteriorate further if he had nothing to focus
on. The response was that he would read and watch television.
43. The man’s personal officer remembered the man asking him on 3 January 2008
to check whether anyone had been in touch about measuring him for his
wheelchair. He described the man as “very calm”, “not agitated or depressed
…To me, he didn’t give any signs that he was going to take his life.”
44. On the afternoon of 4 January, the man’s carer went to his cell to fill a flask with
water for him. He saw the man being sick in the sink, but thought he just had an
upset stomach. Later that evening, the man was in the cell of another prisoner,
playing Triominoes. The prisoner said that the man had vomited, bringing up
blood. He advised him to ask to see healthcare staff but he refused. The
prisoner said in interview that he informed a wing officer. My investigator was
unable to establish if this took place and, if so, the identity of the officer. The
prisoner said that, apart from the vomiting, the man was cheerful and had been
his usual self that evening.
45. Prisoners are locked in their cells for the night at 7.00pm on weekdays. The wing
is patrolled through the night by one officer whose shift officially starts at 8.30pm.
However, most night staff come in early and leave early by mutual agreement
with the day staff. On the evening of 4 January, the night officer on D wing
carried out the required checks on all prisoners and began his usual night
routines.
46. The cell call bell register shows that the man rang his cell bell at 9.44pm and the
night officer responded 40 seconds later. He opened the viewing hatch, looked in
and saw the man sitting on his bed. He asked if he was alright but he did not
respond. The night officer then noticed a piece of paper that had been pushed
under the cell door. It was a note from the man saying that he was in need of
medical attention. It said that he had not eaten a proper meal in 2/3 weeks, and
that he had been vomiting for last 24 hours and was in chronic abdominal pain.
The last paragraph said, “I have taken an overdose of approx 40 paracetamol
13
tablets about 24 hrs ago.” At that time, wing staff could give prisoners eight
paracetamol tablets at a time on request and no record was kept of the issue.
47. The night officer immediately went to advise the Principal Officer, who was in
charge of the prison. He then telephoned the healthcare centre and asked for the
duty nurse to attend. As the man was a category A prisoner, three prison
officers, a senior prison officer, and a dog handler, were all required prior to
unlocking his cell at night. The staff assembled very quickly. While waiting to be
escorted to D wing, the nurse checked the computer system and identified the
medication the man was taking.
48. The nurse arrived on the unit about ten minutes later and assessed the man.
She noted that there was evidence of vomiting in his cell toilet. She knew that 40
tablets was potentially a fatal dose of paracetamol and rang the national 24 hour
helpline at the Poisons Unit for advice. Having told the Poisons Unit that he was
taking prescribed carbamazepine (an anti-convulsant and mood stabilising drug),
she was advised that this would heighten the effect of the paracetamol and that
the vomiting could be a sign of liver failure.
49. An ambulance was called at 10.27pm and arrived at the prison at 10.33pm. The
ambulance left the prison at 11.02pm and the man arrived at hospital at 11.15pm.
50. The man’s condition deteriorated. The handcuffs were removed at the request of
the doctor and he was moved to the Intensive Care Unit. The prison’s Buddhist
Minister visited him. When asked why he had taken the tablets, he is recorded
as saying he felt down at the time.
51. The prison contacted the man’s parents and his mother, father, stepmother, sister
and brother-in-law all visited the following day. His mother, father and
stepmother were with him most of the day and night.
52. I have been surprised to learn that an officer was sent by a Governor to carry out
an Assessment, Care in Custody and Teamwork (ACCT) assessment for the
man’s on the morning of 6 January.
53. The man slipped into a drug induced coma and was placed on a life support
machine. Following attempts to resuscitate him, he was pronounced dead at
12.57pm on 6 January 2008. His father and stepmother were with him when he
died.
54. The Governor advised all staff and prisoners of the man’s passing and offered
support to anyone who felt they needed it.
55. The toxicology report confirmed that the level of paracetamol in the man’s body
was 16.4mg. This is potentially a fatal overdose if not treated within 24 hours.
