Individual at Wandsworth

Investigation into the circumstances surrounding the
death of a man at HMP Wandsworth
in August 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2008
This is the report of an investigation into the circumstances of the death of a man on
Monday 20 August 2007. At 7.35am that morning, the man was discovered hanging
in his cell at HMP Wandsworth. Cardio pulmonary resuscitation was carried out, but
at 8.31am he was pronounced dead. The man was 46 years old and had been in
Wandsworth for five days.
I would like to offer my sincere condolences to the man’s family and friends on their
loss. A key objective of all my investigations is to ensure the bereaved family has
the opportunity to raise any concerns and contribute to my inquiries. The man had
nominated an elderly friend, whom he described as his “adopted” mother, as his next
of kin. Both her family, and the man’s relatives, were contacted by my family liaison
officer. I hope this report offers answers to their questions.
The investigation was led by my colleague who was assisted by another investigator.
A clinical review was conducted by Joint Medical Director, Wandsworth Primary Care
Trust, and I am grateful for his assistance. I would like to thank the Governors and
staff at HMP Wandsworth and HMP Gartree for their co-operation with this
investigation.
The man arrived at HMP Wandsworth from HMP Gartree on 15 August 2007 to
receive visits from his family. He had spent 18 months applying for the visits and
was said to be very excited about them. He was expected to remain in Wandsworth
for at least four weeks. However, in the early hours of 18 August the man self-
harmed and told staff that he felt threatened on the wing. He was placed on the
Prison Service’s self-harm monitoring and support procedures (ACCT), and moved
to the Onslow Centre which houses vulnerable prisoners.
The man was placed in a double cell with another vulnerable prisoner who had
mental health problems. Almost immediately, his behaviour began to deteriorate and
he continually expressed fear of other prisoners. On the day before his death, the
man said on more than one occasion that he intended to kill himself. Staff tried to
reassure him but they did not carry out a review of his risk of self-harm or increase
the frequency of observations.
It is clear from his records that the man had experienced great anxiety on two
previous occasions when he moved from one prison to another. Why he apparently
took his own life cannot be known. However, a number of failings, including poor
communication between staff and a lack of adherence to monitoring procedures,
may have increased his opportunity to do so.
I have made a number of recommendations, reflecting the seriousness of the
matters revealed by this investigation. I apologise for the delay in issuing this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2008
2
CONTENTS
Summary 4
The investigation process 5
HMP Wandsworth and HMP Gartree 8
Key findings 9
Issues 20
Recommendations 26
Annexes 27
3
SUMMARY
In September 2004, the man was sentenced to life imprisonment. He spent a year at
HMP Wandsworth before being transferred to HMP Swaleside. The following day,
the man self-harmed and said he was fearful of other prisoners. He was placed on
self-harm monitoring and support measures and there were no further incidents of
self-harm. On 14 October 2005, he was moved to HMP Gartree following his
request for a transfer.
At Gartree, he was located onto H wing. Three days later, he barricaded himself in
his cell and threatened to self-harm. Again he was placed on self-harm monitoring
and a mental health assessment stated that he had an “abnormal fear of coming to
harm”. It was decided to locate the man in Gartree’s healthcare unit, which is used
predominantly for prisoners who find it difficult to cope in the environment of the main
prison, rather then those with health needs. Neither the incident nor the mental
health assessment was written up in the man’s medical records.
The man remained on the healthcare wing and progressed very well. He obtained
certificates in basic literacy and secured a job within the wing. He had his own cell
and by all accounts was comfortable and stable.
In January 2006, the man made his first application for accumulated visits. He
wanted to go to a prison nearer London to receive visits from a close and elderly
friend who was in failing health. Population pressures meant that transfers were not
possible at that time. The man grew increasingly frustrated with the situation and
frequently put in written complaints to the prison and the Independent Monitoring
Board. He occasionally threatened to self-harm if his visits were not granted.
In July 2007, HMP Wandsworth agreed to take the man and he transferred there on
15 August. He was said to be delighted. However, after three days at Wandsworth,
he self-harmed and was taken to the Care and Separation Unit. An Assessment,
Care in Custody and Teamwork (ACCT) document was opened and he was moved
to the Onslow Centre, the vulnerable prisoners’ unit. He was located in a cell with an
extremely vulnerable prisoner who was awaiting transfer to an outside hospital for a
mental health assessment. This information was not known by staff on the wing,
although the man was known to be unable to care for himself and had received
warnings about the poor state of his cell.
Within a few hours, the man pressed his cell bell, expressed fear of other prisoners,
and asked to be moved off the wing. Staff told him this was not possible at the time.
Over the afternoon and following day, the man did not come out of his cell, nor eat
any meals, and on a number of occasions he said he would harm himself.
Throughout this time, and despite concern from some staff, his ACCT observation
level remained the same.
The man was last seen alive at 6.00am on 20 August 2007. He should have been
checked at least once more before 7.30am. The man was discovered hanging at
7.40am. Cardio Pulmonary Resuscitation was carried out but he was declared dead
at 8.35am.
4
THE INVESTIGATION PROCESS
1. My investigator conducted a preliminary visit to HMP Wandsworth on 22 August
2007 to open the investigation. She visited the cell where the man died. My
investigator also met the Governor of Wandsworth and his appointed liaison
officer. Subsequently, all the relevant documents were reviewed and a
chronology of events established. Feedback on the findings of the investigation
were given to the Governor and the prison liaison officer on a regular basis. It
is understood that Wandsworth is conducting an internal investigation regarding
a number of issues raised in the feedback.
2. Notices were issued to staff and prisoners telling them of the investigation and
offering the opportunity to speak with my investigators. No one came forward
as a result.
3. My investigators met representatives of the local branch of the Prison Officers’
Association and the Independent Monitoring Board (IMB). No specific concerns
were expressed. Numerous attempts were made to contact the officer in
charge of the police investigation, without success, as telephone calls were not
returned. My investigator informed one of the Coroner’s officers about this as
well as other aspects of the investigation.
4. Given that the man had been temporarily transferred from HMP Gartree, my
investigators visited the healthcare unit where he had been located. Gartree
was able to provide considerable additional documentation. Four staff
members were interviewed and one prisoner. My investigators met a member
of the IMB who had known the man as he had written to the Board a number of
times regarding his request for accumulated visits. The Board was shocked to
learn of his death but did not have any concerns regarding Gartree.
5. The Joint Medical Director at Wandsworth Primary Care Trust, undertook a
clinical review of the healthcare provided for the man. The clinical reviewer
conducted a number of joint interviews of medical staff with my investigator, my
investigator. He was provided with transcripts of these interviews and, in
addition, with copies of the man’s medical record.
