Individual at Risley

Investigation into the circumstances surrounding the
death of a man
at HMP Risley in July 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
This is the report of an investigation into the death of a man, a prisoner at HMP
Risley. He died on 13 July 2009 and was discovered in his cell with a ligature
around his neck. He was 25 years old. I offer my sincere sympathy and
condolences to the man’s family and friends. I must also apologise for the significant
delay in issuing this report and any additional distress that this has caused family
and friends as well as the staff at Risley.
The investigation was initially carried out by my colleague. However, he was unable
to continue with the investigation and it was completed by another colleague. An
independent review of the man’s medical care in custody was carried out by a
clinical reviewer on behalf of the local Primary Care Trust. I am most grateful to him
for his assistance. I would also like to thank the Governor and staff of Risley for their
full and ready co-operation during the course of the investigation. I am especially
obliged to the prison liaison officer for his help in liaising with the investigators.
The man had spent much of his adult life in prison. He was most recently sentenced
to 15 months custody on 19 January 2009. Having spent the first few months of this
sentence at HMP Altcourse, he transferred to Risley in April. He was not considered
to be at risk of self-harm or suicide at all during this sentence apart from a period of
24 hours in May when the appropriate suicide prevention measures were taken. He
had told an officer that his partner had suffered a miscarriage and he felt like killing
himself. However, the following day he admitted he had fabricated this story to
obtain a telephone call and denied any feelings of harming himself or committing
suicide.
Staff and prisoners who spoke to my investigators all expressed their shock at the
man’s death, reflecting that he was a well-liked and cheerful prisoner. No one
believed he presented a risk to himself. However, there were occasions, as above,
when he gave false information to obtain additional telephone calls or presented with
physical symptoms which staff suspected were not genuine, perhaps to get admitted
to hospital.
I make four recommendations. Two of these relate to the emergency response. The
first involves the clarification of when staff should enter a cell on their own and the
second gives consideration to the use of emergency codes. Notwithstanding these
points, staff attended his cell very quickly and made an appropriate judgement not to
attempt resuscitation. The third recommendation is in relation to a mental health
referral made for him which was not actioned and ensuring that communication
throughout this process is robust. Lastly, there was no identifiable personal officer
involved with him and I therefore make a recommendation in this regard.
However, my overarching impression of staff is that they invested time trying to help
the man. This included assisting him with any physical health problems, as well as
trying to alleviate some of the difficulties he experienced while being imprisoned
away from his friends and family.
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This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman September 2010
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CONTENTS
Summary
The investigation process
HMP Risley
Key findings
Issues
Conclusion
Recommendations
Family Response
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SUMMARY
Having been released from HMP Altcourse on licence in November 2008, the man
was arrested on further charges on 12 January 2009 and returned to Altcourse. On
reception, he was interviewed by an officer and a nurse, neither of whom assessed
him to be at risk of self-harm or suicide. Indeed, during his time at Altcourse this
remained the case.
He initially settled well in prison, gaining employment and completing victim empathy
and alcohol awareness programmes. However, on 15 April, he lost his job as a
cleaner for being disruptive. He was given notice of an adjudication hearing, due to
the suspicion he was in possession of a mobile telephone and charger. The
following day, he transferred to HMP Risley. It is unclear whether these events were
related.
Again, when interviewed on arrival at the prison, the man denied any thoughts of
self-harm or suicide and said he was happy to be at Risley. On 28 April and again
on 24 May, he made claims to officers that his partner had suffered a miscarriage.
On the second occasion, staff started suicide prevention measures since he also
claimed he felt like killing himself as a result. These measures continued for 24
hours. However, in both instances staff discovered that he had made up the claims
to obtain telephone calls to his partner. As is often the case, it seems he found it
difficult being in prison and not having regular contact with her.
As a result of the second claim that his partner had a miscarriage, the man was
referred to the mental health team. However, no action was taken on this referral
and the team said they did not receive it. I make a recommendation in this regard to
ensure the referral system is robust and staff are aware of the process.
The man complained of chest pains on 1, 21 and 28 June. Each time he was
appropriately assessed by healthcare staff. On two occasions, he was taken to an
outside hospital by ambulance for further tests to be carried out and discharged
within a few hours. The diagnosis was muscular pain and was not thought to be
serious. The clinical reviewer concludes that this chest pain was dealt with
appropriately. For a number of reasons staff were concerned that the symptoms
were not genuine and they therefore submitted information to security about their
suspicions.
On 9 July, the man claimed that his son was in hospital and asked for a telephone
call. Staff established that he did not have a son and again information was
submitted to security that he was trying to obtain extra telephone calls.
Prisoners commented that the man got on well with others on the wing and had an
established group of friends. Some said that he became increasingly upset about
his relationship with his partner the week before he died. On 12 July, two prisoners
noticed a cut on his arm. He said this had happened accidentally and, although the
prisoners were unsure whether this was the case, they did not tell staff about the
injury.
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The following morning, the man was discovered hanging in his cell by staff. All those
involved in the emergency response agreed that it was too late to save him and
therefore no resuscitation was attempted. Staff reacted quickly to the emergency.
However, I give consideration as to whether staff understand when they should enter
the cell alone at night and the benefits of the introduction of a code system to be
used in medical emergencies.
Throughout his time at Risley, the man does not seem to have been allocated a
personal officer or, if he was, the required amount of contact was not recorded in his
wing history sheet. (The personal officer scheme was introduced so that prisoners
are given a named officer that they can approach for advice or to resolve
complaints.) Such interactions may have been useful for a young man who was
clearly finding it difficult being located away from his partner and family. I therefore
make a recommendation in this regard.
Prison staff visited the man’s mother to tell her of his death and a memorial service
was held that morning. Staff and prisoners were also offered support. Overall, I am
satisfied that he was looked after appropriately by both discipline and medical staff
and I concur with the view of the clinical reviewer that his death could not have been
prevented.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 23 July 2009, when the investigator issued
notices announcing the investigation to staff and prisoners. The notices
included an invitation to those who wished to submit information related to the
man’s death to make themselves known to the investigator. No staff or
prisoners came forward as a result.
2. The investigator was given access to the man’s prison files, including the
medical record. He later returned to Risley with another investigator on 5 to 7
October to interview staff and prisoners. The Independent Monitoring Board
(IMB) and the Prison Officers’ Association (POA) did not wish to raise any
issues with the investigator. He was unable to complete the investigation and
it was therefore passed to his colleague in February 2010.
3. An independent review of the man’s clinical care in custody was carried out by
a clinical reviewer on behalf of the local Primary Care Trust (PCT).
4. One of my family liaison officers telephoned the man’s mother on 12 August
to advise her of the investigation and invite her to raise any matters she
wished to be addressed. She raised the following issues:
• The support he received from the Probation Service when released at
the end of 2008 on licence.
• Concern that prison staff did not communicate with each other as she
received calls requesting the same information.
