Individual at Winchester

Investigation into the circumstances surrounding the death
of a man at HMP Winchester in October 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2008
:
This is a report of an investigation into the death of a man who died from a heart
attack at HMP Winchester in October 2007. He was 42 years old and had been in
custody at Winchester for just over three months.
I would like to offer my sincere condolences to the man’s family for their loss.
The investigation was undertaken by an investigator from my office. We would both
like to thank the Governor of Winchester and his staff for their participation and
assistance. Particular thanks are due to the prison’s liaison officer.
The Associate Clinical Director, Primary Care and Governance for the local Primary
Care Trust (PCT) carried out a helpful and thorough clinical review, including a panel
review. Unfortunately, the clinical review was not received until nine months after the
man’s death and this has contributed to the delay in issuing this report for which I must
apologise.
The clinical review raises questions about the man’s health screening whilst at
Winchester and this is explored further in my report. I make seven recommendations
to the Head of Healthcare at Winchester and a further recommendation to the
Governor regarding the prison’s anti-bullying policy. I raise a further issue relating to
the location of non-vulnerable prisoners on a vulnerable prisoners landing. However,
the Governor will already be acutely aware of this matter and, in these circumstances,
I have judged that I do not need to make a formal recommendation.
A copy of this report has also been forwarded to the PCT and to HM Coroner.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2008
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CONTENTS
Summary
The Investigation Process
HMP Winchester
Key Findings
Issues
Recommendations
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SUMMARY
The man was remanded into custody as an unconvicted prisoner to HMP Winchester
on 19 July 2007. He was convicted on 14 September and received a custodial
sentence. His release date would have been in July 2008.
When the man arrived at Winchester he was assessed by healthcare staff in
reception. His height, weight, blood pressure were noted as was the fact that he was
a smoker. Despite being a smoker and moderately obese, no further health tests or a
secondary health assessment were carried out.
The man underwent a mental health review in August, and as a result was prescribed
an anti-depressant. He subsequently told staff that he felt better in mood and was
given a repeat prescription a month later.
He seemed to be a quiet man and did not come to the attention of staff at all. He liked
to spend time in his cell watching television and reading a newspaper. He appeared
to get on well with his cell-mate and seemed to have settled into prison life.
About two weeks before he died, the man sustained two black eyes when he was
assaulted in the shower on the wing. He did not report the assault to staff and was
reluctant to speak about it in detail to his cell-mate. The cell-mate said in his police
statement the investigator that he did alert staff to the man’s injuries, but no action
appears to have been taken, perhaps because the man did not want to report it.
On the morning of 27 October, the man complained of feeling sick and unwell. He
went to lie down in his cell and said that he did not want any lunch, although he asked
his cell-mate to collect his newspaper for him.
Just after mid-day (when prisoners are locked in their cells), the man was still lying on
his bed when his cell-mate heard him make some gasping noises and his eyes
appeared to roll back. The cell-mate felt for a pulse on the man’s neck and wrist, but
could not find one. He raised the alarm by pressing the cell bell and an officer arrived
almost immediately. After assessing the situation, the officer entered the cell and
checked the man’s vital signs. The officer could not detect a pulse or establish
whether the man was breathing and so made an emergency call.
Healthcare staff arrived at the cell very quickly and attempted to resuscitate. Staff
carried out cardio pulmonary resuscitation (CPR) until the prison doctor arrived at
approximately 1.00pm. After examining the man, the doctor pronounced him dead at
1.05pm.
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THE INVESTIGATION PROCESS
1. I appointed my colleague to conduct the investigation on my behalf. Notices
were issued to both prisoners and staff inviting anyone who had information
relating to the man’s death to make themselves known to the investigator.
However, no further witnesses came forward.
2. My investigator was given access to all the man’s prison records, including his
medical records, and police statements taken after he died. All of these
documents were forwarded to my investigator within a few days of the man’s
death.
3. My investigator visited Winchester to carry out taped interviews with staff on 12
February 2008. She had also arranged to speak to the man’s cell-mate, but
unfortunately he had been transferred to another prison without notice.
Instead, a copy of his police statement was provided and so she did not need to
interview him.
4. One of my Family Liaison Officers (FLOs) contacted the man’s brother to
explain the role of the Prisons and Probation Ombudsman and to offer him the
opportunity to participate in the investigation process. His brother did not ask
any questions and said he would await the outcome of my report.
