Individual at Durham

Investigation into the circumstances surrounding the
death of a man
at HMP Durham in May 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2011
This is the report of an investigation into the circumstances surrounding the death of
a man at HMP Durham who was found hanging in his single cell in May 2009. He
was 23 years of age.
I extend my sincere condolences to his family and partner.
The investigation was conducted by one of my colleagues. I should like to thank the
Governor of Durham and his staff for their co-operation throughout this investigation.
The man had been remanded into Durham in March charged with the murder of a
neighbour. This was his first time in custody and it is clear that he found prison
difficult. He had been maintained on suicide prevention monitoring and support
measures (the ACCT process) during two separate occasions during his time in
Durham. However, by the time of his death he was not being monitored as staff felt
that he was no longer at immediate risk.
After the man’s death suicide letters were found in his cell addressed to his parents
and his partner. He had also left an account of his final few days in which he listed
many concerns and complaints about the prison wing where he was located.
The first draft of this report was issued in February 2010. In response to extensive
comments received from the man’s family, I have made a number of revisions to this
report which I reissue as a revised draft.
I make five recommendations. Four of these are about the ACCT process, two of
which are national recommendations. The other recommendation is about guidance
for Family Liaison Officers.
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 the
investigation.
Thea Walton
Acting Prisons and Probation Ombudsman December 2011
2
Summary
The Investigation Process
HMP Durham
Key Findings
The Man’s Journal
Issues
Conclusion
Recommendations
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SUMMARY
The man was a 23 year-old prisoner who was found hanging in his single cell at
HMP Durham on the early morning on a day in May 2009. His was the fourth self-
inflicted death in Durham within a ten week period.
This was the man’s first time in prison custody. He had been in Durham for just
under two months and was there on remand having been arrested following an
incident that resulted in the death of a neighbour.
On his arrival in Durham, the man told staff that he had harmed himself in the past
and that he was having current thoughts of self-harm or suicide. Staff opened an
ACCT1 form and he was initially located on Durham’s induction wing. The following
day he was relocated to the healthcare unit for enhanced observation. That
included a period of a week when he was kept on constant observation.
While in healthcare the man had consultations with a Community Psychiatric Nurse
and with a Specialist Psychiatric Registrar (SpR). The man told the SpR that he had
been an anxious child and had been bullied at school. He told her that he had
started to harm himself while still in secondary school and also told her that he had
always wanted to kill himself.
By the middle of April the man had settled and the ACCT form was closed. A week
later, he was transferred back to E wing to complete his induction. During his time
back on E wing the ACCT form was reopened after he was found lying under his bed
in a tearful state.
Once induction was completed the man needed to be transferred to a residential
wing. He was allocated to D wing, which is used primarily, but not exclusively, for
prisoners with drug addiction problems. This man had no such problems.
The man’s ACCT form was closed four days after his arrival on D wing when the
review panel concluded that he was no longer at immediate risk. The panel did not
read an entry in the ACCT form made two days earlier when he reported making a
ligature at some time in the previous two weeks.
On Friday 15 May the man reported to a senior officer that he was fearful of the other
prisoners on D wing. The senior officer took his complaint seriously and told him that
he would arrange his transfer to a different, and more suitable, wing. He said though
that he would probably not be able to arrange the transfer until the following Monday.
During the early morning roll check on a day in May the man was observed to be
lying face down on the floor with a ligature around his neck tied to the top bunk.
Staff went into the cell and examinations showed that rigor mortis was already
established in his body. Consequently staff appropriately made no attempts to try to
resuscitate him.
1 ACCT (Assessment, Care in Custody and Teamwork) is the process used for monitoring and
supporting prisoners deemed at risk of self-harm or suicide.
4
Following the man’s death a journal was found in his cell in which he had recorded
the events and his thoughts during the final few days of his life. It is clear from the
journal that he felt frightened and intimidated by the other prisoners on D wing. He
also referred to his conversation with the senior officer and that officer’s promise to
move him to a different wing.
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THE INVESTIGATION PROCESS
1. My investigator in this case was assisted by one of my Assistant Ombudsmen.
My investigator first visited Durham on 21 May 2009 when he met the Deputy
Governor, the functional Governors in charge of safer custody and decency, a
representative from the Prison Officers’ Association and a member of the
Independent Monitoring Board.
