Individual at Wormwood Scrubs

Investigation into the circumstances surrounding
the death of a man at
HMP Wormwood Scrubs, in March 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2008
1
This is the report of my investigation into the death of a man on 13 March 2007 at
HMP Wormwood Scrubs. The man was found hanging after being locked in his cell
that evening. He was 37.
I wish to offer my sincere condolences to the man’s family and friends for their loss.
The investigation was conducted on my behalf by my investigator. I would like to
extend my thanks to the Governor and his staff at Wormwood Scrubs for their help
and co-operation.
In addition to my investigation, a clinical review was undertaken by the Hammersmith
and Fulham Primary Care Trust into the medical care that the man received. I am
grateful to the panel for that review.
Like many of the prisoners whose deaths I investigate, this man was a long time user
of illicit drugs who had undergone a drug detoxification regime whilst in custody.
Whilst at times he had problems with withdrawal pains, he gave no indication of any
intention to self-harm. His death was a shock to his family, staff and other prisoners.
I have made three recommendations in addition to those emanating from the clinical
review panel.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2008
2
CONTENTS
Summary 1
The investigation process 2
HMP Wormwood Scrubs 4
What the investigation has uncovered 6
Clinical Review 12
Issues considered during the investigation 14
Recommendations 16
3
SUMMARY
1. The man was remanded to Wormwood Scrubs on 22 January 2007 for an
offence of dishonesty. He used illicit drugs and was being prescribed
methadone. Initially, the man was put onto an alcohol detoxification regime as
he also claimed to drink large quantities of alcohol daily.
2. On 24 January, the man was moved onto the Conibeere unit, the detoxification
unit at the prison. He was assessed as suitable for the methadone
maintenance programme and received the drug at a maintenance dosage.
3. On 31 January, the man told a doctor on the unit that he was having occasional
thoughts of self-harm. The doctor prescribed mirtazapine, an anti-depressant.
4. On 25 February, the man was seen to leave a small container with diluted
methadone inside on top of a bin. The methadone was recovered by staff
before anyone else took it. As a consequence, the man lost his job as a
cleaner on the unit and was put onto a methadone detoxification regime.
5. The man continued on the reducing methadone dosage, experiencing some
withdrawal symptoms. He did not talk about self-harm again. In fact, his family
and solicitor (who saw the man on 7 and 11 March respectively) commented on
how well and positive he appeared.
6. The man finished his methadone detoxification on 11 March. On 13 March, the
man wrote two letters to his girlfriend in which he said that he was still
experiencing withdrawal symptoms. He was also making plans for the future,
explaining that his court appearance the next day would result in another
remand.
7. That evening, the man sat with another prisoner talking about his family. He
showed him photographs and letters which he then asked the man to keep until
his return from court the next day.
8. Shortly before 8.00pm, at the end of the association period, the man returned to
his cell. He asked a prison officer, who was about to lock him in, if he could go
to the medication hatch as he had not already done so. The officer allowed him
to go and the man returned a few minutes later and thanked the officer.
9. At about 8.40pm, a second officer opened the man’s cell to put a newly arrived
prisoner in there to share. The officer saw the man hanging from the window
bars by a ligature made from torn bed sheet. He raised the alarm and he and
other staff attempted resuscitation. Paramedics arrived a few minutes later,
followed by an ambulance and the Helicopter Emergency Medical Services.
10. Sadly, the man could not be revived and he was pronounced dead at 9.28pm.
He was 37 years old.
4
THE INVESTIGATION PROCESS
11. My investigator opened this investigation at Wormwood Scrubs on 16 March
2007. The Governor and his staff produced the man’s core record and a
number of other documents for examination. Notices were distributed around
the establishment notifying staff and prisoners of the investigation. As part of
the investigation process, a number of staff were formally interviewed.
12. Her Majesty’s Coroner was contacted to inform her of the nature and scope of
my investigation and to request a copy of the post mortem report. Upon
completion, this report will be sent to the Coroner to assist with the inquest into
the man’s death.