56. The prison’s Family Liaison Officer made contact with the man’s mother and
father. They both attended a memorial service held in the prison chapel on 11
February and had an opportunity to speak with the Governor. After the memorial
14
service, the man’s friends from the Braille Unit sent letters of condolence and a
translated book to the family.
15
ISSUES
Medical care
57. In his clinical review the clinical reviewer identifies five areas of good practice
operating within the primary care services provided at Wakefield. However, the
man’s medical care was hampered on many occasions by his refusal to attend
hospital appointments. Multiple sclerosis is a disease that is difficult to diagnose.
The symptoms are unpredictable and vary from person to person, and there can
also be periods of remission when symptoms appear to subside. The clinical
reviewer is satisfied that, when the man complained of paraesthesia, appropriate
investigations were undertaken.
58. With regard to the man’s mental health, several psychiatrists who assessed him
came to the conclusion that he was not suffering from mental illness. He was a
quiet and withdrawn individual with a history of periodic self-harm which was not
linked to any intention to take his life. He often refused support that was offered
to him at these times. In later years, as his physical health deteriorated, he
appeared to be more accepting of help. He had agreed to see a psychiatrist who
remained responsible for his mental healthcare until his death. The psychiatrist
said that the man never gave any indication of suicidal intent. He also
recognised that, “a history of previous self-harm and coping with a disabling
physical condition would increase the risk of suicide but there was no indication
from my interviews with him”.
59. The practice at Wakefield at the time was that wing staff were allowed to issue
eight paracetamol tablets at a time to any prisoner who asked for them without
having to make a record. This is likely to have contributed to the amount of
paracetamol that the man was presumably able to stockpile and thus to take.
This practice – which, given the known dangers of paracetamol overdose, I am
bound to say I think was mistaken and lax – ceased during the course of my
investigation. I am pleased that this action has been taken. Paracetamol can
now only be obtained from the nurse during the regular issue of medication.
Significant events
60. From my investigation, it seems that the man found it very difficult to even think
about the offences he had committed. In the assessment report following his
completion of the SOTP, he was said to have admitted that he blocked his
emotions because he felt he could not cope with experiencing them and might
take his own life if he did. He evidently found the SOTP extremely difficult
emotionally. Being told that he would have to repeat this process triggered the
withdrawal from all contact with the sentence planning process. He seemed to
accept that he would spend the rest of his life in prison.
61. It is also clear that the man did not make friends easily. He was a quiet man who
kept himself very much to himself. Having spent seven years on the same wing,
the transfer from C to D wing must have been very unsettling. He was also
located on to the third landing. This meant going up and down stairs which was
already becoming a problem for him because of the onset of multiple sclerosis. I
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do not doubt that staff had good reason to transfer him if they believed he was
trying to escape. Security considerations are rightly paramount in the case of any
category A prisoner. However, a review of the documentation and his need for
peer support might have merited relocation back to C wing once he had been
removed from the E list. I also judge that location on the third landing was not
appropriate in the circumstances.
The Governor should review the process for allocating cells to ensure that
medical restrictions are taken into account within the constraints of
security.
62. The use of the wheelchair became a bone of contention between the man and
prison staff. It is clear from his disability file that the wheelchair had been offered
to help him when he had to travel some distance, in particular to get to the Braille
Unit. It was never intended for his sole use. However, this seems to be against
the spirit of the guidance in PSO 2855, “Prisoners with Disabilities” when it says
that aids to mobility should be retained in possession. In any event, he
commandeered the wheelchair and, as a result, it was not available for
communal use on several occasions. Subsequently, he was still allowed to use
the wheelchair: but only for longer journeys, not to get around the wing.
63. It is evident from the documentation and interviews that the man was starting to
have severe mobility problems. His personal officer said “he would literally have
to hold onto things to walk.” It is unclear from the documentation whether a
referral was made to the NHS for him to be assessed and measured for his own
wheelchair. However there are entries on the wing file that suggest this was
necessary. If this is accurate, and he was considered in need of a wheelchair,
the withdrawal of the chair without providing any substitute walking aid could
have affected his quality of life considerably. In hindsight, given the diagnosis of
MS, it seems to me that this matter could have been handled with greater
sensitivity.
