Individual at Wymott

Investigation into the circumstances surrounding the
death of a man at HMP Wymott
in September 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2010
This is the report of an investigation into the circumstances of the sudden death of a
man at HMP Wymott on 28 September 2008. He was found collapsed in his cell by
evening duty staff. Efforts were made to resuscitate him but were unsuccessful. A
post mortem found that his death was due to choking on a foreign object.
The man was not in contact with any of his family and had nominated a chaplain in
the community as his next of kin. My colleagues and I would like to extend our
condolences to all those affected by his death. I apologise for the delay in issuing
my report and additional distress this may have caused.
An investigator from my office led the investigation. An independent review of the
man’s medical care in prison was commissioned from the Central Lancashire
Primary Care Trust (PCT) and was carried out by the Head of Healthcare at HMP
Haverigg. I am most grateful for their assistance. I would also like to thank the
management and staff at HMP Wymott for their co-operation during the course of
this investigation and their patience with my delay.
The man was convicted and sentenced to four years imprisonment with a four year
extended element in 2002. He completed the custodial portion of his sentence in
May 2005, but was recalled to prison in June 2006 for breaching the terms of his
licence. During his time in prison, the man was under continual review by medical
and mental health staff having suffered from depression and the effects of sexual
abuse as a child. Later in his sentence, he began to harm himself by superficial
cutting and drug overdoses. His mental condition deteriorated throughout 2008.
I am satisfied that the man received equitable and responsive care throughout his
time at Wymott. His death was not preventable. However, I make six
recommendations. Three are addressed to the PCT about healthcare staffing,
medical record keeping and obtaining previous health records. A further two are
jointly addressed to the PCT and Governor regarding attendance by patients at
appointments and the availability of mental health assessments during weekends. I
also reiterate a recommendation I have made in previous investigations at other
prisons regarding the need for up to date information on prisoners’ next of kin.
I am pleased to record that all my recommendations have been accepted and with
the exception of one the necessary changes have already been implemented.
Jane Webb
Acting Prisons and Probation Ombudsman November 2010
2
CONTENTS
Summary 4
The investigation process 6
HMP Wymott 7
Key events 9
Issues considered during the investigation 29
Conclusion 37
Recommendations 38
3
SUMMARY
A male prisoner at HMP Wymott, died on the evening of 28 September 2008 in his
cell on G wing. He was serving a four year prison sentence and a four year
extended term imposed in 2002. He had been released from custody after serving
the custody portion of his sentence but was recalled to prison for breaching the
terms of his licence. He returned to prison on 30 June 2006 and transferred to HMP
Wymott on 11 August, where he remained until his death.
The man was generally physically fit, apart from a sports injury to his knee, for which
he took analgesics. He was later referred to the local hospital for an operation on his
knee which he refused preferring to wear a support and continue taking analgesics.
As his mental condition deteriorated, he became fixated about acquiring these drugs.
He also suffered from depression for which he was prescribed and held his own
medication. He had previously self-harmed by cutting himself but, at the time of his
recall, his mental condition was stable and he was not thought to be at risk of
harming himself.
Soon after the man’s arrival at Wymott, he was assessed by a visiting psychiatrist
who thought that his main issues were anxiety and depression brought about by
being sexually abused as a child. During the following months, the psychiatrist
altered the man’s medication as appropriate and referred him to a cognitive
behaviour therapist. Mental health staff continued to review the man regularly and
his medication was varied in response to his needs.
In early 2008, the man’s mental condition began to deteriorate. He reported bullying
by other prisoners, missed his mental health appointments and reported auditory
hallucinations that told him to assault staff which later, on a single occasion, he did.
He also started to harm himself and was subject to the Assessment, Care in Custody
and Teamwork (ACCT) process (The ACCT procedure provides additional
monitoring and personalised support for prisoners considered to be at risk of
harming themselves or suicide.) In mid-May, a voluntary referral was made for an
assessment of his mental condition at HMP Preston but he became anxious about
the move and it was postponed. His deterioration continued and in mid-July, staff
reactivated the voluntary referral and he transferred to Preston. On arrival, he
became anxious about returning to Wymott, becoming insistent that he no longer
wanted to remain at Preston. The man returned to Wymott eight days later.
The man’s condition continued to deteriorate and his medication was reviewed and
adjusted as necessary. The psychiatrist attributed his increased physical symptoms,
rigidity, grimacing and tremors, to the anti-psychotic drugs which he reduced over an
appropriate withdrawal period until they were stopped.
On Thursday 25 September, the man was unwell and anxious. He was referred, as
an urgent case, to a Primary Care Mental Health Team nurse who saw him the same
evening and referred him the following morning back to Preston for a medical and
mental assessment. Preston agreed to arrange the assessment the following
Monday. The man remained depressed, although his spirits lifted periodically,
throughout the weekend.
4
During the late afternoon of Sunday 28 September, the man missed his tea meal and
had not collected his breakfast pack for the following morning. A wing officer took
the pack to him in his cell. Nothing about his mood or wellbeing alerted her to any
change.
The man was found collapsed and unresponsive on his cell floor an hour and a half
later. Prison and healthcare staff, then subsequently ambulance service paramedics
attempted to resuscitate him. Sadly, they were unsuccessful and paramedics
confirmed his death just before 7.00pm. The prison contingency plan for a death in
custody was immediately implemented. Wymott experienced difficulty in contacting
the man’s named next of kin and police later undertook to inform him.
A post mortem examination took place at the local hospital on 30 September. The
pathologist found that the man had died from choking on a wrapped cereal biscuit,
which was part of his breakfast pack. The police were initially involved but took the
view that the man’s death was not suspicious.
As the man had no family to arrange the funeral the prison made the arrangements.
The Salvation Army Chaplain arranged and officiated at the man’s cremation, which
Wymott funded. Following the cremation, a memorial service was held in the Chapel
at Wymott which was attended by the man’s friends and some staff. His nominated
next of kin was present and, following the service, took away his ashes for burial in
his parish churchyard.
I make six recommendations. Five relate to clinical matters, including medical
records, staffing, attendance for appointments and the availability of mental health
assessments. A further recommendation relates to updating next of kin details.
A response, dated 1 November 2010, to my report was received from the National
Offender Management Service accepting all my recommendations. Necessary
actions have been taken by HMP Wymott and Central Lancashire Primary Care
Trust to implement the changes.
5
INVESTIGATION PROCESS
1. An investigator undertook the initial stages of the investigation but, owing to ill
health, was unable to continue. The investigator met representatives of the
Prison Officers’ Association and the Independent Monitoring Board at the
outset of his investigation.
2. Another investigator took over the investigation in October 2009 and visited
HMP Wymott on 17 November 2009. He met the Deputy Governor, and the
liaison officer, who gave him a full briefing about the circumstances
surrounding the man’s death. The investigator re-issued notices to staff and
prisoners inviting anyone who might have information relating to the man to
make themselves known to him.
3. No prisoners spoke to the investigator as a result of the re-issued notice but
one was interviewed informally. The investigator also met relevant prison
staff including members of the chaplaincy and medical departments and
others who knew the man. Wymott provided copies of the man’s prison
record. The police were involved briefly and took statements from relevant
staff but decided at an early stage that the circumstances surrounding the
man’s death were not suspicious.
4. The Chief Executive of the Central Lancashire Primary Care Trust
commissioned a clinical review that was carried out by a member of staff who
is a Registered General Nurse (RGN), a Registered Mental Nurse (RMN) and
the holder of a Diploma in Community Nursing (DCN) and is Head of
Healthcare at HMP Haverigg. The report of the review was received in
February 2009.
5. One of my family liaison officers spoke to the man’s nominated next of kin on
22 October 2008, to offer him the chance to raise any questions or concerns.
His only question was whether the man’s death was self-inflicted or due to
natural causes. The family liaison officer was unable to contact any of the
man’s family.
6
HMP WYMOTT
6. HMP Wymott is a purpose built prison near Leyland in Lancashire which
opened in 1979. It is a category C training prison holding convicted adult
male prisoners with facilities for vulnerable prisoners who are held in separate
accommodation. (On arrival into prison, prisoners are risk assessed and
given a category based on their offence and the risk that they pose to the
public should they escape. There are four levels of category: A, B, C and D,
with category A prisoners being the most dangerous. Category C is for
prisoners who cannot be trusted in open prison conditions but who would not
have the ability or resources to make a determined escape.) At the time of
the man’s death, Wymott held around 1,140 prisoners. There have been
eight deaths in custody at Wymott since April 2006, none of which appear to
be similar to the man’s death.
7. Since April 2004 healthcare at Wymott has been provided by the Central
Lancashire Primary Care Trust (PCT). Primary healthcare staff are employed
by Central Lancashire PCT. Mental healthcare staff are provided by the NHS
Foundation Trust (Lancashire Care) and are the secondary mental health care
provider for individuals with severe and enduring mental health problems.
Central Lancashire NHS PCT provides primary mental health care for
individuals with mild to moderate needs. The local mental health in-reach
team (MHIT) is based in Leyland and at the time of the man’s death was
staffed by two community psychiatric nurses both registered mental nurses
(RMN’s). Since his death, funding levels have risen and the team numbers
have increased to five. Wymott is not staffed or equipped to undertake mental
health assessments. HMP Preston has facilities to do so and is tasked by the
PCT to maintain designated regional mental health beds for that purpose by
prisons in the area.
8. Wymott prison provides Type 3 healthcare which maintains 24 hour nursing
support but has no in-patient facilities. There is a main healthcare centre with
treatment areas on the wings that are used for dispensing medication to
prisoners. Appointments for clinics are made at the healthcare centre.
9. A three-stage tackling anti-social behaviour (TAB) process to manage bullying
was introduced during 2008. It comprises observation at stage one, formal
warnings and monitoring at stage two and the use of sanctions, including
transfer out of the prison, at stage three.
10. HM Chief Inspector of Prisons (HMCIP) made an announced inspection of
Wymott during October 2008, shortly after the man’s death. The Inspectorate
made several comments in the report that are relevant to this investigation
commenting that, “There was a tackling anti-social behaviour (TAB) policy to
deal with bullying, but staff had not been trained in its use and its application
was poor.” and “No central log of investigations into allegations of bullying
was kept.” The Independent Monitoring Board (IMB) for 2008 – 2009 echoes
the Inspectorate concerns about the TAB process.