5. The Clinical Governance Manager for the Primary Care Trust (PCT), was
invited to arrange for a clinical review to be carried out into the medical care
that the man had received during his time at HMP Winchester. This was
completed and forwarded to my office on 22 July 2008.
6. An inquest into the man’s death was held on 15 July 2008. The jury found that
he had died of natural causes from acute myocardial ischaemia. Although the
inquest has already taken place, a copy of this report will be sent to HM
Coroner.
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HMP WINCHESTER
7. HMP Winchester is a category B local male prison, located just outside of the
main city centre. Built in 1846, most of the prison is of a traditional Victorian
radial design. It has a maximum capacity of 697 prisoners.
8. The prison contains four residential units and one separate unit, West Hill,
which is a training unit for category C adult men. In January 2007, C wing was
closed for refurbishment.
Assessment, Care in Custody and Teamwork (ACCT)
9. ACCT requires any member of staff who identifies concerns about a prisoner
they believe to be at risk of suicide or self harm to take action and to record
those actions. The ACCT document should be available to all staff where the
prisoner is located, including workshops and visits. Within 24 hours of an
ACCT being opened, the prisoner is seen by an assessor and has a case
review meeting. ACCT reviews are held at appropriate intervals and are
attended by the prisoner and a case manager, together with other members of
staff.
Bullying
10. Reported incidents of bullying are reviewed and closely monitored at a monthly
Safer Custody meeting. Each wing has an anti-bullying representative. This is
a prisoner who other prisoners can speak to in confidence and who can also
bring issues on the wing to the attention of wing staff or the Safer Custody
Manager.
Canteen
11. Canteen is the commonly name both for the prison shop where prisoners can
buy or order goods each week to a limited value, and for the goods themselves.
The shop mostly sells food, confectionery, stationery, toiletries and tobacco.
Prisoners can purchase goods with money they earn from working in the
prison, and from their own private cash.
D wing
12. Two landings on D wing are allocated to vulnerable prisoners (predominantly
those charged with or convicted of sexual offences). However, due to the high
number of prisoners overall, non-vulnerable prisoners are sometimes
accommodated there.
Healthcare
13. Winchester provides nurse-led primary care, inpatient care and a pharmacy
service. The healthcare centre is separate from the main prison, although
some healthcare and treatment takes place in treatment facilities on A and B
wings. Healthcare services are commissioned by the local PCT and the
doctors are provided by a local general practice.
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14. Healthcare introduced an electronic record keeping system in June 2007. The
system is designed to provide a full audit trail of medical histories and the
interventions that each prisoner receives or is due to receive.
15. On arrival in reception each prisoner is seen by a nurse or healthcare officer
(HCO) and is screened in order to identify immediate healthcare needs.
Prisoners then have the opportunity to see a doctor within 24 hours if required
and a secondary health screening should be carried out where further details
are taken (such as the prisoner’s community doctor and next of kin details) and
any existing health issues are explored. Prisoners are also asked to sign a
medication compact that gives consent for the prison to access their previous
medical history.
Listeners
16. Listeners are volunteer peer supporters selected, trained and supported by
Samaritans, using their same guidelines, to listen and offer emotional support in
complete confidence to their fellow prisoners who may be in crisis, feel suicidal
or who need a confidential sympathetic ear. The principle of total confidentiality
is central to the work of the Samaritans and this applies equally to their work in
prisons, including that of prisoner Listeners. Samaritans allow exceptions to its
principle of confidentiality only in the following very specific circumstances: if
information is given about terrorism, if they received a court subpoena to
divulge information, if the person is attempting to take their own life or if the
contact threatens the Listener.
Independent Monitoring Board (IMB) report
17. IMB members are appointed to each prison by the Secretary of State for
Justice. They are not members of the Prison Service, nor are they part of the
prison’s management team. They are required to produce an annual report to
the Secretary of State, highlighting both good practice and areas of concern.
18. The IMB’s report for Winchester for the period 2006/2007 notes that, prior to its
closure, C wing held remand prisoners who are now housed on B and D wings.
D wing therefore holds both vulnerable and remand prisoners. This has led to
a reduction in the options for housing prisoners safely and increases the
potential for bullying.
