Individual at Wormwood Scrubs

Investigation into the circumstances surrounding the
death of a man at HMP Wormwood Scrubs
in April 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2010
This is the report of an investigation into the death of a man in April 2009, at
HMP Wormwood Scrubs. He had been in prison for just seven days. He was
located in a gated cell in the healthcare centre where he was found hanging
from pipes in his cell, having made the ligature with a strip of blanket
specifically designed not to tear.
I would like to offer my sincere condolences to the man’s family. I must
apologise for the delay in issuing my report and for any additional distress this
may have caused. A draft of this report was translated and sent to the family.
The investigation was led by one of my colleagues assisted by a fellow
investigator. I would like to thank the Governor and his then Safer Custody
lead for the assistance they gave the investigation team. In particular, my
colleague received good support from a senior officer (SO) throughout the
investigation process.
I must also acknowledge the assistance of Hammersmith and Fulham Primary
Care Trust (PCT), who reviewed the clinical care received by the man during
his short time at Wormwood Scrubs. The PCT set up a clinical review panel
and volunteered the services of two clinical reviewers for joint clinical
interviews. I am grateful to them for their work.
The man was a foreign national (originally from Azerbaijan and a Muslim,
although he claimed to be Russian and a Jew). However, no one from the
prison’s foreign national team spoke to him. He told other staff that he did not
understand why he was in prison. In fact, he was facing a serious charge at
the time of his remand and it was possible that he would be deported.
The man was assessed as at risk of attempting suicide or self harm the
morning after he arrived at Wormwood Scrubs. He was located in a gated cell
in the healthcare centre and given alternative (previously known as
‘protective’) clothing. According to National Offender Management Service
(NOMS) policy, such measures should be used strictly as a measure of last
resort. However, the man was only made subject to low frequency
observations (three times daily and five observations overnight). I explore at
length these judgements and make a total of 15 recommendations. Reflecting
the seriousness of my findings, I will send a copy of my report to the Chief
Operating Officer of NOMS.
This man’s death was the first of three self-inflicted deaths in Wormwood
Scrubs in 2009. The circumstances of the second of those deaths have
matters in common with the facts related here. My investigation teams have
worked closely together to ensure that lessons are learned.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Jane Webb
Acting Prisons and Probation Ombudsman November 2010
2
CONTENTS
Summary
The Investigation Process
HMP Wormwood Scrubs
Key Events
Issues
Conclusion
Recommendations
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SUMMARY
On 14 April, the man was remanded to HMP Wormwood Scrubs. He was
charged with threatening to kill a close family member. Using a false name,
he told staff that he was Russian and Jewish. Although it was not his first
language, he spoke some English and staff said in interview that they
understood what he was saying.
The man explained that he had been treated for his mental health, but could
not recall the details. A request was made for his medical records to be
retrieved from a hospital in East London. After his reception healthscreen, the
man was taken to the first night centre where he stayed overnight.
Following his secondary healthscreen, the man was made subject to suicide
prevention measures. During an assessment shortly after the risk was
identified, he told staff that he did not think he would leave prison alive. He
was assessed as at raised risk of self harm and made subject to half hourly
observations, pending admission to the healthcare centre. Before he was
moved, a locum staff grade psychiatrist assessed the man and agreed that he
was at risk of self harm and would benefit from monitoring in the inpatients
unit. (As a locum staff grade psychiatrist, the doctor was qualified to provide
intermediate psychiatric cover for the healthcare centre at Wormwood
Scrubs.)
A cord loop was discovered tucked into the man’s clothing as he arrived on
the inpatients unit. Staff removed the loop and an entry was made in his
medical record four hours later, but no other reference was made in the man’s
files. A suicide prevention case review was held just after he arrived in the
unit. The review was chaired by the senior officer of the healthcare centre,
and attended by the psychiatrist and two nurses. It was agreed that the man
should go into a gated cell, dress in alternative clothing, and observations
should be recorded at least three times a day and five times overnight.
(When a cell is used as a “gated cell”, the door is locked against the internal
wall and only a gate remains in place which allows constant supervision.
“Alternative clothing” is made of strong material which should not rip for use
as a ligature.)
Over the next few days, the man continued to talk of dying in prison, and said
that he wanted to die by not eating. He was visited by a chaplain three times
and spoke at length about his frustration at being in custody. Arrangements
were made for him to make an international telephone call to his mother and
he made a court appearance. A further case review was held on 20 April, as
part of the mental health service’s ward round. No officers or governors
attended the review and no changes were made to the man’s suicide
prevention support plan. It was noted that an interpreter should be invited to
attend the next case review, which was due to take place on 23 April.
Another prisoner in the healthcare centre was constantly supervised by staff
on the day of the man’s death. The man who died told the agency nurse
carrying out the constant supervision that he was looking for any opportunity
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to kill himself. An entry was made to that effect in the man’s suicide
prevention document late that morning and the agency nurse spoke to the
nurse in charge. The nurse in charge encouraged him to keep a closer eye
on the man than the minimum requirements set out in the suicide prevention
support plan.
Healthcare was seriously short staffed that afternoon and evening. During the
evening shift, there were no officers and only one nurse in charge, and one
agency nurse continuing with the constant supervision. While a prisoner was
being escorted from reception to the healthcare centre, the escorting officers
noticed the man hanging in his cell. He had used an alternative safer custody
blanket (made from the same material as the alternative clothing) attached to
the pipes in his cell.
In this report, I examine safer custody procedures at Wormwood Scrubs and
make several recommendations. I make two national recommendations
about the use of gated cells and alternative clothing. I also consider the
support that the man received as a foreign national prisoner.
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THE INVESTIGATION PROCESS
1. I appointed one of my colleagues to lead the investigation into the
man’s death. She was assisted by another investigator. My colleague
visited Wormwood Scrubs on 28 April 2009, accompanied by her
colleague. My investigator met her liaison officer who had arranged for
the man’s files to be copied ready for collection. She also met a
representative from the Independent Monitoring Board (IMB), none of
whose members had met the man, but who shared overall impressions
of the prison. The local branch of the Prison Officers’ Association held
a meeting in their office to give my investigator an opportunity to
explain the remit of her investigation and to invite trade union
representatives to accompany interviewees. My investigator met the
Deputy Governor because the Governor was unavailable. My
investigator and her colleague were shown around the prison and met
staff on the healthcare centre.
2. I am grateful to Hammersmith and Fulham PCT for their clinical review
of the time that the man spent in prison. Two of their clinical reviewers
also accompanied my investigation team to conduct interviews with
staff and assist with clinical matters. My investigator was kept informed
of the progress of the clinical review and was consulted on the review.
She attended a clinical review panel meeting towards the end of the
process and I am grateful to the PCT for taking on board her
comments. The clinical review is the first annex to this investigation
report.
3. Once the prison had made contact with the family, the prison’s family
liaison officer passed their details to my investigator. One of my own
family liaison officers wrote a translated letter to the family in England
to explain the investigation process. Although the family did not have
any specific concerns about the man’s care, they wanted to see the
investigation report. My family liaison officer also wrote to the man’s
mother in Azerbaijan. I trust that this report addresses the questions
his family may have and helps them better understand the events
leading to the man’s death.
4. After a review of the paperwork, my investigator arranged to attend
Wormwood Scrubs again to interview staff. She interviewed 13
members of staff, but no prisoners contacted her with information.
5. My investigator met the inspector leading the investigation for
Hammersmith and Fulham Police. I am grateful to the police for their
time and co-operation. They shared photographs of the cell after the
man’s death and statements they had taken from staff about the
emergency response.
6. As concerns arose throughout the investigation process, my
investigator fed back to the Safer Custody Manager and confirmed her
findings in writing to the Governor. Due to the seriousness of the
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findings, she also discussed the circumstances of the man’s death with
the NOMS Safer Custody and Offender Policy team’s lead for safer
custody. I am grateful to her for her advice throughout the
investigation.
7. A copy of this report was issued in draft for consultation with the family,
NOMS, the PCT and the Coroner. The family received a translated
copy of the draft report. Following the issue of this report, my
investigator and Deputy Ombudsman met the NOMS Safer Custody
Offender Policy lead for London, Wormwood Scrubs’ Head of
Healthcare and the Safer Custody leads to discuss their feedback. I
am grateful for the comments I received, some of which have resulted
in amendments to the report before its finalisation.
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HMP WORMWOOD SCRUBS
8. HMP Wormwood Scrubs is a large local prison in West London. It can
accommodate 1,281 adult males in its five wings. As a local prison, its
population is transient and demanding, with high numbers of prisoners
arriving from court with a variety of immediate needs including
detoxification. The healthcare centre is divided into a large outpatients
area and a 17-bed inpatients unit, predominantly accommodating
prisoners with mental health conditions.
9. Her Majesty’s Chief Inspector of Prisons carried out a full unannounced
inspection of the prison in June 2008. In her report of this inspection,
she recognised:
“Wormwood Scrubs was subject to constant daily pressure and
it required considerable work by both managers and staff simply
to ensure its successful day-to-day operation.”
Nevertheless, her team were “disappointed” by their findings during the
inspection. Significantly, the prison failed to meet any of their tests of a
healthy prison: safety, respect, purposeful activity and resettlement.
10. Reception, first night and induction procedures were described in the
inspection report as “not sufficiently supportive or consistent” and
“underdeveloped and poorly organised”. (The man was only on the
first night centre for one night and transferred to the healthcare centre
the following morning.)
11. The Chief Inspector found that the inpatients unit was a “reasonable
environment, but had a minimal therapeutic regime”. The investigation
team also found the regime surprisingly more limited in the inpatients
unit than elsewhere in the prison. My investigation team judged that
the physical environment was poor, and characterised by tension
between PCT healthcare professionals and uniformed prison staff.
12. Every prison has an Independent Monitoring Board (IMB) made up of
volunteers who monitor day-to-day life in prison and ensure proper
standards of decency and care are maintained. In their annual report
for 2008-09, the chair of the Wormwood Scrubs IMB wrote of their
concern that “healthcare services are heavily reliant on agency staff”.
The clinical review panel and my investigation team echo those
concerns and I will discuss the impact of staff shortages on the care
that the man received.
