Individual at Winchester

Circumstances surrounding the death of a male prisoner
from HMP Winchester, at the Royal Hampshire Hospital
in November 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2006
This is the report of an investigation into the circumstances surrounding the
death of a male prisoner at the Royal Hampshire Hospital, Winchester, on 29
November 2005. At 2.55pm the previous day, the prisoner had been found
hanging in his prison cell. At the time of his death, he was serving a prison
sentence at HM Prison Winchester.
A post mortem examination conducted on 2 December found that the prisoner’s
death was caused by hanging. The prisoner was 37 years of age.
The investigation was carried out by my colleagues. I also commissioned an
independent clinical review of the management of the prisoner’s health needs
while he was in custody. This was conducted by a representative of the
Mid-Hampshire Primary Care Trust (PCT). I am most grateful to the PCT for
their work.
I should also like to thank the Governor and staff at Winchester for their help and
co-operation during the course of this investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2006
2
Contents
Part One: 1. Summary
2. Investigation methodology
3. The deceased
4. HMP Winchester
5. Events prior to 28 November 2005
6. Events on and after 28 November
7. Examination of the care given to the prisoner
8. Good practice and Recommendations
3
Summary
The prisoner was arrested on suspicion of wounding in the early hours of 30 May
2005. He was taken to a police station near Southampton, where he was
assessed by a Forensic Medical Examiner who considered that he was at risk of
self-harm. The prisoner was taken to Southampton Magistrates’ Court the
following day. He was remanded in custody and taken to Winchester prison,
arriving at 3pm.
During the reception procedures at Winchester, no formal health screen was
completed. However, the nurse who saw him noticed that the prisoner was
extremely withdrawn, uncommunicative and, at times, tearful. He was therefore
admitted to the healthcare centre and made subject to formal self-harm
monitoring procedures through the ACCT system (Assessment, Care in Custody
and Teamwork). Initially, he was placed on a constant watch.
The prisoner remained in the healthcare centre for nearly three months. Whilst
there, he twice attempted to harm himself. On the first occasion, he made
indentations in his abdomen with a plastic knife. On the second occasion, he
attempted to hang himself in his cell using a television cable. Frequent and
regular ACCT case reviews were convened in order to monitor the prisoner’s
risk. Observation levels were varied in keeping with his fluctuating mood and
behaviour. The prisoner was also regularly reviewed by the prison doctor, by a
psychiatrist, and by a Community Psychiatric Nurse (CPN).
On 20 August, it was considered that the prisoner’s mental state was such that it
was safe for him to be discharged from the healthcare centre to a wing where
unconvicted prisoners are normally held. Here, the prisoner shared a cell. As a
precaution, the formal self-harm monitoring procedures were continued for two
more weeks. The prisoner’s ACCT form was closed on 6 September. His
mental state remained under observation by the CPN until 13 September, when
he told her that he felt no need for further consultations. The CPN nevertheless
planned to review the prisoner again once his trial had ended.
In October, the prisoner joined a sports injuries course in the prison’s
gymnasium. By all accounts, he enjoyed the course and made good progress.
On 21 November, the prisoner’s trial commenced at Southampton Crown Court.
Two days later, he was sentenced to two years imprisonment. The CPN was not
told of this and did not see him as she had intended.
During the weekend of 26 and 27 November, the media published details of the
offences the prisoner had committed. According to a friend, this was the cause
of much humiliation and embarrassment to him. During the weekend, he
stopped eating and hardly left his cell. His cellmate reported his concerns to an
officer who initiated fresh self-harm monitoring procedures.
On the afternoon of Tuesday 28 November, the prisoner declined an opportunity
to take exercise. Instead, he remained in his cell alone. At about 2:55pm, an
4
officer found him hanging from the bars of his cell window. No suicide note was
found.
Prolonged attempts were made by prison staff and by a paramedic crew to revive
him. As a result, a slight pulse was detected. The prisoner was therefore
transferred to the Royal Hampshire Hospital adjacent to the prison, where he
died at 4:30pm the next day.
The investigation found that the care afforded to the prisoner in Winchester was
appropriate. The attempts made by staff to revive him are commendable.
I make nine recommendations and draw attention to a number of examples of
good practice.
5
2. Investigation methodology
The investigation began on Friday 2 December when my investigators met with the
Governor, the chairman of the Independent Monitoring Board (IMB) and the
chairman of the local branch of the Prison Officers’ Association (POA) at
Winchester. My investigators explained to them the nature and scope of the
investigation and the report handling process.
On the same day, notices were issued to staff and to prisoners announcing the
investigation and inviting anyone with concerns or information relating to the
prisoner’s death to make themselves known to my investigators.
During the course of the investigation, the prisoner’s former girlfriend was contacted
by one of my Family Liaison Officers. The woman said that she was in touch with
the prisoner’s family and would make sure that they were given the contact details
for my office. She later expressed a number of concerns but neither she, nor the
prisoner’s family, wished to meet with my colleagues at that stage. The concerns
she expressed have been addressed in this report.
A wide range of nursing, medical, and discipline staff were formally interviewed.
Informal discussions were held with other prison staff, the CPN and a prisoner.
On 14 December, my investigator wrote to the prisoner’s former cellmate at his
home address to invite him to be interviewed. Although the cellmate confirmed in
writing that he was willing to be interviewed, he did not respond to any further
communications from my investigator. It has therefore not been possible to
interview him.
6
3. The deceased
The deceased prisoner was born in 1968. He left school with a number of ‘O’ levels
and then attended college where he completed a City and Guilds qualification in
Mechanical Engineering.
After the age of 26, he lost all contact with his parents and siblings.
In March 2004, when he and his then girlfriend were asked to leave their
accommodation, he planned to go abroad with her to work. Four days before they
were due to leave, his girlfriend told him that she did not want to join him and that
she wanted their relationship to end. Shortly afterwards, the prisoner became
depressed and attempted suicide by running a hose-pipe from the exhaust pipe of
his car through the car window. Later, he travelled to Greece where he remained in
deep despair. After five weeks, he returned to England.
On 30 May, the prisoner broke into his then girlfriend’s flat. He intended to see her
and then to commit suicide. He lay under her bed and, when she returned to the flat
with her new boyfriend, assaulted her. The prisoner was later arrested.
On 31 May 2005, he appeared at Southampton Magistrates’ Court where he was
remanded in custody.
At HMP Winchester, he became involved in projects for ‘Children in Need’ and
undertook a course in Basic Sporting Injuries.
He was 37 years old when he died.
7
4. HMP Winchester
HMP Winchester is a Victorian local prison that can hold up to 695 adult male
remand and sentenced prisoners. One of its units, Westhill, operates as a
resettlement unit.
At the time of the investigation, healthcare was provided by the Prison Service under
arrangements made by the Mid-Hampshire Primary Care Trust. These
arrangements were about to be reviewed. The healthcare centre provides 24 hour
medical and nursing cover and has inpatient facilities for up to 22 prisoners.
The prison was last inspected by Her Majesty’s Chief Inspector of Prisons in
December 2004. The report of that inspection commented that training in self-harm
monitoring procedures was a high priority at Winchester. The investigation found
that all staff had been trained in ACCT (Assessment, Care in Custody and
Teamwork) procedures.
The inspection report also drew attention to the need to ensure that all ACCT care
plan and review boards comprise a multi-disciplinary team. This investigation found
evidence that this was still not being implemented consistently.
The death of this prisoner was the first self-inflicted death I have investigated at
Winchester. In September 2003, another prisoner died by his own hand at the
establishment. All recommendations stemming from the investigation conducted by
the Prison Service into that death have been implemented. My investigators found
that, although local contingency plans for handling a death in custody were in place,
there were none for managing a life-threatening situation.
8
5. Events prior to 28 November 2005
At about 1:25am on 30 May 2005, the prisoner was arrested in Southampton on
suspicion of wounding. He was taken into police custody at Lyndhurst Police Station
at about 3am. He was seen in police cells by a Forensic Medical Examiner (FME)
from 5:10am until 5:50am. The FME made the following comments on a Detained
Person’s Medical Form:
“Very low since split with girlfriend 8 weeks ago after 5 years. Girlfriend
started seeing someone else recently. Poor sleep and appetite. Made
bankrupt recently. Previous medical history. Cut wrists aged 20s. Seen
by psychiatrist. No illicit drugs recently. Cannabis years ago. Not in
contact with his family.
“On examination, tearful, low mood, few words. Wishes to
kill himself. Also just wants his life back. Tried tonight to stab
himself. Minor nicks to abdomen. Plan: need to be psychiatrically
assessed.”
.
The FME ticked a box on the form indicating that the prisoner’s risk of self-harm was
high.
The Hampshire Constabulary custody log shows that the prisoner was kept in police
cells for the remainder of 30 May. He slept until about 1pm. At 3pm, he underwent
a mental health assessment. This concluded that, although he was very distressed
at times, he was fit to be interviewed. A recommendation was made that, in the
event of his release from custody, he should receive support from a Community
Mental Health Team.