6. Twenty-four members of staff, both discipline and healthcare, were interviewed
and a number of others were spoken to informally. Some staff members were
interviewed twice to clarify certain matters. Two prisoners at Wandsworth were
interviewed. However, the man’s cellmate in C wing was deported prior to the
start of the investigation, and consequently it was not possible to speak with
him. His cellmate in the Onslow Centre was also no longer at the prison, and
attempts to discover his whereabouts were unsuccessful. Recordings of three
telephone calls made by the man whilst at Wandsworth were made available to
my investigators.
7. One of my family liaison officers contacted the man’s niece. She expressed an
interest in the investigation and has appointed solicitors to represent her. The
man’s nominated next of kin was also informed of the investigation and given
an opportunity to participate.
5
8. A draft copy of this report was sent to the prison service. A number of factual
observations were made and four minor changes have been made. The Prison
Service made one comment asking that recommendations five and eight be
incorporated as one, which is repeated verbatim in the relevant section (on
page 26). The comment has not been accepted and the recommendations
remain unchanged as they refer to separate issues. No further comments have
been received and an action plan has not yet been submitted.
9. Solicitors representing the man’s niece were sent a copy of the draft version of
this report. Their comments have been noted but no changes to the report
were requested.
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HMP WANDSWORTH AND HMP GARTREE
HMP Wandsworth
10. HMP Wandsworth is a large category B local and remand prison in South West
London, built in 1851. With an operational capacity of 1,416 prisoners, it is the
largest prison in the United Kingdom and one of the largest in Western Europe.
Although the residential areas remain in the original buildings, there has been
extensive refurbishment and modernisation of the wings.
11. HM Chief Inspector of Prisons, Ms Anne Owers, conducted a follow-up
inspection of Wandsworth in 2006. She noted that it was an improving prison,
but with a significant way to go. The man was a resident in the Onslow Centre,
a unit of three wings that holds about 321 vulnerable prisoners. (Vulnerable
prisoners are those identified as needing protection from mainstream prisoners.
This is often due to the nature of their offence or their risk of being bullied.)
During the inspection, the Centre was found to have good staff-prisoner
relationships, with 75 per cent of prisoners in the unit saying that most staff
treated them with respect. Wandsworth’s healthcare services are provided by
Secure Healthcare and commissioned by Wandsworth Primary Care Trust.
12. There were seven apparent self-inflicted deaths at Wandsworth between 2005
and the man’s death. A death in January 2006, which has been to inquest,
found that a number of checks had not been carried out by staff as they should
have been. My investigators were told that Governor’s Orders had been issued
in response and we were provided with copies of these.
HMP Gartree
13. HMP Gartree is a category B prison. It holds life sentence prisoners in the first
and second stages of their sentence. Gartree has an operational capacity of
577 prisoners. Two new units were added in November 2006.
14. HM Chief Inspector of Prisons last reported on Gartree in May 2005 when she
found the prison wanting in its delivery of lifer services. She described Gartree
as “showing all the signs of a prison that had been drifting…” In respect of
healthcare provision, Ms Owers described the healthcare services as giving her
cause for serious concern. She was particularly worried that staff shortages,
coupled with inappropriate use of healthcare staff for discipline roles, was
leading to poor service delivery. There were 14 beds within the healthcare
centre, but only two of these beds had been allocated to clinical need. This
meant that healthcare staff were used to supervise non-patient prisoners,
thereby detracting from their clinical duties. This situation continues to date.
Prior to his transfer to Wandsworth, the man had been located on the
healthcare wing as a non-patient prisoner.
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KEY FINDINGS
15. The man was remanded into custody on 17 September 2003. A year later, on
29 September 2004, he was sentenced to life imprisonment with a 14 year
tariff. During this time, he spent 12 months in HMP Wandsworth.
16. On 14 September 2005, the man transferred from Wandsworth to HMP
Swaleside. The following day (15 September), an Assessment, Care in
Custody and Teamwork (ACCT) document (a system used by staff to manage
the care of a prisoner considered to be at risk of harming themselves.) was
opened at Swaleside after the man cut his arm using a razor blade. He was
placed on constant observations in a gated cell in the healthcare wing. At the
time, the man described having a sudden drop in mood upon his arrival at
Swaleside and said the self-harm was impulsive. He mentioned being scared
of other prisoners and requested a transfer. The ACCT was closed on 30
September. On 14 October 2005, the man arrived at HMP Gartree.
17. An F2052SH (a self-harm/suicide monitoring document used prior to the
general introduction of the ACCT) was opened on 17 October 2005 at Gartree
after the man barricaded himself in his cell on H wing and threatened to self-
harm with a razor blade. Again, the man said that he was scared of other
prisoners and did not want his cell door unlocked. On 19 October, he was
moved to the healthcare wing.
18. On 22 October, the F2052SH was closed without any incident of self-harm.
The same day, the man was seen by the Mental Health Liaison Team at
Gartree and a clinical risk management assessment was completed. The
assessment concluded that the man had an abnormal fear of coming to harm,
and his behaviour could become unpredictable in panic causing situations
which might result in self-harm. The advice given was to remove the man from
any such situation. Neither the barricading incident and subsequent ACCT, nor
the assessment, was recorded in the continuous medical record.
19. My investigator interviewed the head of healthcare at HMP Gartree. The head
of healthcare explained that the man had remained on the healthcare wing
following his initial self-harm episode. She said that although it is a healthcare
wing staffed by nurses, the majority of the prisoners are those deemed to have
difficulties coping on the main wings and potentially vulnerable. The man was
considered to be in this category. She said that these men are not necessarily
classed as patients, but as prisoners who occupy healthcare because it is
considered to be quieter and staff are able to give more time to them as
individuals. The prison has no other facility for ‘poor copers’, nor a vulnerable
prisoner wing.
20. The 14 cells in healthcare are all single occupancy and lead from one corridor.
The head of healthcare described the regime as “very relaxed”. She explained
that prisoners “can still access all that the prison offers but they reside in the
healthcare.” However, if prisoners do not want to mix with prisoners from the
rest of the prison, they can remain on the wing during the day.
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21. At Gartree, the man settled well. He made good progress with his reading and
writing and worked in healthcare as a cleaner and painter. In February 2007,
he became an enhanced prisoner. He was popular with staff and prisoners. A
friend on the wing said that, despite his size (he was six feet tall and of heavy
build), he remained very afraid of prison and had difficulty in understanding
things unless they were properly explained.
22. On 20 September 2006, the man made an application to determine his
suitability to undertake the offending behaviour courses available at Gartree
which were necessary for him to achieve his Parole Board goals. The man’s IQ
had been assessed prior to his sentence and was found to be low. This
prevented him from attending the courses. He was referred by the psychology
department to a psychiatrist to see whether a referral to a specialist service was
needed to help him progress. A number of appointments were made but were
cancelled at short notice by the visiting consultant psychiatrist. The man made
a number of formal complaints about this.