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11. The Inspectorate’s report also identified that:
“The mental health in-reach team were able to access the past history of local
patients through the mental health trust electronic records; if patients were
from other areas, records often had to be started from scratch.”
12. The IMB also comments on mental health issues relevant to the man’s case:
• “The Board welcomes the increase in and re-organisation of the
Primary Care Mental Health Care team. However, there remains the
accepted fact that prisoners with mental health problems should not be
held in this type of prison”
“Although the Board considers that discipline staff cope well with prisoners
who have a mental health disorder, their training should include content
that would help them deal better with the ensuing behavioural problems.”
• “The Board suspects that some prisoners resort to the ACCT system in
order to resolve problems that could be resolved in other ways. ACCT
documents do not always follow prisoners to workshops or education, so
that not all officers or instructors are aware of the prisoners’ state of mind.
Additionally the Board considers that observational and conversational
entries in ACCT documents are not always meaningful.”
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KEY EVENTS
13. The man was released from HMP Whatton on licence on 10 May 2005.
Before his discharge, a consultant forensic psychiatrist completed a
psychiatric assessment report, dated 5 May 2005. She concluded that there
was no indication that he suffered from any mental illness and was
unconvinced that he suffered from Asperger’s syndrome. She considered that
the man had borderline learning difficulties. The consultant forensic
psychiatrist referred to a previous clinical psychology report from 2002 by a
consultant clinical psychologist, who concluded that “he has social and
communications difficulties”. The consultant forensic psychiatrist
recommended that there were no clear grounds for referral to mental health
services and hoped that the conditions in his extended licence would provide
a protective structure and a context for ongoing relapse prevention work.
14. The man was recalled to prison at HMP Altcourse on 30 June 2006, because
he had not complied with the terms of his licence. He asked for vulnerable
prisoner status which was granted and he was accommodated in the prison
healthcare department until 3 July, where he also underwent alcohol
detoxification treatment.
15. During his initial healthcare assessments, the man was recorded as having an
old sporting injury to his right knee for which he received analgesics (pain
relievers). He had also been diagnosed with depression for which he was
prescribed citalopram and chlordiazepoxide (antidepressants). He said that
he had been in contact with a community psychiatric nurse (CPN) and had
previously self-harmed by cutting himself but said that he was alright. His
mental condition was noted as normal. A warning, dated 20 July, from the
public protection meeting noted that female staff coming into contact with the
man should be cautious. He remained at Altcourse until 11 August, when he
transferred to HMP Wymott.
16. On arrival at Wymott, the man had a further healthcare reception screening
where he confirmed that he had a history of drug and alcohol abuse and
suffered from depression. His medication was pain relief for his knee injury
and citalopram once daily which the man held in his own possession. He was
fit for most work and the gymnasium but was excluded from work in some
workshops and noisy environments. He was allocated to B wing,
accommodation for vulnerable prisoners, where he could associate freely with
other prisoners on the wing.
17. During the man’s initial mental health screening he said that he was in touch
with an MHIT and that he suffered from autism, Asperger’s Syndrome and
obsessive compulsive disorder (OCD). The man also said that he had
harmed himself in the past and that he was subject to a F2052SH (a
document formerly used to monitor prisoners who were at risk of self-harm –
now superseded by the Assessment, Care in Custody and Teamwork (ACCT)
procedure which assesses, observes and supports prisoners who are
considered at risk of harming themselves). Documentary evidence confirms
9
that these procedures were closed prior to his release from HMP Whatton in
November 2004.
18. The man had no other significant healthcare issues and he signed Wymott’s
medication policy. He was referred to the MHIT and saw one of their
registered mental nurses (RMN) on 16 August. After that meeting, he referred
the man to the visiting psychiatrist, resolved to “liaise with outside agencies
for more background” and added him to the MHIT caseload.
19. The man was assessed on 31 August by the doctor at Wymott about the pain
in his right knee. He was referred for x-ray examination at a local hospital and
received an appointment for 29 September. After examination, an operation
was planned and a further appointment made for 12 December. The man
wrote to the doctor on 25 October, declining the operation and electing
instead to continue wearing a knee support and take pain relieving
medication. He completed a refusal of treatment disclaimer and cancelled all
subsequent appointments at the hospital regarding his knee. His decision
was passed to the hospital on 1 November. He was advised to lose weight
and treatment for the injury was regularly reviewed.
20. Having complained of restlessness, low mood and panic attacks, the man was
seen on 25 September by a psychiatrist. The psychiatrist thought that the
man’s main issues were anxiety and depressive symptoms brought about by
his alleged history of being sexually abused, the associated auditory
hallucinations (hearing imagined voices which the man called “flashbacks”)
and drug and alcohol problems. The psychiatrist concluded that, due to the
man’s worsening anxiety and depressive symptoms, his antidepressant
medication was no longer appropriate and should be altered to an increasing
dose of trazodone (an antidepressant). The psychiatrist arranged to see the
man again in four weeks and noted that he had no thoughts of harming
himself.
21. The man’s knee remained painful and he continued to receive analgesic
treatment. During October and November, he refused to attend several
medical appointments and his general behaviour deteriorated. He also made
several complaints about his mail and pain relief medication which were dealt
with under the Prison Service formal complaint procedure.
22. Another psychiatrist reviewed the man on 26 October and found that the
change to trazodone had not taken place. He wrote asking that the
medication be changed in line with the request made by the psychiatrist in
September and this was altered gradually over the following month. The
other psychiatrist conducted a further review on 23 November, after the
medication change and found that the man’s mental state was improving and
he had no thoughts of self-harm. He said that trazodone was helping him to
sleep and to lift his mood but reported that he occasionally became irritable.
The doctor recommended that the dose should be increased, which was done
immediately, and a further review was set for three months time.
10
23. An RMN from the local MHIT reviewed the man on B wing on 15 January
2007. The man said that the trazodone was not helping him, he still suffered
significant mood swings during the daytime and considered that he needed
further medication. The member of staff discussed the matter with the second
psychiatrist who raised the trazodone dose gradually over the following three
months. The man was also referred for cognitive behavioural therapy.
24. When the psychiatrist saw the man on 2 March, he said he was anxious, on
edge and under stress, which was related to his recall review. The doctor
concluded that the man was undergoing moderate depression and again
increased his dose of trazodone. He also noted that he had no thoughts of
harming himself or others and that he was exhibiting no psychotic symptoms.
The man saw the second psychiatrist again on 18 May and told him that his
mental state was improving although he experienced flashbacks from his past
abuse. The psychiatrist noted that the man was looking forward to being
released from prison. He made a further appointment to see the man in three
months.
25. During the first half of 2007, the man suffered a range of minor dental and
medical complaints for which he received treatment. He also complained
about his medication, treatment and food all of which were resolved using the
formal complaint procedure.
26. On 15 June a nurse examined the man in his cell. He said that he had
vomited a small amount of blood two days earlier and had slight abdominal
pain. Apart from tenderness in his abdomen the results were normal. He was
given lansoprazole to decrease the production of stomach acid and a note
made that if the bleeding recurred he would be taken to hospital. On 29 June,
the man had a blood test including a full blood count, urea and electrolyte
levels, thyroid and liver function tests. The results of the tests were recorded
in his medical record although there is no interpretation of these results.
27. The man lost his job in the prison kitchen on 8 August, after a month’s trial, as
he struggled to cope with the day to day tasks in the washing up area. On the
following day, 9 August, the man’s trazodone dose was altered from 150mg
twice daily to 300mg at night.
28. Having collapsed in the healthcare waiting room, the man was taken by
ambulance to outside hospital on 5 September. The prison doctor wrote in
the referral letter that he thought that the man’s collapse was a vaso-vagal
event (fainting as a result of a drop in the heart rate). The man had told him
that he had epigastric pain (pain in the upper central region of the abdomen)
for a few weeks. Exploratory tests were carried out and he remained in
hospital for seven days. His discharge notes confirm that his stomach and
duodenum (the first part of the small intestine) were normal.
29. On 22 September, the man complained about the reduction in the pain relief
medication for his knee and the prison doctor referred him to a local hospital.
He was strongly advised of the medical need to reduce his weight and agreed
to reduce his co-codamol (pain relief) use to seven tablets per day.
11
30. The man had a review with a different psychiatrist on 8 October. He told the
doctor that he had flashbacks and nightmares over the past two years which
had increased from twice weekly to four times weekly and were related to the
sexual abuse he had suffered. The psychiatrist discussed the possibility of
taking an antipsychotic drug, olanzapine, and planned to see him in one
month. The psychiatrist discussed the case with a consultant psychiatrist.
They concluded that the man did not meet the criteria set out in the
International Criteria for Disease 10th revision (ICD-10) for diagnosis of post
traumatic stress disorder (PTSD) but that his problems were related to the
sexual abuse he had endured. The outcome was to prescribe olanzapine
(5mg) once daily when the psychiatrist saw him next and the MHIT would
monitor the man fortnightly.
31. The man asked for a meeting with the MHIT RMN that saw him on the 16 of
August, this took place on 12 October. He told the MHIT RMN he was
reluctant to wait until his next appointment with the psychiatrist to be
prescribed olanzapine. The MHIT RMN agreed to speak to the doctor about
bringing this forward and the medication was dispensed to the man on 16
October. The man also started counselling sessions on 21 November which
he regularly attended until the course was completed on 12 March.
32. On 25 October, the man had considerable pain in his right knee. The prison
doctor referred him to the orthopaedic department at a local hospital and
increased his pain relief medication. As the doctor considered the man’s
increasing weight was the main aggravating factor, she also referred him to
the prison physical education department for remedial exercise. His co-
codamol prescription was increased and an anti-inflammatory drug
(diclofenac) was also prescribed.
33. Throughout November, the man lodged a series of seven complaints about a
reduction in his pain relief medication, his requested increase in the
olanzapine prescription, his dental aftercare and about a warning he had
received from a nurse about trying to collect his medication early. Enquiries
were made of the appropriate doctors and timely replies sent to him. He was
also referred to MHIT because he wrote in one complaint that, if his
olanzapine was not increased, he could become violent. The psychiatrist he
last saw was contacted immediately but refused an increase in the medication
until he reviewed the man on his next visit. An unsigned note written on the
in-possession page of the drug administration chart covering this period reads
“Please do not alter psychotropic medication”.
34. The prison doctor, saw the man in his cell on 23 November about an infected
toe. While she was there she asked the man why he quite happily sat in
consultations with her and then returned to his cell to write extensive letters of
complaint. He told her that he had no problems today. The man made a
formal complaint on 1 December about the possibility that he would be
released before his sentence expiry date, as he wished to remain in prison
until then. The senior probation officer responded to the complaint explaining
the process adopted by the Parole Board and possible outcomes.