2. My investigator met the police investigator and agreed with him the handling of
the complaints made by the man about the prison.
3. County Durham Primary Care Trust agreed to carry out a review of the man’s
clinical care and treatment at Durham. The PCT commissioned a private
company, Custodial Care Innovative Solutions (CCIS), to conduct the review on
its behalf. CCIS appointed a clinical reviewer to conduct the review. I would
like to thank CCIS and the clinical reviewer for their assistance.
4. My investigator interviewed 14 members of staff. He interviewed one prisoner,
a Listener2 to whom the man had spoken a few days before his death. My
Assistant Ombudsman joined the investigator for some of the interviews. No
other prisoners came forward in response to the posting of notices about the
man’s death.
5. One of my Family Liaison Officers contacted the man’s parents and she and the
investigator visited them at their home. The man’s sister and partner were also
at the meeting.
6. The man’s mother raised a number of concerns. She wanted to know about
staffing levels on D wing and about the training that staff had received. She
wanted to know whether there were any similarities in the circumstances
surrounding her son’s death and those surrounding the deaths of three other
prisoners at Durham during early 2009. She also wanted to know whether her
son had had a promise that he could move to the prison’s healthcare unit if he
wanted to. She questioned why Durham did not have a unit for vulnerable
prisoners. She was also concerned about the way the family was dealt with
following her son’s death.
7. My investigator and family liaison officer also met the man’s grandmother. With
other members of the family she had visited her grandson on the day before his
death when she thought he seemed his usual self. She also said, however,
that he hated D wing and wanted to transfer back to healthcare. She said that
she had observed a gradual deterioration in her grandson. She had once
believed in the British justice system but was losing that faith. The man’s
grandmother thought he had been let down by everyone and she wanted it
known how much his death had affected the entire family.
2 Listeners are prisoners trained by the Samaritans to provide the same service as Samaritans offer in
the community.
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Family response to revised draft report
8. In response to the Ombudsman’s first draft report, the man’s family raised a
number of additional questions. In order to address these questions a revised
draft report was issued. In response to the Ombudsman’s revised draft report,
the man’s family provided further comments through their solicitors. The
response mainly centred on three major themes. The first theme was on
information available on observation of CCTV footage. The investigator had
only been provided with a copy of footage taken during the last 24 hours of his
life and understood that that was the only footage that was available. However,
the man’s mother, in company with her solicitor, attended the prison and
viewed footage taken from midday on 12 May through to 18 May. From their
observations, the family and solicitor noted many more occasions when other
prisoners were at the man’s door compared to what the investigator observed
from his more restricted viewing. The family and solicitor also pointed out that
on some of these occasions prisoners were at the door in full view of officers
and on one occasion a prisoner can be seen bending to take an item from
underneath the man’s door, which he then puts into his back pocket. The
impact on the man of other prisoners appearing at his door is covered in
paragraphs 95, 96 and 114. The additional information gleaned afterwards by
the solicitor does not substantively change the conclusions that are drawn
therein.
9. The second theme upon which the family have commented was on the closure
of the ACCT plan on 14 May. From their observation of the CCTV footage the
family and solicitor have pointed out that the man was unlocked from his cell at
10.57am and then locked back into his cell at 11.03am. They point out that this
means that the ACCT review was completed in just a few minutes. They
invited the investigator to re-interview the staff in light of this evidence before
finalising the report. We did not consider it necessary to take up this invitation.
This is because we were, in any case, critical of the fact that the ACCT plan
was closed without the staff having familiarised themselves with daily entries in
the man’s ACCT plan since the previous review. This recommendation has
been accepted by the service.
10. The third theme was the man’s placement onto D wing. The family and solicitor
have said that the report does not fully explain how the transfer to D wing took
place and whether sufficient account was made of his particular needs before
he was transferred. The investigation found that the most likely reason for the
transfer was the need for the man to be placed in a single cell. The
investigation also found that there was no particular reason at the point of
transfer for staff to believe that he should not go to that wing. The family and
solicitor have said that the CCTV footage of his time on D wing contradicts one
of the findings in the report that there was only one established occasion when
he complained formally to staff about being bullied. However, as the CCTV
recording is silent we cannot be certain about much of what is actually
occurring.