• When she was told the news of her son’s death, she felt too many
questions were asked. She also questioned the subsequent
suggestion by the family liaison officer that she see a medium (a
person who claims to be able to communicate with dead people).
• She was keen to know more about how her son’s medical issues were
treated.
• Whether there was any assessment of her son and his needs following
his transfer to Risley.
• His belongings were removed for a period and then returned with items
missing.
• She had heard that her son had called the Samaritans and wondered
how rigorously this was explored. She believes he should have had his
belt removed.
• Was there any incident or trigger for his actions in taking his own life?
5. The family liaison officer also telephoned the man’s partner on 7 September.
She raised the following issues:
• Was there evidence that he was bullied at HMP Altcourse?
• What mental health assessments or treatment did he receive?
• Had staff noted her warnings about not leaving him with a belt?
• She questioned why she and the family were not immediately informed
of notes left for them by him.
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• She wanted to know details of how he killed himself.
• She had heard from the police that he had fresh cuts on his rectum and
wanted to know more about these injuries.
• She was concerned what had happened to some of his property and
money following his death.
5. I have endeavoured to answer these questions in my report and I hope that it
helps the man’s family, partner and friends to better understand what
happened in the time leading to his death.
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HMP RISLEY
6. HMP Risley is a male category C training prison. 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. Category C
prisoners are defined as those who cannot be trusted in open prison
conditions but who would not have the ability or resources to make a
determined escape.
7. Risley has seven wings and a segregation unit with an operational capacity of
1,085. The prison offers a variety of work, vocational training courses and a
comprehensive education programme. It has 24 hour healthcare provision
which is provided by the local Primary Care Trust (PCT).
8. The prison was most recently inspected by HM Chief Inspector of Prisons on
an announced visit in July 2007. In her report, she said:
“Safety remained a concern, conditions in parts of the prison were poor
and there was still too little for prisoners to do. More positively, there
was some reasonable resettlement work in place … Staff-prisoner
relations were generally poor and were not helped by a weak personal
officer scheme and an ineffective incentives and earned privilege
scheme.”
9. An Independent Monitoring Board (IMB) is appointed to each prison by the
Secretary of State for Justice. Its members are wholly independent of the
National Offender Management Service (NOMS) and the prison’s
management team. Each IMB is required to produce an annual report to the
Secretary of State, highlighting good practice and areas of concern.
10. Risley’s latest IMB report covers the period 1 April 2008 to 31 March 2009.
The Board considered that the standard of healthcare at the prison was very
good. They were also satisfied with the safer custody strategies employed by
the prison and felt confident that incidents of bullying were appropriately dealt
with.
11. The National Offender Management Service is responsible for the
management of prisons in England and Wales. Every three months it
publishes an assessment of each prison’s performance against 34 measures.
Prisons can gain a rating of between one (serious concerns) and four
(exceptional performance). Risley has scored threes (good performance) for
the last two quarters, and twos (requiring development) for the previous two
quarters.
12. The man’s death was the sixth to have occurred at Risley since April 2004,
when this office began investigating all deaths in prison custody in England
and Wales. There has also been a death subsequent to that of his. One of
these previous deaths was self-inflicted and one was due to injuries inflicted
during an assault. The rest were due to natural causes.
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13. Following a death in 2007, I recommended the introduction of codes to
indicate the type of emergency to staff responding to a request for assistance.
Whilst this has been introduced, I am concerned that there is a lack of clarity
amongst staff regarding its use and I therefore make a further
recommendation in this regard. There are few other similarities between the
man’s death and those which occurred previously at Risley.
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KEY FINDINGS
HMP Altcourse, 2 April 2004 – 15 April 2009
14. The man was brought up by his mother. He was diagnosed as having
obsessive compulsive disorder and attention deficit hyperactivity disorder at
an early age. Between eight and 16 years old he attended a boarding school
for children with behavioural problems and left with qualifications in
mathematics, science, English and geography. He also obtained art ‘O’ Level
and NVQ qualifications in bricklaying and catering.
15. After leaving college, the man worked for four years for a company preparing
food. He also worked in the motor trade, at a garden centre and as a refuse
collector for short periods.
16. The man was sentenced to four years imprisonment at Crown Court on 2 April
2004 and taken to HMP Altcourse. This was his first substantial prison
sentence, although he had been in prison before.
17. He initially had some difficulties settling in Altcourse, reflected in the five
adjudications which were proved against him in 2004. (An adjudication is an
internal hearing into breaches of prison discipline by prisoners). However, his
behaviour then improved. He worked as a cleaner and under the Incentives
and Privileges (IP) scheme attained level four status. (IP rewards and
encourages prisoners’ good behaviour and has four levels – reintegration,
basic, standard and enhanced. Enhanced is the highest prisoners can
achieve.) He was released on licence in July 2006. This meant that that he
was under the supervision of the Probation Service and had to comply with
licence conditions, one of which was not to re-offend.
18. Four months after his release, the man committed further offences. Since he
had breached a condition of his licence, he was recalled to prison. He was
taken to Altcourse and, in November, was sentenced to a further three and a
half years imprisonment for these offences.
19. He again appeared to settle in Altcourse and became an IP4 (enhanced)
prisoner. In September 2007, he fractured his jaw. He said this had
happened by accident when he fell into the sink in his cell. He was taken to
outside hospital where he had an operation and received follow-up treatment
at the prison. In January 2008, he completed the Impact on Victims
programme. However, in the months afterwards, his behaviour became
increasingly erratic and he was abusive towards staff on a number of
occasions. As a result, he lost his job as a cleaner and was downgraded to
IP3.
20. At the beginning of May 2008, he told officers that he felt under threat from
other prisoners on his wing. However, he did not provide any names and did
not want any protection. He was advised to speak to officers if the situation
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got worse. Officers had not noticed any hostility towards him but were asked
to remain vigilant.
21. The man moved to another wing at his own request in mid-May and appeared
to settle much better. He completed the Anger Management programme and
gained employment in the servery and later as a cleaner. Officers remarked
in his personal file that his behaviour was “great” and “perfect” and he was
again made an IP4 prisoner.
22. Having had stomach pain for about a week, he was admitted to hospital on 24
July with possible liver failure. The fluid was drained from his stomach and he
discharged himself the same day, remaining on crutches for a further two
weeks.
23. His behaviour began to deteriorate as he came close to his potential release
date, which was scheduled for 10 November. He became abusive and
aggressive towards staff and other prisoners. He was due to be released on
an End of Custody licence. (This was a temporary special dispensation for
prisoners to be released up to 18 days early to ease overcrowding in prisons.)
However, it was a mistake and he was found to be ineligible for release
although the reason is not documented.
24. The man became angry at the decision and threw his television off the
landing. As a result he was taken to the segregation unit for eight days to
ensure his safety and that of other prisoners. (The purpose of segregation is
to maintain safety, order and discipline. A segregation unit provides
temporary accommodation for prisoners who have become violent or
disruptive, committed offences against prison rules or require protection if
they are under threat from other prisoners.) He also had an adjudication
proved against him for endangering the health and safety of himself and
others by throwing his television.