13. The IMB attend suicide prevention meetings and said in their 2008-09
report that “residential staff are aware of the risks of self harm and
suicide”. The report did not comment on the use of gated cells or
alternative clothing in the healthcare centre. When my investigator
spoke to the IMB at the beginning of the investigation, she was told that
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no one had recorded any contact with the man despite his being in a
gated cell and in alternative clothing.
14. The man’s death was the first of three self-inflicted deaths at
Wormwood Scrubs in 2009. There are significant shared lessons
identified between the second death in custody and the man’s death,
especially in relation to safer custody.
Hammersmith PCT and Prison Service staff
15. In January 2007, the employment of all healthcare professionals was
transferred from the Prison Service to Hammersmith and Fulham PCT.
At this time, some officers who were employed by the Prison Service
were also qualified healthcare professionals and had access to
healthcare records. These officers were line managed by the Head of
Healthcare who became a PCT employee. In September 2008, the
Prison Service and the PCT confirmed that officers would be employed
solely by the Prison Service and would no longer have a healthcare
function.
16. During interviews for this investigation, my team found that the
arrangement resulted in the separation of medical matters from the
general care of prisoners in the healthcare centre. Officers had
become demoralised because they perceived that their role had
diminished, and nurses were protective of medical information
considered “medical in confidence”. The impact on the regime in the
healthcare centre was clear. The investigation team were told that
officers did not carry out constant supervision for prisoners, and
described it as a “healthcare problem”, with the result that the shortage
of nursing staff was compounded (a particular problem in the events
surrounding the man’s death). When my investigator asked why a
prisoner dressed in alternative clothing had shoelaces in his trainers,
she was told that it was a “discipline matter”.
17. Officers were based in a separate office to the nurses and were not
involved in ward rounds. Communication between officers and
healthcare professionals was undermined by the re-profiling of staff in
the healthcare centre. It is my view that poor communication and lack
of support between officers and nurses affected the care that the man
received in the last week of his life.
Assessment, Care in Custody and Teamwork (ACCT)
18. Prisons are run under a series of documents called Prison Service
Orders (or PSOs). PSO 2700 governs procedures for looking after
prisoners at risk of suicide or self harm. Assessment, Care in Custody
and Teamwork (or ACCT) is the system used to identify, monitor and
support prisoners at risk of self harm. The ACCT process is used in all
prisons in England and Wales. Any member of staff can start the
ACCT process by raising a Concern and Keep Safe form, explaining
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the reasons for their concern. An Immediate Action Plan is written by
the manager of the wing where the prisoner is located, and within 24
hours an ACCT assessment is carried out by a member of staff who
has the required training.
19. After the ACCT assessment has taken place, a multi-disciplinary ACCT
case review is held to determine what measures can be taken to
monitor and support the prisoner effectively. The prisoner attends the
case review and is encouraged to contribute to the decisions being
made. An ACCT CAREMAP is drawn up with details of each of the
actions necessary to keep the prisoner safe and who is responsible for
carrying out each action. Case reviews are held at regular intervals,
usually monthly, to review the actions and the prisoner’s level of risk.
Gated cells
20. PSO 2700 refers to gated cells as “constant supervision cells”, and this
is what they are called in Wormwood Scrubs’ suicide prevention policy.
Instead of a door on the cell, there is a gate which enables a member
of staff to see the prisoner at all times.
21. According to the guidance, gated cells are used where a prisoner
requires constant supervision. They enable a severely distressed/at
risk prisoner to receive individual support from a member of staff sitting
outside the cell. A prisoner should remain in a gated cell for the
shortest time possible because it compromises their privacy and
dignity. (The man was accommodated in a gated cell despite the low
level of ACCT observations deemed necessary.)
Alternative clothing
22. Alternative clothing (previously known as protective or anti-tear
clothing) is made from a strong material that makes it difficult to tear. It
is used when a prisoner may use his clothing to harm himself or others.
23. When a prisoner is issued with alternative clothing, their own clothes
should be taken away from them, including their shoelaces. PSO 2700
and Wormwood Scrubs’ own suicide prevention policy describe the
removal of a prisoner’s own clothes and their replacement by
alternative clothing as a “measure of last resort”. The PSO demands
that alternative clothing “must only be used for the shortest possible
time”. It is national policy, echoed in Wormwood Scrubs’ own suicide
prevention policy, that an enhanced case review should be held with
more senior prison staff for all prisoners who are on an open ACCT
document and wearing alternative clothing.
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KEY EVENTS
The man’s remand
24. The man was charged by police with assaulting and threatening to kill a
close family member in April 2009. While at a police station, he told
officers that he had suffered a number of injuries during his previous
military career. He said he was suffering from stomach and lower back
pain, and took medication three times a day although he could not
remember what it was. He refused to be examined by the police doctor
or to sign his property record.
25. The next morning, the man appeared at a Magistrates’ Court. He was
remanded into the custody of HMP Wormwood Scrubs until the next
court appearance on 16 April. His remand warrant recorded his false
name and his religion as Jewish.
26. A Prisoner Escort Record (PER) is opened every time a prisoner is
escorted between court and prison to record any significant information
about the journey and to communicate risk factors to escorting staff, for
example risk to self or others. The man’s PER indicated that he was
violent and had a medical condition. There were no other known risks.
27. However, there was a note that the man was on an electronic tag. My
investigation team discovered from the police after his death that the
man was tagged as a result of an international arrest warrant issued for
an alleged offence abroad. Despite this warrant, he had thus far been
allowed to remain in the United Kingdom (UK) because his family
depended on him. The electronic tag was removed when he was taken
into custody.
28. Upon arrival at Wormwood Scrubs, the man was interviewed for his
first reception healthscreen. (A first reception healthscreen takes place
every time a prisoner enters prison. Its purpose is to determine any
immediate physical and mental health conditions that require
treatment, substance misuse matters that need to be addressed, and
any risk that the prisoner may pose of harming himself or attempting
suicide.) At the healthscreen, the man said he had been in prison
before, but could not recall when. (He had used several different
names, so it is possible that he had been in prison before despite there
being no record in his name.)
29. When the nurse asked about his health, the man said that he had
visited his doctor two weeks previously, but again could not remember
anything about it. He also said he was taking medication prescribed by
a hospital for stress. He told the nurse that he had received treatment
from a psychiatrist for stress before coming into prison, so he was
referred for a mental health assessment. He said that he had never
tried to harm himself and “denied any suicidal thoughts”, although he
described how unhappy he was living in the United Kingdom. The man
11
said that he had lost his appetite during the previous two weeks and
had not eaten properly. He was referred to the doctor for his physical
health as the nurse had noted he looked “unfit” and complained of
“back pain”. The nurse then noted that the man’s medical record:
“please get information from GP tomorrow. Appears in satisfactory
health – now!” After the healthscreen, he was located in a double cell
on his own in the first night centre, where he stayed overnight.
30. A nurse carried out a secondary healthscreen the following morning in
the first night centre. The nurse explained to my investigator that the
screen is “related to health promotion”, for example whether the
prisoner wants to stop smoking or requires any vaccinations. The
nurse remembered that the man, “at first sounded very quiet, a bit
disorientated and he was a bit tearful as well which then raised some
concerns”. The nurse was concerned that the man was distracted
during the screen and could not describe his medical problems. The
man told the nurse that he did not want to live any more. The nurse
raised a Concern and Keep Safe form, the first stage of the ACCT
process.
31. After a Concern and Keep Safe form is raised, an ACCT assessor must
interview the prisoner. The nurse assessed the man as requiring
hourly observations until his ACCT assessment had been completed.
A prison officer was the duty ACCT assessor that day and was already
on the first night centre when the nurse finished the man’s
healthscreen. (The officer was on the first night centre because he had
just finished an ACCT assessment of another prisoner.) The nurse
explained his concern about the man and gave the officer the opened
ACCT document.
32. During interview for this investigation, the ACCT assessor assured my
investigator that, although the man’s English was not fluent, he was
able to talk about what was worrying him. The man told the ACCT
assessor that he was unhappy about his personal circumstances and
that he was taking “much medication”, although he still could not
remember what he had been prescribed. When asked whether he had
any current intentions of committing suicide, the man told the ACCT
assessor that he had never harmed himself before and was not
thinking of hurting himself. However, the ACCT assessor recalled in
interview: “he did not know if he would take his life when I asked him,
but did say he did not think he would leave prison alive”. As an
experienced ACCT assessor, the officer was concerned about the
man’s welfare. During interview for this investigation, he explained:
“I didn’t think at that stage that he was, I was going to walk out
the room and he was going to kill himself but I had grave
concerns that something was going to happen to him if we didn’t
put into place some sort of action plan with him straightaway.”
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33. After the ACCT assessment, the ACCT assessor chaired an ACCT
case review. He told the investigation team that his priority was to
relocate the man to the healthcare centre so that his mental health
could be assessed. He was also particularly worried by the man’s
claims that he was not eating (although this was not recorded in the
record of the ACCT assessment). The first night centre’s senior officer
also attended the case review but no healthcare staff were present.
The senior officer for the first night centre agreed with the ACCT
assessor that the man was at high risk of harming himself and that he
should be checked every half an hour until he could be admitted to the
healthcare centre. The ACCT assessor also referred the man to the
mental health inreach team. After his assessment and case review,
the man stayed on the healthcare centre over lunch but refused to eat
his meal.
34. A doctor was employed through an agency to work as a locum staff
grade psychiatrist at Wormwood Scrubs for three weeks during April
2009. Although he could not exactly remember when he started
working at the prison, the locum psychiatrist told my investigation team
that he thought it was on either 7 or 8 April. During interview, he told
the investigation team that he was briefed about inreach practice by the
consultant psychiatrist for the inreach service at the prison and shown
around the prison by a Registered Mental Health Nurse (RMN) who
was the community mental health nurse responsible for the inpatients
unit. The locum psychiatrist said that he had only worked for one day
in a prison before this assignment. The locum psychiatrist had no
formal induction programme and was not trained in the ACCT process.
35. As the only psychiatrist on duty that day, he assessed whether the man
needed to be admitted to the healthcare centre. In interview, the
community mental health nurse remembered escorting the locum
psychiatrist to the first night centre because he did not have keys to
move around the prison. The nurse recalled meeting the man briefly,
describing him as “respectful”. The locum psychiatrist conducted his
assessment in a private room, and recorded in the man’s medical
record that he was “quite low, crying, hopeless, pointless and suicidal
thoughts (hanging)”. He recorded that the man was “not eating or
drinking”. The locum psychiatrist told my investigator he thought that
the man was at high risk of suicide and needed to be admitted to the
healthcare centre for closer monitoring.