On 31 May, the prisoner was taken to Southampton Magistrates’ Court from
Lyndhurst Police Station. The escorting staff noted on a Prisoner Escort Record
(PER) that he was at risk of self-harm or suicide. The escort record was passed to
officials at the court. As the prisoner was considered likely to commit further
offences, he was remanded in custody. He was taken to HMP Winchester later that
day by Reliance, a private security company. He arrived at Winchester at 3pm.
During the reception procedures, the prisoner was completely withdrawn and
unresponsive. The reception officer on duty noticed that he had already been
assessed as being at risk of self-harm by the escorting staff who had brought him to
the prison. This information was recorded on a self-harm warning form that the
officer read and signed. The form showed that the prisoner had made statements of
intent to self-harm or commit suicide, and that he seemed very depressed. The
source of this information was the prisoner’s solicitor.
There is no evidence that the prisoner was subject to any formal health screen
during the reception procedures. The nurse who saw the prisoner in reception told
my investigators that she could not remember whether she completed a first or a
secondary screen but that she would be very surprised if one was not done.
However, she recalled that she was so concerned about the prisoner’s mental state
9
that she decided he should be admitted straightaway to the healthcare centre. The
nurse made the following entry in the prisoner’s medical record:
“16.40. Admitted to healthcare on constant watch.
Very tearful on admission. States we don’t understand.
Proceeded to lie on bed and go to sleep. Pulse 84.
Pupils reacting. Reflex reaction good. ACCT opened.”
The ACCT form is used as a tool by which those prisoners who are considered to be
at risk of self-harm or suicide can be appropriately observed, monitored and
managed. In the form, the nurse wrote,
“Came into reception tearful and non communicative.
Has stated he would like to kill himself and wants his life
back. Girlfriend left him eight weeks ago, made bankrupt
recently. Has cut his wrist in past.”
The prison doctor also saw the prisoner. The doctor decided to place him on a
constant watch in a single, ligature-free, cell (H1-16) because he appeared to be
severely depressed.
The establishment’s Suicide Prevention Co-ordinator completed an ACCT Action
Plan the same day. The action plan included the following:
“Location: In conjunction with the doctor who expressed
severe concerns recommends going in to a gated cell.
Frequency of staff support: Level 1 obs until at least
tomorrow’s case review.
Phone access: offer declined.
Listener access: available.
Other immediate interventions: Medical obs and test to see if o/d
(overdose).”
The Suicide Prevention Co-ordinator told my investigators he vaguely recollected
that the prisoner suggested he might have taken an overdose and was concerned
that this possibility should be further examined. There is no evidence in the medical
record to show whether any action was taken to follow up the Suicide Prevention
Co-ordinator’s remarks.
On 1 June, an entry was made in the prisoner’s medical record showing that he was
tearful and making wailing noises. Also recorded was the fact that he had secreted
a plastic knife and had used it to try to inflict stab wounds to his chest. A form
F213SH (the report of a self-harm injury sustained by a prisoner) was completed
after this incident by a healthcare officer (HCO). The form showed that the prisoner
had moderate indentation marks, but that his skin had not been punctured. The
HCO also made an entry in the medical record to record this incident. As a result of
10
his attempt to self-harm, the prisoner was moved to a gated cell (H1-17). This type
of cell is designed to enable staff to observe the occupant at all times.
At 3.25pm on 2 June, an ACCT assessment interview was carried out by a Prison
Officer. The purpose of this interview was to assess the prisoner’s mental state and
risk of self-harm prior to the first multi-disciplinary case review that was to be held
later that day. There is a requirement for such a review to be completed within 24
hours of the ACCT form being opened. My investigators were told that an attempt
was made on 1 June to hold the review but, on that day, the prisoner was totally
unresponsive to staff. The review was therefore delayed for 24 hours. The review
was conducted by the Head of Healthcare, a Prison Officer who was the case
manager for the prisoner at the time, and a prison doctor. The prisoner was present.
The case review summary recorded that he was still feeling very upset, although he
said that he felt better than he had two days earlier. He told the panel that he
preferred to be in prison and seemed anxious when talking about release. A routine
referral was made to the Community Mental Health Team (CMHT) with the
prisoner’s agreement. He also said he did not feel that he needed to be watched
constantly. The case review concluded that the frequency of observations of the
prisoner was to be reduced from a constant watch to level two (five times each hour)
despite his attempt at self-harm the day before. At interview, the Head of Healthcare
told my investigators that she could not remember at the time whether she knew of
the prisoner’s self-harm the previous day.
On 4 June, a further case review was held. This review was attended by a nurse,
two Prison Officers and the prisoner. The case review summary recorded that the
prisoner appeared brighter and more positive. It was noted that he had engaged in
out-of-cell activities and that he had tried to establish contact with friends and
solicitors. A decision was made to reduce the frequency of observations further,
from level two to level three (twice per hour). The next case review was scheduled
to take place on 14 June. In fact, it was held on 16 June.
On 7 June, the prisoner appeared at court. He was remanded in custody for a
further week. The escort record for his court appearance noted that he was at risk of
self-harm.
On 10 June, a student nurse compiled an initial Care Plan Approach (CPA)
assessment in the presence of CPN. After recording details of the prisoner’s
psychiatric history, the nurse wrote:
“Current presentation/mental state examination:
Good eye contact, good engagement, though due to content of
information given, was extremely tearful and emotional. Sleep
pattern disturbed, but utilising sleep as a coping skill. Now
accepting drinks and meals. Mental state not stable, can change
rapidly dependent upon how he is thinking about events, situation
etc.”
The nurse added:
11
“The prisoner is still at significant risk of further attempts at suicide.
This is supported by his labile depressive state and the
hopelessness he feels if he is not bailed. Has a number of
unresolved issues ranging from child abuse and relationship
difficulties.”
The care plan recommended that the ACCT form should remain open, and that once
bail had been agreed, and once the prisoner had arrived at his bail address, he
should register with his GP. He should then access counselling and consider the
use of anti-depressants. The risk management plan suggested he should continue
with CMHT input and have access to Listeners (prisoners trained by the Samaritans
to support other prisoners in crisis).
On 13 June, the prisoner’s bail application was refused. He reacted badly to this
decision. An entry made in the medical record shows that he was very depressed,
quiet and withdrawn. The signature of the person who made the entry is illegible. In
view of the prisoner’s mental state, it was decided that he should be observed at
level two (five times per hour) overnight.
At 10:30pm the following entry was made in the prisoner’s ACCT form:
“Looked in at 22:20 hours. The prisoner was writing a letter. At
22:30 hours, he was lying on the floor in the right hand side
(FRONT) (sic) of his cell. We could not see his face and he did not
respond to our calls. S.O was called over. He is now on level 2
obs.”
At 10:45pm, the following entry was made in his medical record:
“Officer informed that he can’t see the prisoner. Laying on floor
with head on side ... very depressed ... not talking, just lying there
... Put on level 2 obs for overnight observation … saying that the
only way is to end it all.”
At 11pm, the prisoner was seen still lying on the floor of his cell. However, at
11:20pm, he had moved onto his bed and was asleep. Regular observations were
recorded in his ACCT form throughout the night. These show that he remained in
his bed, either asleep or unresponsive, throughout the whole of the night and well
into the next day.
At 11:40am on 14 June, the prisoner declined lunch. An entry made in his ACCT
form at 1:20pm that day shows that he told a member of staff that there was “nothing
to go on for”.
An entry made in the medical record by a doctor on the following day records that
the prisoner was “very morose and non-communicative, much as before.” In view of
the fact that the prisoner ate only one meal each day, the doctor noted his concern
that his intake of food and fluids should be monitored. He also prescribed
Fluoxetine, an anti-depressant drug.
12
On the same day, the prisoner compiled his own “get better plan”. In it, he wrote
that he needed to understand why he was suffering from depression and that he
wanted to stop his physical symptoms such as shaking, loss of appetite, and crying.
He also wanted to rid himself of thoughts of self-harm. The prisoner wrote that he
wanted to accept any help even if it involved the use of medication. He said he had
intended to start counselling at his bail address but that this had not materialised as
he had been refused bail. He said he wanted “to get off the hospital wing as soon as
items like razor blades are only thought of as shaving implements”. He wanted to be
“strong enough to not have irrational fear in social situations” and to prove that he
was not going back to the same state that led him in to prison. He also wanted to
forge links with his former girlfriend and her family so that the end of a loving
relationship did not mean the end of his life. His concluding remarks in his “get
better plan” were:
“I need to discuss the way forward with someone who can give positive
goals to attain and how to avoid pitfalls, since the time I had my
breakdown and have had to talk with no input from anyone else. I am
struggling on my own.”
A reference to the “get better plan” was made in the prisoner’s medical record after
he had been seen that day during the doctor’s ward round. The doctor wrote that
the prisoner was more positive and that he had discussed his depression with him.
The prisoner agreed to taking Fluoxetine.