25. On 26 November, he was released from Altcourse, subject to licence
conditions, including the supervision of the Probation Service. He was told to
report to the Probation Office at 2.00pm that day as part of his licence
conditions. He did so and met his probation officer. He attended five further
weekly appointments with his probation officer throughout December and
January. The last one took place on 8 January 2009.
26. During this time, the man’s probation officer completed offence-focussed work
with him and started to prepare him for the Think First group (an accredited
programme which focuses on problem solving) that he was due to start within
two weeks. He said that the man did not ask for help with any particular
issues and he appeared to be settling well following his release from prison.
27. The man was arrested on 12 January for committing further offences and was
kept in police custody. By re-offending, he had broken the conditions of his
licence. A report detailing the circumstances of his recall to prison was
prepared by the probation officer and sanctioned by the Parole Board. Two
days later, the man appeared at Magistrates Court in relation to the new
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charges and was remanded to Altcourse the same day. The prison escort
record (PER) identified no risk of harm to himself or others. (The PER is a
form that accompanies staff on all prisoner escorts. It provides a
chronological record of the escort and also serves as a communication tool
about risks a prisoner poses on escort or transfer.)
28. An officer interviewed the man when he arrived at the prison. In response to
routine questions, he said he had no thoughts or history of harming himself or
attempting suicide. He was offered an appointment with the healthcare
department, a prison routine established as research has shown that recalled
prisoners can be more vulnerable than others, but he refused this. He also
had a routine interview with a Carer and denied feeling anxious or having any
concerns about being at Altcourse. (Carers are selected prisoners trained to
provide confidential emotional support to fellow prisoners. Every new prisoner
at Altcourse sees a Carer on their first day in prison and, if required, they have
a follow up the following day with the same Carer.) This was not deemed
necessary in his case.
29. A Cell Sharing Risk Assessment (CSRA) was also completed, which
assessed the man as low risk and therefore suitable to share a cell. No risk to
himself or others was identified. (The CSRA assesses the risk of harm a
prisoner presents to others if they are required to share a cell.)
30. On 19 January, the man went to Crown Court where he was sentenced to 15
months imprisonment. He returned to Altcourse.
31. The offender management unit completed a risk assessment with the man
two weeks later during which he said he had no history or current thoughts of
self-harm or suicide. On 6 February, an officer introduced himself as the
man’s personal officer. The man told him that he had no concerns.
32. Around the end of February and beginning of March, there are several
references in the wing history file to the man being upset because he said his
father was in a coma in hospital. He said he felt frustrated as he was in prison
and therefore could not see his father or help him. He was offered support
from a chaplain or Carer but declined. He was given emergency credit for the
telephone.
33. The man was granted IP4 status on 17 March as he had been working
consistently well as a cleaner and was well behaved. He had also recently
completed victim empathy and alcohol awareness programmes.
34. Just under a month later, on 15 April, the man lost his cleaning job for being
disruptive. He was also given notice that he would have to attend an
adjudication hearing for allegedly being in possession of a mobile telephone
and charger which he had refused to give to staff. This adjudication did not
take place.
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HMP Risley, 16 April – 11 July
35. The man transferred to HMP Risley the following day. My investigator was
unable to establish why he was transferred. The allocations department at
Risley told her in May 2010 that they had only basic information remaining on
their system. From this, they believed that he had been part of a regular
transfer, as prisoners often move from Altcourse to Risley following sentence
if they have a significant amount of time to serve. However, he told the
reception officer at Risley that he had been transferred from Altcourse due to
being caught with a mobile telephone. Altcourse were unable to confirm or
deny this as the records were no longer available.
36. The PER which accompanied him to Risley identified no risk of harm to
himself or others. An induction officer interviewed him when he arrived and
he was given the opportunity to make a telephone call. He said he had no
problems or any feelings of wanting to harm himself and had no issue with
being in Risley. The officer had no concerns regarding where he should be
located and, on a tick box form, described him as “quiet, indifferent and calm”.
He was given a single cell on the induction wing.
37. A nurse completed a healthscreen of the man later that day. He denied any
current thoughts or history of self-harm or suicide or previous mental health
issues. He commented that he was “happy to be at Risley”. The nurse
concluded that he was “fit and well”.
38. The following day, the chaplain visited the man in his cell. It is the
chaplaincy’s duty to speak to all new prisoners within 24 hours of their arrival
at the prison. The chaplain asked him whether he had any history of self-
harm or suicide, recent bereavements or whether he knew anyone who was
seriously ill in hospital. He replied “no” to all of these questions and told the
chaplain that he had family support, naming his mother as his next of kin. The
chaplain also gave him details of what the chaplaincy could offer him.
39. The chaplain told the investigator he did not consider the man to be at risk of
suicide or harming himself. The chaplaincy team at Risley also has a
commitment to visit everybody subject to Assessment, Care in Custody and
Teamwork (ACCT) procedures. (ACCT is the suicide prevention system used
by prisons to identify and support prisoners who are thought to be at risk of
self-harm and/or suicide.) He is an experienced ACCT assessor and
manager and said if he had detected any “slightest hint of risk”, he would have
opened an ACCT.
40. The education department completed an assessment with the man on 22 April
to identify his sentence planning targets. He said he would be keen to work
towards the targets set involving literacy, numeracy and bricklaying.
41. On 28 April, the man told a Senior Officer (SO) that he had spoken to a wing
officer two days previously about his girlfriend having a miscarriage recently
and he wanted to telephone her. The SO tried to verify this information with
wing staff, including telephoning an off-duty officer at home. No one
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remembered having such a conversation with him, nor was it recorded in his
wing history file or the wing observation book.
42. The SO contacted the chaplain, who telephoned the man’s mother. She said
he had made a similar claim while at Altcourse and it was not true. The
chaplain passed this information to the SO who, in turn, asked the man to
come and speak to them both in the wing office. The chaplain asked the man
for his partner’s details and those of the hospital. (This is in line with protocol
at Risley which states that bad news, such as a bereavement, must be
confirmed with an outside authority.) The man said he would return with the
information in ten minutes, but did not do so.
43. The chaplain told my investigators that he believed the man had been trying
to obtain an extra telephone call to his partner. He completed a Security
Information Report (SIR) on the basis of which the security department
authorised the monitoring of his telephone calls. (SIRs hold security
information on prisoners. Any member of staff can record information on a
prisoner, no matter how small or insignificant it seems. The intelligence is
evaluated according to the reliability of the source and the potential impact on
the prison’s security.) The chaplain remained of the view that the man did not
present a risk of self-harm or suicide. The following day, he moved from D to
G wing as part of a normal allocation as he had now finished his induction
period.