36. In his summary of the assessment in the man’s medical record, the
locum psychiatrist recorded that, not only should the man be admitted
to the healthcare centre, he should be accommodated in a gated single
cell in protective clothing. During interview, the locum psychiatrist
explained that the use of a gated cell and protective clothing was
“standard practice” at Wormwood Scrubs. He said that it would give
staff an opportunity to assess the man’s mental health, and he could be
kept safe until the prison had received a clearer picture of his history.
The locum psychiatrist prescribed the man anti-depressants and a
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nutritional supplement to increase his vitamin intake while he claimed
not to be eating.
The healthcare centre
37. Within an hour of the assessment, the man was admitted to the
healthcare centre. When he arrived, the locum psychiatrist, a nurse
and the community mental health nurse started an ACCT case review.
A senior officer manages prison staff on the healthcare centre. She
told my investigator that she noticed an ACCT case review happening
in the inpatients unit at about 4.00pm. She was concerned because
the case manager was an agency psychiatrist. Noticing that he was
not familiar with ACCT documents, she stepped in to manage the case
review.
38. During the case review, the senior officer who manages prison staff on
the healthcare centre noted that the man was experiencing “a number
of domestic and social issues, which have escalated over a period of
time”. He told staff that he felt “safer” in the healthcare centre and the
decision to put him in “gated cell with protective clothing” was agreed
by the multidisciplinary team who assessed him as raised risk. Prison
Service Order (PSO) 2700 – suicide prevention and self harm
management prohibits the use of a gated cell for any prisoner not on
constant supervision. Nevertheless, the locum psychiatrist recorded on
the front of the man’s ACCT document that he should be checked three
times a day and five times at night, described by the senior officer as
“basic routine observation”. During interview, the locum psychiatrist
explained:
“… we had lots of inmates on [the inpatient unit in the healthcare
centre] who had expressed ideas of self-harm who were not
necessarily on constant watch. We felt that the combination of
gated cell, protective clothing, being on an ACCT watch, with
staff on the wing constantly was enough to manage that risk.”
The locum psychiatrist went on to say that being in a gated cell and
protective clothing was “like constant monitoring” and that he felt he
had “eliminated” the risk of the man hurting himself.
39. The senior officer who manages prison staff on the healthcare centre
recorded in the man’s ACCT document that he was “unaware he was
attending court” the following day. During interview, she said that he
understood he had to return to court but did not know when his
appearance would be. When she told the man that the appearance
was the next day, “he didn’t seem shocked or worried about it unduly”.
40. At 8.25pm that evening, a Registered Mental Health Nurse wrote an
entry in his medical record summarising the reason for the man’s
transfer to the healthcare centre. (The signature was not legible and,
despite my investigator’s request, the PCT has not identified the nurse
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who made the entry.) The nurse recorded that the decision had been
made by the inreach team and described the man as “settled and no
further thought of suicide or self harm expressed”. The entry
concludes by mentioning “a cord loop hidden underneath his jogging
suit top” which was discovered when the man arrived on the unit.
There is no other reference to the discovery of this ligature and no one
my investigator spoke to was aware that the “cord loop” had been
discovered. The senior officer who manages prison staff on the
healthcare centre explained that officers cannot read prisoners’
medical records because they are considered “medical in confidence”.
She said she had not read the entry but would have expected
something like that to have been drawn to her attention.
41. The man was given Zopiclone (to promote sleep), settled down at
about 10.00pm and slept through the night. There are five
observations recorded in his ACCT ongoing record. All noted that he
was asleep.
42. The following day, the man appeared at a Magistrates’ Court. His
Prisoner Escort Record (PER) noted that he was at risk of suicide or
self harm and that he was in “strip clothing” while at the prison. Escort
and court staff recorded checks every ten minutes. The man’s next
court appearance was scheduled for 14 May, just under a month later,
and he was remanded back to Wormwood Scrubs. He went back to
the healthcare centre and was again accommodated in a gated cell
wearing alternative clothing. An officer recorded in his ACCT ongoing
record that the man “appeared calm in mood and manner”.
43. The next morning, a Sister from the chaplaincy visited the man on the
healthcare centre. She explained to my investigator that the
chaplaincy team sees all new prisoners to explain their role. When she
met the man and realised that he was on an ACCT document, she
spent more time talking to him. During their discussion, the man told
her that he was anxious to speak to his mother in Russia. He told the
chaplain that he “was not eating and refusing lunch”, but would eat
again after he had spoken with his mother. The Sister asked the senior
officer who manages prison staff on the healthcare centre to arrange
an international telephone call.
44. The senior officer spoke to the first night centre where international
telephone calls could be made. She arranged for the man to make a
call to his mother that afternoon. She told my investigation team that
the man was very grateful, and became tearful and started praying
when he learned he could speak to his mother. The telephone call
took place at about 2.00pm on the first night centre.
45. When the man got back to the healthcare centre, the officer who had
recorded in his ACCT ongoing record that he appeared calm in mood
and manner chaired an ACCT case review with the man and a nurse.
During interview with the investigation team she explained that the
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case review would usually have been part of the inreach ward round,
but “it got quite sort of into the mid afternoon and we decided to do it
because they weren’t coming up to see him as we thought, we have to
do it anyway”.
46. The officer who recorded in his ACCT ongoing record that the man
appeared calm in mood and manner said that she was not prepared to
change the ACCT observations without a doctor present, but held the
review because it was due and to check if there were any further
measures that could be taken to reduce the man’s risk to himself. She
told my investigation team that the only change she was prepared to
make was to increase the observation levels to constant supervision.
She said that she thought the man “was feeling better” after the
telephone conversation with his mother. She recorded that the man
was “vulnerable”, “feels lost”, but had told her that he felt able to “talk
problems through with staff”. She recorded that his level of risk was
the “same” as had been recorded at the previous case review. He was
due to see the inreach team on 20 April, so his observations were to
remain the same until then (three interactions during the day and five
observations overnight). The man ate his teatime meal that evening.
47. The following morning (Saturday 18 April), the man ate his breakfast.
He told the officer who had recorded in his ACCT ongoing record that
the man appeared calm in mood and manner that he had no thoughts
of hurting himself. Later that morning, the Sister from the chaplaincy
visited the man at his cell. He told her that he had managed to speak
to his mother but that she was in hospital. The sister from the
chaplaincy said she was confused about how he was able to speak to
his mother if she was in hospital, but was pleased that he felt better
having made the call. She was concerned that, as an Orthodox Jew,
he would have special dietary requirements. The Sister from the
chaplaincy said she would arrange with the rabbi for the man to have
two kosher meals a day. In the meantime, the kitchen had agreed to
give him one kosher meal a day. (In fact, it was discovered after his
death that the man was a Muslim and would not have required kosher
meals.) The Sister from the chaplaincy told my investigator that she
remembered the man as “talking, talking, talking and angry”. When
asked whether he was upset by the conditions he was accommodated
in (the gated cell and the alternative clothing), the Sister from the
chaplaincy said she thought he would have been “agitated” regardless
of the conditions he was in. His concern was the circumstances that
had led to his imprisonment.
48. The man threw away his lunch. He spent the afternoon out of his cell
speaking with other prisoners who were living in the healthcare centre.
The officer who had recorded in his ACCT ongoing record that the man
appeared calm in mood and manner noted his “very good verbal
response” as he spoke to prisoners and staff about his court case. It is
not recorded whether he ate his dinner, but he asked for sleeping
tablets which were prescribed.
16
49. On Sunday, the man collected his lunch but refused to eat it. He asked
for a headache tablet but an RMN refused until he had eaten some of
his food. The nurse told the man that “a headache can be caused by
hunger”. He spent the afternoon mixing with other prisoners again. He
was given a nutritional supplement that night and slept through the
night.
50. The next inreach ward round took place on the eve of the man’s death.
The ACCT process was combined with the ward round and a case
review was held at the same time. The case review was chaired by the
locum psychiatrist, an RGN and an RMN. There were no officers
present for the ACCT case review. In her record of the case review,
the RGN recorded that the man was “still expressing thoughts of self
harm/suicide by not eating”. She noted that he had “minimal
interaction with anyone”, despite the entries in the ACCT ongoing
record observing him associating with prisoners in the healthcare
centre. She also recorded that he had said, “I pray every night to die”.
51. The locum psychiatrist recorded in the continuous clinical record that
the man, “still feels suicidal, wants to starve himself to death”.
However, he was accepting nutritional supplements. The locum
psychiatrist continued the prescription of anti-depressants (Citalopram)
and added five milligrams of Olanzapine (an anti-psychotic). The level
of ACCT observations were to continue until the next ward round four
days later.
52. The locum psychiatrist asked for an interpreter to be present at the
next ward round, which also would have functioned as a case review.
During interview, he explained his request to my investigator:
“He spoke some English but he was not fluent and I just felt that,
in fact he spoke better than a few other patients we had on the
unit but I just felt that he deserved to have an interpreter so that
we’ll get a complete history.”
53. That afternoon another member of the chaplaincy team visited the man
and spoke to him about his frustration at being in prison. He told her
that he “did not understand the criminal justice system in this country”.
He wanted the police to “listen to his story”, rather than accept the
statement of the victim. She thought the man was able to express
himself and was mainly “angry” during their exchange. She was not
concerned that he was particularly at risk of self harm, and she would
have visited him again had that been the case. After her visit, the man
again spent the afternoon out of his cell, associating with other
prisoners. Again, he refused to eat his dinner that evening but
accepted some of the nutritional supplement. He slept through the
night.
17
The day of the man’s death
54. The RGN who was part of the case review on the eve of the man’s
death came on duty at 7.45am. She was due to work until 9.15pm that
evening. Ordinarily, there would be two nurses assigned to the
inpatients unit and one nurse assigned to the segregation unit. On the
day of the man’s death, the RGN was working on the inpatients unit
with an agency nurse to assist her, who had worked on the unit “once
or twice” and was assigned to constantly supervise another prisoner.
