Individual at Wormwood Scrubs

Investigation into the Death of
a man
at HMP Wormwood Scrubs,
on 28 August 2004
Report by the
Prisons and Probation Ombudsman
for England and Wales
March 2005
This is the report of an investigation into the death of a man. He died at Charing
Cross Hospital on 28 August 2004, shortly after an apparent attempt on his own life
whilst in the custody of HMP Wormwood Scrubs.
The investigator and my office have already expressed their condolences to his
family and I would like to add mine. The loss of a son is always a tragedy,
especially in circumstances such as those described in this report.
The investigation was carried out on my behalf by an investigator from the prison
service and I am very grateful for his efforts. His report has been edited to conform
more to the preferred format of my office. However, the content and, most
especially, the recommendations of the report are those originally made by the
investigator, although I am pleased to endorse them. Fundamental to the
investigation were the two clinical reviews which were commissioned. The first was
conducted by a Clinical Nurse Specialist in Substance Misuse who was asked to
comment on the appropriateness of the man’s drug treatment programme and
identify any issues of concern. The second was undertaken by a doctor from the
Primary Care Trust and he considered the wider aspects of the man’s medical
treatment whilst in prison custody. I am thankful to them both for their part in the
investigation.
The man had lived in this country since 1991. For several years before his death,
he had used drugs on a daily basis and begun to commit offences. His visa had
expired and social security benefits had been withdrawn.
He had been at Wormwood Scrubs for just 13 days before it appears he made a
serious attempt to take his own life. It was only by the good efforts of prison staff
that he began to breathe unaided. Unfortunately, despite prompt hospital treatment,
his recovery was short lived and life support was withdrawn eight days later.
Generally, the prison provided him with appropriate support but there are a number
of local recommendations. I would like to thank the Governor of Wormwood Scrubs
and all the staff involved for their assistance and cooperation with this investigation.
He was found hanging just a quarter of an hour after cannabis was found hidden in
his cell. However, it was the absence of another drug – nicotine – that seems to
have caused him most anguish. I was struck on reading this report by the number of
times he requested tobacco.
In his clinical review, the Clinical Nurse Specialist in Substance Misuse calls upon
the authorities to consider the management of nicotine withdrawal in custody. I think
that is the most important recommendation to emerge from these sad events.
Stephen Shaw CBE
Prisons and Probation Ombudsman
March 2005
2
CONTENTS
Page
FOREWORD
CONTENTS 3
GLOSSARY OF TERMS 6
SUMMARY 8
BACKGROUND 9
HMP WORMWOOD SCRUBS 10
CONDUCT OF THE INVESTIGATION 11
SEQUENCE OF EVENTS 12
KEY FINDINGS 13
Reception 13
Conibeere Unit and CARAT team 13
Healthcare Unit 14
Events of August 2004 16
After the incident 18
COMPLIANCE WITH PRISON PROCEDURES 21
CONCLUSIONS 22
RECOMMENDATIONS AND GOOD PRACTICE 25
3
GLOSSARY OF TERMS
Association Prisoners recreation period / time out of cell
C.N.A. Certified Normal Accommodation: The number of prisoners
a prison can hold without a degree of overcrowding
CPN Clinical Psychiatric Nurse
CPR Pertaining to heart and chest resuscitation
Day Care Centre Organized activity / meeting place within the establishment
for prisoners who have mental health problems
DDN Dual Diagnosis Nurse
DIC Death in Custody
F2050 Main Core Record
F2052SH Form raised when a prisoner is judged to be at risk of self­
harm or suicide
GOV Governor (Senior Managers)
HCO Healthcare Officer
HCPO Healthcare Principal Officer
History Sheet Prisoner's Wing Record
HMCIP Her Majesty’s Chief Inspector of Prisons
Hot debrief Debriefing of staff involved in an incident as soon as
practical after the incident has occurred.
IMB Independent Monitoring Board (Formally BOV)
IMR Inmate Medical Record
IMSU Incident Management Support Unit
In­reach Team Department / Medical Staff responsible for healthcare of
prisoners suffering from mental health problems.