13. One of my Family Liaison Officers contacted the man’s sister and his estranged
wife to tell them about my investigation and to offer the opportunity to raise any
concerns and questions they would like explored and addressed. The man’s
family in Ireland asked for further clarity around the man’s methadone
detoxification and whether he had been involved in a fight prior to his death (the
man’s girlfriend had told them he said that he had been involved in a fight). My
investigator and family liaison officer met with the man’s wife and her family
who also expressed concern about the man’s methadone detoxification, an
apparent injury to his hand and why the man had been moved cells before his
death. They also spoke about the distress caused by the conflicting information
they were given in the immediate aftermath of the man’s death. I have done my
best to address these concerns in the body of my report. I hope this report
helps the man’s family better understand the events leading up to the man’s
death.
14. Both the man’s family in Ireland and his wife received my report. The man’s
family in Ireland did not wish to make any comment on the findings and, for
personal reasons, the man’s wife was unable to provide her feedback ahead of
the report being made final.
5
HMP WORMWOOD SCRUBS
15. Wormwood Scrubs is a category B local prison in West London. It serves
Crown and Magistrates’ Courts in the north west of the city. The prison can
hold up to 1,239 male prisoners. The accommodation comprises five wings, a
detoxification unit named Conibeere, a segregation unit and a healthcare
centre.
16. The prison was last inspected by Her Majesty’s Chief Inspector of Prisons in
October 2005. The report of that inspection was published in December that
year. In her introduction Ms Owers reports:
17. ‘Over the last few years, our inspections have recorded gradual, but
discernable, progress at Wormwood Scrubs. That owes a great deal to steady
and consistent senior management over the last four and a half years … It is
good to report continuing progress at Wormwood Scrubs, a prison that is now a
long way away from the establishment that caused us, and the Prison Service,
such concern. Managers will need to ensure that recent gains are consolidated
and built on, and in particular that proper safeguards and recording procedures
are in place and are regularly monitored.’
18. In their 2006/2007 report, the prison’s Independent Monitoring Board (IMB) at
the prison state their overall judgement of the establishment as follows:
19. ‘During the reporting period, the national prison population in England and
Wales has been at a historic high. Inevitably this has had an effect on the
management of the prison and on the experience of prisoners within the
system. Throughout the year the Board has been aware that there have been
late arrivals at Reception because of the difficulty in providing prison
accommodation in the London area. Furthermore the high number of
applications received by the Board in respect of missing property and the
processing of PIN phone numbers may well be a symptom of the pressures
caused by high population numbers.
20. The Board commends certain new developments introduced during the
reporting period. These include: the Super Enhanced Unit, the Case
Management Protocol for difficult to manage prisoners, and the Integrated Drug
Treatment Strategy (this is scheduled for implementation in September 2007).
21. While recruitment and retention of staff is a concern, there have been relatively
few changes within the senior management team. This has helped to give
stability to the prison. The prison has continued to perform well during a period
when the prison system has been under great stress.’
22. In their 2005/2006 IMB report, the Board had raised concern over the number
of prisoners arriving at the establishment late. The prison responded by saying
that since the report a number of changes and initiatives had been introduced.
Serco, the private company responsible for the movement of the prisoners, had
added several new vehicles to their fleet. The issue of late arrivals was also
6
mentioned in passing in the IMB’s 2006/2007 report. Whilst not directly related
to the man’s death, arriving late did mean that he did not see a doctor until the
following morning.
23. Since I was given responsibility for investigating prison deaths in April 2004
there have been eight apparently self inflicted deaths and three from natural
causes at Wormwood Scrubs. In my report (published January 2007) into the
apparently self-inflicted death of a man in November 2005, I made a
recommendation regarding the clarity and legibility of medical records. This is
not a mere nicety but an essential safeguard and a required standard of the
General Medical Council. I have made the same recommendation in this
report.
7
WHAT THE INVESTIGATION HAS UNCOVERED
24. The man was arrested on 20 January 2007 on suspicion of burglary. He was
subsequently charged with two offences and taken to Brent Magistrates’ Court.
In the ‘further information about risk’ section of the Prisoner Escort Risk (PER)
form, the police officer has written, ‘Depression, methadone user – heroin
addict, cocaine user, PNC shows violent’. (PNC stands for Police National
Computer.)