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11. The family and solicitor have asked about similarities between other deaths at
Durham and that of this man. Relevant information about this is contained in
paragraphs 23, 93 and 94 of the report.
12. The concluding remarks made by the family and solicitor were to question the
Ombudsman’s conclusion about whether there was any more that Durham
could reasonably have done to have prevented the man’s death. They
consider that there was more that the prison could have done. In making that
point they refer to omissions with the ACCT process, the failure to pass on
information about a doctor’s entry in the ACCT plan, the placing of him onto D
wing and not expediting, more speedily, his transfer off that wing. These issues
are covered in paragraphs 99 to 108, 110 to 115 and 122 of the report and the
conclusion of the investigation remains unchanged as a result of the family’s
comments.
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HMP DURHAM
13. HMP Durham is a Category B local prison built in the early 19th Century. It
serves the courts in the local area and it holds just under 1,000 prisoners.
14. The prison comprises seven wings as well segregation and healthcare units. E
wing is the induction wing and D wing is used mainly for prisoners on the
Integrated Drug Treatment Scheme (IDTS). The principle of IDTS is to bring
together the counselling and support aspect of drug treatment with the
prescribing and provision aspect.
15. Following a full announced inspection of Durham in September 2006, Her
Majesty’s Chief Inspector of Prisons published a report which included the
following findings:
“Like all local prisons, Durham suffered from a lack of sufficient, and useful,
activity. There were only 60 full-time education and 310 work places … on
one day of the inspection, we found 400 of the prison’s 913 prisoners locked
in their cells. This is, of course, partly a consequence of a prison that is
operating 55% above its normal accommodation …
“… Support and interventions were available if bullying was identified.
However, there was a considerable amount of undetected bullying and
intimidation of some vulnerable prisoners, who were mixed with other
prisoners …
“The prison had no vulnerable prisoner unit3 and operated a so-called ‘non-
collusive regime’ in which prisoners of all types, regardless of their offence,
mixed in all areas of the prison … 43% of prisoners surveyed reported that
they had felt unsafe at some time, and [23%] said they felt unsafe at present
… Discreet interviews with prisoners who would normally have been held in
separate vulnerable prisoner units revealed significant under-reporting of
bullying and victimisation … as a consequence a number of prisoners …
were afraid to leave their cells.
“The systems to identify and support prisoners at risk of self-harm were
generally of a good standard. Most suicide and self-harm support and
monitoring forms demonstrated a thoughtful and caring approach …
However … despite the fact that there had been nine deaths in custody in
recent years, some of the recommendations resulting from the subsequent
inquiries had not been implemented …
“… the proportion of prisoners reporting that most staff treated them with
respect matched that of comparator prisons. In group discussions, prisoners
reported that the staff were one of the best things about the prison. This
was confirmed by our observations … we found the staff … friendly and
open both towards prisoners and each other. Staff we met were generally
3 Vulnerable prisoners are those who might be at risk from other prisoners, usually due to the nature
of their offences.
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cheerful, interested in their prison, and keen to work towards making it a
decent and purposeful place.
“… Staff talked to us about prisoners in respectful and understanding terms
on most occasions. However, on one occasion inspectors heard a group of
staff discussing some prisoners in derogatory terms when they presumed
themselves to be out of earshot.
“… Prisoners were encouraged to use [out of cell] association periods, and
on some wings records were kept of prisoners remaining in cell and they
were asked why. But not all wings followed this practice, and we were
concerned that many vulnerable prisoners were afraid to mix …”
16. The Inspectorate carried out an unannounced inspection of Durham in October
2009. The report of this inspection is still at draft stage but I understand that it
will reflect much more positive responses from prisoners on the question of
safety. Prisoners at Durham reported feeling safer on average when compared
to those at similar establishments.