The RGN described the shift as “busy”. During interview, she
explained:
“… it was just basically me and I had 16 patients to look after
and then one other patient who is in another unit that was
coming to have his medication there and everything else on the
unit as well. And then lunchtime we had this guy who was then
brought up at 5.30pm, you know, getting phone calls about him,
where he was on the wing and you know they were saying they
wanted to bring him over to us. But then, that particular day as
well we didn’t have any spaces because there was some spaces
that were out of order, so we had to get the bio hazard team …
up to come there and then clean up the cells and that sort of
stuff. But it was quite a busy day for both the nurses and the
officers because there were only two officers on duty.”
55. The RGN made an entry in the man’s ACCT ongoing record when she
came on duty, observing that he was asleep. Later that morning, he
had a long conversation with the agency nurse. Unfortunately, despite
the investigation team’s request, the agency nurse was not available to
be interviewed for this investigation. He recorded his conversation with
the man in detail in the ACCT ongoing record. Notably, he wrote:
“[The man] is expressing active suicidal ideation. He said he is
looking for a small chance so that he can commit suicide. He
pointed to the handle on the door saying, “that is my chance”.
Despite all reassurance given he insists he wants to commit
suicide.”
56. The agency nurse spoke to the nurse in charge, the RGN, about his
concerns. Although the investigation team could not speak to the
agency nurse, he did record a summary of the conversation as follows:
“I discussed this with the nurse in charge and she suggested
that there is a need to keep a closer watch on him. There is the
minimum of three times daily agreed by the team but this needs
to be increased because of his active suicidal ideations.”
18
However, the man’s ACCT observations remained at three
observations a day and five overnight. His level of risk was not
revised.
57. During her interview with my investigation team, the RGN said that the
agency nurse told her that the man was “expressing thoughts of self
harm and suicide”. She discussed with the nurse whether his
presentation had changed since the ACCT case review the previous
day and they agreed that it had not. She explained to the agency
nurse that the number of ACCT observations was set at the minimum
number of “quality conversations” needed to support the prisoner, “but
we always have to keep a close eye on any patient who is at risk of self
harm and suicide”. She told my investigation team that she
encouraged the agency nurse to check the man more frequently than
the required observations, if he needed support.
58. The RGN said that typically only the doctor made the decision to
increase or decrease ACCT observations. She said that a
multidisciplinary team, including officers and healthcare professionals,
can increase observations but this tends not to happen in practice.
She said that nurses would be carrying out general observations hourly
as a matter of routine. She was satisfied that the risk the man posed to
himself was minimised because he was in a gated cell and dressed in
alternative clothing.
59. The agency nurse made a subsequent entry in the man’s ACCT
ongoing record at 11.40am, when he noticed him lying on his bed. At
midday, he collected his lunch from the servery, but no one saw him
eating it. The agency nurse noted that the man went back to bed
having collected his lunch and that his “dietary intake remains nearly
nil”. According to his ACCT ongoing record, the man spent some of
the afternoon watching television.
60. At 5.00pm, the RGN recorded that the man was still expressing
thoughts of self harm and suicidal ideation. She noted that he was
collecting his food but still refused to eat it. There were insufficient
officers on duty to unlock the prisoners on the inpatients unit for
association that afternoon, which meant that none of them had left their
cells, other than to collect meals, since 5.00pm the previous afternoon.
61. One of the two officers on duty that afternoon was the senior officer
who manages prison staff on the healthcare centre. Despite being the
senior officer on duty, she did not check the man’s ACCT record and
had not seen the entry written by the agency nurse earlier in the day.
In interview, she said she would have held a case conference if she
had noticed the entry before her shift had finished. The agency nurse
did not speak to the senior officer about his concerns, having raised
them with the RGN.
19
62. The senior officer finished her shift at 5.00pm (at the same time the
RGN made her entry in the man’s ACCT document). Ordinarily there
would have been three officers working in the inpatients unit during an
evening shift. However, because of staff shortage and illness, there
were no officers on duty that evening. The RGN was given a radio and
told that she could request assistance if she needed it via the
communications room. The RGN and the agency nurse (assigned to
constantly supervise another prisoner) were the only two staff working
in the inpatients unit during the evening shift.
63. At the start of the evening shift, the RGN was contacted by officers in
reception asking for a prisoner to be admitted on constant supervision
because he was at risk of self harm. The RGN contacted the bio
hazard team to clean a cell in preparation for the prisoner, because
there were no other cells available. She co-ordinated the bio hazard
team’s visit.
64. The RGN explained to the investigation team that only healthcare
professionals can carry out constant supervision because of the recent
division between staff employed by the Primary Care Trust and the
Prison Service. The RGN then spent a good deal of time arranging
healthcare cover to conduct constant supervision with the newly arrived
prisoner, leaving only the agency nurse in the healthcare centre
carrying out constant supervision for another prisoner.
65. The RGN managed to secure the services of a healthcare assistant
from 7.00pm to carry out the constant supervision of the prisoner who
arrived that afternoon. The RGN was the only member of staff
available to dispense medication and respond to prisoners’ requests.
She said that she had to calm one angry prisoner down and deal with
another who was anxious. At the same time, the RGN had to make
arrangements for the agency healthcare assistant to be allowed to
enter the prison.
66. The RGN last saw the man at about 6.00pm. He wanted cold water
and the RGN explained that he could get cold water from his cell. She
said that she could get him hot water if he wanted it, but he took back
his cup and walked over to the window. It was the last time she spoke
to the man.
67. The cell where the agency nurse was carrying out the constant
supervision was near the man’s cell, but he was not able to see into it
all the time. At about 6.55pm, the prisoner from reception was being
escorted to the wing by two officers. As the officers walked past the
man’s cell, they glanced in and saw him hanging. He had torn a strip
of his blanket and attached it to pipes. (The pipes had a plastic box
fitted over them to prevent a ligature being threaded through the gap
between the pipe and the wall, but it had come loose at the top.) His
legs were off the floor and he was positioned by the gate.
20
68. One of the officers used his radio to make a “Code One” call, which
means a medical emergency. The other officer went into the cell and
supported the man’s weight. The RGN heard the code and saw the
man hanging. She ran to the staff office, metres away, and collected
the emergency grab bag and defibrillator. (A defibrillator is a machine
that applies electrical impulses to the heart and advises whether there
is any rhythm that might be stimulated.) When she returned to the cell,
she helped one of the officers to support the man’s weight while the
other officer cut the ligature. Having brought the man to the floor, the
officer used his radio to request an ambulance.
69. Upon examination, the RGN found the man was not breathing and his
pupils were dilated. She applied the defibrillator and was advised not
to administer an electric shock. She started resuscitation. The
paramedics arrived at the prison four minutes after the ambulance was
called. Within two minutes, the paramedics got to the healthcare
centre and assessed the man. They asked for a doctor to attend and,
in the meantime, continued the resuscitation efforts. A doctor
pronounced the man’s death at 7.46pm.
70. During their visit to a police station, the investigation team was given
access to the photographs taken in the man’s cell after his death. It
was clear from the photographs that the man was wearing the blue
gown (considered to be safer clothing). However, he was also wearing
elasticated tracksuit bottoms underneath the alternative gown, the type
of trousers issued as standard by the prison.
Family support
71. Within ten minutes of the man’s death a governor was appointed to be
the prison’s family liaison officer and went into Wormwood Scrubs to be
briefed. During the briefing, the prison’s family liaison officer learned
that the man had given a false name when he arrived at the prison, and
his listed next of kin had left the country with no forward contact details.
He contacted the police and asked them to trace the man’s real identity
and next of kin. The police agreed to do this, but told the prison’s
family liaison officer that he would receive no more information until the
next morning.
72. The prison’s family liaison officer was not working the day after the
man‘s death but resumed his efforts to locate the man’s family the day
after that. The police still had no information about the man’s family,
although were continuing to try to trace them. The prison’s family
liaison officer used the telephone record to establish that the man had
called Azerbaijan to speak to his mother. He contacted the Azerbaijani
embassy, who asked that he put his request in writing. The embassy
eventually agreed to contact the family on the prison’s behalf. Over the
next three days, the prison’s family liaison officer recorded several
attempts to confirm that the next of kin had been told about the man’s
death.
21
73. It was not until 27 April that representatives from Azerbaijan’s Ministry
of Justice visited the man’s family in their home to break the news.
Later that morning, the prison’s family liaison officer was telephoned by
a friend of the man’s brother who spoke English. Once the police had
confirmed the man’s brother’s identity, the prison’s family liaison officer
arranged for him to visit the prison and collect his property.
74. As the man had told staff he was Jewish when he arrived at the prison,
the prison’s family liaison officer checked with a Rabbi who was a
member of the chaplaincy team whether any special measures needed
to be taken for his burial. The Rabbi said he would need the man’s
family to confirm that they wanted a Jewish burial before one could be
arranged.
75. After the man’s death, the prison’s family liaison officer has had some
ongoing contact with the man’s brother, although there was some
difficulty with communication because of the language barrier. It
emerged that the man was in fact Muslim, not Jewish, and therefore
was buried according to his faith.
Prisoner support
76. The man who died was in Wormwood Scrubs for only seven days, six
of which were spent in the healthcare centre. Although he did not have
the opportunity to form any friendships, the senior officer who manages
prison staff on the healthcare centre described other prisoners on the
healthcare centre as “shocked” and “taken aback” by his death. A case
review was held for every prisoner subject to ACCT monitoring. The
day after the man’s death, the chaplaincy team visited the healthcare
centre to support the inpatients. Officers reassured prisoners that they
could speak to them with any concerns.
Staff support
77. The tension between healthcare staff and officers in the healthcare
centre was obvious to my investigation team throughout this
investigation. This will be explored in more detail later in this report.
The locum psychiatrist told the investigation team that a debrief was
held the day after the man’s death, which he attended. The RGN did
not attend the debrief, but said that she had been supported through
occupational health services. The agency nurse did not attend the
debrief either and, as an agency nurse, never returned to the prison.
The PCT tried to track the agency nurse for the purpose of this
investigation but without success. The locum psychiatrist said that he
received no ongoing support from the PCT following the man’s death.
Officers told my investigator that they understood how to access staff
care and welfare services though the prison, but relied more on each
other for support.
22
78. Given their role in the circumstances leading to the man’s death, I am
surprised that neither the agency nurse nor the RGN attended the hot
debrief. However, I understand that the RGN preferred to take
advantage of individual support services and I am satisfied that proper
efforts were made to trace the agency nurse, albeit without success.