23. The man first applied for accumulated visits in January 2006. Accumulated
visits can be arranged for prisoners who are unable to receive visits in their
current prison. The reasons may be due to the travelling distance involved for
friends or relatives, or their inability to travel due to age or ill health. In the
man’s case it was a combination of both these reasons. Prisoners are required
to have saved a minimum number of visits before applying. The application
process also requires staff who have direct contact with the prisoner to provide
information on their behaviour and other factors that may have a bearing on
their suitability. The man’s initial application was to go to Wormwood Scrubs to
receive his visits.
24. Following this initial request, the man made regular applications to go to any of
the London prisons. These requests were not facilitated because of the
population pressures at the time. When his applications were not granted, the
man often followed them up with formal complaints. He became increasingly
concerned about the health of his elderly friend who had become ill. On a
number of occasions in 2007, he said that he would harm himself if he did not
get his visits.
25. As well as formal applications through the standard process, the man wrote
directly to Governors as suggested to him by the IMB. In June 2007, the man
wrote to the Governor of Wandsworth. He agreed for the man to be transferred
to Wandsworth for the purpose of receiving his visits.
26. In interview, the head of healthcare was asked about her perception of the man
and her support for his application. She felt that he was so keen to go, and so
desperate to see his family, that along with the progress he had made she had
no hesitation in recommending that he went. The head of healthcare also
mentioned that, in her view, if the man had been unable to go, he would have
been at risk of self-harm. The head of healthcare said that she spoke with the
man about how he would cope in a London prison. He told her he would be
fine, and that he was not going permanently, and was reassured that his cell
would be kept for him at Gartree.
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27. On 8 August 2007, one of the man’s friends in the healthcare wing died in his
cell from natural causes. It is believed that the man was quite upset by this
and was reported to have asked to see a Listener later that day. (Listeners are
trained by Samaritans to provide confidential emotional support to fellow
prisoners in distress.)
28. On 14 August, the man received the news that he was going to Wandsworth for
his accumulated visits. Coincidently, the same day a member of the IMB had
planned to see him in response to an application he had made about his
request for visits. The IMB member told my investigators that she met the man
on the wing, that he was very happy about the news, and had said how much
he was looking forward to going. He ripped up his IMB application in front of
the IMB member and the head of healthcare and thanked them both for their
help. The head of healthcare saw the man on the day he left for Wandsworth
on his way to reception. She said that he was, “over the moon, skipping up the
wing and everyone was clapping and cheering and patting him on the back.”
29. A senior officer who had often processed the man’s accumulated visits
applications, was asked whether he ever had any concerns about the man’s
ability to cope at Wandsworth. He said he had not because he knew that the
man had been to other prisons, including Wandsworth before. He went on to
say that he was unsure whether or not staff at Gartree had been aware of the
man’s full history. The senior officer said that he had not been aware of the
man’s previous self-harming and he had never presented as having such
problems in healthcare.
30. On 15 August, the man arrived at Wandsworth from Gartree. Copies of various
documents would have been attached to the man’s application for accumulated
visits and viewed in advance of his arrival. His medical record arrived with him.
In reception, the man was interviewed and a cell sharing risk assessment
completed (this assessment is used to identify a prisoner’s suitability to share a
cell and any potential risks from locating one individual with another). The man
said that he had no concerns about sharing a cell. He was deemed at low risk
of self-harm. Based on the information provided by the man, he was
considered suitable for any location and was therefore placed in cell C1-13 of
the induction wing.
31. In June 2007, Wandsworth had started to monitor prisoners transferred in
through a ‘Singular Move Register’. My investigators were told that this had
been set up because prisoners were arriving without any record of which
member of staff had authorised the move. However, the man had not been
included on this list and it was not possible to find out who had authorised the
move and what preparations had been made for his arrival. Given that he was
a lifer, and in Wandsworth for accumulated visits, it might have been
appropriate to have located the man on a wing for long-term prisoners rather
than have processed him through C wing as an ordinary newly-remanded
prisoner.
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32. As part of the reception process, the man was assessed by medical staff. The
nurse saw him and wrote in his Inmate Medical Record (IMR), “seen in
reception, to see MO (Medical Officer) – on medication.” When the nurse was
interviewed, she recalled nothing of significance about the man and said she
referred him to the doctor as he was receiving medication. The prison doctor
wrote in his MR, “seen today, Simvastatin 20mg OD – for high cholesterol,
Erythromycin 500mg BD for spots, was here before, used to Wandsworth, Nil
suicidal ideation, Plan – prescribe meds.” The man’s prescription chart
indicates that he was given the medication in-possession for 28 days.
33. Later that evening, the man made telephone calls to family and friends whom
he was hoping would visit. A recording of a telephone conversation was made
available to the investigators. The man sounded very excited about being at
Wandsworth and said that he would see someone the next morning and would
send out the Visiting Orders (VOs). (A visitor must be in receipt of a Visiting
Order to visit. These are sent out by the prisoner in letters and enable the
visitor to book a time with the prison.) The process for accumulated visits can
differ from one prison to another, and it is not unusual for them to be arranged
only when the prisoner has reached the establishment where the visits are to
be held.
34. The following day (16 August), the man completed an application form. He
wrote, “…have come from HMP Gartree to this prison on the 15/8/07 for
accumulated visits. I have been at Gartree since 14/10/05. I have had no visits
at Gartree and have no Gartree VOs.” According to the form, an officer
checked and confirmed that the man was entitled to visits and he was given 22
VOs.
35. The man made another very short telephone call on 16 August. Again he
spoke about the visits and said that he was sorting them out. Some time during
the day, the man and his cellmate were moved from C1-13 to C3-06. This
would have been a routine move from the first night cells to another part of the
induction wing.
36. The following day (17August) at 11.05am, the man rang his friend again and
sounded slightly confused and not as upbeat as two days previously. He said
that he thought a visit had been booked but nobody had turned up. (This would
not have been possible as the VOs had not been sent out.) Again, he said that
he would be sending out some VOs and finished the conversation. (Following
his death a number of VOs were found amongst his belongings in his cell. This
would indicate that he had not sent out all, if any, of them.)
37. During the early hours of 18 August, the prison officer responded to the man
ringing his cell bell. The officer told my investigators that the man had cut his
arm and he gave instructions to the man to tie a towel around the wound. The
man had made a significant cut as the wound went lengthways from his wrist to
his elbow. At this point, the prison officer was unable to gain immediate access
to the cell (night staff do not carry keys on security grounds). He therefore went
and called the night orderly officer. (The night orderly officer is in charge of the
prison during the night and carries keys to access cells in an emergency.) The
11
man was taken to the treatment room and treated by a nurse with the night
orderly officer present.