IRS Incident Reporting System
LIDS Local Inmate Database System (Computer Record)
Listener A prisoner volunteer especially trained by the Samaritans to
listen and support other prisoners who are in need or
despair
MHA Mental Health Act
Normal Location Prisoner’s location in main wing / accommodation area of
prison
OCA Operational capacity: The number of prisoners a prison can
hold allowing for a degree of overcrowding
Offr Officer
Orderly Officer Principal Officer responsible for ensuring the prison regime
is running correctly. Responsible for the management of
Incidents
Oscar One Radio Call sign for Orderly Officer
OSG Officer Support Grade (Prison Officer Auxiliary)
4
PICT Post Incident Care Team – Volunteer Staff who offer
support to colleagues that have been involved in traumatic
incidents
PO Principal Officer
POA Prison Officer's Association (Union)
SMTCO Substance Misuse Through­care Co­ordinator
SN Staff Nurse
SO Senior Officer
SOCO Scenes of Crime Officer
SSN Senior Staff Nurse
Treatment Office or room where medical staff administer treatment to
prisoners or Room dispense medication
Prisoner Status:
Remand Period held in custody prior to Magistrates Court hearing
Trial Period held in custody committed for trial at Crown Court
5
SUMMARY
1. On the instruction of the Prisons and Probation Ombudsman an
investigation has been conducted into the tragic death of a man, a prisoner
at HMP Wormwood Scrubs.
2. At 11:07 am on 20 August 2004, he was found suspended in his cell by a
ligature within the prison's Healthcare Unit. The establishment’s emergency
procedures were activated and prison medical staff attended the scene. He
was taken by ambulance to Charing Cross Hospital where, on arrival, he
was assessed and provided further treatment to aid his recovery. He was
placed on life support equipment.
3. Unfortunately, he failed to regain consciousness and it was assessed that it
was not possible to sustain his life without life support equipment. The
prognosis for him was extremely poor and he was not expected to recover.
4. HMP Wormwood Scrubs informed Feltham Magistrates’ Court of this
prognosis and on 26 August he was given bail. Following medical advice,
support equipment was withdrawn and he died two days later on 28 August.
5. The investigation has revealed good practice on the part of both mainstream
and Healthcare staff. However, there are also lessons to be learned in
terms of managing incidents and liaising with prisoners' families.
6. The clinical reviews focus on the withdrawal of the man from the
detoxification programme and other aspects of his medical needs.
6
BACKGROUND
7. The man was born in Somalia and arrived in this country in 1991 as an
asylum seeker, having fled his native land due to the civil unrest. His visa
expired on 10 April 2003. He described himself to a Probation Officer as
being mentally well, but walked with a pronounced limp due to contacting
polio as a child for which he continued to take medication. From 1998, he
said he began to use drugs on a daily basis and his offending behaviour
began shortly afterwards, the majority of offences being theft or shoplifting.
Police records state that he used many recorded aliases and five different
dates of birth were recorded.
8. He served three short prison sentences prior to his last. The records for the
first two are missing, but those for the third suggest that it was uneventful
and there are no records of him having been considered to have been at
risk of self­harm. His licence expired on 7 December 2003 and eight
months later he was charged again. He was convicted on 6 August 2004
and remanded in custody to HMP Wormwood Scrubs at approximately 6:53
pm the same day. He was due to be sentenced on 26 August.
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HMP WORMWOOD SCRUBS
9. Wormwood Scrubs is a Victorian prison for adult men, both remand and
sentenced, situated in West London and with a maximum population of
1,239. It predominantly serves the London Courts and has an extremely
high reception and discharge rate averaging around 40 new prisoners each
weekday. On 20 August 2004, when the man apparently attempted to take
his life, there were 1,203 prisoners resident at first unlock.
10. The overall establishment rating is three (four being the highest standard
and one being the lowest). The rating is established from a number of
factors including performance against area targets, Prison Service national
Standards, and independent inspection by Her Majesty’s Chief Inspector of
Prisons. In relation to National Standards the prison attained marks of 85%
for both security and non­security standards. The most recent Standards
Audit rated the Suicide Awareness and Self­harm procedures as good.
11. There have been three previous apparently self­inflicted deaths at
Wormwood Scrubs within the last two years.
12. Following her most recent inspection in November 2003, HMCIP commented
that almost all of the recommendations regarding self­harm and suicide had
either been fully addressed or were being responded to. The following
recommendations were made:
· there should be at least one appropriately decorated and furnished
Listener suite capable of accommodating a prisoner and two Listeners
overnight
· work to create five safer cells should be completed
· the range of support mechanisms and specialist services available to
those at risk of self­harm should be expanded
· the rank and workload of the Safer Custody Officer should be reviewed
· staff should have sufficient contact with prisoners to enable them to
assess and monitor changes in mood or behaviour and thereby
anticipate and prevent incidents of self­harm.