23
ISSUES
79. After the man’s arrival at the prison, he was assessed and located in
the first night centre. During his secondary healthscreen, a nurse was
concerned about the man’s risk to himself and started ACCT
procedures. Interim arrangements were put in place for monitoring
him, before he was swiftly assessed by a qualified ACCT assessor. An
experienced member of staff, the ACCT assessor appropriately
recognised that the man needed to be monitored under ACCT, but
thought he would also benefit from the enhanced care available in the
healthcare centre.
80. However, this investigation found serious concerns about safer custody
procedures at Wormwood Scrubs, particularly in the healthcare
environment. Later in this section, I will consider the use of a gated cell
and alternative clothing for a prisoner who did not need constant
supervision, the safeguards that should have been in place for a
prisoner subject to such measures, communication between healthcare
staff and officers, and staffing levels in the healthcare centre.
Medical records
81. During his first reception healthscreen, the man told the nurse that he
had received treatment for his mental health in the community. The
nurse observed that the man was “disoriented” during the healthscreen
and “not straight to the point”. As the man was unclear about the
nature of his medication or treatment in the community, it was noted
that his medical records should be requested from the hospital he had
attended in East London. There is no record that such a request was
actually made, and in fact his records were never retrieved. The man
was in prison for six days after this initial assessment. It was not
acceptable that his community medical records had not been
requested in that time given his level of risk and the difficulty he had in
recalling the details of his treatment.
82. The failure to retrieve his medical records meant that the man’s
medical treatment was compromised. He was prescribed anti-
depressant medication by the locum psychiatrist after his assessment
on 15 April. I agree with the clinical review panel that anti-depressant
medication must be used “in a controlled manner”. The clinical review
panel has commented at length on the appropriateness of the man’s
prescription, and I commend this to the attention of the Head of
Healthcare. I am concerned that medication was prescribed with no
knowledge of the prisoner’s medical history. I agree with the clinical
review panel’s recommendation:
The Head of Healthcare should review the systems and processes
for accessing clinical records held by community care providers
to ensure appropriate and timely request, retrieval and review by
healthcare staff.
24
Gated cell
83. The man spent six of the seven nights he stayed at Wormwood Scrubs
in a gated cell in the healthcare centre. He was in a gated cell when he
died. However, he was not under constant supervision. The locum
psychiatrist decided to locate the man in a gated cell to keep him safe
until a full assessment of his mental health could be carried out. The
locum psychiatrist described it as “standard practice” to accommodate
a prisoner not under constant supervision in a gated cell in alternative
clothing. (I will discuss the use of alternative clothing in the next
section.)
84. Prison Service Order (PSO) 2700 prohibits the use of a gated cell for
any prisoner who is not subject to constant supervision. A gated cell
affords a prisoner no privacy and does little to promote their dignity.
The man should either have been subject to constant supervision or
accommodated in an ordinary cell. In fact, he was in a gated cell on
what the senior officer described as “just a basic routine observation for
anybody on an ACCT” (that is, a minimum of three recorded
observations during the day and at least five overnight).
85. When my investigator asked the Head of Healthcare at Wormwood
Scrubs why PSO 2700 had not been followed, she said, “hand on heart
that until all of this happened I actually wasn’t aware of that in the
Prison Service Order”. It is a matter of self-evident concern that
someone in such an important role was not familiar with the details of
the PSO and the implications when holding someone subject to ACCT
procedures in the healthcare centre. The investigation found that other
healthcare staff were also unaware that prisoners must be under
constant supervision to be accommodated in a gated cell. In fact, the
locum psychiatrist told my investigator that he understood prisoners on
lower level of observations were accommodated in such a cell as
“standard practice”.
86. The lead consultant psychiatrist at Wormwood Scrubs has been
employed since October 2006 to conduct five mental health clinics a
week. He was on leave when the man was at Wormwood Scrubs, but
he briefed the locum psychiatrist on his duties before he went on leave.
During interview for this investigation, the lead consultant psychiatrist
explained that he had always located prisoners in gated cells and was
not aware of the restrictions in the PSO:
“ … until after the incident, not since I arrived here in October
2006 was I made aware … the officers and nurses as well they
happily went along with that, whenever people were put in a
gated cell without being on constant observation.”
87. My investigator was concerned about the use of gated cell following
her opening visit. She observed two prisoners accommodated in gated
25
cells with alternative clothing. She contacted the lead in NOMS Safer
Custody and Offender Policy group (SCOP), who leads policy work
related to PSO 2700. She set out NOMS policy position for the use of
gated cells as follows:
“Policy does not support the use of a gated cell (with the gate in
place) for a prisoner at risk of self harm, without the added
support of constant supervision arrangements. PSO 2700
states gated cells are for use where a prisoner requires constant
supervision and their use (when the gate is in place) to house
prisoners without constant supervision requirements is
prohibited.”
88. The lead on policy work related to PSO 2700 assured my investigator
that she would raise the practice with the London Regional Office for
them to take forward with the prison. My investigator asked the senior
officer who was her liaison officer and the safer custody senior officer
at Wormwood Scrubs how frequently the gated cell was used for
prisoners not subject to constant supervision. The liaison officer
initially agreed to gather that information, but was later instructed that
there was no requirement to do so and told my investigator that it
would not be possible. No mention is made of prisoners subject to
constant supervision or accommodated in gated cells in the prison’s
monthly Suicide Prevention Policy Meeting minutes between February
2009 and April 2009. It is therefore not possible to determine how
common the practice is.
89. In line with normal procedure, the investigation team fed back their
findings to the management team at the prison and wrote to the
Governor with a summary of those findings. In his response to the
feedback letter the Governor of Wormwood Scrubs, wrote as follows:
“Since the death of [the man], there has been a significant amount
of work carried out with the PCT staff regarding the use of the gated
observation cells and protective clothing. Clear guidelines have
been published to all staff and meetings have been held with the
mental health team to instruct them in the proper application of PSO
2700 and the local Suicide Prevention policy … Wormwood Scrubs
no longer holds any prisoner in a gated observation cell unless they
are assessed as needing constant supervision under the ACCT
processes.”
90. During interview, the consultant psychiatrist also reassured the
investigation team that since the man’s death prisoners were not in
gated cells unless they were subject to constant supervision. He
explained that this has led to an increase in the number of prisoners on
constant supervision, rather than a decrease in the use of the gated
cell. As information about the use of gated cells is not routinely
collected, it is not possible to validate the consultant psychiatrist’s
observations.
26
91. The investigation team was sent the Governor’s Order which was
issued after the man’s death and the investigator’s feedback in June
2009. Among other things, the Governor reminded staff that gated
cells were “a measure of last resort” and should be used as specified in
PSO 2700.
92. As I noted earlier, the man was the first of two prisoners to die in the
healthcare centre at Wormwood Scrubs in 2009. The second death
also involved a prisoner who had been in a gated cell, subject to
constant supervision, and had been dressed in alternative clothing. At
the time of his death, the prisoner was not in a gated cell and was
subject to hourly observations, but there were lessons to be learned in
relation to the management of constant supervision. This death is
subject to a separate investigation but the two investigation teams have
worked together to ensure a co-ordinated approach.
93. Given the two deaths in such similar circumstances, and in light of the
acknowledged difficulties of challenging and changing long-standing
practices, I judge that the following formal recommendation may be
helpful:
The NOMS Safer Custody and Offender Policy group and the
Director of Offender Management should work with the Governor
and the Primary Care Trust to ensure that gated cells are used
only in line with Prison Service Order 2700.
Alternative clothing
94. The man was given alternative clothing when he was located in the
healthcare centre. He was issued with a blue gown and two blankets
made of the same strong material, which is intended to make the
garments difficult to tear into strips for use as ligatures.
95. Wormwood Scrubs’ own suicide prevention policy describes the use of
alternative clothing as “a measure of last resort”. As well as
underlining that alternative clothing should be used for “the shortest
possible time”, PSO 2700 also describes it as a measure of last resort.
It goes on to require:
“Decisions to remove all of a prisoner’s normal clothing and
issue alternative clothing (e.g. anti-tear or forensic/paper suit)
must always be made by the case review team on an individual
basis and only when the prisoner’s behaviour is believed to be
life threatening. For example, all prisoners placed in special
accommodation should retain their normal clothing unless the
case review determines otherwise.”
27
96. The clear requirements surrounding the use of alternative clothing were
echoed by the SCOP lead for safer custody. She set out the following
position:
“The removal of normal clothing from an at risk prisoner is
covered in PSO 2700 and also in PSO 1700 and is generally
considered to be a measure of last resort; as such there is a
requirement for such a decision to be taken only when the
prisoner’s behaviour is believed to be life threatening.”
As the man was not subject to constant supervision, the threshold
cannot have been met.
97. The locum psychiatrist decided that the man should wear alternative
clothing. During his interview with my investigation team, he said that
he had made that decision so that the man’s opportunity to harm
himself would be limited. He said he had understood from nursing staff
that it was common practice for prisoners to be dressed in alternative
clothing, and he had observed a number of prisoners in such clothing
during his brief time at Wormwood Scrubs.
98. As I mentioned above, the Head of Healthcare told my investigator that
she was unaware of the details of the Prison Service Order concerning
gated cells or alternative clothing. It is perhaps not surprising,
therefore, that her staff were equally unaware of these provisions. The
RGN described the gated cell and alternative clothing as something
that was used “quite frequently”. She told my investigator that patients
would be put in a gated cell and protective clothing initially, and over
time their care would be “stepped down”. For example, she said after a
case review “you maybe get them off the clothes into normal clothing
then look at closing the gate”.
99. The RGN told my investigator that alternative clothing was being used
less frequently since the man’s death. The senior officer who manages
prison staff on the healthcare centre agreed that the use of alternative
clothing had changed. However, during her interview with my
investigator nearly two months after the man died, the senior officer
told my investigation team about a prisoner not subject to constant
supervision who was nevertheless in alternative clothing.
100. I understand that the locum psychiatrist decided to dress the man in
alternative clothing to keep him safe. However, I am very disappointed
that alternative clothing was not used as a measure of last resort in
accordance with the requirements of PSO 2700 and Wormwood
Scrubs’ own suicide prevention policy.