The review on 16 June was attended only by a Healthcare Senior Officer in his
capacity as the prisoner’s case manager, and by the prisoner himself. The review
summary described the prisoner as remaining low, but talking in a positive manner.
Also noted was the fact that he was awaiting a visit from his legal adviser. Records
show that the prisoner was visited by his legal adviser twice in June, twice in August
and once in November, shortly before he was sentenced.
The next review was set for 30 June.
On 17 June, a Staff Nurse wrote in the prisoner’s medical record:
“The prisoner is brighter in mood than previous meeting, despite bail
being refused. Making a lot of self-motivated moves in understanding
what has caused his depression and led him to his present situation.
Has thoughts of self-harm but are not so frequent or severe. Refuses to
use a razor currently. Is still dealing with low mood by sleeping but has
improved mood by tea time, where he eats his one meal of the day. Will
see again next week.”
This entry was countersigned by the CPN.
On 21 June, a doctor wrote in the medical record:
“Has accepted anti-depressant and has much more
positive attitude.”
13
The prisoner was seen again later that day by the CPN, who noted that his mood
was deteriorating once again. The prisoner, she said, felt hopeless about the future
and could not see anything but pain and loneliness. He was sleeping for a few
hours at night, and had a poor appetite. At times, he was very low and tearful. The
prisoner told the doctor that the only reason he had not killed himself was that he did
not have the means to do so. He saw suicide as the only way to stop his pain. The
doctor added that the prisoner was terrified that his lack of sexual feelings might
become permanent. He felt that he was deteriorating. His sleep was becoming
worse and his thoughts were becoming “like they were on the night of his offence”.
The CPN recorded that she advised the prisoner “to take things slowly and to try to
do more in short bursts”. She planned to see him again on 24 June. The CPN also
made a record of this consultation in the ACCT form and added, “as his energy
increases, he will be at increased risk of suicide”.
At about 9.15pm on 22 June, the prisoner attempted to hang himself with a TV cable
in a ligature free cell. This was recorded in both his medical record and the ACCT
form. The entry made in the ACCT form said that the prisoner was
“… found on the floor with a noose/cable around the outside of the
cell door snapped. Prisoner on floor, opened cell door with officers
and SO, put on bed. Small graze on neck.”
A F213SH (report of a self-harm injury sustained by a prisoner) was completed by a
Senior Officer who also noted that there was a small graze on the prisoner’s neck.
An entry made in the ACCT form shows that a decision was made to place the
prisoner on a constant watch and that this decision was to be reviewed after 24
hours. The prisoner had an undisturbed night.
The following day, a case review was held. This review was conducted by two
nurses. The prisoner was also present. The record of that review shows that his
desire to die was still present. He told the panel that “just because it’s a new day, it
doesn’t alter anything”. He was very reluctant to engage in conversation. As he was
already in a cell that was designated as ligature-free, it was decided that the
frequency of observations could be reduced to level two. This level of observation
required that the prisoner was to be observed five times in every hour. A record of
each observation was to be made at the same frequency and, at times when he was
awake, staff were required to record their conversations with him hourly. The record
shows that this was done.
On 24 June, the prisoner was seen again by the CPN. She wrote in the medical
record as follows:
“The prisoner came to interview reluctantly, appeared extremely low,
made no eye contact at all. Initially only monosyllabic responses,
mumbled. Stated nothing to live for, feels dead, nothing good in life,
no confidence can’t trust anyone, no faith and no-one to love him.
Feels it is getting worse. When asked about the hanging attempt,
stated he had seen how to make a noose on TV. When it broke, he
woke and ‘felt pissed off’. He found the hanging experience
pleasant. The phone call he made afterwards was to his partner
14
whom he has asked to visit. He is expecting her today and wants to
ask her why she doesn’t like him any more. He is also going to ask
her to stop seeing her new partner.
I am concerned that this feels like a repeat of the circumstances of
his index offence and would consider him to be HIGH RISK (sic)
during and after the visit.
Plan-ask the psychiatrist to see him as urgent on Tuesday 28/6.”
The CPN also recorded these details in the ACCT form.
The records show that the prisoner’s girlfriend did not visit him that day. However,
she did visit him once in September, twice in October and once in November.
At 8:50am on Saturday 25 June, a further ACCT case review was held. This was
chaired by a Healthcare Senior Officer and attended by a Healthcare Officer. The
prisoner was again present. The review was summarised as follows:
“The prisoner is refusing to eat or drink at present but is spending
all his time lying on his bed and is making no physical effort to do
anything. Will reduce level to three with the proviso level can be
raised if required.”
A doctor also saw the prisoner that day. The doctor wrote the following notes in the
medical record:
“Asked to see today. Has not been eating properly again, perhaps
for several days. Has been seen to be drinking water and milk. He
should be transferred to hospital for all care. I think his depression
makes him not competent to choose to refuse food and drink to the
death. We had a long chat and he told me that the anti-
depressants had made him feel well enough to really hate himself
and to try to kill himself. He has agreed with me and shook hands
on it to treatments to get him well enough to be able to tell his story
in court, that he was already low and depressed and thinking of
death when he broke into his girlfriend’s place to kill himself. In my
presence, he went on to drink a pint of orange squash and has
agreed to restart his anti-depressants. I have told him that he is ill
with depression and that he cannot rationalise or explain it. But he
has to accept that it exists and can be made better. I have also told
him that because he is ill, I will not allow him to kill himself by
neglect or by actions of his own hand. Plan was restart Fluoxetine,
can have sleeping tablets at night. Encourage to be active
throughout the day. Maintain level two observations.”
The medical record does not make clear what time the doctor saw the prisoner or
what time he made the above entry. At interview, the doctor told my investigators
that he saw the prisoner during the morning. He made a corresponding entry in his
15
ACCT form against a time of 3:30pm in which he repeated the gist of his
consultation but did not mention the need to maintain level 2 observations.
The level of observations instructed by the doctor differed from that recommended
by the Healthcare Senior Officer. The record of observations maintained within the
ACCT form show that staff made entries in the ongoing record at the following times
that day:
Morning: 7:30 Afternoon: 3:30 (Doctor’s entry) Evening: 6:30 Night: 9:45
8:30 3:35 7:10 10:50
9:30 8:05 Midnight
10:40 8:25
8:50
The frequency of these observations conforms neither to level two nor to level three.
The entries suggest that staff may have been confused as to which level of
observations applied.
The next review was scheduled to take place on 4 July.
On 28 June, the prisoner was assessed by a psychiatrist. The prisoner was tearful
during the interview and expressed feelings of worthlessness and hopelessness.
The psychiatrist diagnosed a depressive episode of moderate severity. He
suggested that the prisoner should continue to take Fluoxetine. He also recorded
his view that the prisoner continued to present as a high risk of self-harm and
suicide.
On 4 July, a further case review took place as planned. This was attended by a
Healthcare Senior Officer, a Prison Officer and the prisoner. The review was
summarised as follows:
“Remains unpredictable in mood. When coaxed becomes
interactive and communicates. No real change in progress long
term and just needs constantly encouraging.”
A further case review was planned for 18 July.
On 8 July, the CPN saw the prisoner. Afterwards, she wrote in the ACCT form:
“Continues to feel low and has no enthusiasm to do anything.
Won’t go on exercise as doesn’t like sitting with people as he
doesn’t know what to say - this is very unusual for him. Sleeps lots
day and night. Concentration poor. S/H (self harm) thoughts still
there but not as often - feels he would not be safe (sic) on main
wings as he would find any way to try to kill himself. Has plans but
would not tell me what. Finds it extremely hard being inside when
weather is fine - reminds him of what he would be doing.
Plan: discussed gym, would like to go but knows will need to be told
what to do and when to go. To be referred (to gym). To be
reviewed in 7 days.”
16
On 9 July, it was noted in the ACCT form that the prisoner refused exercise. On 11
July, the following entry was made:
“Enjoyed education session - has decided on a course he will
study. Was much happier, laughing, than last time. Talked about
how he can occupy his time by reading and studying.”
Thereafter, for a short time, the prisoner began to show signs of improvement. A
number of entries made in his ACCT form show that, although, when his mood
dropped, he continued to experience suicidal ideation, he nevertheless felt generally
more settled. Entries made in both the medical record and the ACCT form variously
recorded that he was “doing well”, was in a “good mood”, and was “predominately
cheerful”.
On 15 July, the CPN saw the prisoner again as planned. She wrote in the medical
record:
“At his brightest since coming into prison, though aware
that he still experiences low moods at times which increase
his suicidal ideation. Any transfer to wings should be
considered with input from mental health team in respect
of monitoring his mental state”.
Further entries made in the ACCT form during the latter half of July show that the
prisoner’s mood continued to vary. On 19 July, the psychiatrist wrote:
“Mood variable, low for two days (16/17). Less tearful. Ambivalent about
self-harm when low. Bail application - will be at increased risk of self-harm if
doesn’t get bailed.”