13. The first recommendation has been implemented and a day centre for self­
harming and suicidal prisoners has also been established. The original
work to create safer cells was undertaken but the standard was insufficient
and further attention is necessary before they can be brought into use. A
second Safer Custody Officer has been appointed and staff have been
given individual copies of a booklet outlining the signs and procedures for
responding to potential or actual incidents of self­harm.
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CONDUCT OF THE INVESTIGATION
14. The investigator visited the prison shortly after the man’s death and met the
Deputy Governor, the Independent Monitoring Board and representatives of
the Prison Officers' Association. The man’s prison records were provided,
including the medical records.
15. Formal interviews were conducted with 17 staff, and another eight were
spoken to informally.
16. Unfortunately, the prisoner who found the man was unwell and unavailable
for interview.
9
SEQUENCE OF EVENTS
17. This section of the report lists the significant events of the man’s period in
custody and the events of 20 August.
8 Aug 03 Four months imprisonment at HMP Wormwood Scrubs.
7 Oct 03 Released on Licence from prison
5 Aug 04 Arrested for shoplifting taken to Hounslow Police Station
6 Aug 04 Attended Feltham Magistrates’ Court: Convicted but
unsentenced
6 Aug 04 Received into custody at HMP Wormwood Scrubs
6 Aug 04 Located into prison’s First Night Centre
7 Aug 04 Medical review in FNC & Assessment by Detox team
8 Aug 04 Re­location to Conibeere Unit and detox programme
9 Aug 04 Observed to be concealing medication. Removed
from detox programme
9 Aug 04 Examined by GP: Suspicion of TB – Tests ordered
10 Aug 04 Moved to Healthcare Unit
18 Aug 04 Nursed in cell due to non­compliance of wearing
facemask
18 Aug 04 Banging on cell door, shouting and up all night
19 Aug 04 Nursed in cell due to non­compliance of wearing
facemask
19 Aug 04 Banging on cell door, shouting and up all night
20 Aug 04 10:25 Unauthorised article observed being pulled into cell
20 Aug 04 10:30 Search conducted of the man’s cell and cannabis found
20 Aug 04 10:50 The man returned to cell
20 Aug 04 11:00 The man spoken to by a Nurse
20 Aug 04 11:07 Alarm raised by the prisoner when the man discovered
20 Aug 04 11:12 H3 Landing alarm bell pressed by staff running to cell
20 Aug 04 11:14 H3 staff call Comms room and advise CPR being given
20 Aug 04 11:15 Comms room requests an ambulance
20 Aug 04 11:25 Ambulance arrives at establishment
20 Aug 04 11:46 Ambulance leave establishment with the man and two
staff
28 Aug 04 The man died in Charing Cross Hospital.
10
KEY FINDINGS
Reception
18. The man was received at Wormwood Scrubs at approximately 6:53pm on 6
August 2004 from Feltham Magistrates’ Court, convicted and awaiting
sentence for theft. Records from the police and escort company indicate
that he was not considered to be at risk of self­harm. He was received at
Reception, and seen by Healthcare staff who conducted the First Reception
Health Screen. His drug test gave a positive result for cocaine, morphine
and cannabis. He said in the interview that he had a drug dependency
problem, was losing weight and had experienced problems with a chest
infection. The record notes that he looked thin. He was asked if he had
ever self­harmed or had any mental health problems, and reported that he
had not. He was referred to the prison doctor.
19. The prison doctor examined the man the same evening and, knowing his
history of substance misuse, prescribed medication to sustain him until the
drug detoxification team could formally assess him over the following days.
He was then allocated to the prison’s First Night Centre, where he was
interviewed for the Cell Risk Assessment Form and assessed as low risk
and suitable for shared cell location. The assessment was confirmed by
Healthcare staff who also indicated that there were no concerns about self­
harm.
20. His records do not refer to any events the following day, however he would
have participated in the induction programme. Later he was seen again by
a prison doctor or Healthcare worker and identified for the detoxification unit
aimed to address substance misuse. He signed a consent form agreeing to
take part in the programme and abide by the conditions of admittance to the
Drug Treatment Unit (the Conibeere Unit).
Conibeere Unit and CARAT assessment
21. The Conibeere Unit is a residential area within the prison, accommodating
prisoners referred for drug or substance detoxification. There are 51 beds,
46 of which are allocated to prisoners who are detoxifying. Attendance is
voluntary. There are strict guidelines for compliance in place and all
prisoners are required to sign a compact. A subutex detoxification regime
lasts for 12 days, methadone for ten to 15 days and codiazeproxide
withdrawal from alcohol for up to nine days.