101. As mentioned earlier, the use of alternative clothing was the subject of
a Governor’s Order in June 2009. However, once more I judge that a
formal recommendation to reinforce that Order may be helpful:
28
The Governor must ensure that alternative clothing is only used
as a measure of last resort.
102. The photographs taken by the police after his death showed that the
man was dressed in alternative clothing (a gown) but was also wearing
tracksuit bottoms underneath. When my investigator opened the
investigation, she noticed two prisoners in a gated cell dressed in
alternative clothing. She drew the senior officer’s attention to the
shoelaces that one of the prisoners had in his shoes, contrary to the
strict rules of alternative clothing.
103. Alternative clothing is a measure of last resort, but there are occasions
where the prisoner’s risk of harm is so great they such clothing is
necessary for their own protection. However, there are safeguards in
place for such occasions. The lead from SCOP explained to my
investigator:
“… prisoners must not be left in alternative clothing during any
activities that bring them into contact with other prisoners during
the day PSO 2700 is clear that where there will be contact with
other prisoners, normal clothing must be issued and increased
levels of observation relied upon to reduce suicide risk instead.”
104. The senior officer explained that officers in the healthcare centre
issued prisoners with tracksuit bottoms and a sweatshirt for periods of
association. When they return to their cells, the senior officer told the
investigator that the prisoners dress themselves. She said, “good
practice is to search them, especially for the underwear because that
can easily be missed”. The RGN was clear that it was “not [healthcare
staff’s] responsibility to carry out any searches” and remains the
officers’ responsibility.
105. Given the frequent use of alternative clothing in the healthcare centre
at Wormwood Scrubs, I am surprised that there were no systems in
place to ensure that prisoners dress and undress when they leave
association. The locum psychiatrist’s original decision to give the man
alternative clothing was supposed to remove the risk that he would
harm himself. The elasticated tracksuit bottoms rendered the
increased safety of the undignified alternative clothing redundant.
The Governor must ensure that systems are in place for the safe
use of alternative clothing, when it is necessary.
Managing measures of last resort
106. The man who died tore a strip of the alternative blanket, specifically
designed not to tear, and used it as a ligature. In his cell, pipes running
down the wall by the gate had been boxed in with plastic to prevent
prisoners tying a ligature around them and thus make them safer. The
plastic box was not flush to the ceiling, and it was this point to which
29
the man attached his ligature. Two recommendations follow from
these facts:
The Governor will wish to assure himself that any weaknesses in
the cell fabric that result in avoidable ligature points are removed.
The NOMS Safer Custody and Offender Policy group will wish to
consider if the current anti-tear fabrics in use are the best
currently available.
107. Healthcare staff explained to my investigator that prisoners were put in
alternative clothing and gated cells to remove the risk of self harm,
while they were fully monitored and assessed. They would gradually
decrease these measures as they gained a clearer understanding of
the prisoner’s level of risk. The dignity and privacy of prisoners is
undermined by these measures and I expect their use to be subject to
the closest scrutiny. It is clear from this investigation that such
measures do not – and perhaps cannot – remove all risk of suicide.
108. The use of a gated cell is listed as a measure of last resort in PSO
2700. However, the assumption is that a prisoner in a gated cell is on
constant supervision. Therefore, all of the safeguards that are required
by the Prison Service Order apply to a prisoner who is on constant
supervision rather than in a gated cell.
109. However, safeguards do apply to any prisoner who is dressed in
alternative clothing. PSO 2700 instructs: “Placing an at-risk prisoner in
alternative clothing must trigger enhanced care.” The requirements of
enhanced care are set out in a later chapter in the Prison Service
Order and are intended to assist prisoners who are at a time of crisis
and to offer management support to staff delivering their care. As
discussed above, the use of alternative clothing in this man’s case was
not a measure of last resort, but a starting point from which his care
would be de-escalated. Nevertheless, the use of alternative clothing
meant that the PSO requirements applied in his case.
110. The enhanced ACCT case review team should have been made up by
a governor, a member of the mental health team or a doctor, the
healthcare manager, an appropriate psychologist, and the man’s key
worker. Such a review should have taken place within four hours of the
decision to use alternative clothing. The investigation team interviewed
the Head of Safer Prisons. He said that he visited the healthcare
centre as part of his role, but expected the Safer Custody Manager in
his team to visit more frequently. Neither a governor nor the Head of
Healthcare attended the case review on 15 April when the man was
admitted to the healthcare centre and the decision made to put him in
alternative clothing.
111. The Safer Custody Manager is of the appropriate grade to discharge
the requirements of the enhanced case review in PSO 2700. Despite
30
his frequent visits to the healthcare centre, there is no entry in the
man’s ACCT document to suggest that the Safer Custody Manager
had any involvement in his care. During his visits to healthcare, the
Safer Custody Manager would have seen the man in a gated cell in
alternative clothing, and I am surprised that he did not enquire further
about his situation.
112. After the initial enhanced case review, subsequent reviews are based
on need - but are required at least weekly. The next ACCT case
review for the man took place on 20 April, less than a week after the
initial review. Again, it was not attended by the Head of Healthcare or
a governor. It is well understood that alternative clothing was not being
used in line with the requirements of PSO 2700 as a measure of last
resort. However, I do expect that in future the use of gated cells and
alternative clothing is complemented by the required safeguards
described in PSO 2700.
As the Governor strengthens processes around the use of gated
cells, constant supervision and alternative clothing, he should
ensure that staff follow the requirements of enhanced care as set
out in Prison Service Order 2700.
113. The investigator met two members of the Independent Monitoring
Board (IMB) during her opening visit. She asked them to check their
records for any contact with the man. A member of the IMB is required
to visit healthcare regularly as part of monitoring, yet no record was
made of speaking to the man despite the conditions in which he was
held. I recognise that it was not unusual in the healthcare centre at the
time of the man’s death for prisoners to be kept in a gated cell and
alternative clothing. Nevertheless, I hope this report can be shared
with the IMB to inform their efforts to ensure that standards of care and
decency are maintained.
114. Also during her opening visit, my investigator asked how many
prisoners had been in a gated cell or in alternative clothing in the
previous three months at Wormwood Scrubs. The liaison officer told
her that use of the gated cell and alternative clothing was not
monitored in that way, and no such information was available. The
investigator requested that for the three months following the opening
visit, such information be collated to inform this investigation. The
request was declined on the grounds that there is no requirement to
gather such data routinely.
115. Having personally conducted and overseen investigations in very many
prisons, I know that the use of constant supervision, gated cells and
alternative clothing differs very significantly between establishments. I
am surprised that the use of gated cells and alternative clothing is not
more closely monitored. As measures of last resort, the task of
gathering data on their use should not prove burdensome.
31
The National Offender Management Service should consider
monitoring the use of gated cells and alternative clothing as part
of its Safer Custody strategy.
Communication in the healthcare centre
116. The decision to place the man in a gated cell and protective clothing
was made by the locum psychiatrist. It was then discussed at the
subsequent ACCT case review attended by the senior officer who
manages prison staff on the healthcare centre, a nurse and the
community mental health nurse responsible for the inpatients unit.
When asked how she became involved in the case review, the senior
officer told the investigation team that it was not planned. She said that
she noticed the man’s ACCT document when he arrived in the
healthcare centre. She said that she was concerned that the locum
psychiatrist, with limited prison experience, was chairing the ACCT
case review and wanted to give him additional support.
117. When asked whether she agreed with the decisions made at the
review, the senior officer said: ”well that was mainly the doctor and the
nursing staff.” She went on to raise concerns about the role officers
play in the ACCT process for inpatients. She said that ACCT case
reviews were often carried out as part of the twice-weekly ward round.
Despite most of the healthcare officers being medically qualified, their
role changed at the end of 2008. Previously, officers contributed to the
medical care of prisoners and accessed their medical records, but this
was restricted when their role changed. Officers were no longer
allowed to attend ward rounds because of the medical nature of the
discussion. This effectively meant that officers were not routinely able
to attend ACCT case reviews.
118. The ACCT process is multidisciplinary. The daily contact with officers
provides an insight into an individual’s state of mind. Experienced
officers, such as those on the healthcare centre in Wormwood Scrubs,
are in a good position to suggest actions and activities to support
prisoners and reduce their risk.
The Head of Healthcare must ensure that officers are invited to
attend ACCT case reviews.
119. The senior officer who manages prison staff on the healthcare centre
also told my investigator that she was unaware that a “cord loop” had
been found underneath the man’s “jogging suit top” when he arrived in
the healthcare centre on 15 April. As the senior officer in charge of the
unit, she expected to be made aware of significant information such as
the discovery of a potential ligature. She said that she had not seen
the entry in the man’s medical record because it was “medical in
confidence” and kept in a separate office that officers cannot access.
Although the entry was not made until 8.25pm, it refers to the discovery
of the “cord loop” as taking place on the man’s arrival in the healthcare
32
centre. The case review chaired by the senior officer took place after
the man had been accommodated in the unit. Such a significant
discovery should be sufficient to trigger a case review in its own right.
In this instance, it should have informed the case review that took place
shortly after his arrival, and arguably would have affected the
assessment of the man’s level of risk and level of observations.
120. I have commented many times on the way the principle of medical
confidentiality should be applied. When information has implications
for the safety of the prisoner, the presumption must be that it is shared
with all those involved in his care. However, in this instance not only
did the senior officer not know about the hidden ligature, the locum
psychiatrist told my investigator that he had not been told about the
cord loop either. It is both surprising and disappointing that such an
important find was not recorded in the ACCT document.
The Head of Healthcare must remind staff of the importance of
recording information about risk of harm in both the patient’s
clinical record and the ACCT document.
121. I am also disappointed that staff did not discuss such a significant
finding among themselves, regardless of their discipline. During the
investigation, my team became increasingly concerned about the
relationship between healthcare staff and officers. There was evidence
of poor communication, with each discipline choosing to occupy
separate offices in the healthcare centre. I agree with the clinical
review panel that there was a “non-integrated approach to care
planning and provision on the inpatient unit”. During interview with a
mental health nurse who attended the man’s first case review, the
investigation team were told, “staff are constantly stressed because of
very constrained resources ... There is a lack of cooperation between
the prison staff and clinical staff.”