The Governor should ensure that staff adhere to the requirements of PSO
2855, “Prisoners with Disabilities”.
64. The man’s inability to cope with negative emotions is further evidenced by his not
wishing to be told about a possible diagnosis of multiple sclerosis until it was
confirmed. He constantly refused to attend hospital appointments – in the hope,
perhaps, that it might go away. Once the diagnosis of multiple sclerosis was
confirmed, there is no evidence of any counselling being offered to him or any
consideration of activation of the ACCT process. Had this been considered, he
would have received greater support to come to terms with the diagnosis.
The Governor should advise staff that, when a prisoner is informed of a
progressive illness, they should consider whether it is appropriate to
activate ACCT support. This consideration should be clearly recorded in
the prisoner’s medical file.
65. The letter the man sent to the then Governor in September 2007, in which he
outlined the problems he was having with practical everyday living on D wing,
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was a cry for help. My investigator was provided with a copy of his disability file.
Information in it showed that staff clearly had tried to advise him and provide him
with information. However, there is a distinct lack of practical help recorded. It is
also disappointing to note the Governor’s response to the man’s solicitors in
November. His staff had obviously not researched the man’s situation with any
rigour prior to briefing the Governor to advise the solicitors that he “has no
difficulty accessing any part of the wing regime”.
66. The final significant event prior to the man’s death was his decision to seek
medical retirement. It is clear that he was committed to his work in the Braille
Unit. As a young man still facing many years in custody, this must have been a
very difficult decision for him to make. The request was approved by healthcare
staff, but again there does not appear to have been any consideration given to
providing him with additional support. In fact, the disability file simply notes that
the wheelchair was removed the next day.
The Governor should advise staff to consider what additional emotional
support is required whenever a long term prisoner is medically retired
before retirement age.
The Governor should ensure that the disability officer agrees and monitors
an action plan with the prisoner outlining how they will occupy their time
constructively.
The night of 4 January
67. Taking into account the significant events outlined above and the man’s previous
attempts at self-harm, it is possible that he took the paracetamol as a cry for help,
rather than as a determined attempt to take his own life. All staff and prisoners
who knew him and who were interviewed for my investigation were shocked and
surprised by his death. His personal officer who saw him on 3 January (the day
the man apparently took the paracetamol) said, “To me he didn’t give any signs
that he was going to take his life.” The second prisoner, who was with the man
on the evening of the 4 January, said that “he’d been his usual self”. The man’s
carer, said he was “flabbergasted” when he heard. It seems that no one who
knew the man had thought he would take his own life.
68. The fact that the man pushed a note under his door asking for help may also
suggest that he did not intend to die. We do not know if he knew the effect that
the paracetamol would have when combined with his other medication, or the
time period after which the dose would be fatal. We do know that he had a
history of non life-threatening self-harm when feeling down.
69. The nurse’s response to the emergency was timely and professional. She
managed to elicit important information regarding the man’s medication prior to
being taken to D wing. She quickly completed her assessment, checking his
physical condition and offering reassurance. She confirmed her findings with the
Poisons Unit, and was able to provide them with all the required information to
inform the decision of immediate transfer to hospital. Her quick and professional
approach is to be commended.
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70. The instruction by a Governor for an officer to conduct an ACCT assessment
with the man on the morning of 6 January was plainly unnecessary and
inappropriate. Sending an officer to conduct an assessment at this time could
have been seen as insensitive by both the man’s family and by bedwatch staff. I
am surprised that the Governor was not aware of feedback from escort staff at
the hospital that the man was in a coma and unlikely to survive. A simple phone
call could have avoided this happening.
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CONCLUSION
71. During his long time in prison, the man had difficulty coming to terms with his
offences. He was a quiet man who found it hard to make friends, and he was not
comfortable in social situations. He had a tendency to harm himself – it seems
as a release rather than as a serious attempt to take his own life – when he was
feeling down. He seems to have accepted that he would never be released from
prison.
72. The man had recently been told that he had a progressively debilitating illness
which would make him increasingly dependent on others. His mobility was
deteriorating and he had taken the decision to give up a job he loved. He was
unable to move around the wing easily, and the wheelchair that he had latched
onto as a way of maintaining some independence had been taken away, albeit
temporarily.