25. At the time of his arrest, the man was on a court ordered supervised
methadone programme and was utilising the services of Addaction, a drug and
alcohol treatment charity.
26. At the magistrates’ court on 22 January, the man pleaded guilty to one offence
and was remanded to Harrow Crown Court for sentence. The other case was
remanded to the same court for trial. The man was remanded in custody to
HMP Wormwood Scrubs. He arrived at the prison during the evening. The
exact time of arrival was not recorded on the printed PER form but he did not
leave Brent Magistrates’ Court until 6.04 pm.
27. A cell sharing risk assessment (CSRA) was completed and it was decided that
the man was a low risk (no current indication/evidence of risk, suitable for multi-
cell location). A first reception health screen was completed once the man had
been located on the First Night Centre. The man told Healthcare Worker
Latham that he was receiving 70 mls of prescribed methadone a day and that
he was prescribed temazepam, a medicine which is used in pre-medication for
minor procedures and sleeping problems. He said that he drank 10 – 15 cans
of strong lager daily and used heroin (last time, two days before) and cocaine
occasionally (also two days previously).
28. The man was given a urine test that was positive for heroin, methadone,
amphetamine, cocaine and THC (the active agent in cannabis). He said that he
had received treatment from a psychiatrist for depression that had been
diagnosed by his GP, although he had not been prescribed medication. The
man told the healthcare worker that he had never tried to harm himself and that
he did not feel like harming himself at that time.
29. The man was referred to the doctor regarding his substance misuse but not for
a mental health assessment. The man’s family later told my investigator that
he had in fact tried to take his own life twice in the past by means of an
overdose of pills.
30. The duty doctor had left the prison by the time the man’s assessment was
complete. It is not mandatory that new prisoners see a doctor upon arrival as
long as they are seen by a member of healthcare staff. The duty doctors are
currently contracted to work until 9.15 pm. The prison has a system whereby
the nurse can contact a private company called ‘Primecare’ who provide an out
of hours service. Via Primecare the nurse was able to speak with a doctor to
authorise the prescription of medication.
8
31. Primecare was contacted and 30mg of chlordiazepoxide (librium) was
prescribed for the man’s alcohol detoxification. It is perhaps indicative of the
general poor quality of the medical record that what was recorded on the
prescription chart was chlordiazepam.
32. The man was seen by the duty prison doctor at 11.30 am the following morning.
The doctor noted that it was the man’s second time in prison, that he smoked
40-60 cigarettes and drank 10-15 cans of strong lager a day. The man told the
doctor that he was prescribed 70 ml of methadone and 20 mg of valium daily.
He also said that he had been taking medication for depression but had
stopped. The doctor noted that the man was not suicidal or psychotic.
33. The duty prison doctor wrote in the medical notes that the man was alcohol and
heroin dependent. That would be confirmed by the Conibeere unit later. The
doctor told my investigator that he always adds ‘to receive symptomatic relief’
on the medical record for patients who may suffer withdrawal symptoms. He
cannot understand why he did not do so on this occasion. The man was
started on the course of chlordiazepoxide as an alcohol detox.
34. The procedure at Wormwood Scrubs is that the duty doctors only prescribe
symptomatic relief for drug addicted prisoners. The doctors on the Conibeere
unit prescribe and monitor the detoxification or maintenance regimes.
35. Later that day (23 January), the man asked the first night centre (FNC) staff to
get him onto the Conibeere unit (the specialist detoxification unit) as soon as
possible. He said that he was usually given medication relating to his drug
problems but that the nurse had not given him anything.
36. On 24 January, the man moved onto the Conibeere unit and was seen by a
prison doctor. In addition to the information previously given, the man said that
he had a nine year history of substance abuse and had undergone a number of
previous detoxifications. The man told the prison doctor that he was feeling
solemn that day as it was coming up to the anniversary of his son’s death (29
January). The man admitted that he had previously been on anti-depressants
but denied any current feelings of depression.