17. In their report for the year 2007 to 2008 the Independent Monitoring Board
(IMB) referred to overcrowding at Durham with many prisoners having to share
cells originally designed to hold just one prisoner. The IMB also commented:
“The prison’s budget in 2008/9 was set at £22.8 million. During the year the
prison has been expected to contribute to [National Offender Management
Service] savings targets and this has been done through the centrally
imposed changes to the prisoners’ daily routine (the Core Day). It is
understood that for the next few years the prison will receive the same
budget meaning that any staff and non staff inflation will need to be funded
through savings …
“Throughout the period of this report HMP Durham has retained its level 3
status in the Prison Service’s performance ranking. This implies that the
prison is ‘meeting the majority of targets, experiencing no significant
problems in doing so, delivering a reasonable and decent regime.’”
18. The Prison Service’s performance ranking system referred to in the IMB report
is a quarterly data driven performance assessment for each prison. The
assessment results in prisons being rated at one of four levels: rating 4 equals
exceptional performance; rating 3 equals good performance; rating 2 equals
development required; rating 1 equals serious concerns. Durham’s rating
remained at 3 following the period covered by the IMB’s report and remained at
3 for the time the man was there.
19. The man’s death was the 10th apparently self-inflicted death in Durham since I
took on the responsibility for the investigation of all deaths in prison custody in
April 2004. In two further cases prisoners contributed to their deaths through
their actions but their ultimate intentions were not entirely clear. Durham had a
particularly difficult time in the early part of 2009 with this man being the fourth
self-inflicted death within a ten week period. Of these four prisoners, three,
10
including this man, had been on ACCT monitoring up to or close to the time of
their death. Otherwise, there are few similarities in the circumstances of this
man’s case and the other three.
11
KEY FINDINGS
20. In January 2008, the man was referred by his general practitioner (GP) to his
local community psychiatric team. The GP wrote that he had longstanding
problems with low mood, poor self-esteem and poor coping skills. The GP also
wrote that he had told him that he had a constant feeling of “not wanting to
exist”.
21. Following the GP’s referral, the man had regular consultations with a
community psychiatric nurse (CPN). Following a referral by another CPN, he
was assessed by a consultant psychiatrist in September 2008 who then wrote
to his GP practice saying:
“… There were no thoughts of self-harm at the time of interview although he
reported the future as being ‘pretty glum’. He did not see that anything was
likely to be particularly helpful to him.
“… [He] is a 22-year-old man with a lifelong history of dysthymic symptoms
(chronic low mood) … and a history since his teens of … episodes of
deliberate self-harm … there were no associated features suggestive of a
depressive episode, rather his symptoms appeared to be associated with his
personality and a difficulty taking responsibility for himself. As such,
medication is likely to be of symptomatic but otherwise limited benefit.”
22. On 20 March 2009, the man was arrested at home and charged with murder.
The victim was one of the other residents at the flats where he was living. He
spent three nights in police custody until 23 March, when he was remanded
from magistrates’ court to HMP Durham.
23. Part of the prison reception process is completion of a first reception health
screening assessment. During the assessment, the man revealed a history of
self-harm as well as having current thoughts of self-harm or suicide. He also
said that he had received treatment for depression. In response, staff opened
an ACCT form for him to be monitored and supported in view of the risk that he
might harm himself. He was also asked about his physical health but he denied
having any problems.
24. Another aspect of the reception process is the cell sharing risk assessment. As
the name suggests, this assesses a prisoner’s suitability to share a cell. Staff
are instructed to make best use of documentary evidence in support of their
decisions. The process includes early identification of racist, homophobic or
violent prisoners to help protect potential victims. The process does not provide
an actuarial risk score and does not replace staff judgement. There are three
levels of risk: high, medium and low. There are two parts to the assessment.
The first part is completed by a reception officer. The second part is completed
by a member of the healthcare team who makes his or her own separate
assessment. The locating officer will then allocate the prisoner to a cell and will
base their decision on the information recorded on the cell sharing risk
assessment form. In this man’s case the reception officer decided that his risk
was medium, but the healthcare worker’s opinion was that his risk was low.
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The locating officer that day decided that he was low risk for cell sharing
purposes. She went on to endorse his ACCT to say that he should be located
in a double cell so that he could have support from another prisoner.