73. These circumstances would no doubt have made him feel “down” and may have
contributed to his decision to take an overdose of paracetamol. Whether this was
intended to end his life or to focus attention on his situation cannot be known.
74. Wakefield’s then practice of providing prisoners with up to eight paracetamol
tablets without keeping a record may have assisted the man in stockpiling the
number of pills he was to take. I think this former practice was most unwise, and
have been pleased to learn that a new policy has been put in place during the
course of this investigation. This has meant that I have had no need to make a
formal recommendation. Nevertheless, the NOMS Safer Custody and Offender
Policy Group and Offender Health will wish to consider if guidance should be
offered to all prisons given the evident dangers presented by even relatively
modest quantities of paracetamol.
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RECOMMENDATIONS
1. The Governor should review the process for allocating cells to ensure that
medical restrictions are taken into account within the constraints of security.
This recommendation was accepted. The response was:
“Medical prognosis/diagnosis made by Doctor/medical staff/Physio. Relayed to
relevant managers/ Disability Co-ordinator for reasonable adjustments to be
made within constraints of security. Allocated Accordingly.”
2. The Governor should ensure that staff adhere to the requirements of PSO 2855,
“Prisoners with Disabilities”.
This recommendation was accepted. The response was:
“Requirement of all staff to be familiar with PSO 2855 ‘Prisoner with disabilities’.
To be included as part of the SPDR [appraisal] process for this year. Disability
Liaison Advisors are available on each wing to offer advice and support to staff
and prisoners.
“Circulated to SMT (20/04/2009) to devolve into staff SPDRs 2009 to 2010.”
3. The Governor should advise staff that, when a prisoner is informed of a
progressive illness, they should consider whether it is appropriate to activate
ACCT support. This consideration should be clearly recorded in the prisoner’s
medical file.
The response was:
“The above recommendation implies that ACCT should have been activated to
provide long-term support to someone who is suffering from a progressive
medical condition. Palliative care should have been provided, but not, I would
suggest, under the auspices of ACCT.
The description of ACCT below does mention long-term needs but this is meant
in relation to situations such as repetitive self-harm.
ACCT is a care-planning system whereby staff can work together to provide
individual care and support to prisoners identified as being at-risk of suicide/self-
harm in order to:
(cid:127) Help defuse a potentially suicidal crisis or
(cid:127) Help individuals with long-term needs (such as those with a pattern of
repetitive self-injury) to better manage and reduce their distress.”
Paragraph 68 has been amended to clarify that the aim of the recommendation is
to provide support to prisoners to help them come to terms with a diagnosis,
rather than suggesting that ACCT is used as part of the long term medical
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support.
4. The Governor should advise staff to consider what additional emotional support is
required whenever a long term prisoner is medically retired before retirement
age.
This recommendation was accepted. The response was:
“A review of the current procedures around the medical retirement of Offenders
will be completed. This will also look at what additional support needs to be
provided to those offenders who have already been medically retired.”
5. The Governor should ensure that the disability officer agrees and monitors an
action plan with the prisoner outlining how they will occupy their time
constructively.
This recommendation was accepted. The response was:
“Multi Disciplinary Meeting established to ensure that a prisoner notified of a
progressive illness is supported and constructively occupied. Members of this
meeting will include:
(cid:127) Prisoner
(cid:127) Disability co-ordinator –DLA (Disability Liaison Advisor.)
(cid:127) Member of medical Team Doctor/ Nurse/ Mental Health Team/Physio
(cid:127) Prisoners Case Officer or designated Nurse (dependant on location.)
(cid:127) Representative from Prisoners Activity Area.
(cid:127) Manager from prisoner’s residential unit.
The action plan generated at this meeting will be actively managed by the Case
Officer or Nurse responsible for the prisoner. Advice and support will be available
from any of the above named staff in supporting the member of staff managing
the action Plan.”
Good Practice
The nurse’s quick and professional approach to the emergency when the man
revealed he had taken an overdose of paracetamol is to be commended.
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