44. On 24 May at around 9.00am, the man told an officer that his partner had
recently had a miscarriage. The officer allowed him a telephone call to his
partner. After this he told the officer that he “wishes he was dead” and “feels
like hanging himself”. The officer therefore completed a Concern and Keep
Safe form. (This form can be opened by any member of staff and is the first
step in the ACCT monitoring process.)
45. A second officer then completed an ACCT assessment interview with the man
which examined his feelings, mental state and intentions in more detail. The
officer noted that he felt low and depressed and, although he had no plans to
commit suicide, he felt serious about doing so. They discussed various
coping mechanisms and the impact his actions would have on others.
46. A second SO then completed the Immediate Action plan and assessed that
the man should remain in a single cell and be referred to the community
psychiatric nurse. The SO ensured the man was aware that he could have
access to Listeners and telephone calls to his relatives. (Listeners, much like
Carers in a private prison, are selected prisoners trained by Samaritans to
provide confidential emotional support to fellow prisoners in distress.) The SO
decided that staff should have “meaningful conversations” (supportive
interactions when the member of staff talks to the prisoner) with the man three
times each day, once every night and he was to be checked hourly. The SO
also noted in the care plan that the man’s partner should be contacted by his
personal officer and pin credit (for the prisoners’ telephone system) should
immediately be arranged.
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47. Soon after completing this assessment, the second SO reviewed the man’s
file and realised that he had also made a claim one month earlier that his
partner had miscarried. The SO therefore rang the man’s mother and asked if
she had heard anything in this regard. She was unaware of any information
regarding a miscarriage and believed her son was lying. The SO therefore
asked the man to come to the wing office and asked him for further details.
The man gave inconsistent versions of what had happened. The SO again
telephoned his mother and allowed him to speak to her. However, the man
claimed she was a liar and also called the SO a liar, alleging he had not called
his mother.
48. The second SO said he found the man’s outright denial that he had called his
mother bizarre and was unsure as to whether he had mental health problems.
He therefore referred him to the community psychiatric nurse (CPN) at
6.45pm. Since it was a Sunday, staffing levels were at a minimum. The SO
therefore telephoned the mental health team and left a message on their
voicemail referring the man. The SO said it was his understanding that
normally such a message would be picked up and acknowledged with a
telephone call by the mental health team the following day. As a result of his
suspicions that the man was attempting to obtain additional free telephone
calls, he also completed a SIR.
49. The investigators spoke to the mental health team manager regarding this
referral. She told my investigators that the team had not received the referral.
The usual referral method is to complete a pro forma and hand deliver it to the
mental health inbox in healthcare. She said all staff were aware of this and it
avoided any unnecessary delays in referrals. The referrals are then entered
onto the electronic system. The prisoner is sent a letter and placed on a
waiting list, or seen immediately depending on the risk they present.
50. The following day at 9.40am, the man’s first ACCT review was led by the
second SO with a third officer and the man also present. He admitted that he
had fabricated the information about his partner’s miscarriage in order to
obtain telephone calls. The SO told him that he would still need to be
assessed by the CPN and he agreed to this. The man apologised for wasting
staff time and said he would not do this again. The ACCT was closed and a
post-closure review set for 2 June.
51. In an email to my investigator, the safer custody department said that the
post-closure review was carried out as scheduled. However, there is no
information recorded in the ACCT documentation to indicate that this was the
case and I am therefore concerned that it may not have happened. I note that
the clinical reviewer is of the opinion that it did not take place. (This brief
period when the man was subject to ACCT procedures was the only occasion
when he was assessed to be at risk of suicide during his time in prison.)
52. On 29 May, the man moved to Birchwood (B) wing at his own request, to be
nearer his friend from home. Although located on different floors, his friend
was often in another friend’s cell, which was next to the man’s. He therefore
spoke to him frequently about everyday things such as football. His friend told
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the investigator that he never had any concerns about the man harming
himself and said that if he had been worried, he would have told a wing
officer. He considered that they are all approachable. He said that the man
often came to talk to him and his friends when he found it difficult to cope with
being unable to see his partner. The man’s friend understood this to be the
man’s first relationship while he was in prison.
53. A prisoner occupied the cell opposite the man on B wing. He became friends
with him soon after he was moved to the wing and they talked every day,
often spending time in each other’s cell, collecting their meals together and
shouting through their doors to have a conversation after they were locked up.
He told my investigators that the man was “stressed out” and spent a lot of
time on the telephone to his partner. He thought he found it difficult being
unable to see her and find out what she was doing. The man worried about
her every day. However, the prisoner did not think that he had shared these
feelings with staff.
54. Staff and prisoners said that the man got on well with the other prisoners.
Another prisoner on B wing said that the man was always happy and smiling.
The officer who worked on B wing said the man was cheerful and quiet and
gave him no cause for concern.
55. In the evening of 1 June, the man complained of chest pains to an Officer
Support Grade (OSG). The OSG asked a nurse to visit and assess him. He
was prescribed paracetomol and brufen (both painkillers) and magnesium
trisilicate (used to treat excess stomach acid). The man was advised that, if
his pain persisted, he should press his cell bell. (A bell located in each cell to
be used by prisoners in the event of emergency or if they require a member of
staff’s attention).
56. An hour later, the man again told the OSG his chest hurt. Healthcare staff
attended and attached an electrocardiogram (ECG) to measure the rhythm of
his heart. On the basis of the test and his complaint of shortness of breath,
he was taken to hospital by ambulance. As is routine, he was accompanied by
two officers and an escort chain was used to attach him to one of these
officers.
57. However, at the hospital, officers became suspicious of a member of the
public who walked past the man’s room three times. Therefore, when he
asked to go to the toilet the officers asked him to use the commode in the
room. They were suspicious that he may have wanted to retrieve a package
left in the toilet, which could have contained drugs. He refused this request
and discharged himself at 3.15am, saying that he no longer wanted to see a
doctor. He returned to Risley and the officers recorded their concerns in a
SIR. He was seen by the prison doctor in surgery that morning who believed
the chest pain to be muscular and gave advice and prescribed painkillers.
58. The following day, the man asked a governor to telephone his partner who he
said was worried as the hospital had contacted her the night before when he
17
had been admitted. The governor contacted his partner who was not aware
that he had been admitted to hospital the previous night.
59. On 5 June, a Principal Officer (PO) from the safer custody department
received a telephone call from the Samaritans to say that the man had called
them at 8.30pm the night before. He had told the Samaritans how “low and
depressed” he was due to his wife’s miscarriage. The PO therefore
telephoned wing staff who told him that the man had lied about the
miscarriage.
60. The PO told my investigator that this information had been given to him by the
Samaritans co-ordinator, who trains Listeners in Risley. He said he assumed
that they had either taken the telephone call from the man themselves, in their
capacity as a community Samaritan, or had the information passed to them by
another colleague. Since the Samaritans service is supposed to be
completely confidential, my investigator asked how such information could be
disclosed. The PO said he was not aware of any policy allowing them to do
so but did not question this at the time, as the information was not new to
prison staff.