25. The man’s induction paperwork was marked to show that he was offered a free
telephone call, but he declined the offer. The paperwork also indicates that he
was informed about, and introduced to, the wing Listeners and the Meet and
Greet Orderlies4. Once the reception process was completed he was located
into a shared cell on E wing (Durham’s induction wing). While there he was
asked whether he had any immediate needs for issues to do with legal or
probation matters. He said that he had no such immediate needs.
26. The next day, the man was moved to healthcare for observation of his mental
health state. A ‘Cell Sharing Risk Minimisation Plan’ – another aspect of the
cell sharing risk assessment process – was noted to say that he was high risk
for cell sharing purposes and should be located into a single cell. The
explanation given for this was that he seemed to have ‘mental health issues’,
was ‘potentially volatile’ and had been charged with murder. It is not clear why
these latter two issues did not lead to him being assessed as high risk when the
cell sharing risk assessment was initially completed on 23 March.
27. Durham’s suicide prevention co-ordinator told my investigator that he first met
the man in healthcare on 24 March for an ACCT assessment interview. (The
ACCT process includes a detailed interview to be carried out within 24 hours of
the form being opened.) He said that his impression of the man at that meeting
was that he was a very shy individual whose overriding concern appeared to be
a belief that he had let down his family and partner in committing the alleged
offence. He was very forthright in answer to direct questions although he did
not elaborate on his answers. He revealed a history of previous acts of self-
harm as a way of relieving stress. While he denied any immediate plans to take
his life he also indicated that he could not see any future with a life in prison.
28. On the afternoon of 24 March the man attended an initial ACCT case review.
One of the purposes of the initial case review is to devise how the person can
best be supported. The support plan is then set out on a document known as a
caremap5. The man’s caremap contained the following two actions:
“Assessment by a psychiatric nurse.
“Support through visits, telephone contact and letters with his family.”
29. A Community Psychiatric Nurse (CPN) told my investigator that she worked for
the prison In-Reach team. She first met the man on 25 March after his transfer
to the healthcare unit. She had been asked by the nurse in charge to see him
due to concerns about his mental health. She said that when she met the man
4 Meet and Greet Orderlies, otherwise known as Insiders, are prisoners who speak to new arrivals in
reception or induction to provide information for first time prisoners about life in custody.
5 A caremap specifies the actions to be taken to address the most urgent precipitating problems
leading to a prisoner’s thoughts of suicide or self-harm.
13
she found him to be pleasant and co-operative. She said that this was his first
time in prison and he came from a “good family” so he was not a “typical
prisoner”.
30. The CPN said the man was shocked and confused about what he had done.
She found no evidence that he was psychotic. He said, however, that from a
young age he had felt anxious, different to others and socially excluded. He
had been bullied at school. For a long time he had considered suicide to be an
option. He said that he started to self-harm from the age of 14. He would
either cut or burn himself although he did not understand why. The CPN’s note
of the consultation included the following plan:
“… discussed with [doctor], although no evidence of psychotic phenomena
needs to be assessed by a forensic psychiatrist … I will continue to engage
with him to try to build up a relationship and continue assessing him. He
remains on an ACCT as still at risk of harm to himself.”
31. The nurse in charge of healthcare told my investigator that she chaired several
ACCT case reviews on the man. One of the reviews she chaired was on 28
March which had been brought forward as the man revealed that he was having
constant thoughts of ending his life. The review panel decided that he should
be placed under constant supervision. (With constant supervision a prisoner is
supervised by a designated member of staff on a one to one basis. The
member of staff will keep the prisoner within eyesight at all times and will
remain within a suitable distance to physically intervene quickly if necessary.)
This step was added to the man’s caremap with another addition to encourage
him to become involved with the regime in healthcare.
32. On 28 and 29 March, a senior officer spent time with the man during his period
on constant supervision. The senior officer told my investigators that he had
spoken with the man and he felt he had established a rapport with him. The
man was quite chatty and it seemed to the senior officer that he wanted to talk
with someone. He spoke about where he lived, about his girlfriend and the rest
of his family. He mentioned that he liked foreign languages as well as art and
music. The senior officer told him about the courses he could do in prison and
about the Chaplaincy’s guitar group. He said that they watched a television
programme together and chatted about it. The man mentioned that being in
prison was a “big unknown” to him but he also said how friendly the staff had
been towards him and how different he found it compared to how prison was
portrayed on television. However, at the next case review on 29 March, the
man said that: “… it would be better for everyone if he wasn’t here and they
would soon get over him.”