38. While the man’s injuries were being dressed he was asked by the night orderly
officer why he had self-harmed. The man said that he had heard people talking
and felt threatened on the wing. He went on to tell the night orderly officer that
his self-harm was a way of getting moved from the wing. The man asked the
night orderly officer to be located in a single cell but, after it was checked if
there were any available, the man was taken to the Care and Separation Unit
(CSU). The CSU is an area that is separate from other wings of the prison and
normally used to locate prisoners who are disruptive or who have committed
offences against prison rules. Wandsworth’s safer cells are located in the CSU
although it was not felt necessary to place the man in one of these cells. The
CSU is temporarily housed on an upper floor of the healthcentre while building
work is carried out on a new unit.
39. Whilst in the treatment area, the man also told staff that “something may
happen when C3-06 is opened in the morning.” These remarks were recorded
in the observation book. The night orderly officer said he wrote this because
the man seemed to believe that prisoners would come to the cell next day
looking for him. The other prisoner located in the cell with the man was a
Polish national. He had returned to Poland by the time my investigators visited
Wandsworth.
40. In interview, the night orderly officer described the man as subdued and
vulnerable. He took the man to the CSU after the nurse had treated his
injuries. Once located in the CSU, the man settled for the remainder of the
night. The nurse completed an Initial Segregation Safety Screen which is
required when a prisoner is place in the CSU, whatever the reason. No
concerns were expressed by the nurse.
41. After moving the man, the night orderly officer opened an ACCT document at
1.35am. This process enables prisoners considered to be at risk of self-harm
or suicide to be closely monitored and offered additional support. The person
opening the ACCT is required to record the reason. It is also a requirement to
note action to be taken to keep the individual safe until a full assessment can
be conducted. In the man’s document, the night orderly officer recorded that he
would be located in the CSU until “such a time as space becomes available on
Heathfield unit”. Heathfield refers to the main prison, excluding the Onslow
Centre which holds vulnerable prisoners.
42. At 8.40am, an officer completed relevant documents as the man had asked to
be segregated for his own safety. This meant that he would be placed away
from the general prison population with other prisoners considered to be at risk.
43. At 9.35am, An ACCT assessor from the CSU completed the ACCT assessment
with the man. (ACCT assessors are trained to carry out assessments with
prisoners at risk of self-harm and to formulate a care plan structured to the
individual’s needs.)
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44. During the assessment, the man told the ACCT assessor that he felt his current
problems were due to him becoming overwhelmed by his situation. He also
believed that people thought he was a sex offender and were making threats
towards him. With regard to the man’s mental state at the time of the
assessment, the ACCT assessor recorded that he appeared stable, felt a lot
safer in the CSU, and wished to go to the vulnerable prisoners unit (VPU). The
man also expressed a wish to get involved in education. The ACCT assessor’s
notes of the assessment referred to the man as possibly having a low IQ or
learning difficulty which the ACCT assessor had picked up during the interview.
He said that the man spoke about “mummy” and looking forward to seeing her.
The ACCT assessor said that the man was open and candid about his offence
during the interview. He referred to the injury to the man’s wrist and the scar
from an earlier incident of self-harm which he described as being from elbow to
wrist rather than across the wrist. (The significance of this is that making the
cuts along the arm is thought to cause a greater loss of blood than a cut made
across the wrist.)
45. Following the assessment, a case review was held to decide what interventions
the man required and to determine his level of risk of further self-harm (the
three levels being low, raised and high). The man was considered to be of
raised risk. The ACCT assessor recorded that the man should have three
quality interactions per day and to be observed “regular nocte” (at night). A
routine referral was also made to the mental health in-reach team. The ACCT
assessor did not perceive the man to be such a risk as to be placed in the
healthcare centre.
46. Given that the man was deemed suitable for the Onslow Centre, the officer
telephoned the unit to enquire about a space. In interview, the senior officer
from the Onslow centre recalled this phone call and had told the officer that
they were unable to take any further prisoners as they were full. The senior
officer suggested that it would be better if the man stayed where he was until
Monday when spaces might become available. However, the senior officer
recalled the duty governor informing them that they had to find a space.
47. At 10.00am, the man was taken to the Onslow Centre. The senior officer was
in the office when he arrived and recalled the man being fine. An officer in the
Onslow centre wrote in the ACCT, “received onto Onslow from CSU, given bed
pack, seems in good spirits at present.” When interviewed, the officer
explained that he was the office manager and part of his duty was in relation to
the movement of prisoners. In this capacity it was his job to allocate the man to
a cell. He said that the wing was pretty cramped and there were limited
spaces. The officer was made aware that the man was on an ACCT. He
explained that they always try to put someone on an ACCT in a double cell so
the man was placed in cell K3-10.
48. Another prisoner was already in the cell. His wing history sheet was
subsequently made available to my investigators. The officer confirmed that,
prior to putting two prisoners in a cell together, their cell sharing risk
assessment forms are read and checked for any high risk. The officer knew the
other prisoner in the cell and said he was “very quiet and not a problem”. (This
13
was not a view shared by all staff, some of whom commented on the other
prisoner’s vulnerability as well as his lack of personal and cell hygiene.) The
officer said that there was nothing about the state of the cell to worry him and
that a number of prisoners have hygiene problems. The senior officer on the
centre said that, given that both men were quiet, he felt they would be
compatible. He also mentioned that the position of the cell was such that it was
near the staff tearoom and quite visible. However, it was not anywhere near
the wing office.
49. Following the man’s death, it was discovered that the prisoner had been subject
to a section 37 Mental Health Act order, issued by the court on 10 August 2007.
(This meant that he needed to be transferred within 28 days to an outside
hospital.) It would seem that none of the wing staff was aware of this as it had
not been communicated to anyone and had not been recorded in his wing file.
The day after the man’s death, the prisoner was taken to an outside hospital.
My investigators did not have access to the prisoner’s medical records.
50. The prisoner’s history sheet indicates that a second prison officer gave him an
IEP warning about the state of the cell on 14 August. In interview, the officer
said that he had tried to place a new prisoner in K3-10 but did not consider it
fair to do so as the cell smelled so bad. The second prison officer was aware of
the man as he had been working the night he self-harmed. When he heard that
the man was in cell K3-10, he assumed that the man’s cellmate had been
persuaded to clean his cell and himself. A further entry in the prisoner’s history
sheet indicates that the principal officer spoke to him on 16 August about his
cell and wrote that it would be monitored from then on. There are no further
entries and it is not known what action, if any, was taken by staff to assist the
prisoner. When my lead investigator visited the cell after the man’s death, she
commented to staff about its very poor state.
51. My investigators spoke to a prisoner, who was in an adjacent cell at the time of
the man’s death. He had spent ten days in K3-10 with the man’s cellmate and
had found the experience very uncomfortable. He said that he thought that the
prisoner was mentally ill and unable to care for himself. The prisoner who was
in an adjacent cell also said that the man’s cellmate had been targeted by other
prisoners and called names. The prisoner also described being threatened
through his cell door on one occasion.