22. He was admitted to the unit on Sunday 8 August and was assessed by one
of the permanent nursing staff who told him of the requirement to comply
with medication. He began the subutex detoxification programme. The next
day he was interviewed by a member of the CARATs Team. The team are
not involved in decisions about referrals to the Conibeere Unit or the
prescribing of medication. Their role is to provide support and information
about harm minimisation, relapse prevention and drug awareness. A
member of the team recorded that the man said he wanted to change his
11
lifestyle because he was afraid for his health and that he was ready to take
up all offers of support both inside prison and in the community. In interview
she said that she addressed his immediate needs and provided leaflets to
explain the support that was available. She said that she found him very
pleasant and that he listened to what she was saying. On completion of her
interview, she filed her assessment form and marked it for the drug worker’s
attention on her return. The man was a resident of Ealing, whose council
funded a drug worker to work with prisoners from their borough. He was
referred to her for ongoing support but was not seen until 18 August when
she returned from annual leave.
23. During administration of medication later on Monday 9 August, the
Dispensing Nurse observed that he attempted to conceal his medication
which was in contravention of the unit rules. In interview, she said that the
unit has a zero tolerance policy, which she said he broke as he took the
medication out of his mouth and attempted to conceal it. He was
interviewed by the prison doctor and taken off the subutex programme.
24. Instead the doctor prescribed a programme of symptomatic relief
medication, though it was not actually administered that day. Symptomatic
relief would mean that any complaints, such as stomach ache, would be
responded to with medication to relieve that problem. The Dispensing
Nurse said that she was subsequently informed by another nurse that TB
was suspected. The diagnosis of TB could only be confirmed by testing
sputum samples on three consecutive days. As a precaution against
infecting other prisoners and staff, he was provided with a face mask to
wear outside his cell. He was seen again by a doctor at 5:00pm later that
day regarding the weight loss and other complaints. Sputum, blood samples
and a chest X­ray were ordered.
25. Because medical investigations were continuing and he was only on the
second day of the detoxification programme, the Dispensing Nurse said that
it was recognised that he was not fit for normal location and it was decided
that he should be moved from the Conibeere Unit into the Healthcare Unit.
Unfortunately no beds were available and so he remained overnight on the
Conibeere Unit. Later he gave a sputum sample and was moved during the
afternoon of 10 August to a single cell on H3 landing in Healthcare.
Healthcare Unit
26. The Healthcare Unit has 17 beds. The Unit Manager said in interview that it
is a short­term acute unit for mentally or physically ill prisoners who cannot
function on normal location. It also provides post­operative care and refers
prisoners either to outside hospital or in­reach facilities. Prisoners in
Healthcare are seen by the doctor twice per week. Each patient is allocated
a key worker who is responsible for making entries in the individual’s daily
nursing record. The Unit Manager said that it was practice in Healthcare for
key workers to be told of any incidents, which they would then write up.
12
27. On admission, the man was assessed again and the care plan stated that he
was to continue with sputum testing and, until a diagnosis was given, he
should stay in a single cell and continue to wear the face mask whenever he
was outside it. The daily nursing records from admission on 10 August
indicate that he was reasonably settled.
Medical and nursing staff should be reminded to initiate infection
control procedures as soon as an infection is suspected.
28. The day that he moved to Healthcare, he was seen again by the CARATs
worker. In interview, she said that this had been a quick meeting, but that
she recalled speaking to him and he appeared to be fine. She also said
that, when she saw him, she was unaware of his failure to comply with the
requirements of the Conibeere Unit and that he was waiting to move out to
Healthcare. She said that there was no formal system to inform the
CARATs team that a prisoner had been removed from detoxification.
A protocol should be developed by Healthcare managers to provide
immediate referral to the CARATs team for prisoners who are removed
from detoxification programmes.
29. The Dispensing Nurse told the investigators that she returned to duty on 17
August and was told of difficulties obtaining sputum samples from the man.
She said that when she saw him he was jovial, laughing and mixing with
other prisoners. She said that, later that day or the next, she had occasion
to remind him of the smoking policy in Healthcare as she had found him
stubbing out a cigarette on the landing which was not permitted. On another
occasion, he took his face mask off when outside his cell and she told him
he would need to remain in the cell because of his suspected TB status. In
interview, both she and another Nurse said that Healthcare did not have an
official policy about patients wearing face masks, but that it would be
expected in accordance with directions from the TB Nurse.