122. I believe this had an impact on the care that the man received during
his stay in the centre. The investigation team fed back their concerns
to the Governor during the course of the investigation. He made the
following response:
“There have been identified failures in the communication
between the staff completing the two different roles within the
Healthcare Department however, there has been a huge
improvement in this area and both groups are seeing
themselves more as a team with the primary aim of patient care.
More work is being carried out including regular monthly team
meetings and fortnightly [inpatient unit] operational meetings
between the middle management team.”
123. I am pleased that this matter has been taken forward as a matter of
priority, and understand that the situation seemed to have improved by
the time of my subsequent investigation into the second death in the
33
healthcare centre in 2009. I understand the pressures that officers and
healthcare staff work under, but in such circumstances the support they
can offer each other is crucial.
The Governor and the Head of Healthcare should continue to
promote team work among staff based in the healthcare centre.
Staffing levels
124. In their report, the clinical review panel comment that - despite a recent
recruitment campaign - staff vacancy rates for healthcare staff at
Wormwood Scrubs are at 47 per cent, almost half the required
workforce. The locum psychiatrist is a locum staff grade psychiatrist.
He was assigned to cover his equivalent grade psychiatrist for three
weeks. However, the consultant psychiatrist for the inreach service at
the prison and therefore senior to the locum psychiatrist, also took
leave at that time and arranged for remote cover in case of
emergencies. This meant that the locum psychiatrist was the only
psychiatrist available at the time that the man was at Wormwood
Scrubs. The locum psychiatrist was given a telephone number for the
consultant psychiatrist’s colleague at a Mental Health Trust and asked
to contact her if he needed additional support.
125. All healthcare staff told the investigation team that the majority of
prisoners in the healthcare inpatients unit have mental health
problems. Psychiatric support is fundamental to such prisoners’ care
plans. I am disappointed that the cover for two psychiatrists fell to one,
less experienced and more junior psychiatrist, with little additional
support. I agree with the clinical review panel’s recommendation:
The Head of Healthcare, lead GP and Consultant Psychiatrist are
asked to review the current arrangements for temporary staff
supervision. These must be explicit and take into account the
level of skill and relevant experience of these staff.
126. The locum psychiatrist explained in interview that he had very limited
experience in a prison (one day in an open prison some time before he
worked at Wormwood Scrubs). He told the investigation team that his
induction constituted a briefing from the consultant psychiatrist prior to
his leave, and a briefing from the senior nurse practitioner. He did not
receive ACCT training nor any information about the requirements of
working in a prison environment. As he was not a full time employee at
the prison, he did not carry keys and had to be escorted by a member
of the nursing team.
127. The locum psychiatrist told the investigation team that the inreach
service supported him well during his time at Wormwood Scrubs. He
acknowledged his limited prison experience but felt he had sufficient
understanding of the ACCT process and Prison Service requirements
to provide cover to an adequate standard. When asked if he used the
34
contact number given to him for emergencies, he told the investigation
team that he only used it after the man’s death. The clinical review
panel shared my concerns at the information given to agency staff. I
endorse the following recommendation:
The Head of Healthcare, Consultant Psychiatrist, Lead GP and
Clinical Governance should review the current local induction
policy to ensure it contains treatment, referral, communication,
and escalation of care guidelines.
128. On the evening of the man’s death, the RGN and the agency nurse
were the only two members of staff working in the healthcare centre.
There are supposed to be three officers on duty during the evening
shift. However, due to high levels of staff sickness and a training
programme elsewhere in the prison, there were no officers supporting
the RGN in healthcare on the evening of the man’s death.
129. In interview, the RGN described the busy evening shift she worked that
evening. The other nurse on duty with her was an agency nurse who
was employed to carry out constant supervision on another prisoner in
the unit. I understand that efforts were made to recruit additional
healthcare staff and that the PCT have had difficulties attracting staff to
work in prison healthcare. However, I am disappointed that no officer
was detailed to work in the healthcare centre that evening. There is no
doubt that the small number of staff in the healthcare centre on the
evening of the man’s death affected the care that the man received.
He was able to take his life in a gated cell without staff noticing. I do
not think that the RGN was personally at fault. Rather, there were
simply not enough staff to effectively discharge the prison’s duty of
care to healthcare inpatients.
130. When the investigation team communicated this concern to the
Governor, he responded:
“The officer staffing levels were short that evening due to high
levels of sickness and the necessity for some staff to attend
Control & Restraint training. When there are no discipline
officers available to work in the healthcare, the provision is that
the PCT nurses manage patient care whilst they are locked in
their cells. There has been no reoccurrence of this problem
since 11th May 2009 when the staffing levels were increased to
allow adequate cover for shortfalls.”
I hope that the Governor will continue to monitor the staffing levels in
the healthcare centre.
Under exceptional circumstances, when the minimum staffing
levels cannot be met, the Governor and the Head of Healthcare
must ensure that at least one officer is detailed to work in the
healthcare centre for every shift.
35
ACCT observations
131. I have already explained that the man should have been subject to
constant supervision as he was located in a gated cell. At the time of
his death, the locum psychiatrist had recorded that staff should engage
in at least three meaningful interactions with the man during the day
and observations should be made a minimum of five times during the
night.
132. On the morning of his death, the agency nurse recorded serious
concerns about the man’s risk of self harm. The man had said that he
was looking for a “small chance to commit suicide” and indicated that
the door handle of the gated cell was his chance. The agency nurse
recorded the conversation in the ACCT document and discussed his
concerns with the RGN. The agency nurse recorded that the RGN
advised that observation levels should be increased. However, no
ACCT case review was held and the man’s observations were not
altered.
133. Unfortunately, the agency nurse was not available for interview for this
investigation. However, the RGN recalled the conversation she had
with the agency nurse that day. She said that she had explained the
required level of observations was the minimum and the agency nurse
could speak to the man more often. She told the investigation team
that she would not normally hold a case review without a doctor for a
prisoner in a gated cell and alternative clothing. The RGN said that
she knew that the man’s case would be looked at the following morning
during the ward round when the doctor would be present. The RGN
said that she could have exceptionally held a case review, but she
thought that the man’s risk was reduced due to his situation in the
gated cell and alternative clothing.
134. I am concerned that a prisoner’s level of risk would not normally be
reassessed without the presence of a doctor. All staff, healthcare and
officers, should feel empowered to change the level of support for
prisoners in the ACCT process.
135. I am also concerned at the reliance on a single member of staff (the
psychiatrist next on duty) to make decisions about the level of risk that
each prisoner poses to himself. Although I recognise how busy she
was that afternoon, I am surprised that the RGN did not consider the
man’s claims to be sufficiently serious to trigger a case review. Staff of
any discipline and grade, officers or healthcare, should feel confident
about contributing to the ACCT process.
The Governor and the Head of Healthcare should satisfy
themselves that staff are confident in ACCT procedures, including
considering refresher training for all staff.
36
Foreign national prisoners
136. The man who died was from Azerbaijan and a Muslim. He reported to
staff that he was Russian and a Jew. In general, staff said he
communicated reasonably well but that he struggled with English.
137. I commend the senior officer who manages prison staff on the
healthcare centre for arranging for the man to make an international
telephone call to his mother when he needed extra support. And in
previous investigation reports I have commented on the good work
done by the Foreign National team at Wormwood Scrubs. However,
the man had no contact with the Foreign National team during his short
time in prison. Following the investigator’s feedback to the Governor in
this respect, he responded:
“The Foreign National Team meet with all Foreign National
Prisoners during their induction period but, due to his location in
the Healthcare, [the man] was missed. Work is being carried
out with the induction team to ensure that this does not occur in
the future.”
I am pleased that the Foreign National team are routinely involved in
the induction process. I am grateful to agree with the Governor for
ensuring that those prisoners who are located in the healthcare centre
soon after arrival due to their increased vulnerability are not
overlooked.
138. Despite staff assurances that the man was able to communicate
effectively, the locum psychiatrist asked for an interpreter to be present
for his next ACCT case review. When asked about this in interview,
the locum psychiatrist said he thought it would give the man an
opportunity to speak more freely about what was on his mind. Staff
reported that the availability of interpreters and the translation service
was never problematic. Although the man seemed able to
communicate well, nuances are often missed when speaking in a
different language. I hope that in future cases there might be earlier
consideration of involving an interpreter in ACCT case reviews.
Food refusal
139. The man told staff that he did not want to eat because he “wanted to
die”. The investigation team asked the RGN whether she had
observed that he was not eating or drinking. She said that the man
would claim not to be eating, but would take some bread or drink some
tea.
140. The locum psychiatrist was concerned about the man’s claims not to
be eating or drinking. He prescribed a protein drink (Ensure) to
37
supplement his meals, which the man drank. The locum psychiatrist
said that “it was not like he was not eating at all … he was not eating
adequately”. The locum psychiatrist was confident that the prescription
of Ensure was appropriate to manage the man’s poor dietary intake.
141. I agree with the clinical review panel’s recommendation that food
charts should be started for prisoners who refuse food and drink for
prolonged periods of time. I understand from the man’s records that he
often claimed he wanted to die through not eating. However, I also
note the occasions when he ate. Had he completely refused food for a
prolonged period, I would have expected a food refusal log to have
been started by staff. It is a requirement that staff start a formal food
refusal chart after three days of food refusal.
142. As his records show that he drank Ensure and ate on several
occasions, it seems that there was not a period of three days or more
when he refused food completely. However, I cannot determine that
the monitoring of the man’s dietary intake was recorded adequately in
the ACCT document and his clinical record as entries were not
consistently made at each meal time. I acknowledge that there is no
requirement to monitor a prisoner whose food refusal has not been
absolute for three days or longer. Nevertheless, given the seriousness
of the man’s claim to refuse food because he “wanted to die”, it might
have been prudent to have opened a food refusal log.
38
CONCLUSION
143. Shortly after the man arrived at HMP Wormwood Scrubs he told staff
that he would die in prison. Staff quickly identified him as at risk of self
harm and assessed his needs. The decision to accommodate him in a
gated cell in alternative clothing was undoubtedly made with the best of
intentions to reduce his opportunities for harming himself. However,
there is no substitute for a co-ordinated multi-disciplinary approach to
supporting a prisoner at risk of self harm, and this was lacking.
144. I am disappointed by what this investigation has revealed about safer
custody procedures at Wormwood Scrubs at the time of the man’s
death. The challenges of delivering individualised care in such a large
local prison are evident. However, I hope that the Governor, Head of
Healthcare and PCT will work together to bring the establishment in
line with the expectations of NOMS in providing a safe and decent
environment for all prisoners.