33. An officer made an entry in the man’s ACCT form in the late morning of 31
March after they had spoken. The man had said in their conversation that he
was unsure whether he had any future as he thought his family “would be better
off without him”.
34. A Specialist Psychiatric Registrar with County Durham and Darlington
Community Health Services was interviewed by my investigators. Her duties
14
include weekly visits to HMP Durham for consultations with prisoners on her
psychiatric case load. The frequency of consultations with individual prisoners
is dictated by their needs. She first met the man on 31 March. As it was their
first consultation it would have taken around one hour. She said that he spoke
about a good upbringing but also said he had been an anxious child lacking in
confidence and that he was bullied at school. He spoke about feeling different
to other people and said that he had felt that way since primary school.
35. The man told the Specialist Psychiatric Registrar he started harming himself
towards the end of his time in secondary school and also said that he had
always wanted to kill himself. Her note of the consultation included that after
obtaining many GCSE passes, the man dropped out of college due to bullying.
He obtained a job with a well known optical store but stopped going to work as
he could not cope with the pressure. She described the man as dishevelled,
flat in mood and making little eye contact. He became tearful when he spoke
about his alleged offence. At the end of the consultation the Specialist
Psychiatric Registrar decided that she needed to see the man again in view of
his long standing chronic low mood and poor problem solving skills, both of
which made him more vulnerable to self-harm.
36. A senior officer spent the night of 1 into 2 April supervising the man. The senior
officer told my investigator that the man was very chatty. He spoke about his
girlfriend, his hobbies and his taste in music. He also spoke a little about his
alleged offence and seemed full of guilt and remorse for what had happened.
The senior officer said the man was frightened about being in prison, but at that
early stage his principal emotion was one of numbness.
37. The man had a further review with the CPN on 2 April. Her note of the
consultation included that:
“… [the man] felt that it was his right to take his own life and this has been a
view that he has held for many years … He could not see any future and
even when released his life would be spoilt anyway, having a criminal
record. His girlfriend and parents are sticking by him. He feels that if he
were dead they could grieve [and] then get on with their [lives] …”
38. The CPN did not make an entry in the man’s ACCT form following their
consultation and my investigator asked her about this. She said that she would
ordinarily make an entry in an ACCT form but accepted that she did not do so
on this occasion. She thought that the most likely explanation was that she had
been so busy that day that she had forgotten.
39. The man had another ACCT case review on 3 April. A Registered Mental
Nurse (RMN) was one of the panel review members. Having reviewed the case
papers, the RMN told my investigators that he did have some recollection of
that review. He recalled the man telling the panel that the intrusion of being
maintained under constant supervision was making him quite self conscious.
The RMN said that, ideally, prisoners should be maintained on constant
supervision for as brief a period as possible. In terms of the general practice
regarding clinical input on ACCT case reviews, he said that that was dependent
15
on need. In the case of prisoners in contact with the mental health team there
should be contact between the ACCT case manager and the team. The record
of the case review that day included that the man seemed a little brighter in
mood. The panel decided that supervision of the man could be reduced from
constant to five observations per hour. (Durham’s suicide prevention co-
ordinator was another of the panel members).
40. The man spent twenty minutes talking with a Listener on the morning of 6 April.
After seeing the Listener he told an officer that he was feeling “okay”.
41. On 7 April, a colleague of the Specialist Psychiatric Registrar was scheduled to
review the man on her behalf. Unfortunately, the colleague was not able to see
the man due to time constraints. In a letter to the prison’s Medical Officer (the
lead doctor), the colleague explained that he had spoken with two of Durham’s
nurses who informed him that the man was “picking up slowly”. They told him
that there had been no episodes of self-harm, nor any threats of self-harm. He
added that the Specialist Psychiatric Registrar would be reviewing the man in a
week’s time.
42. At an ACCT case review the following day, the man told the panel that he now
felt that he had more to live for. He explained that he was receiving support
from his family and his partner and that was preventing him from “doing
something serious“. Two of the panel members were mental health nurses.