The next ACCT case review took place, as planned, on 18 July. This time, only
the Healthcare Senior Officer and the prisoner were present. The Healthcare
Senior Officer wrote the following remarks in the case review summary:
“Still has his ups and downs in moods, but generally feels more
settled with situation. Discussed future hurdles and how possibly to
deal with them.”
A further case review was to take place on 2 August.
Between 19 and 26 July, there were no further notations of any significance in the
ACCT form. However, on 26 July, the CPN wrote:
“States has struggled over past week and a half. Thought of how
would kill himself but didn’t make any attempts - feels good weather
made him feel bad as he is unable to go out walking in it. Mood
has lifted since and currently has no thoughts of suicide. Be aware,
if he does not get released on bail on Monday (1 August) he will be
a very high risk of suicide attempts. I will review on Tuesday.”
17
During the following week, the prisoner remained in a stable, though passive, mood.
At 9:30pm on 31 July, the eve of his court appearance, a member of staff in the
healthcare centre made the following entry in the ACCT form:
“Spoken to the prisoner, asked if okay. Said no not really. Asked if
I could help. Said no. No-one can any more. Asked if he would
like Listener. Said no thanks.”
At 6:50am the next day, the Head of Healthcare wrote in the ACCT form:
“In court today. 2nd bail application. Review if returns - at higher
risk of self-harm. See trigger points.”
Later that day (1 August), the prisoner appeared at Southampton Magistrates’ Court.
His application for bail was again refused. Upon his arrival back in the healthcare
centre at 6pm, it was noted that he “was not happy with today’s day at court”. At
8:15pm, it was further noted that the prisoner was having a “quiet, settled evening”,
and that he was “responsive and appeared to be dealing with his day”.
The prisoner was observed regularly through the night. After sleeping normally, he
woke at 5:30am the next day. He then read for a while and fell asleep again. At
10am, he cleaned his cell and was described as “happy to interact” although “a bit
fed up”. At 4pm, he was seen by the psychiatrist who wrote in the ACCT form:
“Mood better. No tearfulness. Thoughts self-harm at times. No
current wish to act on thoughts.”
The case review held on 2 August was attended only by the Healthcare Senior
Officer and the prisoner. The case review summary described the prisoner as
“rather down as was expected. Generally cheerful and philosophical in manner and
looking positively at next court appearance.”
On 16 August, the prisoner was seen again by the CPN, who made the following
entry in the ACCT form:
“Remains very angry re situation, determined to have revenge if he
gets sentenced. Willing to start looking at his thinking and how it
affects his mood and behaviour. Review in 2 weeks.”
On 18 August, another review was held, this time attended by a nurse, a healthcare
officer and the prisoner. One of the nurses summarised the review as follows:
“Remains insular, spending majority of his time asleep as this
makes time pass. Mood generally quite angry. Is spending time
with CMHT, who are endeavouring to focus on positive approaches
to his thoughts.”
2 September was set as the date for the next case review. However, on 19
August, the Healthcare Senior Officer convened a review at which he and the
prisoner were the only people present. My investigator was unable to establish
18
why this review followed so quickly after the review held the previous day. The
Healthcare Senior Officer wrote in the review summary:
“Sounds more positive and wants to go to the main prison as wants
more to do. Discussed issues re coping and mixing with the main
prison population, which he realises will be a challenge. Appears a
lot more settled in mood.”
As the Healthcare Senior Officer was not available for interview during the course
of the investigation, my investigators were unable to discuss with him why the
decision to consider the prisoner’s discharge from the healthcare centre followed
so quickly after the review on the previous day during which the subject of
discharge was not mentioned. However, it is clear from an entry made in the
medical record on 20 August that the Healthcare Senior Officer had discussed the
prisoner’s case with the CPN the previous day. The entry, made at 9am, reads as
follows:
“Discussed the prisoner’s request to go to the main prison with the
CPN yesterday. Agreed will follow up on the wing. Have had long
discussion with the prisoner about issues on the main prison, i.e.
feeling like self-harming and addressing those issues. Wants to do
more as getting frustrated in HCC. Wants he says to go to gym
and access library as examples. I voiced my concerns re
manipulative behaviour (wanting to go to main prison and act
inappropriately). Told if there were any concerns he would be
moved back to HCC. Doctor involved in decision and aware of
issues discussed.”
A discharge care plan was made out by the Healthcare Senior Officer who wrote:
“Summary of inpatient stay:
Admitted initially for observation due to being withdrawn and self-harm issues.
Has over time improved and now fit and has requested to go to the main
prison. On ACCT which has been handed over to C Wing staff with briefing.
Discharge agreed by:
CPN
Doctor
Healthcare Senior Officer
Care plan whilst on ordinary location:
Will be reviewed by doctor and CPN within 7 days
of discharge. Is aware of help from wing staff and Listeners.
Continue and review ACCT.”
The doctor told my investigators that, although he continued to have informal contact
with the prisoner, he had no further formal consultations with him after his discharge
from the healthcare centre.
19
At 10.45am on 20 August, the prisoner was transferred to C Wing where
unconvicted prisoners are normally held. He was located in a shared cell (3-28).
The ACCT form remained open. Regular entries were made in the ongoing record,
although few of those entries reflect the level of interaction between staff and the
prisoner. They paint a picture of a man who seemed to be content to remain in his
cell reading or watching television rather than engaging in other activities. However,
they do show that the prisoner’s mental state did not deteriorate in the immediate
aftermath of his discharge from the healthcare centre.
On 6 September, after the prisoner had ceased to show signs of suicidal ideation, a
final ACCT case review was convened. At this review, a decision was made that the
self-harm monitoring procedures to which he had been subject since his arrival at
Winchester in May were no longer necessary. The ACCT form was therefore closed
by a Senior Officer in the prisoner’s presence. No other members of staff were
present. A post-closure interview was to be held the following day. The
investigation found no evidence that the post-closure review took place. The local
suicide prevention policy requires that, following the closure of an ACCT form,
prisoners should be interviewed every 14 days in order to measure the extent to
which they are coping and that details of the interviews are recorded in their core
prison file. Although the F2050A (Record of Events) contains a number of entries
about this prisoner, none refers to post-closure ACCT interviews. My investigators
could find no evidence that such interviews took place.
On 9 September, after a further appearance at court, the prisoner refused to change
into prison clothing. He was charged under the prison disciplinary code. At the
ensuing disciplinary hearing, he was given three days cellular confinement and
stoppage of half his prison earnings for five days.
On 12 September, the prisoner appeared again at court. Once again, bail was
refused. He was due to return to court on 17 November. The escort record noted
no known risk of self-harm.
On 13 September, the prisoner was seen for the last time by the CPN. He made it
clear that he wished to have no further input from her. The CPN told my
investigators that this was a positive response from the prisoner. He said that he felt
so much better that he did not require further help from her. Nevertheless, the CPN
told the prisoner how to contact her should he change his mind, and told him that
she intended to review his case after his trial. This was due to commence at
Southampton Crown Court on 21 November.
In early October, the prisoner joined a Basic Sports Injuries course in the gym. This
required his attendance every weekday for five weeks. My investigators were told
by the PE staff that he was an able and enthusiastic student. They considered that
his attitude during his time in the gym was consistently positive.
On 28 October, the prisoner was placed on a second disciplinary report for fighting.
At the ensuing disciplinary hearing, he pleaded guilty to the charge. He was given
stoppage of half his prison earnings for 10 days and loss of canteen (use of the
prison shop) for seven days.
20
On 21 November, the prisoner’s trial began at Southampton Crown Court. On 23
November, he was sentenced to two years imprisonment. Staff at Winchester
thought that the length of the custodial sentence was a pleasant surprise to him.
The CPN told my investigators that she was not informed by staff in the prison that
the prisoner had been sentenced, and that she was disappointed that she could not
therefore review his case as she had intended.
During the weekend of 26 and 27 November, following his sentencing, details of the
prisoner’s trial were reported in the national and local media. A fellow prisoner told
my investigators that this was a source of significant distress to him. That prisoner
said that, during the latter half of October and the whole of November, they spent
many hours in the gymnasium together as students on the Sports Injuries course.
Apparently, the prisoner enjoyed his participation in the course and, although he
often talked about his domestic circumstances, he did not display any signs of
depression or suicidal thoughts. The prisoner’s friend knew there had been
widespread publicity over the weekend which had given lurid accounts of his
offence. The friend said he tried to prevent the prisoner seeing any newspapers.
However, he told my investigators that another prisoner, whom he did not wish to
identify, passed a press cutting underneath the deceased prisoner’s cell door. The
friend said that, immediately after seeing the article, the prisoner suddenly changed.
He did not leave his cell, did not eat and did not engage with anyone. The friend
blamed the media coverage for the prisoner’s death.
On 27 November, a Prison Officer was told by the prisoner’ cell mate that the
prisoner was not eating. When the officer spoke to the prisoner, he explained that
he was not on a hunger strike and was drinking regularly. As the officer knew that
the prisoner had already been subject to self-harm monitoring procedures, he
decided to open a further ACCT form. The prisoner was to be placed on level three
observations. An immediate ACCT action plan further required that he should be
kept in a shared cell, and that he should be given access to telephones and to
Listeners as required. He was also to have his meals delivered to his cell each day
so that his eating pattern could be closely monitored. The prisoner was to be seen
by someone in the healthcare centre as soon as possible. There is no evidence in
the ACCT form or the medical record to show whether he was seen the next
morning by anyone from the healthcare centre.