37. The prison doctor prescribed a methadone maintenance programme starting
with 20 ml a day until his 70 ml prescription could be confirmed. The man had
not received his librium that day and the doctor decided that the librium
detoxification (part of the alcohol detox) was to be repeated. The man’s
methadone prescription was confirmed and his maintenance dose was
increased to 50 ml a day on 26 January.
38. On 31 January, the man saw the prison doctor. He requested counselling as
he was having occasional thoughts of self-harm. The doctor noted that the
man had no plans or attempts to self-harm. After further discussion he was
prescribed mirtazapine, an anti-depressant, for a period of 14 days. His mental
state was to be reviewed at that time. In fact, there is no evidence that such a
9
review took place, although the man was seen by other doctors and healthcare
staff on several occasions prior to his death. The man also complained of a
lump on his right hand which had appeared over the last two to five days. He
was prescribed an antibiotic for the abscess.
39. The prison doctor is an agency doctor who was contracted to work on the
Conibeere unit in early 2007. It has not been possible to interview him as he is
travelling abroad for several months.
40. An entry on the man’s history sheet on 4 February states:
a. ‘causes no trouble on CBU (Conibeere unit), always polite and follows
regime.
b. Says he is okay and no problems at present.’
41. On 15 February, the man’s methadone dose was reduced to 45 ml a day. On
18 February, he began to work as a cleaner on the Conibeere unit. It was
noted on the CSRA form that he was happier as he got more time out of his
cell. Throughout his time on the unit it was recorded that the man was coping
well with the methadone maintenance regime and had no concerns. His
methadone dosage was reduced again to 40 ml on 22 February.
42. On 25 February, the man attempted to leave some diluted methadone on top of
a bin. It was found by staff before anyone could take it. The man was tested
and found to be positive for opiates. It was noted in his medical record that
further methadone was to be withheld until the man had seen the doctor. He
was seen by the prison doctor the following day and his regime was changed
from maintenance to detoxification. It was noted that the man was not happy
with that outcome but stable in mood.
43. When the man entered the Conibeere unit and started the methadone
maintenance programme he signed a consent/agreement form. That form
makes it clear that, if he passed his methadone to anyone else, he might be
placed on symptomatic treatment as soon as possible and his methadone
stopped.
44. The man lost his job as a cleaner as a result of leaving the methadone on the
bin.
45. On 28 February, the duty doctor reviewed the man’s mirtazapine prescription
and decided to continue it for another 28 days. In his interview, the duty doctor
explained that he was asked to extend the man’s medication as it was about to
run out and there was no doctor on the Conibeere unit. He did so knowing that
the man was being monitored on the unit by the medical staff.
46. Although what he did is accepted medical practice, the duty doctor has decided
that he will no longer prescribe medication under those circumstances without
meeting with the patient and reviewing his record. (the duty doctor was part of
the clinical review panel and concurs with their findings in this regard.)
10
47. By 4 March, the man’s methadone had reduced to 20 ml a day. The following
day he was tested again and the result showed only the prescribed methadone.
48. On 6 March, the man complained of aches and pains, cold sweats, diarrhoea
and not eating or sleeping properly. A doctor explained to the man that he had
to keep to the protocols and continue with the detox regime. He was
prescribed zopiclone again to help with symptomatic relief.
49. The man had a visit from his mother-in-law, his wife and children on 7 March.
They later told my investigator that they were surprised how well the man
appeared and that he was in such good spirits. However, he did complain to
them of withdrawal symptoms and they felt that the man was not coping well on
the dosage of methadone he was on.
50. Another CSRA entry dated 10 March said:
‘Has become increasingly unsettled since losing his job as a cleaner. I
feel this man needs a move off the unit to start afresh somewhere else.’
51. The man’s wife spoke to him on Sunday 11 March. She told my investigator
that the man was again in good spirits, talking about his court case the next day
and asking for his children to send in photographs for him to put into matchstick
frames he had made.
52. The man appeared at Harrow Crown Court on 12 March and was further
remanded. When he returned to Wormwood Scrubs he was placed in a cell on
B wing (B4-20). (It had already been decided that, as he had finished his
methadone detoxification the day before, he would not need to return to the
Conibeere unit.) It was noted on his medical record that he might require
medication for symptomatic relief.