12
35. The psychiatrist he had last seen reviewed the man on 7 December and
increased his olanzapine to 10mg nightly. He also prescribed sertraline 50mg
(an antidepressant) to be taken every morning. During the review, the
psychiatrist noted that the man’s trazodone medication had been stopped
suddenly at the beginning of November. No reason for the cessation is
evident and the psychiatrist wrote to a doctor at the Lancashire Care NHS
Trust about the abrupt termination. The psychiatrist recorded that the man felt
his future was bleak and he preferred not to think about his release although
on some days he felt excited and wanted to be out of prison. The doctor set
the next review for one month’s time.
36. A doctor at a local hospital examined the man’s knee on 12 December and
he underwent an MRI (magnetic resonance imaging) scan and x-rays. The
man wrote a letter to the healthcare manager at Wymott on 18 December
requesting that all further escorted hospital appointments be cancelled
because he found them degrading and uncomfortable. He wrote a further
letter to the manager about the orthopaedic consultant’s view that he had
severe arthritis in his right knee and there was not much that could be done
about it. He cited this as the reason for cancelling any further appointments at
either Chorley or Preston hospitals.
37. The man was reviewed by the psychiatrist on 4 January 2008, when he told
the doctor that his auditory hallucinations had lessened slightly but that he
was edgy, sometimes verbally aggressive and less motivated. He said the
sertraline had produced side effects affecting his stomach and bowel, and so
the prescription was discontinued. They discussed the doctor’s intention to
prescribe Zispin (an antidepressant) to help him sleep and stimulate his
appetite. He warned the man about the common side effects he might
experience. His intention was also to increase the man’s olanzapine but he
was unable to do so immediately because the prescription card was still with
the pharmacy on B wing. They discussed the change and, with the man’s
agreement, decided to make the alterations on his next visit. The man made
a formal complaint the following day about the lack of the prescription card.
He received an appropriate response on 7 January from a nurse.
38. The man wrote to the MHIT RMN on 6 January, complaining that he had not
yet received the Zispin. He asked him to find out why and visit him to let him
know the outcome. The MHIT RMN contacted the psychiatrist who agreed
that the prison doctor could prescribe the medication in his stead. The MHIT
RMN wrote to the prison doctor on 7 January requesting the alterations. A
handwritten note on that letter reads “done 10.1.2008” which is initialled but is
illegible. No supporting note on the prescription chart or in the medical record
documents this change. The man submitted a further formal complaint about
not receiving Zispin on 11 January and refused to be seen by the prison
doctor that afternoon. The response to the man’s formal complaint dated 15
January, from a nurse, includes a reference to a prescription sheet. The
sheet identifies that he received four 15mg tablets on 10 January which were
to last until 13 January when a week’s supply could be given to him. No
record of the prescription is available.
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39. The MHIT RMN saw the man again on 23 January at his request. The man
was feeling under pressure because his new probation officer wanted him to
complete a sex offender treatment programme (SOTP). He also said that he
felt no benefit from the Zispin he had been taking and requested that the dose
be increased. The MHIT RMN said he would speak to either the prison doctor
or the visiting psychiatrist on his next visit to Wymott.
40. The man’s request for paracetamol for a cold on 1 March was refused as he
was already receiving co-codamol and had been issued with 16 paracetamol
tablets on 24 January. The nurse advised the man about the dangers of
paracetamol overuse. She also completed an incident form in respect of his
attempt to obtain the drug. During the following weeks the man declined to
attend dental appointments for continued treatment. He also refused to move
cells when required and was dealt with under prison disciplinary rules.
41. Due to a shortage of time, the man was not seen by the psychiatrist on 15
February and a further appointment was made for one month’s time. He was
reviewed on 14 March and the doctor noted in his report that the man looked
distressed and lost. The man told the doctor that he had begun to hear voices
again telling him to hit “figures of authority”. He mentioned that he now
quarrelled with other prisoners when they bullied him. He also told the doctor
that since his last review he had taken five overdoses of ibuprofen and co-
codamol (28 tablets on each of two occasions) and with co-proximol
(unspecified quantities on the other three occasions) which he had obtained
from other prisoners. According to the man, his intention on two occasions
was to sleep and to kill himself on the other three. None of these incidents
came to the attention of prison staff. He denied, during the review, any
existing ideas, intent or plans to harm himself. The man’s next review date
was set for one month later and the MHIT was to see him in seven days. His
olanzapine prescription was raised to 20mg and his Zispin increased to 15mg
both to be taken nightly. Both were to be administered by the nurses rather
than held in his possession because of his reported overdoses. His co-
codamol prescription was similarly put on a “not in possession” basis except
for one tablet each day to be taken at lunchtime.
42. In the first few days of April, the man’s personal officer, reported that he
seemed withdrawn. He was not mixing during wing association and was quiet
towards staff. When he was approached about the change in mood he told
the officer that he thought it was due to his medication and no other issues
were apparent.
43. An entry on the man’s wing history sheet dated 16 April alerted night staff that
he had spoken of harming himself. When interviewed, he said that the
comment had been made in a “mad moment” and he did not mean it. He
reaffirmed this a week later when spoken to about starting a SOTP course
which he said he was looking forward to. On 18 April, the man declined to
see the psychiatrist and was rescheduled for the psychiatrist’s next visit.
44. A security information report was submitted on 23 April, detailing suspicion by
wing staff that the man was being bullied for his medication. As a result, a
14
Tackling Antisocial Behaviour (TAB) document was opened in relation to the
man and the man suspected of bullying him. The man also made a formal
complaint to the healthcare manager about the reduction of his co-codamol
prescription by the prison doctor.
45. The MHIT RMN saw the man in B wing on 2 May following concerns
expressed by healthcare staff about how he was functioning and the
deterioration in his mental health. The man denied any mental health
concerns and showed no overt symptoms, although the MHIT RMN thought
that he was experiencing auditory hallucinations. He described the man’s
mood as flat and his movements rigid. The MHIT RMN requested a physical
examination, which was performed in a series of appointments over the
following week. The man did not complete his final appointment on 7 May,
returning to his wing from healthcare before the scheduled blood pressure
and electro cardiogram (ECG) tests were performed.
46. The man was told on 6 May by a senior psychologist, that he would no longer
start the SOTP because of concerns about his physical and mental health.
He replied that he was fine.
47. The psychiatrist and the MHIT RMN reviewed the man in B wing on 9 May.
He had refused to see them in healthcare due to feelings of paranoia while in
the waiting room. He looked unwell, said he felt low and continued to
experience auditory hallucinations. A plan was formulated, dependant on the
outcome of a re-scheduled ECG, to modify his medication by either increasing
mirtazapine (an antidepressant) or replacing it with trazodone. Finally, a
referral was completed for the man to be transferred to the healthcare centre
at HMP Preston for a period of assessment. The referral was faxed to
Preston that day.
48. The MHIT RMN saw the man again on 23 May in B wing where he asked
about the proposed medication change. The MHIT RMN explained that the
change would not happen until the ECG had taken place and gained
agreement from the man that he would attend healthcare for it. The man
raised the subject of his transfer to Preston saying that, because he thought
that he would not return to his cell on B wing at Wymott, he did not want to go.
The MHIT RMN considered that the man was unlikely to engage with the
assessment process. He contacted Preston with a request to put the transfer
on hold and planned to discuss the matter with the psychiatrist, re-list the man
for the ECG at Wymott and consider referring him back again to Preston if
there was any further deterioration in his condition. The man refused to
attend healthcare for the ECG on 29 May, which was re-listed for 5 June.
49. The psychiatrist again reviewed the man on B wing on 30 May. He noted that
because the man had missed the previous three appointments, it was
necessary to see him on the wing. This was not an ideal situation as the
appointments were restricted to ten minutes which was insufficient to
complete a review. The psychiatrist recorded that the man appeared unwell
and had a vacant expression. He requested further blood tests and, if the
results were normal, to increase the man’s mirtazapine from 15 mg to 30 mg
15
and then to 45mg two days later. He also emphasised that the man was not
to have any medication in his possession and noted that the MHIT RMN
would review the man after the medication changes had taken place. If he
was no better, a transfer to Preston should be organised.
50. The man’s ECG took place on 5 June and test results were within normal
limits so his mirtazapine was adjusted on 9 June in line with the psychiatrist’s
instruction. The man did not attend the subsequent review of his case on 20
June. His personal officer observed that because the man was now being
supervised by healthcare staff and he was receiving the proper level of
medication, his behaviour had improved. He was in better spirits but confined
his personal interactions to one other prisoner.
51. Prisoners on B wing reported to staff that the man had become incontinent on
several occasions. A nurse spoke to the man who thought it was caused by
his olanzapine prescription. She referred him to the prison doctor and the
MHIT team. Due to the man’s condition, on 25 June he was placed on the
waiting list for I wing, a small unit specifically for elderly and disabled
prisoners.
52. Following an argument with another prisoner on the morning of 30 June, the
man made several superficial scratches on his left forearm. Healthcare staff
attended to him and immediately placed him on the ACCT procedure An
ACCT assessor and member of the Wymott chaplaincy, interviewed him
noting that he had no intention of killing himself and was very anxious that he
move cell and receive his medication. A comprehensive care plan was written
part of which involved the man being moved to a cell on another spur. The
man remained on the ACCT procedure until his death.
53. The MHIT RMN met the man on B wing on 3 July and discussed the proposed
increase in his mirtazapine prescription. The man agreed with the increase to
45mg but said that if that did not work he wished to go back to trazodone.
The MHIT RMN agreed to discuss this with the psychiatrist. The following day
the man was reported by workshop staff to be asking other prisoners for
paracetamol. He denied this, but said that he had toothache. He reported
“special sick” (a procedure available to prisoners to see medical staff at short
notice without the normal application process) on four occasions between 28
June and 6 July and on each occasion was given analgesics.
54. The man spoke to a Listener (a prisoner trained by the Samaritans to provide
confidential emotional support to other prisoners in distress) on Saturday 5
July, who referred him to mental health services. An officer also spoke to the
man that day who told him that he had experienced a flashback during the
previous night and, as a result, had wanted to cut himself. The officer relayed
the information to healthcare staff who said they would tell mental health staff
on Monday.