52. At weekends, there are fewer staff available and, according to the landing
officer in Onslow Centre that day (Saturday, 18 August), they were very short
staffed. At midday, the landing officer wrote in the man’s ACCT document,
“declined his meal. Appears fine.” However, in interview, the landing officer
gave a fuller description of how the man presented. The man was apparently
very scared and covering his head with a blanket. The landing officer observed
him to be quite disturbed. However, he did not feel he was at risk of self-harm
and, when he asked the man how he was, he replied he was “fine”. He said he
wanted to get out of Wandsworth and did not want the cell door open or the
light switched on. The landing officer saw the man a number of times over the
weekend and told my investigators he appeared the same each time. He said
14
that he spoke to other staff, including the senior officer, about the man’s
behaviour.
53. At 1.45pm, the man pressed his cell call bell. This was answered by an officer
who wrote in the man’s ACCT document:
“Rang cell bell. Stated that he needs to go the block otherwise he is
going to do something stupid. Requested not to have his cell door
unlocked as there are people on this unit that have come over from C
wing that he knows. I informed the man that I would pass info onto SO
on his return at 14.15hrs.”
54. The officer has since left Wandsworth but agreed to speak with my
investigators. She said that when she got to the cell the man was standing in
front of the cell door, and was excitable and distressed. She told him that
everyone was at lunch but she would pass on her concerns. She felt that by
the time she left the man he had calmed down considerably. The officer said
that she passed on her concerns to the senior officer and he sent two other
officers, both ACCT assessors, to see the man.
55. The next ACCT entry is from a member of the chaplaincy team who saw the
man in cell while routinely visiting the wing at 2.15pm. A note in the ACCT
document says, “appears agitated about location”. At 3.10pm, the fourth prison
officer saw the man and wrote in the ACCT:
”The man requesting to return to CSU as he states that there are
prisoners on unit who will harm him. Explained to the man that a move
to CSU will not take place today. However, he is happy to be located
on 2’s landing on unit, also explained this will not take place until
Monday. Has requested to remain in cell and separate unlock for
meals until this has taken place. States he has no thoughts of self-
harm at present.”
56. In interview, the fourth prison officer said that the senior officer had asked her
to go and speak to the man and she had attended with the third prison officer.
(In interview, the third prison officer said he could not recall anything about the
man.) The fourth prison officer said that the man was “fine” after speaking to
them.
57. The officer recalled that she and the fourth prison officer tried to find another
cell. As they could not find anywhere suitable, it was decided that the move
would not take place until Monday. She was not aware of any discussion about
the man moving back to the CSU. The duty governor recalled a conversation
with staff from the Onslow Centre about the man being moved to a single cell.
She had told them that the man was not suitable as he was on an open ACCT.
58. The reason why the moves were not possible until Monday are unclear, and the
movements book for Onslow Centre indicates that a move to K2 landing was
considered and was then crossed out of the book. The movements book on
15
the unit, which records the arrival and departure of all prisoners, indicates that
the man was the only person to move onto the wing during that weekend.
59. At 4.20pm, the landing officer wrote in the ACCT, “… declined his meal. Stated
that he was fine.” The next entry at 7.30pm states, “… laying in bed. Asked if
ok, stated that he was feeling fine.”
60. Night staff begin their duty at 8.45pm but they often arrive at around 8.00pm.
At this time, the wing was staffed by three night officers who were responsible
for patrolling the wing and carrying out and recording checks on those prisoners
subject to ACCT documents. Before starting their duty, the night staff carried
out a roll check and reported their numbers. In the Onslow Centre, there were
five prisoners on open ACCTs over the weekend. One of the night duty
officers, commented to my investigators that this was fewer than usual.
61. Between 9.00pm and 5.20am, the man was observed nine times by one of the
three officers on nights. Each time, the man was described as asleep. After
the check by the night staff at 5.20am, the man was not seen again until
7.45am. The observation book indicates that the first night officer handed over
to another officer at 6.00am.
62. At 7.45am, the landing officer wrote in the man’s ACCT document, “… appears
fine, asked if he could be moved off the wing, I told him to write to the Governor
to come off the rule.” When interviewed, the landing officer confirmed that he
had asked the senior officer about the man’s request and relayed to the man
the response that he would have to write to the Governor. The landing officer
said that the man presented in the same way as he had the day before, with the
blanket over him and saying he was scared.
63. At 10.05am, the fifth officer wrote in the ACCT form, “The man seems very
scared and considers almost everyone to be a threat. He has asked to remain
locked in his cell during association.” At 12.00 noon, he wrote, “The man
declined his lunch despite the fact it was brought to his door as he says he is
too scared to leave his cell. He was encouraged to eat but said if he is not
moved to a different prison he will kill himself.”
64. At interview, the fifth officer said that he remembered the encounters with the
man clearly. He said that the man was quite distressed so he spent some time
trying to reassure him that the wing was a safe place. He said that both the
man and the other prisoner wanted to stay in their cell, and the other prisoner
had his own concerns about being verbally bullied on the wing. Despite this, he
recalled the other prisoner trying to reassure the man. The fifth officer told
them both they could use the cell bell if they needed to do so and not just as an
emergency, and he felt that they were reassured by this. He also asked a
prisoner, as a ‘buddy’, to speak to the man.
65. This prisoner worked on a voluntary basis offering a sort of buddying role. In
interview, he confirmed that the fifth officer had asked him to go to cell K3-10
on Sunday afternoon to see if he could reassure the man. The buddy prisoner
said that the man seemed very agitated and afraid. He recalled that he said,
16
“They are out to get me.” The buddy prisoner thought the cell was in a very
bad state.
66. The observation book indicates that the duty governor visited the Onslow
Centre at 2.20pm. In interview, the senior officer said he spoke to the duty
governor and told him that staff were trying to deal with the man and help settle
him down. When approached by my investigators, the duty governor could not
recall any discussion concerning the man.
67. At 4.15pm, the fifth officer wrote, “… declined association and his tea meal. He
continues to say he will kill himself if not transferred.” The fifth officer said that
this was passed on to the senior officer and staff on the wing. He thought he
could remember the man being discussed at a lunchtime briefing. He said that
he had tried to reassure the man that he was safe and to allay his fears. He
told him he would be moved the following day. The senior officer said that he
continued to encourage his staff to build up a rapport with the man.
68. By this time, the man had made several statements, recorded in his ACCT
document, that he would “kill himself”. He had also declined all meals since his
arrival in the Onslow Centre. Despite this, there was no case review on his
ACCT and no change to the level of observations.
69. The cleaning officer was responsible for monitoring prisoners coming for their
meals. In interview, he said that he was aware that the man had not come
down for his meals but had been told that the man had declined them. He said
that declining food can be different from refusing it as prisoners have access to
food other than that from the servery. He also explained that a food refusal log
is not started until after three days of food refusal.