61. Since the man had not been issued with the Samaritans telephone (a mobile
used solely for calling the Samaritans) at any time on 4 June, the PO was
concerned that he may have had access to his own mobile, which is against
prison rules. When asked by officers, the man denied calling the Samaritans.
62. The PO submitted an SIR and as a consequence the security department
authorised that the man’s mail and telephone calls should be monitored
between 12 June and 7 July. His letters were routinely monitored from this
point onwards but there is no information about monitoring his telephone calls.
Despite several requests to the prison, my investigator was unable to obtain
any information about how frequently this occurred.
63. The man again complained of chest pains during the evening of 21 June. A
nurse assessed him twice and used an ECG to monitor his heart. A record of
which was sent to the local hospital for analysis and the result was normal.
The nurse therefore asked the doctor to review him the following morning. A
prison doctor assessed him on 22 June during morning surgery and gave him
further advice and reassurance. The doctor still thought that the pain was
muscular.
64. A week later, during the evening of 28 June, the man complained of chest
pains to a second OSG. The OSG immediately contacted healthcare and a
second nurse attended. The nurse assessed him, prescribed painkillers and
advised him to ring his cell bell again if the pain got worse.
65. The man rang his cell bell half an hour later and the second nurse returned,
having been contacted by the second OSG. The nurse carried out some
tests, including an ECG and contacted the hospital with the results. Having
reviewed them, the hospital told the prison to keep monitoring him at regular
intervals.
18
66. The second OSG continued to observe the man and around midnight found
him on the floor in his cell complaining of chest pains. He immediately
contacted the healthcare department and the night orderly officer, a third SO,
who went straight to his cell. (The night orderly officer is in charge of the
prison and, as well as making regular patrols of the prison, must respond to
any emergencies). The SO called an ambulance and the man was taken to
hospital. The second nurse told the clinical reviewer that on this and other
occasions when he assessed him, he did not believe he had any mental
health issues.
67. All the tests at the hospital revealed results within the normal limits and the
man returned to the prison at 3.00am the following morning. He was advised
that any pain was muscular and should resolve itself within two weeks with
the prescribed anti-inflammatories (ibuprofen). Later that morning, he told
officers he was experiencing some lower rib pain and was given a painkiller
by a nurse.
68. Officers who had taken the man to the hospital completed an SIR as they
questioned whether his symptoms had been genuine. (This was in light of the
previous SIR submitted when he went to hospital around a week earlier.) In
addition, although he had appeared to be unconscious, he still had certain
reflexes, for example when they moved him he put his hand out. It was
recommended that, in future, an alternative hospital should be considered and
he should be escorted by three officers and placed in two sets of handcuffs.
69. On 9 July, the man asked an officer if he could make a telephone call to his
son who was in hospital. This was authorised by the wing SO but, when the
officer allowed him to make the call, he did not mention his son. The officer
therefore checked the wing file where he saw the record of the man’s previous
attempts to gain telephone calls. The officer then telephoned the man’s
mother, father and partner who confirmed that he had no children.
70. The officer said the man had looked worried prior to making the telephone call
and he therefore asked his partner if he was having any difficulties she knew
of. She said that he found it difficult being in prison, not knowing what she
was doing all the time. She told the officer that he also told lies in Altcourse in
order to get telephone calls. The officer therefore spoke to him who admitted
that he had made up the story and apologised for this. On the basis of this,
information was again submitted to the security department who authorised
the reading and monitoring of mail and telephone calls until 6 August.
12 July
71. On 12 July at 10.32am, the man made a telephone call to his partner, and
asked if they should end the relationship. He said he had made a cut on his
arm the previous night and felt suicidal. This and other telephone calls he
made later that day were not listened to until after his death by a third OSG,
who recorded a brief summary of each call. Whilst my investigator had
access to this summary document it was not possible for her to obtain a copy
19
of the transcript of the telephone calls as they had been erased from the
system.
72. The prisoner who occupied the opposite cell said that the man seemed upset
following this telephone call and asked him to make a telephone call for him to
his partner, despite this being against prison rules. Around 20 minutes later,
the prisoner made the call as a favour for a friend. He asked the man’s
partner if she was happy in her relationship with him which she confirmed she
was. The prisoner told the man this.
73. In the next half an hour, the man made another two telephone calls to his
partner during which he again mentioned he was feeling suicidal but that he
was trying to calm down. He then ran out of credit and said he would see her
on Wednesday.
74. The man’s friend said that for the week before he died he had seemed
particularly stressed about issues with his partner. On 12 July at around
4.30pm, the friend noticed that the man had a cut on his arm which he said
had happened when he was making his bed. He was unsure whether to
believe this, but said the man was joking as normal with him and his friends.
He also noticed the cut and gave him a plaster to cover it.
75. The same afternoon, the second prisoner said that the man had come over to
his cell and asked for some paper. This was unusual as he had never been in
the prisoner’s cell before. However, the prisoner said he seemed cheerful.
He did not know of any issues the man had with other prisoners and was
shocked when he found out he had died. Later that day, the prisoner helped
the man write his partner a letter in which he asked her to come and see him
the following Wednesday. He said he was finding it difficult to cope without
her in prison. This letter was found in the outgoing post box after the man had
died and a copy was provided to the investigator.
76. That day, the man made an application to see the dentist as he had
toothache. He also made an application to transfer to HMP Stafford so that
he could be closer to his family and it would be easier for them to visit. He
placed both applications in the wing box but, since it was the weekend, it was
not emptied until two days later.
77. The man collected his evening meal at 4.45pm and was locked in his cell at
5.00pm. The man’s friend saw him when he collected his meal from the
servery and said he seemed the same as usual. He said he had no concerns
that the man was a risk to himself, otherwise he would have spoken to
officers. He did not believe the man was having any problems with other
prisoners and said he had a good group of friends on the wing.
78. The first prisoner told my investigators that later on that evening the man
shouted to him from his cell that he felt “stressed out”. He asked what was
wrong but he did not reply. The prisoner said he was very shocked the
following morning when he was told he had taken his life. He said if he had
had any idea he was considering harming himself, he would have told staff.
20
79. The second OSG began work three hours later. His first job was to check
every prisoner, including the man, and get a response from them. He then
signed the log book to indicate that everything was in order and the officer on
the day shift went off duty. He remembered hearing the man joking with the
prisoner in the cell opposite him around this time.
80. The OSG was then locked on the wing on his own. He was carrying a radio
and a sealed pouch containing a cut-down tool and a cell key to be used in
the event of an emergency. (Cut down tools are used to cut ligatures. All
staff in closed and semi-open prisons who have contact with prisoners are
issued with and must carry their own tool.) The OSG has to patrol the wing
every hour and push the pegging points on his rounds to prove he had done
so. (Pegging is when an electronic scanner is used to provide an auditable
register of the patrol.) He received a visit from the orderly officer three times
during his shift, as is the agreed protocol.