55. On Sunday 6 July, a nurse gave the man two paracetamol tablets because he
had refused co-codamol. He also asked for some to take away which she
refused. Another nurse, later that same day, was called to B wing where the
16
man said he had taken eight paracetamol tablets for toothache. The nurse
told him that he would be given no more paracetamol that day and made him
aware of the dangers of taking more than the permitted dose of the drug.
56. Some ten minutes later, staff saw the man collecting paracetamol tablets from
other prisoners and told them he intended to kill himself. The nurse was
recalled to the wing immediately where the man told her that he had taken ten
more paracetamol and said that he was determined to take his own life. The
man was taken to a local hospital at about 12.30pm and told escorting staff
that he was being bullied on the wing. Later the same afternoon, medical staff
at the Accident and Emergency (A&E) unit discharged the man back to
Wymott as no treatment was required. On his return, he was transferred from
B wing to a single cell on G wing.
57. The man saw the MHIT RMN on G wing after his first ACCT review on 8 July
and told him that he felt much better since his move. He felt safer and had no
thoughts of harming himself. He said that the overdose was as a result of
bullying on B wing, which he was then reluctant to discuss, and a re-
emergence of his flashbacks which distressed him. The MHIT RMN broached
the subject of reactivating the referral for a mental health assessment at HMP
Preston. To his surprise, the man agreed and the MHIT RMN said he would
see him again later in the week.
58. A Senior Officer (SO), and G wing manager, said that it was apparent that the
man’s mental state was deteriorating. The SO said that his “speech wasn’t
right” and for want of a better description, he held his hands in front of himself
“like a begging dog” and grimaced. He reported these changes to healthcare
staff before the man’s voluntary transfer to the mental health ward at HMP
Preston. His opinion, in common with other staff who dealt with the man, was
that he should not have been in Wymott because of his mental condition.
59. The man spoke to a Listener early on the evening of 10 July about his
anxieties. Later he was happier and mixing with other prisoners on G wing.
However he told G wing staff at 10.30am on 11 July that he had taken ten
paracetamol at about 8.00pm the previous evening and a further two that
morning. A nurse contacted the poisons unit at St. Thomas’ Hospital, London
who advised that if the man weighed over 80kg his body should be able to
cope with the paracetamol levels indicated. The man was 87.5kg and so no
medical intervention was necessary. The nurse contacted the MHIT RMN
who saw the man later that day and noted that he gave recurring flashbacks
as the reason for taking an overdose. The MHIT RMN planned to see the
man again on 14 July and requested a review by the psychiatrist after his
return from annual leave.
60. Preston mental healthcare staff visited and saw the man on 15 July and
agreed to accept him for a period of assessment the following day. The man
then attended an ACCT review. It was agreed between him and mental
health staff, (including those from Preston) that the ACCT process should
remain in place and be reviewed on his reception at Preston. During the
17
meeting, the man said that he was concerned that he would “do something
stupid” if the ACCT process ceased.
61. The man was received into healthcare at HMP Preston during the late
morning of 16 July where his medication was continued as prescribed at
Wymott. At 1.55pm he spoke to a registered mental nurse and expressed
thoughts of harming himself because he was anxious about whether or when
he could return to Wymott. He had an ACCT review at 4.45pm and told the
staff that he had current thoughts of harming himself. The ACCT process
remained open. He was observed hourly throughout the day and night and
was reported to be more settled during that evening.
62. Over the following few days, the man settled down although he repeatedly
asked when he would return to Wymott. He periodically said that he was
experiencing thoughts of harming himself and was depressed. The man had
a further ACCT review on 21 July. He became more persistent about his
return to Wymott and reported that he was being bullied by other prisoners.
He became adamant that he no longer wanted a psychiatric assessment or to
remain at Preston and signed a disclaimer to that effect. Arrangements were
made with the MHIT and Wymott for him to return on 24 July.
63. On 23 July, the man was in good spirits and went to an appointment at a local
hospital about his two episodes of fainting earlier in the year. On his return to
Wymott on 24 July, no change in the man’s health was recorded and he was
considered to be physically fit. He underwent his sixth ACCT case review that
evening. He was in good spirits, although he regretted not being able to
complete his assessment at Preston where he said he felt threatened and
intimidated by other prisoners. A further ACCT review was scheduled for 28
July. The man was subsequently observed half hourly throughout the night.
64. In the late morning of 26 July, a prisoner told an officer that the man was
trying to obtain paracetamol from other prisoners. He spoke to the man then
searched him and his cell but found no medicines. He spoke to him again at
about 5.00pm. The man was very subdued and anxious that he may be
moved from G wing although no such move was planned.
65. At 11.05am on the morning of 27 July, the man asked a member of staff for a
sticking plaster. He said that he had caught his arm on his door bolt but
emphasised that it had not been a deliberate act. At 2.30pm, he made the
same request but this time he had made superficial cuts on his wrists with a
razor blade which he said he had inflicted because of flashbacks. Healthcare
staff treated him and, later that afternoon, the G wing SO, his ACCT case
manager, and an officer reviewed his case. The man appeared to have no
other coping mechanism other than cutting himself. The officer demonstrated
an alternative strategy which would not cause any injury. The man spoke to
the officer who had searched him the previous day again at around 4.45pm
and was again anxious about moving from G wing.
66. On Monday 28 July, the man was upbeat. He told staff that, although he felt
depressed, he was coping and was looking forward to attending work as a
18
cleaner in the tailors’ shop that afternoon. However he later changed his mind
telling staff that he did not like one of the prisoners working there and asked to
be moved to the laundry. By 11.30am on 29 July, the man was asking staff
“every five minutes” to be allowed to work in the laundry but, because of his
mental state, his request was refused. The man was moved into a Listener’s
cell over the lunch period. He attended work in the afternoon and later told
the G wing SO that he was being called names and wanted the prisoner
involved removed from the tailors’ shop. The SO told him that he would open
a TAB document so that the situation was monitored.
67. That afternoon, the MHIT RMN reviewed the man who was in a persistent low
mood. He felt that his current antidepressant was not helping him and wanted
a change back to trazodone. He also described experiencing intrusive
thoughts telling him to attack officers and staff which had led to him “pushing
past” one of the female instructors.
68. The MHIT RMN confirmed that the incident had taken place and wrote that
wing staff should be made aware that the man was feeling violent. He
recommended that the man see the psychiatrist as soon as possible and be
designated unfit for work due to his mental state. He went to work on the
morning of 31 July and was later charged with an offence under Prison Rules
for assault on the member of staff. The man told a member of staff that it was
the only way he could get out of the workshop and said that he was being
bullied. At an ACCT review at 2.30pm that day, he told the staff, which
included a member of the MHIT, that he had “seen red” and the instructor
reminded him of his childhood abuser.
69. The man asked to see a Listener at 6.10am on 1 August but spoke to the
night officer instead, telling him he was anxious that he would lose his
privileges as a result of the assault on a staff member. He returned to bed
and was asleep again by 7.00am. The man was taken to the Care and
Separation Unit (CSU) at 8.45am for a disciplinary hearing. The duty nurse
noted that he was fit for the adjudication but was not fit for cellular
confinement (a possible punishment if found guilty). The case was adjourned
and referred to the Wymott police liaison officer who considered that there
was not enough evidence to take police action for indecent assault. He later
warned the man about his behaviour.
70. Following the outcome of the adjudication and his return to G wing, the man
made superficial cuts to his wrists with a razor blade. He was seen as an
emergency by the nurse and the wounds were dressed. At about 4.00pm, he
took part in an ACCT review. The MHIT RMN, who was at the review, said he
would discuss the alteration of the man’s medication with the psychiatrist.
71. A nurse was called by wing staff to see the man at 6.15pm on 3 August. He
complained of vomiting and had a rash round his eyes, nose, ears and
forehead but was otherwise well. The nurse advised him that, if the rash got
worse or spread, he should report it to staff immediately. The nurse returned
at 7.30pm and noted that the rash had reduced but was still on his face. The
prison doctor examined the man the following day and reviewed his pain relief
19
medication. The man’s co-codamol prescription was stopped and he was
given Piriton (an anti-histamine) and Gaviscon (for heartburn and indigestion)
to alleviate his symptoms. A note was made that, should the man vomit
again, he should be referred to the A&E department at the local hospital.
72. During 4, 5 and on the morning of 6 August, the man asked to speak to
Listeners. He stayed in a Listeners’ cell with two Listeners over lunchtime on
6 August. The MHIT RMN reviewed the man again that afternoon after which
he contacted the psychiatrist who agreed to increase his mirtazapine
prescription. The MHIT RMN wrote to the prison doctor requesting the
change. He also planned to speak to the counsellor who saw the man earlier
in the year to establish whether he was suitable for a further period of support
from her.
73. The Salvation Army chaplain at Wymott spent some time with the man in the
chapel during the morning of 7 August and commented that he appeared
relaxed and comfortable. However, later in the morning the man complained
about another prisoner calling him names. Later the same day, he was
wandering about the wing “acting strangely” and asking to see a Listener.
However, when the Listeners arrived, he ignored him. Over the following few
days the man made further requests to see Listeners. He also became
agitated on a number of occasions because healthcare staff were late arriving
on G wing to issue medication. His mood fluctuated between high spirits and
telling jokes to staff and being agitated or in a low mood. During his next
ACCT review on 11 August, he said he was still anxious about the outcome of
his adjudication and that he had asked for a transfer to HMP Usk.
74. The MHIT RMN spoke to the man at around 12.30pm and again at 4.00pm on
14 August. The man complained at the later meeting that the provision of his
mirtazapine at 45mg was erratic, as he often only received 30mg. The
relevant Prescription and Administration Chart indicates that the man received
30mg until 11 August after which the dosage was increased to 45mg. Despite
the increased prescription the man felt no better and the MHIT RMN noted
that he was due to see the psychiatrist in about two weeks.
75. Wing staff noted that during the next few days the man was wandering around
the wing and often seemed anxious until he received his medication. He also
spoke to Listeners on 19, 20 and 21 August. Throughout this period he was
observed to have restful nights and mixed well with his peers on the wing. On
Sunday 24 August, he was recorded by the officer, who had offered advice
about coping strategies, as spending most of the afternoon waiting near the
wing treatment room for his medication. The same officer noted the following
morning that the man was again outside the treatment room waiting for his
medication. The man made the effort to speak to the officer and tell some
jokes and said that he had followed the advice about coping strategies instead
of cutting himself. Another officer later also recorded that the man was often
waiting outside the treatment room.