70. Following the serving of the tea meal at around 5.15pm, all prisoners were
located in their cells and the wing reduced to minimum staffing (known as patrol
state). Staff continued to check on the man. They recorded these checks in
his ACCT document throughout the evening until the arrival of the night staff.
71. From 9.00pm on Sunday 19 August until 5.30am on Monday 20 August, the
man was seen nine times by the three officers on night duty. Each time the
officer commented that the man appeared asleep. In interview, the third night
officer said she could recall that the man was fully dressed and lying on top of
the bed. She said that this was not especially unusual for prisoners but did
mean that she remembered the man.
72. The observation book indicates that at 6.00am the first night officer, who was
the orderly assist officer, handed over to another officer and the roll was 386.
At this point, the three night staff left the wing despite their shifts not officially
finishing until 7.30am. This left the other officer responsible for counting the
whole of Onslow Centre as well as checking the prisoners on ACCT
documents. The officer did not recall any handover discussion with the first
night officer about the man that morning. The officer was on a day shift which
officially started at 7.15-7.30am. However, in interview he said that he typically
arrives for work early and takes over from the night officers regardless of his
17
start time. He said he would come in and do the count. He would also check
and sign for those on ACCTs and let the night staff go.
73. At 6.00am, the day officer completed an entry in the ACCT stating that the man
was “on left side, appears to be asleep”. According to the documentation, this
was the last time that the man was seen alive.
74. The landing officer began his duty at 7.30am on 20 August. After the routine
early morning meeting (where the man was discussed), the landing officer went
to see him. He intended to help him write the letter to the Governor. On
arriving at the man’s cell, the landing officer looked through the observation
panel and saw the other prisoner asleep in bed. The man appeared to be
standing at the back of his cell. The cell was quite dark as the man had
previously asked that the light should not be switched on. However, when the
landing officer opened the cell and approached the man it became apparent
that he was hanging.
75. The landing officer immediately blew his whistle to alert other staff. (There are
alarm bells situated around the wings and officers have radios, but they also
carry whistles in order to raise alarms quickly.) On hearing the whistle, staff
were quick to respond. The senior officer and the fifth officer were two of the
first to arrive and, while the senior officer supported the man, the fifth officer cut
the ligature from the window bars. The fifth officer recalled that the ligature was
not very long and the man appeared to just be standing at the back of the cell.
The senior officer cut the ligature from around the man’s neck. Whilst this was
being done, the two landing officer’s escorted the man’s cellmate out of the cell.
The other prisoner had been asleep and awoke when the landing officer raised
the alarm.
76. Once the ligature had been removed, the man was initially placed onto his bed
but was then laid on the floor to enable Cardio Pulmonary Resuscitation (CPR)
to be administered. The officer who had responded to the initial call for
assistance, began CPR.
77. There are variations in the accounts of the staff present, and it is not be
possible to give a definitive version of exactly what then happened. However,
two nurses were already in the Onslow Centre and went to the cell having
collected some emergency equipment on the way. A call had been put out for
Hotel 3 the emergency nurse. The first nurse began to give the man mouth to
mouth resuscitation while the officer continued with the chest compressions.
However, when interviewed, the officer that gave CPR told the investigators
that he felt that the mouth to mouth had not been administered correctly. He
explained that when the first nurse was blowing into the man’s mouth his chest
was not rising, an indication that the air was not reaching his lungs. The other
nurse then produced an oxygen cylinder and a manual oxygen mask which the
nurse attempted to place on the man’s face. However, the officer told the
investigators that this had been placed upside down by the nurse. In his
frustration, he took the mask from the nurse and handed it to a fellow officer,
the fifth officer, and told him what to do while he continued chest compressions.
In interview, the fifth officer also stated that the nurse had placed the mask on
18
the wrong way and that he had been compressing the bag under the
instructions of the officer giving CPR. However, the two nurses said in
interview that they were using the equipment correctly and performing CPR
effectively. Emergency nurse arrived at some point during the resuscitation
attempt.
78. The healthcare officer arrived at the cell and brought with her a portable
defibrillator. When applied to a patient, the defibrillator will tell the user whether
or not a pulse is present and if appropriate will administer a shock in order to
restart the heart. Someone suggested that in the man’s case the machine had
indicated a pulse was present. There appears to have been much confusion at
this point, and the man was placed in the recovery position as some staff
believed that a pulse had been found. The nurses said that they continued to
work on the man.
79. The paramedics arrived a short while later and were briefed as to what had
been done. They entered the cell and continued to administer first aid, but after
a short while they pronounced the man dead. A record of their actions
confirmed that when they reached the cell the man was in the recovery
position. The man was pronounced dead at 8.31am. Following the man’s
death there was a hot debrief in which all staff involved were advised of the
care and welfare services available to them.
80. Staff broke the news of the man’s death to his next of kin after obtaining the
details from Gartree. His next of kin then informed the man’s family. The
prison’s family liaison officer kept in close contact with family members and
next of kin, assisting them in resolving difficulties. The liaison officer showed
great tact and sensitivity in supporting the two families through a very difficult
situation.
19
ISSUES
Should Gartree have provided more information to Wandsworth?
81. When the man applied to take accumulated visits, Wandsworth required
information about him from HMP Gartree. The form used to request the
information appears to be one that is used across the prison estate. It is fairly
brief and does not ask any specific questions about the individual’s past
custodial behaviour, such as previous self-harm. It asks only for a brief write-
up on the individual’s behaviour. The man had been residing for some time in
the healthcare wing at Gartree as a non-patient prisoner. His behaviour on the
wing had been very good, he had built up a good rapport with the staff, and this
was conveyed on the form. At this stage, the man was not in any way
vulnerable as he was very comfortable on the wing amongst staff and prisoners
he knew well. He also had his own relatively spacious and comfortable cell.
82. However, the man had initially been moved to the healthcare wing on constant
observations after self-harming, albeit that this had been in October 2005. He
had also self-harmed at other establishments soon after arriving. In addition,
the man had learning difficulties which made it more difficult for him to
understand things. None of these details had been shared with Wandsworth.
At the very least, the ACCT information should have been disclosed.
83. This information does not appear to have been deliberately withheld by
Gartree. After residing in healthcare for a period of time, the man was not
perceived as a ‘poor coper’.
84. During the investigation it became apparent that the healthcare centre at
Gartree is used more for the purposes of housing those prisoners who find it
difficult to cope than those needing in-patient care. In fact only two of the 12
beds are assigned to those requiring medical attention. Most prisons have a
wing, similar to the Onslow Centre, dedicated to accommodating vulnerable
prisoners, but Gartree uses the healthcare centre for this purpose. The
interaction between nursing staff and the prisoners is very good, but they tend
not to regard them as vulnerable as they perhaps would in any other prison.