13 July
81. The second OSG said that, unless a prisoner was subject to ACCT
procedures or rang their cell bell during the night, he would have no reason to
check on them between the start and the end of his shift. At 5.55am he
started checking each cell on the wing by opening the observation flap,
switching on the light and getting a response from each prisoner. Ten
minutes later, he got to the man’s cell and opened the flap. The OSG initially
thought he was standing with his back to him so he kicked the door to get his
attention and spoke to him.
82. However, the officer then realised that the man was hanging from the light
fitting. He immediately radioed the control room and asked Oscar One (the
third SO) and Oscar Two (a fourth officer) and the nurse to report to B wing as
soon as possible. (Oscar One and Oscar Two are the radios assigned to staff
responsible for responding to emergencies.) The OSG said he was asked for
further details of the nature of the emergency over the radio and he said that it
was a hanging.
83. At the time, the third SO was unlocking the main gate and had therefore taken
his radio off momentarily, as was the normal procedure. The fourth officer
was standing nearby and heard the call for immediate assistance on B wing
over his radio. The officer shouted to the SO that there had been a hanging.
Another officer and a fourth OSG, who was standing next to him, immediately
started running to the man’s cell. The SO asked another officer to collect the
nurse from the healthcare centre (who would have been locked in there) and
meet them at the cell. The OSG said the SO told him not to enter the cell on
his own and he would be there within two minutes.
84. The duty nurse had to respond to any medical request for assistance,
emergencies or otherwise. When she heard the radio call for assistance she
began packing her emergency bag. She then heard that it was a hanging and
radioed control to ask them to request an ambulance immediately.
21
85. Around a minute after the initial call for assistance, the fourth officer arrived at
the cell and shouted to the man through the observation flap. He could see
that the man had his back to the door and had tied his belt round his neck and
to the light fitting. He said the man did not look as though he was actually
hanging or suspended, more that he had bent his legs and was “slumped
down”.
86. Having received no response from the man, the fourth officer unlocked the
door and was about to go into the cell when the fourth OSG and third SO
arrived around 30 seconds after him. They all went into the cell and
immediately judged that rigor mortis had begun, with some pooling of the
blood in the bottom of his legs. The officer cut the ligature while the other
officers supported him and lowered him to the floor. They were in agreement
not to start resuscitation since he was cold to the touch, he was rigid and his
arms and legs did not straighten when they laid him on the floor. The SO
removed the belt from the man’s neck.
87. By this stage, the nurse had arrived from the healthcare centre. She also
agreed with the officers’ assessment that the man had died and there was no
purpose in starting resuscitation. She said it was obvious to her that he had
been dead for a number of hours. The OSG was asked to leave the cell by
the SO as he believed he was in shock. The OSG sat down nearby and the
nurse checked on his well-being.
88. The paramedics arrived at the man’s cell at 6.19am. Their opinion was also
that he had died. They attached their defibrillator to him as is protocol to
confirm that there was no cause to treat him and it confirmed “life extinct”. (A
defibrillator is a portable electronic device which measures electrical activity in
the body and advises on the action to be taken.)
89. The man had left a letter in his cell which asked his mother to look after
herself and his siblings. He said he was sorry but it was “time to go” and his
life was not worth living any more. He also apologised to the person who had
to cut him down.
90. The duty governor told all the prisoners on the wing of the man’s death at
6.40am and they were allowed out of their cells to talk to each other. Those
subject to suicide monitoring procedures were also checked and those who
were friends with him were spoken with in more depth.
91. The chaplain was called into the prison. When he arrived at 7.50am, he went
straight to the man’s cell where he prayed over his body as his religion was
registered as Church of England. Staff in the chaplaincy organised a
memorial service for him in the prison chapel at 11.00am. Nineteen prisoners
from his wing attended. The chaplain also spoke to the other prisoners on the
wing.
92. Staff were seen by the care team that morning and were also interviewed by a
governor. Two debriefs for staff were held, one that morning and another
22
around two weeks later. Staff said they felt very well supported in general.
However, some staff said that they were on leave the following week and
were not contacted during this time. They therefore found it more difficult
coming back to work the week after. For example, an SO was asked
questions by his team regarding the man which he could not answer as he
had not been kept informed.
93. A duty governor and a Principal Officer (PO) were immediately appointed as
family liaison officers. The duty governor, along with the chaplain, told the
man’s mother of his death at her home that morning. His mother wanted to
inform his partner and father herself.
94. The PO told the man’s mother that he had not left any letters in his cell since
she was unaware that the police had already taken them. The police gave his
mother a copy of them the following day. The PO remained in contact with
the family. The prison offered to pay the funeral expenses and returned his
property to them promptly. His partner visited the prison on 21 July and
spoke to prisoners and staff who had known him.
95. One of the family’s concerns was that they felt the PO inappropriately
recommended that they see a medium following the man’s death. My
investigator spoke to the PO who explained that she had had some relevant
personal experience and had been speaking about what had helped her
situation. She said that she did not advise his mother to see a medium. It is
clearly impossible to determine the exact nature of the conversation after the
event but given the potential for misunderstanding or misinterpretation, it may
be advisable to avoid discussion of such subjects in future.
96. I am aware that the man’s partner said she was told by police that he had
fresh cuts to his rectum. She wanted more information regarding this. At the
time of completing this report I have not had sight of the post mortem report
and am therefore unable to comment further. However, the coroner’s officer
told my investigator that the provisional cause of death has been registered as
hanging. The toxicological report indicated that he tested negative for drugs
and alcohol.
23
ISSUES
Monitoring under the suicide and self-harm procedures
97. The man had not been considered at risk of self-harm or suicide while at
Altcourse and the same assessment was made by officers and healthcare
staff when he transferred to Risley. The only time he was subject to ACCT
procedures was on 24 May 2009, following his claim that his partner had
suffered a miscarriage and he felt suicidal.
98. The following day, the man admitted that he had fabricated the story to try and
get a telephone call to his partner. He denied any feelings of self-harm or
suicide and the ACCT was closed appropriately. The post-closure review was
set for 2 June. My investigator was told by the safer custody department that
it took place. However, she has not had access to any documentary evidence
to support this assertion. Whilst I do not make a formal recommendation in
this regard, I would ask the Governor and head of safer custody to satisfy
themselves that post-closure reviews take place and are documented as
required.
99. The man made three telephone calls to his partner on 12 July, during which
he said that he was considering suicide and had cut himself the previous
evening. However, prison staff did not listen to these calls until after he had
died. I have found no other evidence that he presented a risk of harm to
himself and therefore assess that staff used ACCT measures in an entirely
appropriate manner.
100. The clinical reviewer also made similar observations. He concludes, “My
judgment is that while the man’s attempt at fatal self harm on 13 July 2009
was foreseeable it was not predicable or preventable.”