76. The man was now working in the commercial engineering workshop full-time
and it was recorded on 26 August that he was happy there. During an ACCT
20
review, he said he had no issues with his medication and no problems on G
wing. He did however say that over the past week he had thoughts of
harming himself but re-iterated that he had overcome them and spoken to
Listeners. A decision to extend the ACCT process for a further seven days
was made and the next review was scheduled for 1 September. He remained
in good spirits for the next few days.
77. An officer, a Counselling, Assessment, Referral, Advice and Throughcare
service (CARATs) worker, spoke to the man on 28 August. The man told him
that he was having flashbacks and was not feeling well but was not worried
about harming himself. (CARATs is a scheme for prisoners with substance
misuse problems that gives advice and support, runs programmes and refers
them to other services.) The man asked the officer if CARATs staff could see
him on a monthly basis. He noted that the man was more mobile and lucid
than he had appeared lately.
78. The following day, the psychiatrist and the MHIT RMN reviewed the man. He
appeared to have deteriorated and they noted that he grimaced involuntarily.
He initially agreed to a change in his antidepressant medication but, as the
meeting concluded, changed his mind and said he wanted to remain on his
current prescription. The MHIT RMN undertook to monitor the man’s
response to his medication and to see him weekly if possible. The
psychiatrist planned to see him again in four weeks, when he would conduct a
neurological examination.
79. At 8.45am on 30 August, the man pressed his cell call bell and told wing staff
that he had cut his wrist with a razor blade in response to a flashback. He
also told staff that he had flushed the blade down the lavatory. On searching
his cell officers found a bloodied razor blade hidden in a cupboard.
Healthcare staff cleaned and dressed the wound. An ACCT review was
convened that afternoon where the man apologised for his actions. Staff
again advised him about coping strategies. He remained settled for the
remainder of that day but seemed periodically anxious about his medication
the following day.
80. When he returned to work on Monday 1 September, the man’s mood was
stable and he remained settled until 9.30am on 3 September, when a member
of the workshop staff saw him scratching at his arm with a small clip. He was
taken to the healthcare centre but no treatment was required. Later that day,
the man attended an ACCT review where he explained that he had attempted
to harm himself because he was experiencing flashbacks. He apologised for
causing any trouble. The tone of this review was more robust than usual in
that the MHIT RMN told him that he must take responsibility for his actions, for
using his coping mechanisms and listening to advice. The man agreed that
he would try and the MHIT RMN referred him for further counselling regarding
his alleged childhood abuse. The workshop staff also agreed to allow the
man back to work on a last chance basis.
81. On 4 September, the man saw the Salvation Army chaplain, as part of a
regular interaction. The chaplain said that they discussed some of his
21
problems and the man was anxious to see him again the following Thursday.
The man remained calm and in a positive mood for several days, although
anxiety about when or whether he would get his medication was always
present.
82. During the man’s ACCT review on 10 September, the staff present, including
the MHIT RMN, agreed that there was no justification for the suicide and self-
harm monitoring process to continue. The man became very concerned and
said he would feel better if it were left in place. After a lengthy discussion, a
compromise was reached to keep the process open until 16 September.
Another prisoner reported to workshop staff on 11 September that the man
tried to obtain the other man’s prescription medication. He denied the
accusation.
83. The man was given two paracetamol on 12 September after reporting “special
sick” complaining of a headache. On the same day, while waiting to see the
psychiatrist in the healthcare centre, the man claimed that other prisoners
were bullying him over the assault on a female staff member. Healthcare staff
recognised this was his strategy to get staff to send him back to G wing before
seeing the psychiatrist and moved him to another waiting room. On
examination, he was found to have rigidity in his upper extremities, tremors
and was grimacing. The doctor felt the symptoms could be related to the
olanzapine prescription and instructed that the dosage be reduced gradually
and be stopped after six days. The reduction started on 16 September and
ceased on 21 September.
84. On 16 September, the man was allowed to stay with a Listener in his cell over
the lunch period. An ACCT case review was conducted at 3.00pm where the
subject of closing the process was discussed. The man did not initially agree
but when it was explained that there would be no decrease in support for him
he agreed and a post closure review was scheduled for a week later. On the
following morning, he became very anxious because he was not required for
work. An ACCT case review was convened at 9.30am and monitoring under
the process was reactivated, although the man assured the meeting that he
had no intention of harming himself. The Salvation Army chaplain saw him on
18 September and thought he was relaxed and on a more even keel and they
discussed the possibility of him starting an art course. The man later reported
“special sick” with a headache and was given two paracetamol tablets.
85. At about 8.00am on Friday 19 September, the man asked wing staff if he
could speak to a Listener. The duty officer asked him if he could wait 15
minutes until cells were unlocked and the man agreed. No record of him
seeing a Listener is available but at 8.52am he told an officer that he had
taken 24 paracetamol and 12 Brufen (ibuprofen, a painkiller) tablets at about
8.15am. Healthcare staff were called who administered carbomix (a charcoal
based medication administered to absorb toxic substances in the stomach)
and he told them he had only swallowed 15 tablets. A nurse reported the
matter to the doctor and MHIT and undertook to perform a blood test four
hours later. These tests revealed that the levels of paracetamol and salicylate
22
(a substance found in aspirin based medicines) in the man’s blood were
below that which could be detected by analysis at the local hospital.
86. At lunch time, the man asked to be put in a cell with a Listener and, later in
the day, he took full part in the association period with other prisoners and
collected his medication as normal. The night officer checks made on him
during that night indicate that he appeared to sleep throughout. The man
remained positive during that weekend until late Sunday morning, when at
11.45am staff were told that the man was trying to obtain paracetamol from
other prisoners. He and his cell were searched but no medicines were found.
87. During the morning of 22 September, the man went to work and had a good
morning there. Later in the afternoon, he went to the chapel and took part in
an Alpha course (a course on the basics of the Christian faith, which is
described as an opportunity to explore the meaning of life). Three reports by
staff on that day say that he thoroughly enjoyed the course and was in an
upbeat mood. The man used the “special sick” procedure and obtained two
paracetamol for a headache. He remained in a positive frame of mind until
lunchtime on 23 September when he asked to speak to a Listener and
remained in the Listener’s cell over the lunch period. At 3.30pm, he attended
an ACCT review and said that due to his continuing flashbacks he felt low but
that the Alpha course was the only positive thing.
88. On the morning of 24 September, the man told workshop staff that he was
having flashbacks. They considered that the risk of keeping him in the
workshop was too high and sent him back to his wing. Later in the morning,
he spoke to the Salvation Army chaplain and became more relaxed. He used
the “special sick” process again to obtain two paracetamol tablets. The man
remained anxious for the rest of the day and at 5.10pm used the Listeners
service. At 7.30pm, he was still anxious and ten minutes later he was
reported by prisoners to be asking others for medicines. A G wing SO and
other wing staff recovered an unspecified quantity of paracetamol tablets from
him. She, the SO, considered that the man required excessive staff
resources. She contacted a Registered Mental Nurse (RMN) and member of
the Primary Care Mental Health Team (PCMHT), who told her that the man
was due for a computerised tomography (CT) scan which he would try to
bring forward. (A CT scan is a computerised x-ray process which shows more
detailed images than those from a traditional x-ray.)
89. During the late evening of 24 September, the man appeared to have settled.
However, by 11.00pm he had attracted the attention of the night patrol officer,
and asked for a Listener because he was having more flashbacks. When
officers came to unlock him, he refused to speak to the Listener. Half an hour
later, just after midnight, he again rang his cell call bell and again asked to
speak to a Listener. The Listener went into the cell with him for about 40
minutes but later told staff that the man had not spoken to him and appeared
to be abusing the Listener system. At just after 2.30am on 25 September, the
man rang his cell call bell complaining that he was continuing to have
flashbacks and that the Listener could not give him any advice. The night
patrol officer asked him if he had hurt himself. He replied he had not, so she
23
advised him to get some sleep and see healthcare staff the following day.
The man seemed content and went to bed. The night patrol officer noted that
the man had used the cell call bell on 15 occasions that night and asked day
staff to speak to him about abusing the facility.
90. At 8.00am, the officer conducting the roll check reported that the man was
feeling unwell and had vomited into his cell lavatory. (The roll check is the
physical count of the number of prisoners on each wing.) At 9.00am, he
attended the chapel where, the Salvation Army chaplain said, he was clearly
unwell and anxious about not going to work. At around midday an officer said
that the man appeared very vacant and confused. He therefore telephoned
healthcare staff and asked them to check him when he collected his
medication. The SO wing manager also contacted healthcare staff in the
early afternoon raising concerns about the man’s health and mental state and
asked them to see him. Two Staff Nurses examined the man at around
2.45pm and said that he appeared to have deteriorated. They noted that he
had a shuffling gait and his arms and hands shook. They described him as
vacant, only answering questions after a pause and noticed a rash around his
eyes and head which he told them he had been scratching. The man also
told them he was feeling low and felt unwell. One of the nurses tried, during
the afternoon, to contact MHIT staff, without success. She eventually left a
voicemail message for the PCMHT asking them to assess the man.
91. A PCMHT RMN assessed the man at 7.15pm on G wing. He noted his
physical condition, including the rash on his forehead and swelling below his
eyes. The man said that these were not bothering him, in contradiction to
what he had told nursing staff earlier. The PCMHT RMN made a three point
plan for the following day requesting a routine blood test, an ECG and
planned a discussion with Inpatient Services at HMP Preston, with a view to
them admitting the man to a regional mental health bed, at the prison, for
assessment. By 7.45pm the man had gone to bed and slept through the
night.
92. At 8.00am the following morning, Friday 26 September, the man was anxious.
Despite the arrangements made by the PCMHT RMN, the man went to the
workshop and missed his medical appointment. A request for a full medical
and mental assessment was however sent to Preston at 10.00am, who
responded that they would arrange an assessment the following Monday.
The man remained anxious and returned to his wing in the middle of the
morning. He was reassured by wing staff about his removal from the
workshop which he appeared to accept. An officer spoke to him around
12.30pm after he had collected his medicine and lunch and he appeared
happy. Ten minutes later, he said that he felt low about losing his job and
asked to speak to a Listener, with whom he spent the lunch period in his cell.
Later, in the evening he was mixing with other prisoners and engaging in
conversation with staff. A wing SO thought he seemed more settled than
earlier.