The first entry in the new ACCT form was made at 5:45pm on 27 November, when
a Prison Officer recorded that the prisoner said that he “was ok”. Later that evening,
a note was made in the record that he was seen lying on his bed watching television
and that, at about 10pm, he appeared to be asleep. Further entries were made in
the record at hourly intervals throughout the night. Each entry shows that the
prisoner was observed as being asleep.
At 6:35am on Monday 28 November, the last entry was made for that night. It
recorded that the prisoner appeared asleep on his back and that there were “no
problems at staff handover”.
21
6. Events on and after 28 November 2005
No further entries were made in the record until 9:40am on 28 November when the
Duty Governor recorded his management check of the ACCT form. He commented
that a review date was to be set. The first review would have been due that day. An
entry made in the ACCT form by the establishment’s Suicide Prevention Co-
ordinator shows that he was planning to convene a case review on the prisoner that
afternoon.
An entry made at 12:10pm that day by a Prison Officer shows that the prisoner was
“laid in bed. When asked if he was ok, said ‘yes, marvellous pasta and potato put in
his cell’.”
It is normal practice at Winchester for officers to be deployed from one wing to carry
out a task in another. This was the case when, at 2pm, the time came for prisoners
in C Wing to be unlocked for exercise. The task of staffing the exercise yard fell to
those officers available in C Wing. Once they were in place on the exercise yard,
officers from A Wing unlocked C Wing prisoners for exercise. One of those officers
was responsible for unlocking the prisoner’s landing. However, the officer told my
investigators that he could not specifically recall unlocking the cell in which the
prisoner and his cellmate were located. However, it is clear that the cellmate left for
exercise, and that the prisoner declined. He therefore remained locked in his cell,
alone. The officer who unlocked him did not know that he was subject to an ACCT
form.
At about 2:50pm, the cellmate decided he wanted to leave the exercise yard early. A
Prison Officer offered to take him back to his wing as she wanted to see someone else
on C wing. On returning the cellmate to his cell, the officer looked through the
observation panel in the door and saw the prisoner hanging from the cell window by a
ligature made from his bed sheet. The cellmate was immediately located elsewhere in
the wing. As my investigators were unable to interview him, it has not been possible
to establish what level of care he was given.
The Prison Officer immediately blew her whistle to alert other staff. She entered the
cell, approached the prisoner and supported his body weight. Two other officers
arrived soon after and together they helped to lift the prisoner so that the ligature could
be removed. One of the officers told my investigators that he took about 20 seconds
to untie the ligature. The prisoner was then laid on the floor of the cell in the recovery
position.
Although there was no contingency plan in place to guide staff as to what procedures
to follow when a life threatening situation is discovered, the Orderly Officer of the day
nevertheless cordoned off the area and controlled access into, and egress from, the
prisoner’s cell. The Orderly Officer also appointed a log keeper who recorded events
as they occurred.
Very soon after, two nurses arrived. They found that the prisoner was heavily
incontinent of urine and was warm to the touch. No vital signs were evident. One
nurse also said that the prisoner was heavily marked around his neck. She noticed
some dried blood but no evidence of a major wound. The two nurses began to apply
22
cardio-pulmonary resuscitation (CPR) with the help of a Prison Officer. One of the
nurses also alerted the communications room by radio to the need for the prison
doctor and an ambulance to be called. She told my investigators that she asked three
times for the doctor to come to C Wing and that, on the third occasion, she became
cross because no-one had arrived.
At interview, the doctor concerned told my investigators that he was in Westhill Unit
when he received a telephone call asking him to go to C Wing. He therefore
terminated his consultation and left for C Wing. He said that he probably took about
five minutes to reach the wing. It was only upon his arrival in the wing that he realised
that the prisoner had been found hanging. He said that the person who called him
merely said words to the effect, “the nurses would like you to attend C Wing. There’s a
problem there.” The doctor was clear that he was not told that a prisoner had been
found hanging.
A Prison Officer was in the communications room and in charge of the radio net at the
time. Also on duty in the room were two further members of staff who were
responsible for carrying out other tasks. The officer told my investigators that he
received the nurse’s radio call at about 3pm. He said that her call made it clear that
there was a life-threatening situation in C Wing and that a doctor and an ambulance
were required. The officer confirmed that one of the other members of staff in the
communications room called an ambulance and made a telephone call to the
healthcare centre asking for immediate assistance from the duty doctor. He said that,
a few minutes later, the nurse asked again over the radio for the doctor to attend. The
officer said that a further call was then made to the healthcare centre. It was then
confirmed that the doctor was on his way.
The log shows the following:
3:00pm Initial radio call made by the nurse requesting the
presence of the prison doctor and an ambulance
3:01pm Ambulance called
3:05pm Ambulance arrived
3:07 pm Doctor called again
3:09pm Ambulance staff arrive on C wing
3.40pm Ambulance leaves prison
Although the log does not show the time the doctor arrived at the cell, there is no
reason to doubt that he went to C Wing as quickly as he could after receiving the
telephone call in Westhill Unit. Any difficulties in contacting him were likely to be due
to the fact that he did not carry either a pager or a radio.
While they were waiting for the ambulance to arrive, the staff in the cell continued to
apply CPR to the prisoner. According to one of the nurses, an oxygen cylinder that
had been brought to the cell appeared to be empty. Another cylinder was therefore
requested. It was later confirmed that the original cylinder was fully serviceable but
that it had not been turned on correctly. A defibrillator was also brought to the cell at
the nurse’s request. She later told my investigators that this could not easily be used
on the floor because of the presence of so many body fluids. She therefore placed the
23
defibrillator on top of a cupboard but this too became problematic because the leads
were not long enough for the pads to be attached to the prisoner’s chest.
The resuscitation attempts therefore continued without the defibrillator. Two Prison
Officers helped to apply oxygen while chest compressions were applied by the nurses.
The nurses told my investigators that they thought that the prisoner was not likely to
be successfully resuscitated. Nevertheless, they persevered until a paramedic crew
arrived at the cell. Before they could use their defibrillator, the prisoner’s bed had to
be lifted and placed against the cell wall. The paramedic crew applied Adrenalin and
then connected their own defibrillator to the prisoner’s chest. They managed to
achieve a slight cardiac output. They therefore decided to transfer the prisoner to the
Accident and Emergency Department at the Royal Hampshire Hospital immediately
adjacent to the prison. The prisoner had to be carried out of the wing to the
ambulance in a “casevac chair”. This difficult task was controlled by one of the Prison
Officers.
The ambulance left the prison at 3:40pm and arrived at the hospital a few minutes
later. When he arrived at the hospital, the prisoner’s heart stopped beating but a
cardiac output was soon restored.
The same day, the Governor chaired a debrief of the staff involved in the discovery of
the prisoner and in the attempts to revive him. Those staff interviewed as part of the
investigation said that they were satisfied with the level of care offered to them by the
Governor, his senior managers and the establishment’s care team.
As no next of kin details were given by the prisoner when he was initially received at
Winchester in May, the Duty Governor in the prison at the time telephoned the
prisoner’s solicitors to find out if they were aware of any next of kin. They were not.
The Duty Governor therefore used the prison’s record of telephone calls made by the
prisoner through his phone card to establish an appropriate contact number. By this
means, the Duty Governor was able to contact the prisoner’s former girlfriend at about
4pm to inform her of what had happened. She arrived at the hospital later that day.
At about 5:40pm, the prisoner was transferred from the Accident and Emergency
Department to the intensive care unit where he was placed on a life support machine.
During the night, his condition began to deteriorate. He died in the hospital at 4:30pm
the next day. Following his death, his former girlfriend was invited to the prison where
she spent time talking to staff and to the prisoner’s friend.
The Duty Governor informed the prisoner’s solicitor of his death on 30 November and
asked him to take on the role of next of kin if no family members could be traced. At
10:45pm that day, the prisoner’s sister-in-law called the prison. The next day, during a
telephone conversation with the Duty Governor, she confirmed that the prisoner’s
parents and three siblings were aware of his death and that they wanted to be
involved in arranging his funeral. She passed the Duty Governor their contact
numbers. Some time later, the prisoner’s parents made contact with the Duty
Governor.
The prisoner’s funeral took place on 13 December. A representative of the Governor
attended. The funeral costs were met by the Governor.
24
Examination of the care given to the prisoner
Here I examine:
• the assessment and treatment of the prisoner’s mental health needs.
• the assessment, monitoring and management of his risk of self-harm or suicide.
• the response after he was discovered hanging.