After discussion, the panel decided that his observations could be reduced to
two per hour.
43. The man was still in healthcare on 14 April, when he attended a further ACCT
case review. All the issues on the caremap had been addressed and the notes
made about the review included that he was presenting as much brighter and
much improved. The note went on to say that he was more settled and was
mixing well with others and that all those at the review were in agreement that
the ACCT form should be closed. A post closure review was scheduled for 21
April. (The entries in the ACCT form show that on most days while the form
was open he had taken part in some form of out of cell activity such as going to
exercise or education. Most commonly, he simply spent time on association
with other prisoners.)
44. Later on 14 April the man had a further consultation with the Specialist
Psychiatric Registrar. She told my investigators that, as it was a review
appointment, it would have been a briefer consultation than their first. It would
have lasted around 15 to 20 minutes. She said that the man had improved
from the time of their first meeting. This time he made more eye contact and
was more reactive in mood. Although the man denied any current plans of self-
harm, he said that he continued to have such thoughts and they were always in
his head. The Specialist Psychiatric Registrar’s recommendation was for him to
continue with the anti depressant medication Citalopram which he had just
started taking.
45. For the week following the closure of the ACCT form the comparatively brief
records made in that period suggest that the man was continuing to settle quite
16
well. At a routine post closure ACCT review on 21 April he was noted to have
said that he was feeling “really good” and not feeling at risk of self-harm or
suicide at that time. An entry in his clinical records that same day, however,
shows that he had asked to speak to a Listener although he then declined the
opportunity when the Listener went to his cell.
46. The man had a discussion on 22 April with one of Durham’s doctors who noted:
“Interviewed in cell … Good rapport, rational, articulate. Requesting a
transfer to normal wing as he needs to ‘get on with prison’. Also on a normal
wing he may be allowed access to a guitar as music is very important to him.
Denies any current suicidal thoughts or self harm but I am not entirely
convinced and will discuss with colleagues before discharging him.”
47. The following day, the doctor authorised the man’s discharge from healthcare
noting that he had no current medical problems but that there should be a
follow-up check by the mental health nurse.
48. Durham’s suicide prevention co-ordinator told my investigator that, by the time
the man had returned to E wing on 23 April, there was a marked improvement
in his mood and demeanour. He had acquired some photographs to mount on
the pin board in his cell and invited him into the cell to look at them. These
included photographs of his partner and of his pets. He appeared more relaxed
and seemed to believe that he had a chance of getting bail. He also thought
that he might get a lesser sentence than he had previously believed and spoke
about how he would rebuild his life after release. The suicide prevention co-
ordinator told my investigator that he saw the man numerous times ‘in passing’
at around this time and he appeared much less agitated and much less worried
about prison life. He said the man did mix with other prisoners, but tended to
associate more with the older prisoners and preferred to meet with smaller
groups.
49. The man had a mental health review on 27 April with the CPN who noted:
“[The man] stated that moving to the main jail has helped a little. He feels a
little less stressed ... although not actively suicidal, it is still an option. He
has used the Listeners on a couple of occasions. Although admits to finding
it difficult to talk generally to people, found it had helped a little …”
50. On 3 May, during a check of the man’s cell during the lunch period, staff found
a home-made bladed weapon that he said he had made over a week before.
The suicide prevention co-ordinator told my investigator that, when he found out
about this incident, he went to speak with the man and asked him if he had
made the weapon for protection. His reply was that he had made the weapon
in order to harm himself if he happened to feel low in mood.
51. A landing officer based on E wing told my investigators that he had been on
annual leave when the man was transferred to E wing. He returned to work on
3 May and met him for the first time that day. When the officer unlocked the
man’s cell at about 4.00pm, so he could collect his evening meal, he found him
17
lying under his bed in a distressed state. The officer said that he was weeping,
although not crying out loud. He asked the man to come out and to sit on his
bed, which he did straight away. The officer knew that the man had had a visit
that afternoon and asked him if it was that which had upset him. The man
denied that it was anything to do with the visit but would not say what it was that
was upsetting him.