93. The man appeared to sleep during that night but rang the cell call bell at
5.55am on Saturday 27 September. He told the night patrol officer that he
24
was depressed and experiencing flashbacks. She offered the use of a
Samaritans telephone (a telephone dedicated for use by prisoners who want
to contact the local Samaritans service) but he declined. She spoke to him for
a few minutes finally advising him to try to get some sleep. At 8.00am, the
man told the officer unlocking the cells, that he felt depressed. The officer
said that it would be about half an hour before a Listener could speak to him
which he accepted and replied that he was going to get some rest. The
officer noted in the man’s ongoing ACCT observation record that he had
made comments about depression and feeling sick. The man had a quiet day
punctuated by sleeping and collecting his medication. An officer did however
note at 4.30pm that the man had missed his lunch but he would ensure that
he received his evening meal. The man was checked by evening and night
duty staff and appeared to sleep through the night.
28 September
94. At 6.05am on the morning of 28 September, the man told the night officer that
he wanted to speak to a Listener but was asleep when the day staff saw him
at 8.00am. He later went to chapel.
95. In a note retrospectively made in the man’s Continuous Clinical Record on 29
September, a nurse said that she was told by wing staff that the man had
complained of coughing up blood. She checked him at around 2.00pm but
saw no evidence of the condition. She noted that he had complained recently
of similar events, although no record of them is available. The nurse also saw
the man at about 3.30pm when she dispensed his medication and asked if he
had coughed up more blood. He had not and said he felt alright.
96. A G wing officer, spoke to the man several times during the day and said he
appeared “quite chipper”. He told her at around 11.30am that he was going to
have a sleep in the afternoon. When she saw him again later, he said that he
could not sleep and wandered off aimlessly about the wing. He spoke to her
later and asked if she thought he would ever get over his depression. She
told him that with the right help from the MHIT it was possible. He told her
that he was going to the chapel on Monday which he said he enjoyed.
97. At about 4.30pm, prison staff on G wing began locking prisoners in their cells.
The officer locked up G1 landing after the prisoners returned with their meals.
When she locked the man’s cell, G1-17 she saw that he was in bed and had
not collected his meal. After locking up the cells she spoke to the officer in
charge of the food servery, who confirmed that the man had not collected his
tea or his breakfast pack. (Prisoners are given a plastic bag pack containing
the following morning’s breakfast at the same time as they collect their tea.)
They were aware that the man had taken his lunch. The officer thought that
going without food for 24 hours from lunchtime to lunchtime was too long, so
she took a breakfast pack to the man in his cell. When she arrived, he got out
of bed and collected the pack from her and wished her goodnight. After
leaving his cell she went to the wing office and made her final observation
entry in his ACCT document at 5.00pm.
25
98. On weekend evenings, prisoners on G wing remain in their cells. There is a
single patrol officer on the wing and the period is known as “patrol state”. The
evening patrol officer in charge of G wing on the evening of 28 September
had worked for the Prison Service for three months at the time. The patrol
officer carries a pass key to allow him access to the wing but because he is
on his own does not carry a cell key. He does however carry a sealed pouch
containing a cell key for access to cells in an emergency if it is safe to do so.
He also carries a radio.
99. The evening patrol officer took over at about 5.25pm following a briefing by
the day duty senior officer. He checked the five open ACCT documents on
the wing noting the frequency of visits required by each. He remembers that
the man who died was last visited by staff at 5.00pm and required one visit
during the evening. The evening patrol officer then went round the wing
ensuring that all cell doors were shut, including G1-17. At about 6.00pm, he
answered a cell call bell on G2 landing and spoke to the prisoner requiring
attention. Just after 6.20pm he went round the wing counting and checking all
the prisoners.
100. When the evening patrol officer reached G1-17 he saw the man lying on his
back on the floor. His head was underneath the bed on the left side of the cell
with his body and legs stretched across the cell towards the cupboard on the
right side. The man was wearing only his boxer shorts which were around his
lower legs. He also saw a patch of brownish vomit on his chest. The evening
patrol officer called him by name several times while knocking and kicking the
door but got no response. He radioed the prison control room at 6.25pm
asking for medical assistance for a Code Blue emergency on G wing. (A
Code Blue call signifies that the patient is experiencing breathing difficulties or
is not breathing.) No further details are given across the radio network for
security reasons. He then ran to the wing office, where he telephoned the
control room to give them more detail.
101. Returning immediately to the cell, the evening patrol officer met the orderly
officer, who in response to the radio message had come to the wing via the
outside door next to G1-17. (The orderly officer is the member of staff in
charge of the prison during the patrol state.) The evening patrol officer told
the orderly officer what he knew and, after looking through the observation
panel, he went into the cell. The evening patrol officer remained outside. The
orderly officer went in, stepped over the man, turned towards the door and
knelt beside him. He tried to get a response from the man by shouting his
name and shaking his arm. He also tried to find a pulse in his neck but found
no signs of life. He said that the man was warm to the touch.
102. Control room staff contacted the healthcare centre just after 6.25pm and told
the duty nurse, that there was a Code Blue emergency on G wing. She went
immediately to the wing, entering through the outside door adjacent to G1-17,
arriving at the cell a few minutes after the orderly officer who told her the man
was not breathing. She told him to start cardiopulmonary resuscitation (CPR)
and to call an ambulance. She then went to the wing treatment room on the
second landing to collect the emergency response bag and defibrillator. (A
26
defibrillator is a portable electronic device which measures electrical activity in
the body and advises on action to be taken.) At Wymott emergency response
bags containing medical equipment are held in wing treatment rooms so that
medical staff have access to appropriate equipment on arrival rather than
trying to hurry to a medical emergency carrying a heavy bag of equipment
having first collected it from HCC. The treatment room on G wing is about 30
yards away from the man’s cell and up one set of stairs. The control room log
shows that orderly officer used his radio to ask for an emergency ambulance
which was called at 6.33pm.
103. While the duty nurse was away from the cell, two officers arrived. The first
officer to arrive went directly into the cell to assist the orderly officer in giving
the man CPR. The other officer, observing from outside the cell, said that
from the man’s position on the floor and the faeces on the back of the
lavatory, it was his impression that he had been using the lavatory, had risen
from it and fallen forward to the floor.
104. The duty nurse arrived back at the cell a few minutes later with the emergency
bag. She attached a defibrillator to the man’s chest and allowed the machine
to cycle through its automatic process. It did not detect a shockable rhythm
and CPR was continued. This process was repeated several times. The man
was not breathing and the nurse could not find a pulse, or get a reaction from
his eyes by shining a torch into them.
105. From what he had seen of the man’s condition the officer that had remained
outside the cell formed the opinion that he may already have died. He went to
the Security Department office to collect a camera to photograph the cell and
returned about five minutes later. When he returned, he saw that the man
had been moved to allow resuscitation attempts to take place but took a
series of photographs. Those photographs are no longer available having
been deleted from the computer on which they were stored.
106. Prison staff continued CPR until a paramedic from the local ambulance
service arrived at around 6.45pm. The duty nurse briefed him on the man’s
condition. He removed the prison defibrillator from the man’s chest and
attached the one he had brought with him. At around 6.50pm two further
ambulance crew joined their colleague at the cell. The paramedics could get
no response from the man and they confirmed a few minutes later that he had
died.
After the man’s death
107. After confirmation of the man’s death the orderly officer left the assistant
orderly officer at the cell and returned to the control room to implement
Wymott’s contingency plan for a death in custody. When he arrived at the
control room the duty governor was there and was aware of the situation. The
orderly officer confirmed the man’s death to the duty governor and between
them they fully implemented the contingency plan. All individuals and
organisations identified in the plan were told of the death and the log
completed. The duty nurse told the healthcare manager and the local PCT.
27
108. Immediately after the man’s death his cell was locked and an officer was
appointed log keeper outside cell G1-17. In these circumstances a log keeper
maintains written notes of staff, police and other legitimately interested people
visiting the cell and any relevant actions. He remained at the cell maintaining
the log until relieved at 9.00pm.
109. A police sergeant and police constable went into the cell at 8.07pm. Later, at
8.20pm a member of staff from Wymott Independent Monitoring Board visited
the cell. At 9.05pm, the Governor, the police constable and two funeral
directors removed the man’s body which was taken from the prison to the
mortuary at the local hospital.
110. The duty governor held a hot debrief for prison staff involved before they went
off duty. (A hot debrief is a meeting for staff to discuss emotive issues and
any lessons learned following serious events such as deaths in custody.) A
member of the Wymott Care Team also spoke to all staff that were on duty at
the time of the man’s death and offered them support.
111. As the man’s next of kin details were not up to date, the Governor asked the
senior probation officer at Wymott to trace any family. He made exhaustive
efforts using Probation Service and police resources to contact both the man’s
family and his last named next of kin. He was unsuccessful but police later
traced and broke the news to his nominated next of kin.
112. A post mortem was held on Tuesday 30 September at the local hospital.
During the examination, a wrapper containing a biscuit was found in the back
of his throat obstructing his airway. Another similar wrapper was found in his
mouth. Post mortem samples of blood were examined which found that the
man had traces of mirtazapine and olanzapine. These were deemed by the
pathologist to be at a level within the therapeutic range and played no part in
the man’s death. The pathologist concluded that the cause of death was:
• acute upper airway obstruction and
• choking on foreign material (biscuit encased in wrapping)
113. The Salvation Army chaplain arranged and officiated at the man’s funeral at
the local crematorium. The prison met the expenses. The funeral was
attended by two funeral directors and crematorium staff. Following the
cremation, a memorial service was held in the chapel at Wymott and was well
attended by the man’s friends and some staff. His next of kin was present
and, following the service, received his property. He also took away the
man’s ashes for burial in his parish churchyard.
28
ISSUES CONSIDERED DURING THE INVESTIGATION
Clinical care
114. A clinical review was commissioned from the Central Lancashire Primary
Care Trust and was carried out by the Head of Healthcare at HMP Haverigg.
The review was received in February 2009.
Physical health
115. From the outset, the man was in close contact with healthcare staff. He had
no significant physical healthcare issues on reception, except an old sporting
injury to his right knee for which he received appropriate pain relief medicine.
He was referred to the local hospital and an operation was planned which he
declined, electing instead to continue wearing a knee support and take
analgesics. He cancelled all subsequent appointments.