53. The man wrote a letter (not sent) to his girlfriend in which he spoke of his plans
for the future and requested a visit. He also wrote that he was feeling unwell
now that his methadone had finished and he expected to be sick for a week.
He wrote another letter to his girlfriend at 4.30 am on 13 March, also not sent.
Although the man complains of back pain, the tone of the letter is positive and
forward looking.
54. The man’s solicitor visited him during the afternoon of 13 March. He told my
investigator that he was shocked when he was told the following day that the
man was dead. He said that he found him in very good spirits and not overly
concerned about the charges he was facing. He said that he was due in court
again on 14 March, but that the man was not worried about that and knew that
the appearance was only going to result in a further remand.
55. During evening association the man met another prisoner, whom he had known
before moving onto the Conibeere unit. The other prisoner subsequently said
that the man seemed pleased to see him and wanted to show him some
photographs. The man took a tray of letters to the other prisoner’s cell and
began to go through them. He said that the man was complaining about having
11
been taken off his prescription medication. In a statement taken on 23 August,
The other prisoner says:
56. ‘The impression I gained was that this (the move from maintenance to detox)
had been a few days before and not on the actual day of our meeting. The
man didn’t appear to be having any problems with this at the time when I spoke
to him; he did not seem well, but he was a heroin addict.’
57. The other prisoner also said that the man told him that his girlfriend did not
want to know him any more, that he had no tobacco and that he might face
additional charges. The man said it was all looking pretty grim. The other
prisoner gave the man some tobacco and biscuits which he said appeared to
cheer him up a bit.
58. As association was coming to an end, the man got up to return to his own cell.
The other prisoner asked if he was going to take the letters with him. The man
asked him to keep them until he returned from court the following day. The
other prisoner said that the man did not say that he was depressed to a point
where he would consider taking his own life, and the other prisoner did not
have any concerns either.
59. At 7.39 pm, the man rang his girlfriend. The call lasted less than a minute. My
investigator has spoken to the man’s girlfriend and she confirmed receiving the
call. She said that the man seemed alright and that nothing upsetting was said
by either party.
60. Shortly before 8.00 pm, the man returned to his cell. The first prison officer was
about to secure the door when the man asked if he could go for his medication.
The officer asked why he had not gone during the unlock period. The officer
remembers the man’s reply as something like, ‘I didn’t remember, a little bit
hazy, sorry I didn’t remember.’ The officer allowed the man to go down to the
dispensary to try and get his medication. He returned about five minutes later
saying ‘thank you very much’ to the officer before he was locked in for the night.
The prescription chart shows that the man collected medication for
symptomatic relief of withdrawal pains.
61. The First Night Centre was being refurbished at the time and all new prisoners
were being located on B wing. At about 8.40 pm, the second officer went to the
man’s cell with his cellmate, a new arrival from court. The officer looked
through the cell door viewing flap and saw the man standing at the window.
The officer opened the cell door and called out, ‘I’ve got a cellmate for you’. He
got no response and had actually walked into the cell when he noticed that the
man was suspended from the window by a ligature made from ripped green
bed sheet. The officer ran out onto the landing. He shouted out that there was
a ‘Code One’ and the location. (Code one means a serious medical
emergency, such as a hanging.) As there were a number of staff around, he
was sure that he had been heard. He returned to the cell and lifted the man to
relieve the pressure on his neck. The prisoner with the officer asked if he could
help and tried without success to untie the ligature. A third officer arrived in the
cell and managed to untie the ligature from the window.
12
62. The man was laid on the cell floor and a fourth officer arrived with the
emergency box. Using the cut-down scissors he removed the ligature from
around the man’s neck. The officers could not detect a pulse, and the man was
not breathing, so they commenced Cardio Pulmonary Resuscitation (CPR). A
nurse and a fifth officer arrived and took over the CPR.
63. The Control Room Log has the ‘Code One’ call logged at 8.43 pm. An
ambulance was called at 8.45 pm. Paramedics arrived at the main prison gate
at 8.50 pm and an ambulance arrived a minute later. One of the prison doctors
arrived at the man’s cell around the same time. A doctor part of the Helicopter
Emergency Medical Service (HEMS) arrived at 9.01 pm. Sadly, despite the
efforts of the healthcare professionals to revive him, the HEMS doctor
pronounced the man dead at 9.28 pm.