19. The IMB also had concerns that beds in healthcare were being used for
prisoners without health problems because of overcrowding in the rest of the
prison.
20. There were three deaths at Winchester during the IMB’s reporting year, all from
natural causes.
Her Majesty’s Chief Inspector of Prisons’ report
21. The HM Chief Inspector of Prisons undertook an announced inspection of
Winchester in April 2007. Her inspection report noted that Winchester
remained a reasonably well-performing local prison, in spite of the pressures on
the system as a whole. However, the HM Chief Inspector of Prisons noted that
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there were some warning signs including “the lack of sufficient activity spaces
in the main prison, dislocated resettlement arrangements and, in particular, the
fact that residential staff are not fully engaged in the support and rehabilitation
of prisoners”.
22. The report said that Winchester was a reasonably safe prison, and that suicide
and self harm was managed well. However, although there was little indication
that bullying was a major problem, the anti-bullying arrangements were weak
and vulnerable prisoners continued to be identifiable and to feel less safe than
others. Only four incidents of bullying had been identified at the time of the
inspection in 2007, which seemed unfeasibly low, and not all of the suspected
bullies were being monitored. Vulnerable prisoners on D wing were wing were
easily identifiable by different colour cell cards. They felt less safe than other
prisoners and the wing was not an appropriate place to hold the mix of
prisoners it contained.
23. The HM Inspector of Prisons reported that new arrivals were seen in reception
by a nurse or healthcare officer using the standard prison reception screening
form. A prisoner could see a doctor within 24 hours if necessary. No
secondary health screening took place and there was no input from healthcare
during a prisoner’s induction which meant that prisoners’ healthcare and health
promotion needs were not fully assessed.
24. Winchester has policies to cover the provision of chronic disease management.
The HM Chief Inspector of Prisons noted that prisoners with diabetes received
a good standard of care and patients with asthma were able to see a nurse on
request, although regular long term monitoring was not available. Input into
other long term conditions, such as heart disease, was provided by the doctors
rather than nurses.
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KEY FINDINGS
25. The man arrived at Winchester prison on 19 July 2007 as an unconvicted
prisoner. He was convicted on 14 September and sentenced to 12 months
imprisonment at Crown Court. His prospective release date was in July 2008.
he was located onto D wing as he was regarded as a vulnerable prisoner due
to the nature of his offence.
26. A health reception screening was undertaken on 19 July by a member of
healthcare. During the screening, the man’s blood pressure was taken and his
height and weight recorded. The clinical reviewer notes that, despite his being
a smoker and moderately obese, no cholesterol screening or other health
screening for chronic disease was undertaken. The man’s medical history was
not recorded and it was also not noted whether he had had any significant
clinical episodes, including depression. It was also not recorded whether he
was prescribed any medication or whether they discussed any pre-existing
medical conditions. There is no evidence in his medical records that a
secondary health screening was ever carried out.
27. On 2 August, healthcare received a fax from an outside Community Mental
Health Team confirming that a consultant psychiatrist was to visit the prison to
see the man to carry out an initial assessment (indicating that he had been
assessed in the community for mental health issues). This took place on 10
August.
28. Four days later, the man saw a doctor at the prison as he was feeling
depressed. The doctor prescribed an anti-depressant (Fluoxetine), but an
ACCT was not opened. On 17 August, the man had a mental health review
when it was noted that his mood had improved slightly and that he had a new
cell-mate who he got on well with. He also started taking the anti-depressants
later that day. There is no reason recorded in his records to explain why there
was a three day delay in his being prescribed, and taking, the anti-depressants.
29. The man had another mental health review on 24 August. He reported that he
felt physically unwell. There was a discussion about his mental health and a
note for healthcare to ‘discuss physical health issues with C2. Letter to follow’.
It is unclear what this referred to and no follow up action appears to have been
taken.
30. On 30 August, the Community Mental Health Team forwarded a letter to
healthcare requesting a follow up appointment with the man. There is no
evidence that this took place either.
31. The man was assessed by a nurse in the mental health clinic on 17 September.
The man said that he no longer felt down in mood (he had told the doctor on 14
August that he felt depressed) or had any thought of self harm. He told the
nurse that he had applied for a transfer to HMP Usk and asked to be
considered for employment in workshop five to earn more canteen, as he was
not receiving any visits. This was the last entry made in his medical records
before he died.