116. The man gradually became much more focused on his medication,
particularly the analgesics. He made a series of formal complaints about
variations in his medication which attracted appropriate responses. In the
main, his prescriptions had been varied by doctors and were responsive and
proportionate to his needs. However, one of the man’s medicines (trazodone)
had been stopped suddenly at the beginning of November for no apparent
reason. The prescribing psychiatrist wrote to the Lancashire Care NHS Trust
about the abrupt stopping of the drug. There is no recorded outcome
resulting from that letter.
117. The man’s worsening physical appearance during 2008 caused concern
among healthcare and wing staff. During early August, the man had a rash
around his eyes, nose, ears and forehead and complained of vomiting but
was otherwise well. In the early morning three days before his death, a wing
officer reported the man vomiting in his cell. At around midday, the wing
manager was concerned about him and asked healthcare staff to see him.
Two staff nurses did so and saw deterioration in his physical condition.
Primary Care Mental Health Team staff were asked to assess the man
urgently and saw him that evening. A blood test and ECG were requested for
the following morning and arrangements were made with wing staff for the
man to attend healthcare. However, he went to work and missed his
appointment. A referral to HMP Preston for a medical and mental
assessment was made later that day but he died before that assessment took
place.
118. The clinical reviewer comments that staff at Wymott felt that the man had
“impaired mental clarity, poor motivation and concentration”. It is of concern
that there appears to be no robust method to ensure that a patient, who is
mentally unwell is reminded or encouraged to attend appointments. While it
would be wrong to compel prisoners who decline or refuse treatment, it is of
concern that a man who was anxious and depressed missed appointments
because of his incapacity.
29
The PCT and Governor should put in place a robust process to ensure
that prisoners with reduced mental capacity attend their appointments
with healthcare professionals.
119. The man was again examined by a nurse on the afternoon before his death,
having complained that he was coughing up blood. She saw no evidence of it
but was aware that he had complained recently of similar events. The nurse
saw the man later that afternoon to dispense his medication and he told her
that it had not happened again.
120. Commendably the G Wing officer was concerned that the man, having missed
his tea meal and not collected his breakfast pack, would not eat again until
mid-day on the following day. She took him a breakfast pack before going off
duty. He was alone in his cell. He wished her goodnight and appeared quite
normal to her.
121. The man was found collapsed in his cell an hour and a half later and was
pronounced dead half an hour after that. A post mortem examination
indicates that he died as a result of an obstruction, a wrapped cereal bar
which was part of the breakfast pack, in his throat. How that obstruction got
into his throat is not known. However the officer who gave him his breakfast
pack should not feel that she was responsible for the man’s death.
122. When the man was found, the single nurse on duty at Wymott attended. On
her arrival at the cell, she relied upon the assistance of a first aid trained
prison officer to continue CPR while she collected equipment from the wing
treatment room. The outcome of the attempt to preserve the man’s life is
unlikely to have been different had more than one nurse been present.
However, both the clinical reviewer and HM Chief Inspector of Prisons, in
paragraph 4.7 of her 2008 report, indicate that a single nurse on duty at
Wymott at this time of day is unsatisfactory. The staffing profile recommends
three duty nurses. The clinical reviewer recommends a review of staffing
levels and an increase to meet the optimum level. I agree.
The PCT should review nurse staffing levels to ensure that adequate
nursing cover is available at all times.
Mental health
123. Within a few weeks of his recall to prison, the man had undergone mental
health screenings at two prisons and held his antidepressant medication in-
possession. He was referred to the MHIT and saw a psychiatrist in
September 2006, who thought his mental health issues were brought about by
suffering sexual abuse during childhood and consequently, he suffered
auditory hallucinations.
124. The clinical reviewer identifies that no previous records from the community
were available in the man’s medical record and that healthcare staff do not
routinely request community records or information. She concludes that “it
may not be relevant to the care the man received but should be a
30
consideration for its relevance in other incidents”. An inspection by HMCIP,
which took place soon after the man’s death, found that the mental health in-
reach team were able to access the past history of local patients through the
mental health trust electronic records. However, if they were from other areas
new records had to be started. The MHIT RMN made an action note in
August 2006 to seek further information from outside agencies about the man.
There is evidence to suggest that he did so, indeed his interaction with and
knowledge of the man suggests that he probably had such information. He
did not, however, record or file that information in the man’s medical records.
125. There is no record of staff seeking the man’s permission to request his
previous medical and mental health records. No-one appears to have made a
formal request for such records or, if they did, the request and its outcome
were not recorded. In the normal course of events, as time progresses,
historical information of that nature becomes less pertinent but at the outset
could be an important factor in the decisions made by clinicians. I fully
endorse the clinical reviewer’s view that this did not affect the treatment the
man received, but it is conceivable that in a different set of circumstances that
information may be important.
The PCT should ensure that staff comply with the requirements of PSO
3050 (Chapter 2, Retrieving Information) regarding the acquisition of
previous medical and mental health records.
126. During the following months, the psychiatrist altered the man’s medication as
appropriate and referred him to a cognitive behaviour therapist. Mental health
staff continued to review the man regularly and, following deterioration in his
mental health, his antidepressant medication was varied and increased. In
late 2007, an anti-psychotic drug was also prescribed and the dose was
steadily increased. In early January 2008, the psychiatrist discussed with the
man his intention to start him on another antidepressant drug. He was unable
to prescribe it immediately and arranged, with the man’s agreement, to make
the prescription on his next visit some weeks later. The next day, the man
wrote a letter of complaint to the MHIT RMN about not yet receiving the new
prescription. In an attempt to alleviate the man’s worry, the nurse arranged
for the medication to be given to him a few days later. However, no note to
document that event is evident on the prescription chart or in the medical
record. The only indication that the drug was dispensed is in a response to a
formal complaint made by the man about not receiving it. The response
identifies that he received an interim supply of tablets and a further supply a
few days later. I am satisfied that the drug was prescribed and issued to the
man, but the lack of documented evidence is of concern.
The PCT must ensure that staff adhere to the Nursing and Midwifery
Council guidelines and on record keeping is consistent with all current
professional guidance. Medical record entries should include the
accurate completion of medication prescription and administration
charts.
31
127. In February, the man missed his next appointment with the psychiatrist but
was seen in mid-March when his condition had worsened. During this
assessment he reported auditory hallucinations that told him to hit figures of
authority. He also said that he was being bullied by other prisoners, an
accusation he made frequently in support of various requests. The man also
claimed that he had recently taken five overdoses of analgesics. None of
these overdose events were reported to or witnessed by prison staff and,
consistent with previous assertions, he denied having ideas of self-harm.
During early April, the man had become withdrawn from staff and prisoners.
Later in the month, he declined to see the psychiatrist after becoming anxious
about being in the healthcare waiting room, a pattern he repeated on several
further occasions, resulting in missed appointments.
128. In response to concerns raised in early May about the man’s deteriorating
mental health, a full physical examination was requested to take place in a
series of appointments over the following week. The man became anxious
while waiting for the final appointment and returned to his wing before the
tests were completed. He refused to see the psychiatrist and MHIT RMN in
the Healthcare Centre. In mid-May, a voluntary referral was made for him to
transfer to a regional mental healthcare bed at HMP Preston for assessment
but he became anxious about the move and it was postponed. The senior
psychologist, reacting to concerns about his mental condition, removed the
man from a proposed SOTP course.
129. Having missed several more appointments, the psychiatrist visited the man on
his wing for about ten minutes, insufficient time to complete a meaningful
review. However, further blood tests were carried out and the results
triggered a further increase in his medication after which, on several
occasions, the man became incontinent. In an attempt to reduce his anxiety
he was put on the waiting list for a place in Wymott’s unit for elderly and
disabled prisoners.
130. Wing staff reported a further deterioration in the man’s condition highlighting
rigidity in his body and involuntary contortion of his face. In mid-July the MHIT
RMN, with the man’s agreement, reactivated the voluntary referral for
assessment at HMP Preston. He was quickly assessed by Preston mental
health staff and transferred the following day. He immediately became
anxious about his return to Wymott and over the following days became more
insistent that he no longer wanted to remain at Preston. In support of that
decision, he reported that he was being bullied by other prisoners. It was
evident to mental healthcare staff that in his current state of mind the man
could not draw benefit from the assessment and, as a voluntary patient, he
was returned to Wymott eight days after arrival.
131. The man’s mental condition took a worrying turn when he reported hearing
voices telling him to attack prison staff. Wing staff were warned and he was
referred to the psychiatrist. The following day, he assaulted a female staff
member. His explanation was that he was being bullied and it was the only
way he could get out of the workshop. Later, he gave a different explanation
saying that he had assaulted her because she reminded him of his alleged
32
abuser. He was assessed by a nurse prior to his adjudication hearing, who
deemed him fit for the procedure although not for cellular confinement. The
case was adjourned, referred to the police and the man was eventually
warned by police regarding his future conduct.
132. The man’s antidepressant medication was again increased. Although his
concern about obtaining his medication was ever present, that anxiety
increased markedly whenever there was a delay in issuing it. His moods
fluctuated between high spirits and low moods and/or agitation. The
psychiatrist found increased rigidity, grimacing and tremors, symptoms which
he attributed to the anti- psychotic drug. In response the medication was
reduced over six days until cessation and a neurological examination was
requested for one month later.
133. On Thursday 25 September, wing staff reported that the man was clearly
unwell and anxious. Nursing staff also noted a marked deterioration in his
condition. He was seen during the evening, as an urgent case, by a Primary
Care Mental Health Team nurse who arranged for blood and ECG tests the
following morning and planned to discuss the man with Inpatient Services at
HMP Preston. The following morning the man remained anxious, went to
work and missed his appointment. (I have made a recommendation on this
point earlier in my report.) At 10.00am, a request for a full medical and mental
assessment was sent to Preston who said they would arrange it the following
Monday. The man remained anxious but appeared to improve during that
day.
134. The clinical reviewer recommended that the referral process to Preston in-
patient facility be reviewed. Her view is that the assessment agreed for the
man between Wymott and Preston to be arranged on Monday 29 September
may not have prevented his death, but the availability for assessments to take
place over the weekend, and I would add any other public holiday period,
would improve the referral process to prevent delays in transfer. She
recognised that to do so would increase staffing levels at Preston. With minor
modification, I re-iterate that recommendation.
The PCT and Governor should review the referral process to the HMP
Preston In-Patient facility, with a view to putting in place out of hours
assessments of patients who may need to transfer.