101. Both the man’s partner and his mother said that they had told the prison that
they did not think he should be allowed to keep his belt as they were worried
about the risk he may present to himself. However, this is not documented
anywhere in his paperwork, nor did any of the staff recall such information
being passed to them. The PO appointed family liaison officer told my
investigators that any concerns regarding an individual would be logged by
the duty governor and passed to relevant staff. I make no formal
recommendation in this regard but the Governor might wish to satisfy himself
that such information is being routinely passed on.
102. However, even if staff had this information, unless they assessed the man as
at risk of suicide or self-harm, they would have been unlikely to remove his
belt from him. Prison policy states that such items can be considered for
removal if the prisoner is assessed to be at risk of harming himself. However,
even in such situations, this decision is not automatic and must be taken after
careful consideration. The removal of a prisoner’s personal belongings may
cause them further distress and reduce their dignity.
24
Personal officer scheme
103. Staff at Risley were unable to tell my investigator who the man’s personal
officer was. At the time, a prisoner’s personal officer was recorded on a board
on the wing and, when the prisoner or officer moved wings, their name would
be replaced. Thus, there is no record in the written documentation identifying
his personal officer.
104. The Risley personal officer handbook outlines that each prisoner should have
both a personal officer and reserve who are responsible for ensuring frequent
contact with the prisoner. The guidance notes that a minimum of two quality
entries must be made per month in the prisoner’s history sheet. It goes on to
say the personal officer contributes to:
“ … supporting a prisoner with any motivational issues, assisting him in
accessing provision and utilising it appropriately, providing advice and
guidance and receiving feedback from him regarding his progress
through elements of his sentence plan … The personal officer is
responsible for supporting the prisoner to sustain links with external
agencies and support networks, families/carers and community
facilities.”
105. The handbook also says that personal officers are expected to attend ACCT
reviews and complete a target sheet once a fortnight which should include
information relevant to an individual’s progress through his sentence. For
example, his attitude, issues with other prisoners and family ties.
106. In her most recent inspection report of Risley, HM Chief Inspector of Prisons
had concerns regarding the personal officer scheme at Risley and described it
as “weak”. From the information provided to my investigator, it was not
possible to confirm whether the man had a personal officer and if he did, who
this was. Certainly the guidance in the personal officer handbook was not
followed and there are insufficient entries in his wing history sheet to
determine this. It may have helped him to have a more personal relationship
with an officer whom he could confide in, as well as providing a more
consistent and cohesive approach to his issues. This is a matter of concern
to his family as they were contacted by different members of staff asking for
the same information. The contacts must be particularly distressing with the
hindsight which follows his death.
107. Despite this lack of evidence regarding the man’s personal officer, it should be
noted that staff spent considerable amounts of time trying to verify issues
which he said were upsetting him, despite him having fabricated stories on
previous occasions. He also received appropriate care in relation to his chest
pain despite suspicions that his symptoms may not be genuine.
108. I am aware that since the man’s death Risley has drafted a new personal
officer scheme policy which will shortly be introduced. A prisoner’s personal
officer is now also recorded on the National Offender Management
25
Information System (NOMIS), a computer system which has been installed at
Risley since his death. I therefore make the following recommendation:
The Governor should satisfy himself that the personal officer scheme is
operating effectively and in accordance with the local protocol.
Mental health referral
109. On 24 May, the man made inconsistent claims regarding his partner having a
miscarriage. He accused his mother of lying that it was not true and the
second SO of lying that he had telephoned her. The SO recorded that he
made a referral to the mental health team by telephoning them and leaving a
voicemail. He believed this would be actioned the following day. However,
the mental health team manager said the team did not receive it and the usual
process was to submit a written referral to the team’s inbox. Therefore he did
not receive any mental health support.
110. The clinical reviewer makes the following observation:
“My reading of the referral is that it was based on the precautionary
principle. In addition, the man had come into contact with other
members of the healthcare staff including a GP. None of these
professionals took the view that he had a mental health problem. His
record from HMP Altcourse indicates that he had no documented
history of mental illness or self harm.
“In the light of the above my view is that, it is reasonable to assume
that even if he had a post ACCT closure interview and been seen by
the mental health team it is unlikely that his risk category of self-harm
in the future would have been upgraded. It is arguable that he might
have benefited from a mental health assessment. However it would be
stretching any sensible reasoning to infer or assert that a mental health
assessment would have led to a different outcome.”
111. Despite this, it is crucial that there is clarity in the mental health referral
process and those prisoners who need to be assessed gain the appropriate
access to services. The SO believed he could complete a telephone referral,
but the mental health team told my investigators that they require hand
delivery of a written pro forma. It is of further concern that the mental health
team did not receive the second SO’s voicemail. The clinical reviewer also
concurred that he believed mental health referrals may need to be more
clearly communicated. I therefore make the following recommendation:
The head of healthcare should review the referral process for obtaining
a mental health assessment and ensure all staff are aware of the correct
procedure to follow.
26
Treatment of the man’s chest pain
112. The clinical reviewer makes the following conclusion regarding the
assessment and treatment of the man’s chest pain:
“Although he appears to have complained of chest pain over a period
of time during his stay at HMP Risley, there were three [on 1 June, 21
June and 28/29 June 2009] times on which he called the night staff.
On each occasion he was properly examined. An ECG was taken on
each occasion and on two occasions he was sent to hospital, albeit
that on the second occasion he was only taken to hospital as this was
dictated by protocol.
“He was also seen by a doctor at the prison on two occasions following
the night time episodes of chest pain. A diagnosis of pain of
musculoskeletal origin was made by the doctor and this was supported
by the assessment in the accident & emergency department.
“The plans to meet the man’s needs were comprehensive. His
symptom of chest pain was properly assessed and managed. His
healthcare needs were sufficiently and appropriately assessed on
reception and in custody at HMP Risley. He was assessed [correctly]
to have no significant chronic or active physical or mental health
problems.”
113. Staff had some concerns as to whether the man’s symptoms were genuine
and there were security issues in taking him to an outside hospital. Despite
this, they always acted in an entirely professional manner, making sure he
had thorough assessments and was given the opportunity to receive
treatment he required.
Going into cells at night
114. Having discovered the man hanging, the second OSG said he was instructed
over the radio by the third SO not to go into the cell until someone else
arrived. This was not confirmed by the SO, but in any event he told my
investigators that in this situation he believed the OSG had acted correctly by
remaining outside the cell. The SO said from the way the man was positioned
it was an unusual way to be hanging and therefore may not have looked like a
life threatening situation. Other staff made reference to the fact that he was
not actually suspended off the floor but was “slumped”.
115. However, when requesting assistance, the OSG said he thought a prisoner
had committed “suicide” and that it was hanging. This indicates that he
believed it to be a life threatening situation. The OSG believed he could go
into a cell at night with Oscar One’s permission if a prisoner was bleeding and
he had a chance to stop the bleeding. The SO said that an OSG can go into
the cell if they can save a life, but they must first of all inform the orderly
officer that they are going inside.