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32. About a week before he died, the man sustained two black eyes. His cell-mate
was the anti-bullying representative on the wing and asked what had
happened. The man said he had been punched in the face whilst he was in the
shower, but would not give any further details and did not report it to staff. In
his police interview, the cellmate said that he told some prison officers on the
wing about this and they advised him to speak to the man and try to find out
what had happened. The man told him that he had been punched twice in the
face whilst he was in the showers, but said he had not seen who had done this.
He also told the cellmate that he did not want to speak to staff about it.
Events on 27 October 2007
33. The cellmate recalled in his police interview that on the morning of 27 October
he made the man a cup of tea at approximately 10.15am. At about 10.30am
the wing was unlocked for association (when prisoners are free to move about
the landing). The man collected some clean bedding and took a shower. The
cellmate noticed that on the way back from the shower the man was crouched
outside of their cell, holding on to the balcony rail. The cellmate asked the man
what he was doing, and he replied that he did not feel too good and felt sick.
The cellmate remembered that the man looked white and was shaking. He
then said he had pains in his chest. The cellmate told him to go into the cell
and lie down, which he did. He turned the light off and pulled the cell door to, to
allow the man to rest.
34. The cellmate said he spoke to a prison officer and told him that the man did not
look well and was very white. The cellmate said that the officer made a joke
about this, so he walked away. The officer told my investigator that he did not
recall having this conversation with the cellmate, but if he had been informed of
an emergency situation he would have dealt with the matter accordingly. The
cellmate returned to the cell at about 11.00am, ready for lock up. He said that
the man was still on his bed and still looked white. Nevertheless, the man said
that he felt better.
35. At approximately 11.45am, the prisoners were unlocked for lunch. The man
told his cellmate that he was not hungry, but asked if he would collect his paper
for him. The cellmate collected his own lunch and then asked a second officer
if he could collect the man’s paper as the man was not feeling very well. The
man was still on his bed and watching television when his cellmate returned to
their cell. The man told him that he felt sick, so he gave him some of his own
Gaviscon indigestion mixture.
36. Approximately 15 to 20 minutes later the cellmate heard the man make a noise,
as if he were gasping for breath. One of his eyes closed and the other seemed
to roll back. The cellmate thought that the man might have been having an
epileptic fit. He told the man to try to breathe slowly and thought that he could
hear him say this. The man seemed to take a big breath and then appeared to
stop, making no further noise. The cellmate placed his hand on the man’s neck
and wrist, but could not feel a pulse. The man felt cold and his lips appeared
blue in colour. The man then pressed the cell bell to call for help.
37. An officer was carrying out lunchtime patrol duties and checking prisoners who
were on Assessment, Care in Custody and Teamwork documents (ACCTs) on
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D wing. The man’s cellmate called out to him that he did not think his cell-mate
was very well.
38. As the wing was on lunchtime patrol state (when all prisoners are locked in their
cells and a skeleton staff patrol the landings), and there were very few staff
available, the officer who was carrying out lunchtime patrol duties needed to
appraise the situation before entering the cell. He looked through the door
observation panel and could see the man lying motionless on his bed. He then
entered the cell and attempted to get a response by shaking him and shouting
his name. The officer raised a Code One alarm call (an emergency call) for
assistance using his radio and shouted for another officer on the wing to help.
In the meantime, the officer checked for a pulse in the man’s neck, but found
none. He then placed him in the recovery position.
39. As soon as the other officer on the wing arrived at the cell, he moved the man’s
cellmate, who seemed upset and located him with one of the Listeners on the
wing. The officer who was carrying out lunchtime patrol duties was still trying to
gain a response from the man when two healthcare nurses, arrived. They had
heard the emergency call over their radios at 12.45pm and arrived with their
emergency bag and a defibrillator (a machine that is used to administer an
electric shock to the heart in order to re-establish normal heart rhythm) within
two minutes.
40. The officer who was carrying out lunchtime patrol duties told the nurses that he
could not find a pulse and moved out of the way to allow them to examine the
man. One of the nurses turned the man on to his back and tilted his head to
clear his airway. The nurse recalled that the man’s eyes were open and his
pupils appeared to be fixed and dilated. He did not appear to be breathing,
there was no rise and fall from his chest and he had no carotid (neck) or radial
(wrist) pulse. He appeared blue in colour (cyanosed).