The assessment and treatment of the prisoner’s mental health needs
• Formal health screening
Upon his arrival at Winchester on 31 May, the prisoner was immediately admitted
to the healthcare centre. He was also made subject to formal self-harm
monitoring procedures, through the use of the ACCT form, after the nurse who
saw him in reception noticed that he was totally withdrawn and unresponsive. I
consider that the decision to admit the prisoner to the healthcare centre was
entirely appropriate. However, the decision was not based on any formal
assessment of the prisoner’s physical or mental health needs. Prisons are
required to conduct a first, and then a secondary, reception health screen on all
prisoners as soon as they arrive. In the case of this prisoner, no first or
secondary health screen was carried out. This is likely to have been the result of
the fact that the prisoner was withdrawn and unresponsive during the reception
procedures.
I take the view that, in such circumstances, formal health screening should
take place at the first available opportunity after the remaining reception
procedures have been completed.
• Follow up action on remarks made in ACCT form
The Suicide Prevention Co-ordinator at Winchester drew up an Action
Plan as soon as the ACCT was opened on 31 May. In it, he drew
attention to the need for a medical check to be made in order to verify
whether the prisoner had taken an overdose of drugs in the recent past.
There is no evidence that this recommendation was followed up. The
credibility of ACCT action plans will be eroded if their recommendations
are not taken seriously and acted upon.
The Governor should remind his staff of the need to check that ACCT
action plans are appropriately followed up and that management
checks are carried out to ensure that this is done.
• Mental health assessment, monitoring and review
The prisoner was seen by a doctor in the healthcare centre immediately upon his
admission. The doctor decided that the prisoner should initially be placed on a
constant watch as his risk of self-harm was considered to be high. The first ACCT
action plan assessment was carried out by the Head of Healthcare and the prison
doctor. One of the outcomes of this assessment was that the prisoner was referred to
25
a Community Psychiatric Nurse (CPN) from the Community Mental Health Team
(CMHT). On 10 June, a Care Plan Approach assessment was carried out by a
student nurse under the supervision of the CPN. On 14 June, the prisoner made out
his own ”get better plan” in which he articulated his own worries as well as a number
of possible solutions for dealing with them. The prisoner’s plan was discussed with
him by the doctor.
The prisoner remained in the healthcare centre for nearly three months. During that
period, and indeed after his discharge to the main prison, his mental state fluctuated.
His care was underpinned by a Care Plan Approach assessment, an ongoing nursing
care plan, ACCT procedures and by frequent and comprehensive reviews by three
different specialists - the prison doctor, a psychiatrist and the CPN. Regular ACCT
case reviews were held, with the prisoner present at each. Comprehensive notes
were made in the prisoner’s medical record each time he was seen. With the
exception of one occasion, when an entry made in the ACCT form did not refer to the
level of observations mentioned in the medical record, corresponding information was
logged in each document. By this means, there was effective cross-communication
between those who were engaged in assessing, monitoring and managing the
prisoner’s general mental health and those who were responsible for monitoring his
risk of self-harm. When he was discharged from the healthcare centre to the main
prison in August, a proper discharge plan was made out, the aim of which was to
structure his post-discharge care in the wing.
In July, the CPN notified the PE staff at Winchester of the prisoner’s desire to use the
gym. As a result, he later joined a Basic Sports Injuries course, perhaps the most
positive and stimulating activities he undertook in prison. While he was on this course,
he demonstrated few signs of depression.
The monitoring of the prisoner’s mental health by the CPN continued until 13
September when the prisoner told her that he felt no need to see her again. The CPN
regarded this as a positive development, but nevertheless made a plan to see the
prisoner again as soon as his trial had been concluded. This began on 21 November
and ended two days later when the prisoner was sentenced to two years
imprisonment. Unfortunately, the CPN was not informed that he had been sentenced.
She told my investigators that, had she been so informed, she would have seen him
again as planned.
• The treatment of the prisoner’s depression
The need for the prisoner to consider the use of anti-depressant medication was first
mooted on 10 June, when a student nurse conducted a Care Plan Approach
assessment of his mental health needs. On 14 June, the prison doctor decided to
prescribe Fluoxetine, an anti-depressant drug. Although entries made in the medical
record refer to the fact that the prisoner occasionally declined his medication, no such
clarity is evident in the prescription charts.
On 25 June, the doctor wrote in the medical record that the prisoner told him that the
anti-depressants had made him well enough to hate himself and to try to kill himself.
The doctor reassured the prisoner that the treatments he prescribed would “make him
well enough to be able to tell his story in court that he was already low and depressed
26
and thinking of death when he broke into his girlfriend’s place to kill himself.” As a
result, the prisoner agreed to restart his anti-depressants.
The doctor told my investigators that he regarded the prisoner as a man “who did not
have a ‘doctor culture’. Rather, he had a ‘sort-yourself-out’ culture.” The doctor
understood that the prisoner was the sort of man who would have resisted medication.
He agreed that Fluoxetine can increase the risk of self-harm or suicide as it starts to
work. He persuaded the prisoner of the importance of working through the initial
period. By explaining to him that he had to accept that he was ill with depression
rather than trying to rationalise it, the doctor thought that he had succeeded in
restoring his belief that the treatment was appropriate and that he could be made
better.
I conclude that the individual and combined efforts of the doctor, the
psychiatrist and the CPN, together with the nursing staff, to assess, monitor,
review and manage the prisoner’s health needs were entirely appropriate. They
should be commended for their efforts.
However, the Governor should ensure that accurate details are recorded on
prescription charts of any drugs prescribed, the dates when they are
administered and the dates when they are not taken.
The assessment, monitoring and management of the prisoner’s risk of self-harm
or suicide
• Opening of first ACCT form
Formal self-harm monitoring procedures were invoked for the prisoner upon his
arrival at Winchester on 31 May. The concerns expressed in the escort record prior
to his appearance at court the previous day were properly passed from the police to
the court officials, and onwards to Reliance, the private security company that took
the prisoner to the prison. The reception officer on duty at the prison noted that a
self harm warning form had been raised.
• Case reviews
Upon his admission to the healthcare centre during the evening of 31 May, the
prisoner was placed on a constant watch. The first ACCT case review should have
taken place within 24 hours of the form being opened. However, as the prisoner
was completely withdrawn and unresponsive on 1 June, the case review was
justifiably delayed until the next day.
Thereafter, regular and timely ACCT case reviews were held, the summary of each
of which was appropriately recorded. The prisoner was present at every review and
was therefore given an opportunity to be actively involved in decisions that affected
him.
At the case reviews held on 18 July, 2 August, and 19 August, the panels were
comprised of only one member of staff. The review held on 6 September, at which
the decision to close the ACCT form was made, was also attended by only one
27
member of staff. The establishment’s own suicide prevention policy requires that
case reviews should be attended by the Case Manager, the prisoner, unit staff and
representatives of any other departments that work closely with the prisoner. The
local policy does not state how many staff should be present when an ACCT form is
to be closed. My investigators were told that it was not always possible for more
than one member of staff to attend because of other demands on staff time. I accept
that, in a busy local prison such as Winchester, staffing levels and other operating
difficulties can obstruct the achievement of the required standards. However, I
believe that in an area as important as suicide prevention, standards must not be
allowed to erode and that the multi-disciplinary approach to ACCT (where ‘T’ stands
for teamwork) must be preserved.
The Governor should take steps to ensure that his policy for the operation of
the ACCT system sets out a clear minimum attendance standard for all types
of case review. The Governor should also ensure that the agreed standard
should be audited routinely in management checks.
• Post-closure ACCT reviews and interviews
On 6 September, after the prisoner’s ACCT form was closed, it was determined
that a post-closure review was to take place the following day. The investigation
found no evidence that this review took place. Furthermore, the local suicide
prevention policy requires that, following the closure of an ACCT form, the
prisoner should be interviewed every 14 days in order to measure the extent to
which he is coping and that details of the interviews are recorded in the
prisoner’s core prison file. None of the entries made in the prisoner’s F2050A
(record of events) refers to post-closure ACCT reviews or interviews. My
investigators could find no evidence that such interviews took place.
The failure to carry out post closure reviews and interviews could, I believe, have
potentially serious consequences. Whilst I accept that there can never be a
guarantee that the conduct of post-closure reviews and interviews will prevent a
prisoner’s suicide, a failure to carry them out will deny staff an opportunity to
measure any changes in the mental state of a prisoner once the closely structured
support of the ACCT system has been removed. In the case of this prisoner, the
fact that no such reviews and interviews were carried out was mitigated, for a short
while, by the CPN’s continuing interest in him. However, this does not reduce the
significance I attach to the need for staff to follow the post-closure procedures that
are already explicit in the establishment’s suicide prevention policy document.
The Governor should take urgent steps to ensure that post-closure reviews
and interviews take place as a matter of routine. Checks carried out by
managers should incorporate regular audits of this function.
• Self harm attempts
On 1 June, the prisoner’s first full day in the healthcare centre, he made moderate
indentations in his abdomen with a plastic knife issued to him for use at meal times.