Healthcare should revise and implement its policy for the control of
infectious diseases as soon as possible.
30. On 18 August, the drugs worker visited the man to offer support and
complete documentation to enable future assistance to be provided. The
nursing record for the day says that he did not comply with the requirement
to wear the face mask. A similar entry was made in the landing observation
book and he was returned to his cell. It appears that this was not the first
time that it had happened and, in interview, the HCSO confirmed that she
repeatedly asked him to wear the mask. She said that, for the safety of
other prisoners, there was no alternative but to return to his cell. She said
this meant that he was nursed in his cell, but that he came out for a shower
and could come out for exercise if wearing the face mask. The HCSO said
that the man said he would comply with the requirement if he was given a
cigarette but that she refused to do so.
31. There is a later record that, at lunch time, he threw his tea and then his
lunch through the door hatch of his cell saying it was not enough for him.
13
He was kept in his cell as a result. In interview, a Nurse confirmed that she
made the entry in the nursing record, but that she did not recall him being
returned to or nursed in his cell. She said that she did recall the incident of
food being thrown and said that some of it stuck to the ceiling. During the
night he was recorded as being very noisy most of the time, banging on the
door and demanding tobacco.
32. The entry for 19 August states that he was still noisy and was banging the
door and hatch, shouting and very demanding. Again he was kept in his cell
all day. He was quiet and more polite as the day went on. The Nurse
confirmed that the laboratory mislaid one of the sputum samples and so it
was not tested and a repeat was required. That night, he was disturbed
again and the record states that he was up the whole night, shouting,
screaming and banging on the door.
Events of 20 August 2004
33. The Nurse said that the next day, 20 August, she went to explain to him that
the sample needed to be repeated and went to his cell to give him a sputum
pot. However when she returned to collect it, he said that he had given it to
one of her colleagues. The HCSO confirmed that the Nurse was
unsuccessful in obtaining the sample and said that she returned to the office
and reported that he continued to refuse to wear the face mask. She asked
her colleagues about the sample but none of them had collected it and so
she took a further pot to him, which he declined. The nursing record says
that he was very noisy in the morning and that he wanted cigarettes.
34. At 10:30 am, staff on the landing were told by officers from A Wing that they
had seen something being pulled on a line from outside of the window and
into E3­09, which was the man’s cell. The HCSO alerted the HCPO and
went to the cell together with the Nurse. He was taken to an adjacent area
and given a rub down search before remaining with the HCPO. The HCPO
described the man as being quite calm whilst this was going on. The senior
officer and nurse carried out the search and cannabis was found by the
HCSO in the toilet area. The man was shown the cannabis and denied that
it was his. He was told that he would be placed on Governor’s report for
possession of the drug. The HCPO said in interview that the man started
talking incoherently and very quickly, but he had not considered that he was
mentally ill. He thought that the man was trying to block out what was being
said to him as though it was nothing to do with him. The HCSO said that the
search continued and a long piece of twine was discovered in the mattress.
She said that when it was shown to him, he became upset and angry. He
began to chant, which she said was like praying, but that he was not
distressed or crying.
35. At 10:50am, the search was completed, the man was returned to his cell and
locked in again. The staff returned to their duties, the HCPO going to the
Security Office and the HCSO to the Healthcare office to complete the
paperwork for the search and the Governor’s report.
14
36. The Nurse went to the man’s cell at approximately 11:00 am as she wanted
to ask again for a sputum sample. In interview, she said she thought that,
after the search, he might have been more amenable. She said that when
she got to the cell, she saw him lying on the floor but that she thought he
was alright, even though he didn’t respond to her. She did not think he was
unconscious, but that he just chose to ignore her. She left the area.
37. At approximately 11:07 am, another prisoner from H3 landing informed a
Nurse that he had discovered the man hanging in his cell. In his police
statement he said that when he was returning to his own cell, H3­10, he
looked into the man’s adjacent cell and saw him. He said that the man
appeared to be standing against the back wall with his back towards the
window. He thought this strange and approached the door. When he looked
inside he saw that there were white laces round the man’s neck and that he
seemed to be staring upwards. The prisoner told the police that he shouted
for help and two members of staff arrived.