41. The nurse requested an emergency ambulance, indicating the urgency of the
situation, and the attendance of the prison’s duty doctor. The nurse then began
to attempt cardio pulmonary resuscitation (CPR) with the officer who had been
carrying out the lunchtime patrol duties. The nurse placed a mouth-to-mouth
resuscitation aid in the man’s mouth so the officer could administer breaths
safely. The nurse commenced chest compressions at a ratio of 30
compressions to two breaths.
42. After 90 compressions, the nurse assessed the man. There was still no
response and he still did not appear to have a pulse. The second nurse
attached a pulsometer to the man’s finger to determine his oxygen saturation
level, but there was no reading on the machine (indicating no oxygen).
43. The second nurse attached the pads of the defibrillator to the man’s chest. The
first nurse on scene shocked the man twice on the instruction of the machine,
but it did not result in his circulation returning so they recommenced CPR. The
first nurse on scene also attempted to insert an airway into the man’s mouth,
but this was unsuccessful. At this point, the first nurse on scene also attempted
to administer oxygen to the man by using an ‘ambu-bag’, whilst the second
nurse continued with chest compressions.
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44. The first nurse on scene said that he believed at this stage that the man had
already died, but they continued with CPR. He thought that rigor mortis had
begun to set in as he had difficulty inserting the airway into the man’s mouth.
45. The prison duty doctor arrived shortly afterwards. The nurses and the officer
moved away to allow the doctor to examine the man. After carrying out checks,
the doctor confirmed that he had died and certified this at 1.05pm.
46. A matter of minutes later, the ambulance crew arrived at the cell. They did not
attempt CPR or examine the man as the duty doctor had already examined him
and pronounced that he had died.
47. The officer who had been carrying out lunchtime patrol duties began to keep a
log of events and continued to update this until the police arrived. The log was
passed to the police who secured the cell and began to take statements from
staff and prisoners. Afternoon association was cancelled on D wing. The
officer spoke to a number of prisoners to let them know what had happened
and that there would be no afternoon association. I understand the prisoners
were very understanding of the situation.
48. The officer who had been carrying out lunchtime patrol duties and a prison
governor went to speak to the cellmate. He had seemed to be very shaken and
was obviously upset by what had happened to the man. He remained with the
Listener for the rest of the day. All prisoners who were on an ACCT on D wing
when the man died were reviewed.
49. Later that day a briefing was held for staff, and all those who were involved in
discovering the man and attempting to resuscitate him were invited to attend.
Staff were also reminded of the availability of the prison’s Care Team if they
needed to speak to somebody.
Events after 27 October
50. A post mortem was held on 29 October at hospital. It found that the man had
severe coronary artery disease and died from an acute myocardial ischaemia
(heart attack).
51. The man’s brother told my FLO that Winchester had explained to him what had
happened and had been very helpful. They offered to assist with the man’s
funeral costs and returned his belongings.
52. The parents of the man’s cellmate wrote to the prison on 4 November. In their
letter they thanked staff for the kindness and care they had shown to their son
and for allowing him to telephone them as he had been distressed.
53. An inquest was held on 15 July 2008. The jury concluded that the man had
died from natural causes.
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ISSUES
Clinical care
54. The clinical reviewer found that there was a lack of information in the man’s
medical records relating to his general physical health. Despite the reception
screening indicating that he was a smoker and moderately obese, no
cholesterol screening or other health screening for chronic disease was
undertaken. There was also no evidence of a secondary health screening
being carried out, despite this being usual practice in the Prison Service.
The Head of Healthcare should ensure that reception health screenings
and secondary health screenings are carried out for every prisoner and
all findings are recorded in the prisoner’s medical records.
The Head of Healthcare should ensure that the process for assessing
prisoners on reception health screenings complies with the assessment
screening tool. This recommendation was also made in a report into a
death of a man at Winchester in January 2008.
The Head of Healthcare should put in place a system to ensure that all
prisoners with chronic disease are identified on admission and seen by a
doctor at the earliest possible time. I also made this recommendation in a
report in January 2008.