Consequently, when completing the form for Wandsworth, the man was not
described in such terms.
85. The clinical reviewer comments that the information about the man’s previous
problems was not clearly made available to the staff at Wandsworth. He makes
a recommendation which I fully endorse.
The Prison Service should ensure that, when a prisoner who has had
behavioural problems in the past is transferred for any reason, the
sending prison clearly highlights the issues so that a suitable risk
management plan can be put in place. This is particularly pertinent if
there has been ACCT monitoring.
86. Once Wandsworth agreed to have the man for a period of time for accumulated
visits, his details should have been placed on their ‘Singular Transfer Register’.
20
As a life sentence prisoner, some plans could have been put in place. Instead,
it was left to the man to make an application for his VOs, and his telephone
calls suggest that this caused him some degree of confusion.
The Governor should remind relevant staff of the importance of keeping a
transfer register.
Was the other prisoner a suitable cellmate?
87. When the man arrived at the Onslow Centre he was on an open ACCT
document. He was placed in cell K3-10 with the other prisoner who was
himself extremely vulnerable. During the investigation it transpired that the
other prisoner was awaiting a transfer to an outside hospital for a mental health
assessment. However, this information had not been shared by healthcare with
the Onslow staff who were responsible for looking after him.
The Governor should ensure that all departments within the prison,
including healthcare, share between them all information that might be
important in respect of the well-being of a prisoner and others.
88. The officer who found the cell for the man said that space in the unit was very
limited and, having checked the other prisoner’s cell sharing risk assessment,
he deemed him a suitable cellmate. The other prisoner did not have any risk
markers and was not a threat to the man. However, he was highly vulnerable
and his wing history document made reference to warnings he had been given
in relation to his personal and cell hygiene. One entry even said that it had not
been possible to place another person in the cell with him, but this had not
been read before the man was allocated to the cell.
89. The other prisoner was described to the investigators by at least two other
prisoners as having mental health problems. A prisoner who had previously
shared with him said that other prisoners had threatened the other prisoner by
shouting through the door. He also said that the condition of the cell was
unbearable. It is hard to imagine that the staff did not notice these things.
90. In this case, two extremely vulnerable and at risk prisoners were locked up
together. Due to their individual problems they were incapable of offering each
other support. In fact, despite the attempts by staff to reassure the man that he
was safe, he was locked up with a mentally ill individual who was the target of
bullies. This probably did little to ease his fears. However, there is no
suggestion that the man was at risk from the other prisoner and they were
described as appearing to get on well together.
The Governor should remind staff that, when allocating prisoners to cells,
in addition to information in the cell sharing risk assessments, they must
take account of all relevant factors regarding the suitability of the existing
occupant and the condition of the cells.
91. The clinical reviewer comments in his report that the medical documentation in
October 2005 clearly said that the man, if stressed or anxious, was likely to
21
self-harm or exhibit other abnormal behaviour. He also mentions the advice
noted by the mental health team at Gartree for the man to be removed from
stressful situations immediately. The clinical reviewer says that moving the
man in with another prisoner with a disruptive behaviour pattern clearly did not
provide an environment with a reduced level of stress, and (while this is to
speculate) may well have contributed to his suicide.
Should the man’s ACCT observations have been increased?
92. When the man was relocated from the CSU to Onslow Centre there is no
evidence of a case review being carried out. It is a requirement within the
ACCT procedures for a case review to be held whenever a prisoner arrives on
a new wing. The purpose of this case review is to enable the prisoner to inform
staff of any concerns that they may have, and to ensure that the appropriate
level of observations has been assigned. When the man arrived on the Onslow
Centre, the officer who was in charge of movements at the time and the senior
officer spoke with him briefly. The man was then taken to his cell.
93. When a prisoner is placed on ACCT monitoring, the case review will determine
how often staff should interact and observe them. These observations and
interactions should be re-assessed at all case reviews. In addition, a case
review must be held following any further acts of self-harm, or if there are any
other significant events that may increase the individual’s risk. It is expected
that, if a prisoner continues to self-harm or gives cause for concern, their level
of observations would be increased.
94. The man was distressed from the moment he arrived on the Onslow Centre.
He not only refused meals, but also refused even to venture outside his cell.
His landing officer told my investigators that he asked for the light to remain off
in his cell. In addition, the landing officer said that he constantly had a blanket
over his head and spoke about his fear of other prisoners.
95. Within four hours of arriving on the Onslow Centre, the man informed a
member of staff that he needed to return to the CSU otherwise he “was going to
do something stupid”. These comments were recorded in his ACCT document
and passed to the wing SO. There was also an entry in his ACCT from a
member of the chaplaincy team who had seen the man while visiting the wing
over the lunch period. The entry said, ”appears agitated at location”. When an
officer who had been sent to see the man by the wing SO tried unsuccessfully
to find another cell, it was agreed to keep him locked in his cell, and opened
separately for meals. This was recorded in the ACCT document. However,
this was not a case review and no change to the frequency of observations was
made.
96. The man continued to refuse his meals and remained in his cell. On Sunday 19
August, he told a member of staff that if he was not moved he would kill
himself. He repeated this later in the day. Despite this significant threat, and
his refusal to eat or leave his cell, no case review of the ACCT monitoring took
place and no increase in the level of observations was made.
22
The Governor should assure himself that staff are properly trained in the
monitoring of prisoners under the ACCT procedures, with a particular
focus on conducting case reviews and being responsive to new
information.
Roll checks
97. During the investigation, it became apparent that there were differences of
opinion in the way that staff at Wandsworth viewed the roll check procedures.
The Prison Service has a National Security Framework (NSF) that specifies the
required systems to be used for various procedures, including roll checks. The
NSF says that there should be at least four routine roll checks within every 24-
hour period.
98. This was reiterated to staff at Wandsworth in a Governor’s order issued on 25
February 2005 relating to roll checks during the day. It says that roll checks
must be carried out on at least four occasions, one of these being “when day
staff come on duty to relieve night staff”. The order also says that, on
completion of the checks, staff will sign for each landing in the book provided
on each wing. The documentation provided during the investigation indicates
that these mandatory instructions were not being followed at the time of the
man’s death.
99. At Wandsworth, the staff detailed to work a night shift begin their duty at
8.30pm and finish at 7.30am. When they commence duty, the night staff carry
out a roll check to confirm the number of prisoners in their care before day staff
leave. A further count of all prisoners is conducted at 6.00am.
100. On arrival, day staff should conduct another count to confirm the number of
prisoners before night staff leave. A record of the figures is held on each unit.
The numbers are reported to a central point where numbers from all wings are
collated and confirmed before prisoners are unlocked.