38. The Nurse alerted the HCSO and together they went to the cell and saw the
man suspended by a ligature attached to the window bars. The Nurse and
the HCSO entered the cell with the prisoner. The prisoner told the police
that, when he saw that the staff were having difficulty he untied the laces from
the window frame so that the man could be lifted to the floor. The HCSO said
in interview that she thought that the ligature had been looped rather than
tied against the man’s neck. The ligature was untied, and together they laid
him on the cell floor. The Nurse said that she checked for vital signs after but
was unable to find any response. She immediately commenced CPR and the
HCSO asked for the prisoner to be taken from the cell and looked after.
39. Other staff from the unit, including the Unit Manager, responded to the alarm
and emergency resuscitation equipment was taken to the scene. Eight
members of the prison’s Healthcare staff and a prison doctor attended the
scene. The Unit Manager said that he was a First Aid trainer at the prison
and he asked for the emergency bag. He used the proxymeter to measure
oxygen but found that there were no signs of life. They continued to
administer CPR and requested an ambulance, a request which the prison’s
communication log shows being made at 11:15 am.
40. Meanwhile staff carried on with CPR and found a response when the man
began to breathe again. The Nurse said that she began chest compressions
whilst the Unit Manager carried out mouth to mouth resuscitation. This
continued for about ten minutes and then another Nurse took over from her,
although she was in attendance. On interview, she said that she realised that
more oxygen would be needed, and went to H2 landing to get some. When
she returned she helped to monitor the man’s vital signs and closed his eyes
to protect them.
41. The operational governor responsible for Healthcare was on H2 landing when
the alarm sounded and went to the scene. He said that he saw the staff in
the cell and that they needed room to move. He marshalled others away. He
considered that it was a medical matter which Healthcare staff were dealing
15
with, and so he remained outside the cell throughout. He was there when the
prison doctor and the duty governor arrived. The operational governor for
Healthcare said that he did not consider that he had taken charge of the
scene but that the orderly officer had done so. He said that his part was only
to ask whether the man was alive when he left the prison, and that he also
informed the duty governor of what was happening.
42. The prison doctor arrived at the cell and he also checked for the man’s pulse
and breathing. He said in interview that the procedures appeared to be being
carried out correctly and so he allowed staff to continue with their
interventions.
43. The Assist Orderly Officer also attended the scene when he heard the alarm.
He did not think that any staff were managing the scene outside the cell, and
the Orderly Officer of the day stated that he had not taken on the role either.
The Governor should remind all staff of their roles and responsibilities
during an incident, including that of a designated person in charge of
the scene.
44. The prison’s communication log records that the ambulance arrived some ten
minutes later at 11:25 and the paramedics were escorted to the Healthcare
Unit. On their arrival at the scene, responsibility for the medical care of the
man was passed to the ambulance staff. The Unit Manager prepared a letter
to accompany the man to the hospital. When the ambulance left the prison,
he was alive. A risk assessment was completed and two staff were identified
to accompany him and provide the hospital bed watch.
After the incident
45. The log goes on to state that the ambulance left the prison with the man at
11.46 am. Two members of staff accompanied him and he was taken to
Charing Cross Hospital.
46. At 12:50 pm, the Head of Healthcare telephoned the man’s family to inform
them of his admission to this hospital. In interview, he said that at first the
man’s mother did not seem to understand that it was a serious matter and he
felt that this might have been because English was not her first language. He
suggested to her that she might like to attend the hospital herself.
47. Later, all the medical staff involved in the incident were spoken to by the
unit’s managers and confirmed that they were alright. The Governor spoke
to the staff involved and their names were also passed to a Governor who
was taking over as duty governor and was also a member of the prison’s Staff
Care team.
48. A formal debriefing meeting did not take place after the incident but the
Governor said that all staff were spoken to personally instead. He said that
he served the prisoners' meals so that staff could compose themselves.
Another Governor said that he did not call a debrief as some of the staff had
gone off duty by the time he arrived.
16
The prison’s contingency plans should include a formal debrief after all
such incidents, which should always include the Staff Care team
amongst those attending.
49. The prison’s security department secured the cell in case the man did not
survive and the police were required to attend. Subsequently information
was received from the hospital that the prognosis for him was poor, and the
police were informed.
50. An Officer said that he was the escort when the man received his CT scan
and had asked nursing staff about his condition. He was told that the
prognosis was not good and so made contact with the prison to inform them.