64. The man had listed his sister as his next of kin. She lives in Ireland and the
prison made arrangements for the local police to break the news. The man’s
wife found out about his death from his sister. His wife’s mother then
telephoned the prison to find out what had happened. She does not know
whom she spoke to, but was told that the man was found on his bed when an
officer was locating another prisoner in his cell. The officer was unable to rouse
the man and he was eventually pronounced dead. The man’s mother-in-law
then spoke to his sister who told her about the man being found hanging from
the window bars. The man’s wife and her family were upset by the
contradictory information. The man’s wife spoke to the prison’s family liaison
officer, the next morning. He explained that the man had listed only his sister
as next of kin. He apologised for the conflicting information they had been
given.
65. The prison has contributed towards the cost of the man’s funeral expenses as
required by the relevant Prison Service Order. The prisons family liaison officer
has continued to liaise with both sides of his family.
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CLINICAL REVIEW
66. A clinical review of the man’s treatment in custody was undertaken on behalf of
the Hammersmith and Fulham Primary Care Trust by a panel.
67. The panel concluded that:
a. The man received timely access to the substance misuse programme,
however it is evident that he was not compliant with the terms and
conditions he contractually signed.
b. Although he received medical treatment for his feelings of self harm,
the documentation of his physical and verbal actions do not provide an
adequate understanding of his mental status.
c. It is documented that the man was observed whilst on the substance
misuse programme, however there is no evidence that he was
proactively followed-up with guided questioning or counselling after his
verbalisation of self harm thoughts. This may have been useful
considering the man’s reported history of self harm attempts.
d. The man’s key worker describes him as a private and personal man.
From the evidence available it is not known whether specific
interventions could have been implemented to prevent his death.
e. Improvements in record keeping, the assessment of depression, and
the following-up of offenders with mental health history combined with
thoughts of self harm may help prevent this occurring in the future.
68. The panel made six recommendations:
69. Documentation Education to highlight the importance of documentation in line
with General Medical Council and Nursing and Midwifery Council UK
recommendations. This should include:
(cid:127) The recording of observations
(cid:127) Legibility of records
(cid:127) The development of a cover sheet designed to highlight key items of
medical history, treatment milestones, and information identified during the
course of treatment/remand.
70. Care planning Wormwood Scrubs uses the Central, North and West London
policy for care planning. Recommend an audit of local implementation of this
policy. Recommend training in care planning to ensure care is multidisciplinary
in nature and takes into account the medical history of the patient.
71. Assessment of depression Adoption of the PHQ9 (a nine question
questionnaire to help patients to grade their depression), or other nationally
recognised grading tool of depression.
72. Treatment for depression Depression to be managed in line with NICE
guidance. The National Institute for Health and Clinical Excellence (NICE) is
the independent organisation responsible for providing national guidance on
the promotion of good health and the prevention and treatment of ill health.
14
73. Patient information sheets (condition and medication specific) to be given to all
offenders treated for depression.
74. The development of a robust system designed to flag actions for follow-up by
members of the healthcare team. This should include:
(cid:127) A named clinician/key worker
(cid:127) A named person with responsibility for actions.
75. Clinical information system The adoption of a computerised clinical information
system may assist in implementing the above recommendations.
15
ISSUES CONSIDERED DURING THE INVESTIGATION
76. Whilst conducting this inquiry my investigator found it difficult to read the
majority of the medical record notes. I note that the clinical review panel
resorted to asking the Clinical Services Manager at the prison, to try and
interpret certain sections of it. It is imperative that the medical record be legible
for the patient to receive the correct care. The lack of legibility of prison
records, especially medical records, has been the subject of many
recommendations in my fatal investigation reports.
77. Healthcare staff should be reminded of the requirements of accurate and
contemporaneous record keeping in accordance with the required
standards of the General Medical Council and the Nursing and Midwifery
Council.