101. However, the investigation found that the numbers recorded for the Onslow
Centre were those recorded by night staff from their 6.00am checks. This
appeared to be the case in all the records examined. It was also found to be
common practice for day staff to arrive for duty as early as 5.30am, and in
some cases for a single member of staff to relieve up to three colleagues. This
would leave just one officer to manage an entire wing and monitor those
prisoners who were considered at risk of self-harm. This was the case on the
morning of the man’s death. My investigators interviewed a number of staff
responsible for these checks and all confirmed that these practices were
commonplace.
102. There was no recorded evidence of roll checks being conducted by day staff
between 7.15am and 7.30am. In fact the roll checks recorded at 7.30am in the
wing log were often those signed by night staff (following their 6.00am checks)
who had left the establishment at least an hour before, after being relieved by
early day staff.
23
The Governor should take measures to ensure that roll checks are carried
out at the correct times and by the staff responsible for conducting them.
ACCT monitoring
103. Of five prisoners on ACCT monitoring on the weekend of 18-19 August 2007,
my investigators were able to see documents for two of them, including the
man. Both had significant gaps between the 6.00am check and the next time
they were seen. This meant there was a period of time in the morning where
some at-risk prisoners had only been checked once during a period of three
hours. The prescribed number of checks during the night for prisoners subject
to an ACCT is hourly. Staff at Wandsworth appeared to have conflicting views
as to when the night state actually ended and the core day began. This in turn
gave rise to inconsistencies in the frequency of the checks during the early
hours before shift handover.
104. Due to day staff arriving early for their shifts, all staff treat their arrival as being
the start of the core day. This means that the prescribed hourly checks for
prisoners on ACCTs are ending early. Core day ACCT checks are in some
cases less frequent. This was true of the man’s observation requirements.
105. On 20 August, the man was last seen at 6.00am by a member of the day staff
who had arrived early for duty. He recorded this check in the man’s ACCT
document. There were no further entries or observations until the landing
officer discovered the man hanging at 7.40am.
106. According to the correct ACCT observation procedures for night staff, the man
should have been seen at least twice before 7.40am. Night staff are not due to
finish their shifts until 7.30am, the official end of night state and beginning of the
core day. Therefore, a check in relation to the ACCT document was missed at
7.00am. It is also the case that, if a roll count had been carried out by the day
staff at the beginning of their shift, the man would have been observed again
between 7.15am and 7.30am.
107. It is not known at what time the man took his own life, but he was last seen
alive at 6.00am. Accordingly, if the ACCT and roll checks that should have
taken place in the 95 minutes preceding the discovery of his body had been
conducted, this might have led to earlier discovery and more timely
intervention.
108. Following feedback to the Governor, my investigators were informed that an
internal investigation was to be conducted and a number of staff had been
temporarily re-deployed. Although I have no wish to point the finger at
individual members of staff, this is as it should be. However, my investigators
were concerned that these shortcomings were not the inactions of a small
number of staff, but appeared to be longstanding common practice that had the
full knowledge of some senior and principal officers. Checks of ACCT
documents would have revealed that prisoners were not being checked during
the early morning period and that, as in the case of the man on 19 August
2007, were not in fact observed until 7.45am.
24
The Governor should ensure that all members of staff at every level are
made fully aware of the importance of conducting ACCT checks as
prescribed.
The Governor should assure himself that a robust system is put in place
to ensure that managers and senior staff regularly check ACCT
documents and that all procedures are correctly implemented.
The resuscitation attempts
109. The clinical reviewer looks in detail at the resuscitation attempt and comments:
“Resuscitating this man would have been very unlikely to succeed.
There did seem to be some confusion about the actual attempt. If a
review could take place immediately after any such resuscitation
attempt, the sequence of events could be clearly documented and
agreed on, and therefore any learning could be identified.”
110. Comments made by the staff involved in administering first aid to the man
indicated that there had been confusion. Rather than the situation becoming
more controlled when the nursing staff arrived, evidence suggests that
communication in the cell broke down, with officers and nurses disagreeing as
to how treatment should be given.
111. There was further confusion amongst the staff as to whether or not the man
had a pulse, and this led to a member of staff giving an instruction for the man
to be placed in the recovery position.
112. The clinical reviewer states:
“There was some disparity between the account of the prison staff and
the ambulance crew. When the ambulance crew arrived at the
resuscitation attempt it is clear from their records that the patient was
lying in the recovery position and that no active attempts were taking
place to resuscitate him. Two of the nurses that I interviewed were
quite clear that they were actively resuscitating him when the
ambulance crew arrived. I must admit that I find this slightly puzzling
and would tend to accept the ambulance crew’s description of events
as they are more used to dealing with these situations.”
113. Furthermore, the clinical reviewer comments on the management of the man’s
airway and makes the following recommendation which I endorse:
The airways used by the nursing staff seem very basic and it would be of
benefit if staff likely to be involved in resuscitation attempts are provided
with adult pocket face masks as used in the NHS.
25
Conclusion
114. Although the man had been assessed as having an ‘abnormal fear of coming to
harm’ that could lead to self-harm in challenging or stressful situations, he had
been excited by the prospect of receiving visits from his friends and family.
However, it is clear from his records that he experienced great anxiety on two
previous occasions when he moved from one prison to another. We cannot be
certain of the reasons why he apparently took his own life. However, it is clear
that a number of failings, including poor communication between staff and a
lack of adherence to monitoring procedures, may have increased his
opportunity to do so.
26
RECOMMENDATIONS
1. The Prison Service should ensure that, when a prisoner who has had
behavioural problems in the past is transferred for any reason, the sending
prison clearly highlights the issues so that a suitable risk management plan
can be put in place. This is particularly pertinent if there has been ACCT
monitoring.
2. The Governor should remind relevant staff of the importance of keeping a
transfer register.
3. The Governor should ensure that all departments within the prison,
including healthcare, share between them all information that might be
important in respect of the well-being of a prisoner and others.
4. The Governor should remind staff that, when allocating prisoners to cells,
in addition to information in the cell sharing risk assessments, they must
take account of all relevant factors regarding the suitability of the existing
occupant and the condition of the cells.
5. The Governor should assure himself that staff are properly trained in the
monitoring of prisoners under the ACCT procedures, with a particular focus
on conducting case reviews and being responsive to new information.
The Governor feels that recommendations five and eight relate to the same issue
and should be incorporated as one.
6. The Governor should take measures to ensure that roll checks are carried
out at the correct times and by the staff responsible for conducting them.
7. The Governor should assure himself that a robust system is put in place to
ensure that managers and senior staff regularly check ACCT documents
and that all procedures are correctly implemented.
8. The Governor should ensure that all members of staff at every level are
made fully aware of the importance of conducting ACCT checks as
prescribed.
The Governor feels that recommendations five and eight relate to the same issue
and should be incorporated as one.
9. The airways used by the nursing staff seem very basic and it would be of
benefit if staff likely to be involved in resuscitation attempts are provided
with adult pocket face masks as used in the NHS.
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