He contacted the prison again to report that family members had arrived, but
he did not speak to them directly. The Officer said that he had not asked for
a member of the prison’s management team to come to the hospital, and that
none of them had done so during his period of duty. The attendance of a
member of the prison management team could have improved the information
available to the family and also provided support for staff who were placed in
a potentially difficult situation.
A member of the management team should attend the hospital in all
such situations to provide support and information for the next of kin
and the staff.
51. The Governor said that he was duty governor that weekend and he asked the
HCPO to visit the hospital and liaise with the man’s family. The HCPO said in
interview that he was asked to introduce himself to the family, offer
condolences, a contact number and any information. He was unaware of
what the role entailed as well as being ignorant that funeral expenses were
available.
Staff should be selected for the role of family liaison who have not been
directly involved in the incident and they should be fully trained
beforehand. Full records of contact with families should be kept and
senior managers should provide all necessary support.
52. The Governor said that information about the man’s condition came to him
from the escorts or from the HCPO who reported to him each day after he
returned from the hospital.
53. The man was due to attend Feltham Magistrates’ Court on 26 August and so
the Governor informed them of the incident and of the man’s poor prognosis.
A formal request was made for bail and this was granted later in the day.
When bail was confirmed all prison staff were withdrawn from the hospital.
However, later that day the Governor received a further warrant from the
court, which directed that the man should remain in the prison’s custody. He
telephoned the Clerk of the Court for an explanation and the Clerk
subsequently confirmed that the judges had agreed to bail. The Orderly
Officer was informed and the Governor believed that he then removed the
escort.
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54. Despite the efforts of hospital staff, the man died on 28 August in Charing
Cross Hospital.
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COMPLIANCE WITH PRISON PROCEDURES
55. Wormwood Scrubs has a Suicide Prevention policy entitled “Caring for
prisoners at risk of self­harm”, which is comprehensive and generally
conforms to current Prison Service Directions. It outlines the systems for
monitoring F2052SH records and these are also satisfactory. However, the
policy is dated July 2003 and has not been reviewed recently. In interview,
the prison’s Suicide Prevention Coordinator said that he intended to review it
following the investigation into the man’s death.
The prison’s Suicide Prevention policy should be reviewed after all such
incidents and again when investigation reports are received.
56. The prison also has contingency orders covering suicides and incidents of
self­harm. These were comprehensive and complied with Prison Service
requirements.
57. The investigation team also reviewed the Healthcare Unit’s infection control
policy. It was encouraging that the policy was available. However it only
contained general guidance and did not include specific advice for prisoners
either suspected of having infections such as tuberculosis or diagnosed with
the same. For example, the policy does not refer to the requirement of
prisoners suspected of having TB to wear a face mask. In interview the
prison’s TB nurse said that the policy was being reviewed and would be
extended to include these situations.
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CONCLUSIONS
Reception
58. This was not the first time that the man had been in custody and he was likely
to have been familiar with the prison’s regime as well as the support available
to assist with withdrawal from drugs. He was correctly processed through
reception, including the Healthcare screening which identified his drug
dependency and appropriate medication was prescribed to meet his
immediate needs. He was appropriately placed in the First Night Centre and
then in the Conibeere Unit.
59. However, it is of concern that, despite giving his medical history to doctors at
the police station, on reception and at the review of 7 August, it was only at
5:00pm on 9 August, after his removal from the detoxification programme,
that the first suggestion was made that TB should be considered. By this
time, he had been at the prison for three days and would have come into
contact with numerous prisoners and staff. This was the first time that
preventative actions, such as wearing a face mask, were ordered.
Removal from the detoxification programme
60. Prior to reception into the Conibeere Unit, the man was informed that
attempts to conceal medication would result in withdrawal from the subutex
detoxification programme, and this was reiterated on reception. The policy
recognises the danger of medicines being available to other prisoners. When
a nurse observed his attempt to hide his medication, he was referred to the
doctor who correctly ordered his withdrawal.
Healthcare
61. The man was appropriately moved to the Healthcare Centre, where he had
better access to medical staff and it was easier to provide the isolation
necessary to reduce the risk of cross­infection. There were no problems
during his first days in Healthcare; however, after more than 10 days staff had
still not managed to have three sputum samples tested, which could have
meant that he might have received more appropriate treatment, or been freed
of the requirement to wear the face mask. The delays with the tests meant
that he was nursed under a restrictive regime for the whole of his time in
Healthcare. He was told that association would have been permitted had he
been wearing the mask, but as he refused to do so he was locked in his cell
for much of the time and withdrawn from the company of fellow prisoners,
neither of which would have improved his mental health. Healthcare staff had
a duty to protect the health of others, but more timely and efficient treatment
for the man would have been to his benefit. Furthermore it is not apparent
that he received an early explanation for the delays which could have helped
to alleviate his frustration with his situation.