27
116. Risley has a local policy which outlines the procedures to follow in the event
of an actual or suspected death in custody at night. It says that if it can be
done safely, the person discovering the situation should enter the cell and that
if the person is hanging, they should support the body and cut the person
down. They should place the person on the ground and check for signs of
life, attempting resuscitation if assessed as appropriate.
117. Another protocol details when a cell can be unlocked at night using the sealed
pouch. This says:
“All wing patrols carry a sealed pouch (containing a cell key and class
two key) attached to their chain. This is to enable the night patrol to
respond quickly and open a cell door quickly if it is thought that a
prisoner’s life is in danger (ie fire, self-harm). The night patrol should
exercise extreme caution when opening a cell door on their own and
should consider the possibility that the incident is not genuine. The
night orderly officer should always be informed by radio before a cell
door is opened. Unless a life is obviously at risk then the presence of
the night orderly officer should be awaited.”
118. NOMS’ Chief Operating Officer wrote to all Governors on 26 January 2010.
This followed concerns raised by my office in previous investigations
regarding staff understanding of when they can enter a cell at night. Although
his letter was sent after the death of the man, it is clearly relevant to this
investigation. He outlined that all staff must be aware of local procedures for
what they should do if faced with a potentially life-threatening situation when
there are no other staff in the immediate vicinity.
119. Given that the OSG said he had been instructed not to enter the cell, it is
understandable that he did not do so. Other staff were also present very
quickly at the man’s cell to open the door.
120. However, I am concerned that the OSG believed the only situation in which he
could enter a cell was if someone was heavily bleeding and he could stop the
bleeding. The protocol makes reference to other emergencies when a
prisoner may be in danger such as a hanging or if the cell is on fire and that if
safe to do so the night patrol should enter immediately in such situations.
However, I do also recognise that the man was not suspended from the floor
and that this may therefore have given cause for confusion as the SO
explained. I therefore make the following recommendation:
The Governor should ensure that all staff working at night, including
Operational Support Grades, are aware of their roles and
responsibilities, especially regarding going into cells in the event of an
emergency.
The use of emergency codes
121. Following a death at Risley in 2007, I recommended that a code system
should be introduced to use in emergencies, to help define the nature of the
28
emergency to those summoning assistance. Whilst my investigators saw
evidence that this has been introduced, it is apparent that staff were unclear
about its usage.
122. The SO said that emergency codes had been in place at Risley since around
October 2008. These are code black for a potential hanging or if the prisoner
is unconscious, code red if the prisoner was bleeding and code yellow for a
less serious injury. The nurse said that she believed the codes in operation at
the prison were white, red and yellow.
123. The OSG said that, whilst he was unaware of the codes to use in the event of
an emergency, he believed that those senior to him would use them. As the
nurse commented, even if the OSG had known the codes, the shock of
discovering someone hanging or otherwise injured can often lead the person
to forget to use the correct code. The OSG was clearly quick to respond to
the emergency and, critically, he requested healthcare and management
assistance, also verifying the nature of the emergency when asked.
124. None of the policies relating to night staff response to emergencies which
were seen by my investigator detail the code system. They simply refer to the
night patrol requesting emergency assistance. It therefore seems that,
although these codes have been introduced, staff are not clear about their
use. I therefore make the following recommendation:
The Governor should remind all staff about the correct use of
emergency codes and ensure that advice relating to the code system is
incorporated into all the policies relating to an emergency response.
29
CONCLUSION
125. The man had been in prison for most of his adult life. During his most recent
sentence from January 2009, he was not considered a risk of self-harm or
suicide. I judge that this assessment was sound. The period of around 24
hours during May 2009 when he was on an ACCT was a result of a lie he told
about his partner to obtain a telephone call to her. He subsequently denied
any thoughts of suicide or self-harm.
126. Staff took considerable time to try and verify the difficulties the man said he
was experiencing, whether connected to his partner or when he said his son
was in hospital. They also ensured that he received the appropriate
assessment and treatment chest pain despite their concerns as to whether
these symptoms were genuine. I have found that staff acted with patience
and compassion for him.
127. The prisoners who knew the man said he was becoming increasingly upset
about being unable to see his partner in the days before his death. However,
he seemed to be making plans for the future and had applied to move to a
prison nearer his family and friends to make their visits easier. No one, staff
nor prisoners, believed he was a risk to himself and his death came as a
shock to all those who knew him. He did not share the depth of his distress
and I am satisfied that nothing could have been to prevent his death.
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RECOMMENDATIONS
1. The Governor should satisfy himself that the support officer scheme is
operating effectively and in accordance with the local protocol.
This recommendation was accepted. Series of Personal officer briefings and
awareness sessions have been conducted. Awareness training is continuing
to be carried out on Induction for relevant new /transferred in staff.
2. The head of healthcare should review the referral process for obtaining a
mental health assessment and ensure all staff are aware of the correct
procedure to follow.
This recommendation was accepted. A new system has been implemented
which complements the verbal request for a mental health assessment.
The requestor now completes a carbon copy assessment referral form a copy
of which is kept in the ACCT document. The system has now been
embedded and is monitored by the Safer Custody Manager
3. The Governor should ensure that all staff working at night, including
Operational Support Grades, are aware of their roles and responsibilities,
especially regarding going into cells in the event of an emergency.
This recommendation was accepted. Night operating procedures were
reviewed in July 2009. A further review of procedures was carried out in
February 2010 and implemented in way of an LSI and LSS.
4. The Governor should remind all staff about the correct use of emergency
codes and ensure that advice relating to the code system is incorporated into
all the policies relating to an emergency response.
This recommendation was accepted. A new code system was introduced in
March 2008. Also, the safer custody PO has carried out a series of staff
briefings and awareness sessions for all directly and non-directly employed
staff w/c 12 July 2010. To date 8 Roadshows have been attended by 87 staff.
Further Roadshows are planned to inform staff in remaining areas including
night staff.
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FAMILY RESPONSE
1. The report was sent to both the man’s mother and his partner. His mother
asked for clarification regarding the prisoner’s comment during interview that
the man had a broken rib and marks on his legs. I have found no evidence of
either of these injuries in his clinical record or other documentation. His chest
pain had always been diagnosed as muscular. Without sight of the post
mortem report I am unable to comment further.
2. The man’s friend told my investigators that a card and collection had been
made following the man’s death. His mother asked where this had been sent
since she had not received anything. The prison financial department were
unaware of prisoners withdrawing any money from their accounts for this
reason. The man’s friend has since been released from the prison and, at the
time of writing, further enquiries were being made with other prisoners and
staff on the wing.
3. The man’s partner continued to question why he was allowed to keep his belt.
She said she had spoken to an officer who said he had concerns about his
mental health and she asked the officer to remove his belt. His partner also
confirmed that she had a miscarriage around the end of January 2009.
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