He did so while he was on a constant watch. It is clear that this was a minor act of
self-harm rather than an attempt on his own life. Plastic cutlery is legitimately issued
28
to prisoners to enable them to eat their meals. Tempting as it is to suggest that
prisoners who are considered to be at risk of self-harm should not have such
implements in their possession, to deny them their use would be disproportionate
and not in the interests of basic decency. I also believe that to restrict the issue of
plastic cutlery to meal times would carry no guarantee that prisoners would not use
them inappropriately. However, the fact that the prisoner was able to harm himself
in this way at a time when he was on a constant watch is a cause for concern. The
door of the cell in which he was located was fitted with a large observation hatch that
afforded some observation into the cell. The officer who was watching the prisoner
discovered the act immediately and reacted appropriately. After he had self-harmed,
the prisoner was moved to a “gated cell”. This was fitted with a metal grill-gate
instead of a solid door, thereby affording optimum observation.
It would be sensible for the Governor to consider whether more gated cells
should be provided in the healthcare centre so that no prisoner in need of
constant watch is observed only through an observation hatch in a solid cell
door.
A case review took place the day after the prisoner’s self-harm attempt. At this
review, a decision was made to reduce the level of observations from constant
watch to five times per hour. The case review summary does not make mention of
the events of the previous day. At first glance, the decision to reduce the frequency
of observations the day after the prisoner had tried to harm himself seems
inappropriate. However, at the review, he articulated his concerns clearly and said
that he felt better than he had two days before. He told the review panel that he
appreciated the support he was receiving, that he was willing to see someone from
the Community Mental Health Team and that he did not feel that it was necessary
for staff to watch him constantly. I am satisfied that, given the prisoner’s improved
demeanour that day, the decision to reduce the level of observations was
understandable.
However, staff need to be careful to read previous entries in the ACCT form
when conducting case reviews so that their decisions are based on the best
and most up to date information.
At 9:15pm on 22 June, the prisoner was found on the floor of his cell in the
healthcare centre with a snapped television cable around his neck after trying to
hang himself. Although his life was not endangered, he nevertheless sustained a
graze on his neck. He was immediately placed on a constant watch in a ligature-
free cell. He then had an undisturbed night. The next day, a case review was
convened. The panel decided that, as the prisoner was in a ligature-free cell, his
level of observations could be reduced from a constant watch to level 2 (five times
per hour).
There must be concern that television cables in prisoners’ cells (particularly in
healthcare) are of such a length that they can be fashioned into ligatures. I am
also concerned that the prisoner was able to try to hang himself by this means
when located in a cell described as ligature-free. The decision to reduce the
level of observations after his self-harm attempt was driven by this same factor.
At interview, my investigators suggested to the doctor that it was inappropriate
29
for television cables to be available as ligatures. He understandably took the
view that the television set, with its connection to the mains electricity supply,
was a much more dangerous self-harm implement than the television cable
because prisoners could electrocute themselves by smashing the screen and
touching the electrical circuitry inside the set. My investigators discussed this
issue with the Deputy Governor at Winchester who put forward the view that it
was possible to place selected television sets behind a perspex screen and to
shorten the cables. I agree with the Deputy Governor’s suggestion.
The Governor, in conjunction with the NOMS Safer Custody Group should
consider the benefits of this suggestion.
• Record keeping
On 25 June, the doctor saw the prisoner at the request of healthcare staff who were
concerned that he was not eating properly. The doctor made a record of his
consultation in both the medical record and the ACCT form. The medical record
does not make clear what time the doctor saw the prisoner. At interview, the doctor
told my investigators that he saw him during the morning. The entry he made in the
ACCT form was made against the time of 3:30pm. In the medical record, the doctor
recorded that level 2 observations were to continue, but he did not mention this in
the ACCT form. On the same day, a case review was held at 8:50am, chaired by
the Healthcare Senior Officer, who decided that the prisoner should be observed at
level 3. This conflicted with the doctor’s instructions in the medical record. The
actual observations made of the prisoner that day do not properly match the
requirement for either level 2 or level 3 and suggest that staff may have been
confused as to the which level of observation applied.
The Governor, in conjunction with the prison doctor, should ensure that
entries made in medical records are accurately reflected in ACCT forms, within
the bounds of medical confidentiality, so that no confusion arises about the
level of observation to be adopted.
• The prisoner’s deterioration after his trial
On 21 November, the prisoner’s trial began at Southampton Crown Court. Two days
later, he was sentenced to two years imprisonment.
The CPN told my investigators that no-one from the prison informed her of the fact
that the prisoner had been sentenced. She was disappointed that she was therefore
unable to review him as planned.
The Governor, in conjunction with the prison doctor, should ensure that such
important details as the sentencing of a prisoner whose mental state is under
review by the Community Mental Health Team and by psychiatrists is promptly
communicated to all the agencies involved in his care.
Staff thought the prisoner’s relatively short sentence came as a pleasant surprise to
him. Although his mood had varied in recent weeks, his mental state had improved
a little prior to being sentenced. However, over the weekend of 26/27 November the
30
details of his offence were publicised in the local and national media. Another
prisoner, who undertook the Basic Sports Injuries course with the prisoner, and who
became his close friend, told my investigators that he had tried to prevent the
prisoner from hearing or seeing the publicity. The friend said that another prisoner,
whom he did not name, pushed a newspaper containing an article about the
prisoner’s trial under his cell door. The friend said that the prisoner reacted very
badly. He stopped eating and did not leave his cell. The friend blamed the media
coverage for the prisoner’s death.
On Sunday 27 November, a Prison Officer was told by the prisoner’s cellmate that
the prisoner was not eating. The prisoner explained to the officer that he was not on
a hunger strike and that he was drinking regularly. As he knew that the prisoner had
already been subject to self-harm monitoring procedures, the officer nevertheless
took the precaution of opening a new ACCT form there and then. The prisoner was
to be placed on level 3 observations. This required staff to make a written record of
any conversations with the prisoner once per shift and at hourly intervals during
patrol states (i.e. when prisoners are locked in their cells and minimum staff are on
duty). I regard this as appropriate in the circumstances. An immediate ACCT action
plan further required that the prisoner should be kept in a shared cell, and that he
should be given access to telephones and to Listeners as required. He was also to
have his meals delivered to his cell each day so that his eating pattern could be
closely monitored. Furthermore, he was to be seen by someone in the healthcare
centre as soon as possible. There was no evidence in the medical record or in the
ACCT form that anyone from the healthcare centre saw him the next morning. At
first glance this seems unfortunate. However, at the time the ACCT was opened,
the prisoner was not actively suicidal. The reason for recommending that he should
be seen by the healthcare staff was because he had not been eating. I therefore
raise no criticisms about the fact that he was not seen the following morning.
By the time the investigation commenced, the cellmate had been released from
prison. My investigators wrote to him at his home address to invite him to be
interviewed. The cellmate later replied, saying that he was willing to be interviewed
and was happy to receive a telephone call, on a given number, to discuss where and
when the interview might take place. However, he failed to respond to the numerous
calls my investigators made. As a result, it was not possible to interview him.
The evidence provided by the prisoner’s friend suggests that the prisoner was
devastated more by the publicity surrounding his trial than by the sentence he
received. The friend had the presence of mind to report his concerns about the
prisoner to an officer. This was a responsible and commendable act. The officer
opened an ACCT form as a precaution against the possibility that the prisoner had
commenced a hunger strike and because he knew that he had been the subject of
formal self-harm monitoring procedures earlier.
The actions of that officer were commendable.
Observations were recorded in the prisoner’s ACCT form throughout the remainder
of the evening of 27 November, the following night and the morning of Monday 28
November. At 12:10 pm, a Prison Officer took the prisoner’s lunch meal to him in his
cell and asked him if he was alright. He said, “Yes, marvellous.”
31
At about 2pm on 28 November, the prisoner declined exercise and remained in his
cell alone. He was found hanging by an officer an hour later, towards the end of the
exercise period. At interview, that officer told my investigators that, when she
delivered the prisoner’s lunch meal to him just after midday, he gave no signs that
he was contemplating suicide.
I have considered whether, given the fact that he was the subject of formal self-harm
monitoring procedures, it was appropriate for the prisoner to be left alone in his cell
during the exercise period. With the benefit of hindsight, he may well have been
planning to commit suicide, but the presenting risk indicators at 2pm that day were
not suggestive of an imminent attempt on his own life.
I conclude that nobody was at fault for allowing the prisoner to remain alone
during the exercise period. However, as a precaution, the Governor should
consider the merits of ensuring that any prisoner subject to an ACCT form and
left alone in his cell (during exercise for example) is observed five times an
hour for that period.
The investigation found that it is not unusual for staff from one wing to unlock
prisoners in another wing for activities such as exercise. This was the case where
this prisoner is concerned: his cell in C Wing was unlocked at about 2pm by an
officer from A Wing. This practice gives rise to the possibility that prisoners
considered to be at risk of self-harm or suicide are not known by the staff who unlock
them.