62. Increasingly he refused to cooperate with the requirement to wear a face
mask and so he was confined to his cell for medical reasons. He was
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informed that normal association would be available to him if he wore the
mask, but did not cooperate. It would have been preferable for the unit to
have had an infection control policy which stipulated this requirement, and for
the decision to have been formalised by the doctor or a case review.
63. It seems that the man felt short of tobacco and that he attempted to negotiate
increased cigarettes in exchange for wearing the face mask. Prisoners in
Healthcare receive their canteen on Monday.
Searching the cell
64. Staff described the cell search as being carried out according to approved
procedures, including their response to the unauthorised property found
there.
Medical intervention
65. When the man was discovered hanging in his cell, the other prisoner,
Healthcare and wing staff responded quickly and effectively, to the extent that
their efforts improved his condition to one where signs of life were present.
The intervention by prison medical staff was also of a high standard and
greatly increased his chance of survival. The ambulance was requested and
arrived promptly and an escort was arranged so that he could be taken
immediately to hospital.
Management of the incident
66. Notwithstanding the efficiency with which staff responded to the incident, it
appears that no one manager took charge of the whole situation. As a result
an incident log was not commenced, although it should have provided
important evidence. Although staff responded promptly and professionally,
including sealing the cell to preserve evidence, this appears to have been the
result of individual initiative rather than any organised contingency plan.
Staff debrief
67. The man was alive when he left the prison and staff had duties in respect of
the other prisoners. Even though several managers spoke individually to
staff, a formal debrief was not carried out. The debrief would have been an
opportunity to provide staff support, identify emerging issues and any action
to be taken, including assistance for the other prisoners.
Contact with the family
68. Prompt contact was made with the man’s family. However on recognising
that English was not their first language, they might have benefited from the
use of an interpreter. Fortunately the information was received correctly and
his family arrived at the hospital promptly.
69. No management staff went to the hospital where they could have offered
support and provided information. Escort staff and a Healthcare officer were
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left unsupported to deal with any issues which might have arisen. Not only
did this mean that the prison’s obligations to the family were not fulfilled, but
staff were also placed in a potentially difficult position.
70. One member of staff was asked to act as the prison’s liaison officer, but did
so without a proper awareness of what the role involved and without making
any record of his contacts with the family. He carried out the duties to the
best of his ability, but without full knowledge, for example without
appreciating the support available to cover funeral expenses.
71. The member of staff selected for the role had been involved in the initial
response to the incident and had delivered CPR. This was inadvisable as it
placed him in a position which might compromise future evidence to the
coroner. In selecting the particular member of staff for the role, the prison
failed in its duty of care to him.
Release on bail
72. The prison correctly informed the courts of the man’s attempt to take his life
and there appears to have been a breakdown in communication as to
whether and when bail would be granted. No documents have been provided
to the investigation team which would verify the decisions and the authority
for them.
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RECOMMENDATIONS
All the recommendations of the investigation team are directed to the
Governor of Wormwood Scrubs.
1 Medical and nursing staff should be reminded to initiate infection
control procedures as soon as an infection is suspected.
2 A protocol should be developed by Healthcare managers to provide
immediate referral to the CARAT team for prisoners who are removed
from detoxification programmes.
3 Healthcare managers should revise and implement its policy for the
control of infectious diseases as soon as possible.
4 The Governor should remind all staff of their roles and responsibilities
during an incident, including that of a designated person in charge of
the scene.
5 The prison’s contingency plans should include a formal debrief after all
such incidents, which should always include the Staff Care team
amongst those attending.
6 A member of the management team should attend the hospital in all
such situations to provide support and information for the next of kin
and the staff.
7 Staff should be selected for the role of family liaison who have not
been directly involved in the incident and they should be fully trained
beforehand. Full records of contact with families should be kept and
senior managers should provide all necessary support.
8 The prison’s Suicide Prevention policy should be reviewed after all
such incidents and again when investigation reports are received.
9 The recommendations of both clinical reviews should be implemented.
GOOD PRACTICE
The Governor should commend the efforts of all staff involved in
delivering CPR to the man and recognise their attempts to revive him.
The prisoner who discovered the man should also be commended.
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