55. The man was prescribed Fluoxetine on 14 August 2007, although his medical
chart indicates that he did not start taking this medication until 17 August. This
delay is not accounted for in the medical records, nor was it explained to the
clinical reviewer. This particular anti-depressant is noted as having indigestion
as a known side effect. The British National Formulary (BNF, which provides
healthcare professionals with authoritative and practical information on the
selection and clinical use of medicines) advises caution of the use of this type
of anti-depressant in patients with chronic heart disease. However, healthcare
had not identified this risk in the man. There appears to have been no review
carried out for him, once he had started on the Fluoxetine.
The Head of Healthcare should ensure that all prescriptions for
medication are recorded accurately and any delays in issuing medication
are accounted for.
The Head of Healthcare should ensure that every effort is made to obtain
the medical records of prisoners, including a copy of the prisoner’s
general medical practice records. The medical history should be
appropriately summarised in the prisoner’s medical record.
56. The clinical reviewer has also said that his medical records appeared to be
factual, consistent and accurate. However, they were not comprehensive and
did not provide current information regarding his care and condition. Also, no
care plan was provided for him. The clinical reviewer noted that the records
were legible and accurately dated as they are computerised, but they were not
timed. Also, there was no clear audit trail of dispensing of medication
(indicated by the gap of three days between Fluoxetine being prescribed and
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being dispensed). The clinical reviewer also said that the medical records did
not provide an accurate audit of events on the day the man died. He has
judged that there was a delay in alerting staff to the emergency whilst the man’s
cell-mate attempted to rouse him.
The Head of Healthcare should remind staff that medical records should
always be kept in chronological order and updated appropriately. This
recommendation was also made to Winchester in January 2008 in
relation to a death of another prisoner.
The Head of Healthcare should consider the advice given to all prisoners
regarding their health and the health of others. This should ensure that
all prisoners are aware of the procedures to follow should they become
concerned about their own health or the health of another prisoner.
Use of D wing
57. Whilst accepting that the high prison population places a great strain on local
prisons like Winchester, I do not believe it is acceptable to mix vulnerable
prisoners and non-vulnerable prisoners on the same landing unless this is part
of an expressly integrated regime. This point is also made in Ms Owers’
inspection report. However, I am confident that the Governor is aware of this
issue and have decided that in the circumstances any formal recommendation I
might make would be otiose.
Bullying
58. Despite being assaulted in the showers about a week before he died, the man
did not want or feel able to report this to staff. He was also reluctant to discuss
this in any detail with his cell-mate who by chance was also the wing’s anti-
bullying representative. This may have been due to the weakness of the
prison’s anti-bullying policy which was highlighted in the Ms Owers’ inspection
report. However, it is hard to imagine that the man’s two black eyes could have
gone unnoticed by all the wing staff.
The Governor should revisit the prison’s anti-bullying policy to ensure
that a system is in place for prisoners to report instances of bullying and
feel safe in doing so. These incidents should be monitored at the
monthly Safer Custody meetings.
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RECOMMENDATIONS
To the Head of Healthcare
1. The Head of Healthcare should ensure that reception health screenings and
secondary health screenings are carried out for every prisoner and all findings
are recorded in the prisoner’s medical records.
2. The Head of Healthcare should ensure that the process for assessing prisoners
on reception health screenings complies with the assessment screening tool.
This recommendation was also made in a report into a death of a man at
Winchester in January 2008.
3. The Head of Healthcare should put in place a system to ensure that all
prisoners with chronic disease are identified on admission and seen by a doctor
at the earliest possible time. I also made this recommendation in a report to
Winchester in January 2008.
4. The Head of Healthcare should ensure that all prescriptions for medication are
recorded accurately and any delays in issuing medication are accounted for.
5. The Head of Healthcare should ensure that every effort is made to obtain the
medical records of prisoners, including a copy of the prisoner’s general medical
practice records. The medical history should be appropriately summarised in
the prisoner’s medical record.
6. The Head of Healthcare should remind staff that medical records should always
be kept in chronological order and updated appropriately. This
recommendation was also made to Winchester in January 2008 in relation to a
death of another prisoner.
7. The Head of Healthcare should consider the advice given to all prisoners
regarding their health and the health of others. This should ensure that all
prisoners are aware of the procedures to follow should they become concerned
about their own health or the health of another prisoner.
To the Governor
8. The Governor should revisit the prison’s anti-bullying policy to ensure that a
system is in place for prisoners to report instances of bullying and feel safe in
doing so. These incidents should be monitored at the monthly Safer Custody
meetings.
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