Indeed, the officer who unlocked the prisoner told my investigators at interview that
he did not know that he was subject to ACCT procedures. This issue was discussed
with the Deputy Governor, who takes the lead in setting and reviewing suicide
prevention policy at Winchester. He told my investigators that, irrespective of which
wing they work in, staff are expected to familiarise themselves with the names and
cell locations of those prisoners subject to ACCT procedures - the details of whom
are listed on a white board in each wing office. The officer who unlocked the
prisoner for exercise on 28 November told my investigators that he was not aware of
any such policy.
The Governor should remind his staff of the requirement to familiarise
themselves with the names and cell locations of prisoners subject to ACCT
procedures
The response after the prisoner was discovered hanging
The prisoner’s former girlfriend told one of my Family Liaison Officers that she had
been told, on one occasion, that 20 minutes had elapsed before any attempts to revive
the prisoner were initiated. She said that, on another occasion, she was told that 40
minutes had elapsed. My investigators found no evidence to suggest this was the
case at all. As soon as the officer discovered the prisoner hanging, she blew here
whistle to alert other staff to the emergency. Within seconds, she was joined by other
wing staff. Two nurses also arrived at the cell within a very short space of time.
32
My investigators found that, when the nurse asked the communications room to ask
the prison doctor to come to the prisoner’s cell, the request was relayed to the
healthcare centre by telephone. At the time, the doctor was engaged in a consultation
in Westhill Unit. There was therefore a slight delay in finding him. The doctor told my
investigators that when he received the call for help he was not told that the prisoner
had been found hanging.
In order to minimise the possibility of such difficulties in the future, the
Governor should consider what better arrangements might be put in place for
contacting duty doctors in emergencies, such as issuing them with a pager or
requiring them to carry a radio. Local contingency plans for the management of
life threatening situations should set out the procedures to be followed,
including clear instructions for contacting the duty doctor, and should ensure
that the type of emergency is communicated straightaway to those required to
respond.
• Attempts to revive the prisoner
In spite of their view that it was unlikely that the prisoner could be successfully
resuscitated, discipline staff, nursing staff, and the paramedic crew persevered. As a
result, a slight cardiac output was achieved.
The efforts of those staff who were involved in the discovery of the prisoner and
in attempts to revive him are worthy of praise.
• Contacting the next of kin
When the prisoner was received at Winchester on 31 May he volunteered no
information as to who was his next of kin. This was probably due to the fact that, at
the time, he was completely withdrawn and unresponsive. After his admission to
hospital on 28 November, efforts to contact his next of kin were seriously hampered by
the fact that no details were available in his core file.
The Governor should ensure that if, during the initial reception procedures, it is
not possible to record next of kin details in prisoner’s core records, this is done
as soon as possible afterwards.
33
7. Good practice and Recommendations
Good practice
(cid:131) The individual and combined contributions of the doctor, the psychiatrist
and the CPN in the care of the prisoner at Winchester are worthy of
praise.
(cid:131) Those staff who were involved in the discovery of the prisoner hanging
should be commended for their rapid response and for their perseverance
in trying to revive him in very harrowing circumstances.
(cid:131) The cellmate should be commended for bringing his concerns about the
prisoner to the attention of a Prison Officer on 27 November.
(cid:131) That Prison Officer should be commended for taking the initiative in
opening a new ACCT form.
Recommendations
I make the following recommendations: (responses from the Prison Service are
shown in italics and in brackets after each recommendation)
1. Reception health screening
(cid:131) The Governor should ensure that, on the rare occasions when, because of
a prisoner’s behaviour, reception health screening cannot take place
during the reception procedures, arrangements are made for the
screening to take place at the first available opportunity after the
remaining reception procedures have been completed. (Accepted.)
(cid:131)
2. Record keeping
(cid:131) The Governor should ensure that entries in the medical record are legible and
that the author of each entry is clearly identifiable. (Accepted.)
(cid:131) The Governor, in conjunction with the prison doctor, should ensure that
entries made in medical records are accurately reflected in ACCT forms
within the bounds of medical confidentiality so that no confusion arises about
the level of observation to be adopted. (Partially accepted- the Prison Service
stated that this was the responsibility of the doctor, not the Governor - but that
a local protocol would be produced and guidance issued to advise all
healthcare staff that entries in the IMR are reflected in the ACCT within
bounds of medical confidentiality.)
(cid:131) The Governor should ensure that accurate details are recorded on prescription
charts of any drugs prescribed, the dates when they are administered and the
dates when they are not taken. (Accepted.)
34
(cid:131) The Governor should ensure that if, during the initial reception procedures, it is
not possible to record next of kin details in prisoner’s core records, this is done
as soon as possible afterwards. (Accepted.)
3. Observation of prisoners at risk
(cid:131) The Governor should consider whether more gated cells should be provided
in the healthcare centre so that no prisoner in need of constant watch is
observed through an observation hatch in a solid cell door.(Partially accepted-
a needs analysis will be carried out by the Healthcare Manager.)
(cid:131) As a precaution, the Governor should consider the merits of ensuring that any
prisoner subject to an ACCT form and left alone in his cell (during exercise for
example) is observed five times an hour for that period. (Partially accepted-
This should be considered on an individual basis and will be incorporated in
the Care Map and on all ACCT reviews.)
4. Local contingency plans for the management of a life-threatening situation
(cid:131) The Governor should ensure that local contingency plans are issued for
the management of a life-threatening situation. (Accepted.)
(cid:131) The Governor should consider issuing duty doctors with a pager or requiring
them to carry a radio whilst in the prison. The arrangements for contacting duty
doctors in an emergency should be reflected in local contingency plans.
(Accepted.)
5. ACCT procedures
(cid:131) The Governor should take steps to ensure that his policy for the operation of
the ACCT system sets out a clear minimum attendance standard for all types
of case review. The Governor should also ensure that the agreed standard
should be audited routinely in management checks. (Accepted.)
(cid:131) The Governor should remind staff of the need to be careful to read previous
entries in the ACCT form when conducting case reviews, so that their
decisions are based on the best and most up to date information. (Accepted.)
(cid:131) The Governor should remind his staff of the need to check that
ACCT action plans are appropriately followed up and that
management checks are carried out to ensure that this is done.
(Accepted.)
(cid:131) The Governor should take urgent steps to ensure that post-closure interviews
take place as a matter of routine. Checks carried out by managers should
incorporate regular audits of this function. (Accepted.)
(cid:131) The Governor should remind his staff of the requirement to familiarise
themselves with the names and cell locations of prisoners subject to
ACCT procedures. (Accepted.)
35
6. Television sets
(cid:131) The Governor, in conjunction with the NOMS Safer Custody Group should
consider the benefits of placing selected television sets behind perspex
screens and shortening television cables. (Partially accepted- Installation
of perspex boxes can lead to the introduction of additional ligature points.
There are no plans to do this. Television cables can be shortened if
required. This would be risk assessed on an individual basis.)
7. Inter-agency communications
(cid:131) The Governor, in conjunction with the prison doctor, should ensure that such
important details as the sentencing of a prisoner whose mental state is under
review by the Community Mental Health Team and psychiatrists is promptly
communicated to all the agencies involved in his care. (Partially accepted-
This is not the doctor’s role - doctors are not always in a position to know this
information immediately. However, procedures are in place to ensure that
any change of status of any prisoner will be highlighted at reception/induction.
A mechanism for improving the cascading of change of status information to
relevant agencies will be considered by the Safer Custody Committee.)
8. Use of oxygen cylinders
(cid:131) The Governor, in conjunction with the doctor, should ensure that appropriate
staff receive initial and refresher training in the operation of oxygen cylinders.
(Accepted.)
9. The Governor should consider the following points made in the Clinical Review:
• Defibrillators
As a matter of urgency the Governor and PCT should ensure that all staff in
the prison, from the most junior to the most senior should know how to get hold
of and use the semi automatic defibrillators that the prison has bought at
considerable expense. They are designed for use by untutored laymen and they
will save lives, but only if used immediately a cardiac collapse occurs.
Consideration as to how to deal with defibrillation in a wet environment would
make dealing with hangings not only safer but also more pleasant. I wonder if it
might be useful to discuss with the ambulance service what they do in such
circumstances.
(Partially accepted. A training needs analysis is currently being carried out to
determine who requires this training. It would prove impractical to give all staff
this training. Priority will be placed on healthcare staff and all first aid trained
staff.)
36
• Health screening
A random check should be made of at least 20 prisoners’ records (10 in
healthcare and 10 on the wings) to ensure that the Reception Medical Screen
has been scrupulously completed in every case. If any are found to have been
inadequately completed, then all prisoners’ IMRs should be checked to ensure
that the Reception Medical Screen has been scrupulously completed in every
case. This applies to the Secondary Health Assessment too. Without it, the
simplest of audits will be impossible as there will be no record of prisoners’ height
and weight, blood pressure, smoking habits etc. The importance of completing
the Reception Medical Screen properly needs to be reinforced to Reception Staff
frequently. Now that doctors do not meet each prisoner on arrival it is the only
mechanism whereby they are alerted to a new person’s health needs.
(Accepted.)
37
1