135. The day before his death, the man told staff he was depressed but refused
the use of a Samaritans telephone. At 6.05am on Sunday 28 September, he
asked to speak to a Listener but was asleep when staff went to his cell. He
spoke to healthcare staff and a wing officer several times and was thought to
be in good spirits. They spoke about his depression and he told the officer
that he was looking forward to going to the chapel on Monday. When the
officer took his breakfast pack to him in his cell nothing in his demeanour or
mood alerted her to any change. The man was pronounced dead two hours
later.
33
136. Owing to his deteriorating mental health, the man required a high degree of
input from healthcare, mental health specialists and wing staff over his time at
Wymott. His case underlines the difficulties in managing mental illness in a
prison environment and the view was expressed by some wing staff that he
should not have been at Wymott. Their view being that he would have been
better served by being transferred to either a health service or prison
establishment specialising in mental healthcare. It is a view echoed generally
in the IMB annual report for 2008-2009 but the clinical reviewer made no
comment on this aspect.
137. The man’s case was managed on a daily basis by wing and healthcare staff
who were aware of and reactive to his needs. It is my judgement that the man
received treatment at least equitable to that he could have expected in the
community. I have found that he was given thorough, detailed and
individualised support from a range of professionals who worked consistently
together. I also note that wing staff and managers were sympathetic and
supportive throughout.
Self-harming
138. The man was recalled to prison having been released a year previously. He
was known to have self-harmed during his earlier custodial period and had
been subject to suicide and self-harm prevention measures. Although he was
a depressive, he regularly maintained that he was not at risk of harming
himself. He told the psychiatrist in March 2008 that he had taken a total of
five overdoses of analgesics during the recent past. None of these events
were reported to or seen by prison staff and he again denied that he had any
intention to harm himself.
139. As prison staff were unaware of these instances, implementation of the
suicide and self-harm monitoring process was not considered as a result of
the man’s revelation. However, the man’s assertion was rightly taken
seriously and his permission to hold in-possession medication was
immediately withdrawn, except for a single analgesic tablet in-possession
daily. Immediately after the psychiatrists review, the man tried to obtain
additional analgesics in-possession from healthcare staff. The request was
refused and the nurse correctly completed a security incident form in relation
to the attempt. The man maintained that he was not at risk of harming
himself.
140. At the end of June, the man began harming himself by superficially cutting his
arm with a razor blade. He was immediately, and correctly, made the subject
of the ACCT monitoring procedure. He also reported several times that he
had taken overdoses of drugs, which on each occasion turned out to be false.
Once on the ACCT process, he quickly came to rely on it for support.
Supervising staff made proper efforts to bring it to a close, as the need for it
reduced, but the man reacted adversely to the proposal and remained subject
to monitoring until his death.
34
141. The man’s death was due to an obstruction, a wrapped breakfast cereal bar,
in his throat. Although not certain, it is likely that the man’s reported vomiting
and coughing of blood just prior to his death was the result of his inserting
objects into his throat. Given the evidence in the post mortem of bruising to
the back of the throat and the presence of petechial haemorrhages, it appears
that this action probably formed part of his self-harming behaviour. His death
was due to his own actions and we do not know whether his intentions were
to take his life. I judge that the man was well supported by wing, medical and
mental health staff at Wymott during his sentence.
Bullying
142. The Chief Inspector of Prison’s report commented that there is a strategy to
tackle bullying at Wymott but that it was deficient in several areas, namely that
staff had not been trained in its use and its application was poor. The
Independent Monitoring Board‘s report for 2008 – 2009 also expressed similar
concerns.
143. The man complained of bullying in the last nine months of his life. His
complaints were often in support of various requests he made such as to
move from Preston back to Wymott, or returning to the wing from healthcare
before appointments were fulfilled. On one occasion, staff thought he was
being bullied for his medication and opened an anti-bullying document (TAB)
which was closed soon afterwards when it became apparent that it was not
the case. They were also reactive to his complaints, although it was apparent
that they were triggered by his mental condition, again opening a TAB
document and closing it soon afterwards when no evidence of bullying was
discovered.
144. I am in no doubt that the Chief Inspector’s comments were valid and current
at the time of the man’s death. However, in my opinion the man was
appropriately supported in relation to his allegations of bullying whether they
appeared to be genuine or as a result of his mental health issues.
Family issues
145. The man was not in contact with any member of his family. He was thought to
have no family outside those he alleged had abused him as a child, although
he did make references on one or two occasions to other family members.
Their whereabouts however is unknown. The people with whom he had
corresponded and telephoned were solicitors and probation officers. The man
named, as his next of kin, a clergyman who worked in a hostel where he lived
prior to his recall to prison. At the Governor’s instigation, extensive efforts
were made by the senior probation officer at Wymott to contact the man’s
nominated next of kin or a family member regarding his death. The officer
was unsuccessful as the details were out of date. His named next of kin was
eventually traced and informed by the police.
35
146. It is saddening when a prisoner dies without anyone, other than people who
deal with them professionally, knowing about their death. There appears to
be no standard guidance on the maintenance of next of kin information and I
have commented and made recommendations on this in previous
investigation reports.
The Governor should implement a formal process to ensure that up to
date next of kin data is maintained throughout a prisoner’s sentence.
An annual check of the information held by the prison should be carried
out during the sentence planning process.
147. The Salvation Army chaplain at Wymott organised and conducted the man’s
funeral which was only attended by the funeral directors and crematorium
staff. It is regrettable that no member of the prison management team or wing
staff that knew the man represented HMP Wymott at the funeral. The
subsequent memorial service was well attended by prisoners and staff. In my
view, representation by senior Wymott staff would have been appropriate and
within the spirit of the guidance for family liaison officers supplementary to
PSO 2710.
36
CONCLUSION
148. The man had a long history of offending and was known to mental health
professionals for many years prior to his recall to prison in 2006. He had
regular contact with both primary medical and mental health professionals
from his reception until his death almost two years later.
149. Following his recall to prison, he refused surgical intervention to rectify an
injury, preferring to be treated by the regular use of analgesics. The
medication became problematic in that they gave him an unhealthy focus
which, as his mental condition deteriorated, evolved into a fixation with
acquiring them.
150. The man’s mental health issues were quickly recognised after reception and
were appropriately treated. He was monitored and reviewed regularly and his
therapies were adjusted as circumstances indicated. Over many months his
mental condition deteriorated and he required increasing support which he
drew from prison staff, Listeners and medical and mental healthcare
professional staff all of whom contributed to a resource intensive support
network. It was mentioned during several interviews with staff that the man
should not have been in prison at all and staff felt ill equipped to deal with his
problems. While this is a view that attracts some sympathy, the reality of the
matter is that he was at Wymott, his was a difficult case, and the staff caring
for him did so to the best of their ability. I commend them for their continued
support for the man.
151. The man’s self-harm was either superficial in the case of cutting himself or
overstated when claiming to have overdosed. His actions appear to have
been a mechanism to cope with his escalating mental problems and were
directed at gaining attention rather than a serious attempt to hurt himself. It is
likely that his unexplained vomiting was as a result of a similar strategy where
he pushed objects into his throat. Tragically, on the evening of 28 September
a wrapped breakfast cereal bar became lodged in his throat leading to his,
probably, unintended death.
152. The man benefited from continuous review and treatment by mental health
professionals and he was well supported by all those staff that regularly came
into contact with him. I judge that he received a good standard of care and
treatment to manage his medical, and particularly, his mental healthcare
needs which was sustained throughout his time at Wymott despite being a
significant drain on resources. I judge that the man’s death could not have
been prevented.
37
RECOMMENDATIONS
1. The PCT and Governor should put in place a robust process to ensure that
prisoners with reduced mental capacity attend their appointments with
healthcare professionals.
The recommendation was accepted and HM Prison Wymott commented that:
“If prisoners with reduced mental capacity are not attending appointments with
healthcare professionals then the following action takes place:
For mental health appointments or reviews the Healthcare professional visits
the patient on the residential unit ensuring attendance or questioning non
attendance
For routine GP / Nurse Practitioner appointments requested by the prisoner,
the prisoner is provided with an appointment slip and advised by Residential
staff at unlock times of their appointment. There would not normally be a
follow up however if a GP has requested to see the prisoner this would be
followed up by nursing staff.
If a prisoner fails to collect routine treatments from the hatch nursing staff
would approach Residential Officers to ensure the prisoner is aware he has
treatments to collect and ensuring that he receives his medication.”
The action has been completed.
2. The PCT should review nurse staffing levels to ensure that adequate nursing
cover is available at all times.
The recommendation was accepted and HM Prison Wymott commented that:
“Staffing levels are maintained to ensure there are 3 Nursing staff on duty until
they handover to the night shift Nurse.”
The action has been completed.
3. The PCT should ensure that staff comply with the requirements of PSO 3050
(Chapter 2, Retrieving Information) regarding the acquisition of previous
medical and mental health records.
The recommendation was accepted and HM Prison Wymott commented that:
“Central Lancashire PCT and Lancashire Care Foundation Trust Service
managers should review there systems to ensure that the requirements of
PSO 3050 (Chapter 2, Retrieving Information) are followed.”
The action is to be completed by March 2011.
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4. The PCT must ensure that staff adhere to Nursing and Midwifery Council
guidelines and record keeping is consistent with all current professional
guidance. Medical record entries should include the accurate completion of
medication prescription and administration charts.
The recommendation was accepted and HM Prison Wymott commented that:
“All patient records at HMP Wymott are maintained electronically as of July
2010. All PCT staff have received a clinical update regarding record keeping
and medicines management to ensure they are aware of and compliant with
Nursing and Midwifery Council Guidelines.”
The action has been completed.
5. The PCT and Governor should review the referral process to the HMP
Preston In-Patient facility, with a view to putting in place out of hours
assessments of patients who may need to transfer.
The recommendation was accepted and HM Prison Wymott commented that:
“The PCT transfer policy into HMP Preston in-patient facility has been
reviewed and the requirement to assess prisoners prior to admission has
been removed. This will enable those prisoners who present with an acute
need to be admitted at the earliest opportunity, including out of hours if
required.”
The action has been completed.
6. The Governor should implement a formal process to ensure that up to date
next of kin data is maintained throughout a prisoner’s sentence. An annual
check of the information held by the prison should be carried out during the
sentence planning process.
The recommendation was accepted and HM Prison Wymott commented that:
“A process to ensure next of kin information is up to date has been introduced
through the Personal Officers scheme on the residential units. This
information is checked at least annually by the Offender Management Unit to
inform the sentence planning process.”
The action has been completed.
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