78. When the man was discovered hanging in his cell, the prisoner who was about
to be placed into the cell tried without success to untie the bed sheet ligature.
An officer arrived and untied the ligature from the window bars, but it was not
until another officer arrived with the cut-down scissors that it was removed from
around the man’s neck. I do not believe that the delay in removing the ligature
was significant in the man’s death. Nevertheless, I am pleased to report that
staff at Wormwood Scrubs are now personally issued with specialised cut-down
knives.
79. The man’s wife and mother-in-law found it very upsetting that they had not
been contacted when the man died. The man had listed his sister as his next
of kin when he arrived at Wormwood Scrubs. Although the man had sent his
wife a visiting order enabling her to visit him, that information was not readily
available to the officers making the arrangements to inform the man’s next of
kin.
80. The man’s sister rang his wife and told her of his death. His wife’s mother then
contacted the prison to find out more details. She was given incorrect
information about how and where the man had died, although she only
discovered the errors when she spoke with the man’s sister again. I am sure
that whoever it was who spoke to the man’s mother-in-law that night was
merely trying to be helpful, but procedures need to be in place to ensure that
only correct information is given out.
81. The Governor should ensure that all staff understand the correct lines of
communication for the families and friends of deceased or ill prisoners
and that information is only passed by those authorised to do so.
82. On 31 January 2007, the man told the prison doctor that he was having
occasional thoughts of self-harm. After further consultation he was prescribed
mirtazapine. An ACCT booklet was not opened. (ACCT stands for
Assessment, Care in Custody and Teamwork and is an assessment and care
planning system which aims to identify individual needs and offer personalised
care and support before, during and after crisis, in a safe and caring
16
environment.) It has not been recorded that the man spoke again about any
thoughts of self-harm.
83. Whether or not to open an ACCT is a judgement that has to be made by the
member of staff concerned. As previously mentioned, the prison doctor was
supplied to the Conibeere unit by an agency. Currently, agency staff are given
training in the use of prison keys and about security issues. As a general rule,
agency doctors are not ACCT trained at Wormwood Scrubs, although during
consultations a trained nurse is present.
84. There is insufficient information in the medical record for me to form a view as
to whether an ACCT should have been opened in this case, and the prison
doctor is not available for interview at the time of writing. Nevertheless, I
believe that information about ACCT and what to do if agency staff have
concerns that a prisoner will self-harm should also be included in their training.
85. The Governor should consider including information about ACCT within
the initial training package for agency staff.
86. In addition to my own recommendations, I commend those made by the Clinical
Review Panel.
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RECOMMENDATIONS
(cid:127) Healthcare staff should be reminded of the requirements of accurate and
contemporaneous record keeping in accordance with the required
standards of the General Medical Council and the Nursing and Midwifery
Council.
(cid:127) The Governor should ensure that all staff understand the correct lines of
communication for the families and friends of deceased or ill prisoners
and that information is only passed by those authorised to do so.
(cid:127) The Governor should consider including information about ACCT within
the initial training package for agency staff.
Recommendations from the Clinical Review
(cid:127) Documentation Education to highlight the importance of documentation
in line with General Medical Council and Nursing and Midwifery Council
UK recommendations. This should include:
i. The recording of observations
ii. Legibility of records
iii. The development of a cover sheet designed to highlight key items of
medical history, treatment milestones, and information identified during
the course of treatment/remand.
(cid:127) Care planning Wormwood Scrubs uses the Central, North and West
London policy for care planning. Recommend an audit of local
implementation of this policy. Recommend training in care planning to
ensure care is multidisciplinary in nature and takes into account the
medical history of the patient.
(cid:127) Assessment of depression Adoption of the PHQ9, or other nationally
recognised grading tool of depression.
(cid:127) Treatment for depression Depression to be managed in line with NICE
guidance. Patient information sheets (condition and medication
specific) to be given to all offenders treated for depression.
(cid:127) The development of a robust system designed to flag actions for follow-
up by members of the healthcare team. This should include:
i. A named clinician/key worker
ii.A named person with responsibility for actions.
(cid:127) Clinical information system The adoption of a computerised clinical
information system may assist in implementing the above
recommendations.
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