39
RECOMMENDATIONS
1. The Head of Healthcare should review the systems and processes for
accessing clinical records held by community care providers to ensure
appropriate and timely request, retrieval and review by healthcare staff.
The Head of Healthcare partially accepted this recommendation. In
her response, she wrote:
This is normal practice, however we do rely on the prisoner to give us
all the relevant contact information in terms of name known by. On this
occasion we were not afforded [the man’s] name – he was in custody
under another name and we were not informed otherwise until he had
passed away.
2. The NOMS Safer Custody and Offender Policy group and the Director
of Offender Management should work with the Governor and the
Primary Care Trust to ensure that gated cells are only used in line with
Prison Service Order 2700.
The NOMS Safer Custody and Offender Policy Group and the Director
of Offender Management accepted this recommendation and set out
the following response in their action plan:
a. A Governor’s Order have been published identifying to all staff the
necessary requirements when locating prisoners to or employing the
use of a ‘Gated’ cell. This Order will be re-issued in May 2010.
b. All prisoners located to gated cells, when used as such are now
subject to Constant Supervision.
c. A local Policy document ‘Constant Supervision, Gated Observation
Cells and Alternative Clothing’ has been drafted and now agreed
between the PCT HC Provider and Prison. This document provides
clear guidance and instructions to staff from both organisations as what
is required when directing / authorising a prisoner to be accommodated
into a gated cell.
d. Staff from the PCT HC Provider and Prison will attend a
presentation of the document’s contents to be delivered jointly by the
prisons Safer Custody Manager and Modern Matron responsible for the
inpatient unit to ensure the document and its contents are fully
understood.
e. A log has been implemented within the healthcare inpatient unit to
record all prisoners placed on Constant Supervision. The log will record
under whose authority this action was initiated and the times and dates
of when the subsequent Enhanced Case Reviews take place. This log
will be used as a prompt to unit staff to ensure that the later takes place
within required timeframes.
40
f. Compliance to this recommendation and the proposed action will be
monitored by the Safer Custody Manager and H3 Modern Matron by
means of Action Point 2(e) above.
The prison have informed this office that these actions were all
completed by the end of May 2010, apart from the last action at (f)
which is ongoing.
3. The Governor must ensure that alternative clothing is only used as a
measure of last resort.
The Governor accepted this recommendation. In his response, he
referred to the actions listed under recommendation 2, but went onto
note the following ongoing actions:
a. The Local policy ‘Constant Supervision, Gated Observation
Cells and Alternative Clothing’ includes at Para 6 of the document
directions as to the use of Alternative clothing and emphasises that this
option should only be used as “a measure of last resort”. The
Paragraph also refers the reader to Chapter 8.9 of PSO 2700 and
operational instructions 2 and 24 of the suicide prevention policy for
further clarification.
b. Compliance to this recommendation and the proposed action
will be monitored by the Safer Custody Manager and H3 Modern
Matron by means of Action Point 2(e) above.
4. The Governor must ensure that systems are in place for the safe use of
alternative clothing, when it is necessary.
Again, the Governor accepted this recommendation, noting the
following actions, in addition to those listed under recommendation 2:
a. The Local policy ‘Constant Supervision, Gated Observation
Cells and Alternative Clothing’ includes at Para 4 (f – m) and at Para 5
& 6 instructions of how a prisoner should be managed whilst monitored
under Constant Supervision and whilst in alternative clothing.
b. Instructions referred to at 4.b. above have been compiled into a
reference / information pack for issue to the staff members
responsible for conducting observations of the prisoner.
c. A review of current stock of Alternative clothing has been carried
out within the prison Healthcare Inpatient unit and the Segregation
Unit. Instructions have been issued that all worn and unserviceable
items should be replaced from the establishment stores, where a stock
of new and unused clothing is held.
41
d. The Safer Custody Co-ordinator will carry out random checks of
this clothing to ensure that this action is ongoing. Any incidents of the
discovery of unserviceable clothing will be reported through the Safer
Custody Manager to the relevant Functional Head for appropriate
follow up action.
5. The Governor will wish to assure himself that any weaknesses in the
cell fabric that result in avoidable ligature points are removed.
The Governor only partially accepted this recommendation, with the
following response:
a. Gated cells within the Healthcare Inpatient Unit are not fitted to
Safer Cell specifications. There exist therefore, as with most other cells
on the unit a number of possible ligature points within the cell.
However, the risk of a prisoner being afforded sufficient time to secure
such a ligature is now considered minimal by the fact that if in a gated
cell he will be subject to Constant Supervision.
b. Having stated the above (5.a) the Safer Custody Team in
conjunction with the establishment works department have reviewed
the fabric of the gated cell accommodation in the healthcare unit with a
view to limiting the possibility of ligature points and in particular the
ligature point that the man used. Initial materials used to seal the gap
between the lock back / pipes and the wall proved unsuccessful and a
more substantial covering will be employed.
c. The lack of ‘Safer Cell’ accommodation within the inpatient unit
has been recognised. A successful bid was therefore made and
funding provided to convert two existing cells on the unit to Safer Cell
specifications. These are now in place and provide a safe step-down
ability for prisoners being removed from Constant Supervision.
5. The NOMS Safer Custody and Offender Policy group will wish to
consider if the current anti-tear fabrics in use are the best currently
available.
The NOMS Safer Custody and Offender Policy group have accepted
this recommendation, with the following response:
Regime Services are keeping the use of anti-tear fabrics under review
taking into account any new products that come onto the market.
7. As the Governor strengthens processes around the use of gated cells,
constant supervision and alternative clothing, he should ensure that
staff follow the requirements of enhanced care as set out in Prison
Service Order 2700.
The Governor accepted this recommendation and referred to the action
points set out in response to recommendation 2.
42
8. The National Offender Management Service should consider
monitoring the use of gated cells and alternative clothing as part of its
Safer Custody strategy.
The National Offender Management Service initially partially accepted
this recommendation. In their first response, they wrote “The use of
gated cells and alternative clothing is monitored on an individual basis.”
However, in discussions with the investigation team, they have since
accepted this recommendation and agreed to at least “consider” the
broader monitoring the use of gated cells and alternative clothing as
part of the Safer Custody strategy.
9. The Head of Healthcare must ensure that officers are invited to attend
ACCT case reviews.
The Head of Healthcare accepted this recommendation, again referring
to the actions set out under recommendation 2, above. In addition, she
set out the following actions:
a. An information sharing protocol has now been agreed between
the PCT and prison, which will allow all medical information to be
shared between clinical and those discipline staff signed up to the
document. The Governor has directed that it be a condition of working
within the healthcare inpatient unit that all Officers agree to sign up to
this protocol. This will in effect remove any perceived barriers to
Officers attending Ward Round discussions and will cement a
multidisciplinary team approach to all care pathways.
b. The agreement has been submitted to the Prison Staff
Association (POA) who have stated that they have no objections to the
contents of the protocol or to their members signing it.
c. A joint PCT / Prison Management approach is to be employed to
implement the protocol. All H3 unit prison discipline staff will receive a
presentation as to the protocol’s contents and meaning. They will then
be invited to sign up to the document.
d. The Safer Custody Team, in conjunction with the PCT
Management will monitor future ACCT reviews to ensure compliance.
10. The Head of Healthcare must remind staff of the importance of
recording information about risk of harm in both the patient’s clinical
record and the ACCT document.
The Head of Healthcare accepted this recommendation, with the
following response:
43
Refresher training to be organised again for all staff. Notice to staff to
be circulated amongst all healthcare staff and the importance of the
ACCT document reinforced.
11. The Governor and the Head of Healthcare must continue to promote
team work among staff based in the healthcare centre.
The Governor and the Head of Healthcare accepted this
recommendation, and planned the following actions to address it:
a. Regular H3 Team meetings have been organised to ensure that
staff from both disciplines share common problems and contribute to
their resolutions.
b. All staff have been encouraged to share the unit’s landing office
as the main focal workstation for unit staff.
c. PCT and Prison Managers continue to monitor the situation and
work towards a more integrated workforce. It is hoped that with the
introduction of the Information sharing protocol this will enhance this
process.
12. The Head of Healthcare, lead GP and Consultant Psychiatrist are
asked to review the current arrangements for temporary staff
supervision. These must be explicit and take into account the level of
skill and relevant experience of these staff.
The Head of Healthcare, lead GP and Consultant Psychiatrist accepted
this recommendation, with the following action:
Current induction document to be reviewed and amended where
necessary to reflect supervision arrangements and escalation lines.
13. The Head of Healthcare, Consultant Psychiatrist, Lead GP and Clinical
Governance should review the current local induction policy to ensure it
contains treatment, referral, communication, and escalation of care
guidelines.
The Head of Healthcare, Consultant Psychiatrist, Lead GP and Clinical
Governance accepted this recommendation, agreeing to review the
current induction document and amend where necessary.
14. Under exceptional circumstances, when the minimum staffing levels
cannot be met, the Governor and the Head of Healthcare must ensure
that at least one officer is detailed to work in the healthcare centre for
every shift.
The Governor and the Head of Healthcare partially accepted this
recommendation, and set out the following three-part response:
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a. At the time of the man’s death the PCT had commissioned
Discipline Officer coverage for periods only when prisoners located on
that unit were out of their cells on activities. Officer coverage has now
been extended to cover patrol periods and the Officer group increased.
Since this increase there have been no reoccurrences of no Officer
being on duty in the unit during the day / evenings periods.
b. Where necessary the establishment’s Orderly Officer has
deployed Discipline Officers to supplement H3 Unit staffing in order to
maintain sufficient Officer cover.
c. Night cover for the unit remains the responsibility of the PCT
Nursing staff, with Discipline Officer response supplied from the main
prison night compliment as required.
15. The Governor and the Head of Healthcare should satisfy themselves
that staff are confident in ACCT procedures, including considering
refresher training for all staff.
The Governor and the Head of Healthcare accepted this
recommendation and set out the following actions to implement it:
a. All staff within the unit will be refreshed in the ACCT procedures.
b. Work is currently underway to organise training of Nurses and
Nursing Assistants from the main agency which supplies staff to the
PCT / Prison. This training will cover all aspects of Constant
Supervision and the ACCT process.
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