52. The officer estimated that he spent around ten minutes with the man and was
joined by two of his colleagues. The staff discussed whether the ACCT form
should be reopened. The man did not want the ACCT form reopened but the
staff considered that it was appropriate to do so in view of his demeanour. Staff
tried to persuade him to collect a meal but he declined to do so. Once the
evening meal had been served, the landing officer checked with the safer
custody team whether he needed to open a new ACCT form or whether the
previous one could be reopened. He was advised that he could reopen the
earlier ACCT and that is what he did. By the time the officer had done so, it
was around 5.00pm and that was the end of his shift. He could not recall
having any further personal contact with the man.
53. The case manager for an ACCT case review with the man on 4 May recorded
that, while the man denied having thoughts of suicide or self harm, he was
reluctant to engage in conversation and would not make eye contact. She
noted the man saying that he had made the bladed weapon to use on himself.
She told my investigators that she thought the ACCT form should remain open
and she told him of that decision. She could not recall his reaction.
54. A number of entries in the man’s ACCT form on 6 and 7 May indicate that he
was feeling a lot better compared to how he had been on the day the form was
reopened. He said that he had no concerns when told on 7 May that he would
be moving wings that day. (Prisoners remain on E wing only while they receive
their induction. They then move to the residential wings while the freed-up cells
on E wing are taken by new arrivals.)
55. (The role of a moves officer entails finding accommodation for newly arrived
prisoners and to move other prisoners to allow facilitate the accommodation of
the new prisoners.) The moves officer for 7 May told my investigators that he
would have moved around 20 prisoners off E wing that day. He could not
specifically recall moving the man, but assumed that he must have done. He
thought that the reason the man went to D wing, the Integrated Drug Treatment
Programme (IDTS) wing, was because he was not suitable to share a cell and
D wing would have been the only wing with a vacant single occupancy cell.
(The man was still deemed to be high risk for cell sharing purposes.)
56. Durham’s suicide prevention co-ordinator told my investigator that he did not
see the man after his move to D wing, but his view was that he would not have
coped well on that wing. His personality would probably have led to him being
a target for bullies who would have hoped to take any prescribed medication
from him. He said that the man was not the type of person who would complain
about being bullied as he would not want to bother staff about such matters.
18
57. An officer on D wing told my investigator that she had worked on all the wings
in Durham and for the past five years had worked on D wing. She said that
although D wing was very busy and very noisy, she had not observed any
incidents of bullying. The officer thought that she first met the man on 11 May.
At breakfast time that day she had gone to his cell to check that he was alright.
He told her that he was worried because a very expensive item had been
mistakenly recorded on a catalogue order form. She went to check what had
happened and then returned to his cell to tell him not to worry as the prison
realised it was a mistake.
58. Later that day the D wing officer had a longer conversation with the man. She
went into his cell and he spoke about his concerns over his court case. She
told him not to worry as hopefully the court would look leniently upon the
mitigating factors. There was also a lighter side to their conversation when he
spoke about his girlfriend and about his pets. The officer told my investigator
that she saw a photograph on his pin-board and she asked him if it was a
sheep. The man laughed and told her that it was an albino hedgehog. She
thought that she spent around 20 minutes talking with him.
59. The man’s next consultation with the Specialist Psychiatric Registrar was on 12
May. She told my investigators that before seeing him she checked his clinical
records and those indicated that he had continued to improve. When they met,
he told her that he was generally okay but was struggling during association
periods as the other prisoners on the wing were drug users. He said that he
had asked for a transfer to a different wing. He also said that his ACCT form
had been reopened when staff found a blade in his cell. He also told her that
he had used the blade to cut his wrist although staff were not aware of that.
She asked him whether he had done anything else to harm himself, and he said
that he had also tried to use a sheet as a ligature but staff were again unaware
of that.
60. Following the appointment, the Specialist Psychiatric Registrar dictated a
record of the consultation which was later typed and inserted into the man’s
clinical records. Her record included that:
“[The man] was taking Citalopram [an anti-depressant] when I last reviewed
him, although has stopped taking it …
“[He] appeared less withdrawn than when I initially assessed him. He
continues to present however with some evidence of low mood and suicidal
ideation on a background of chronic dysthymia (a depressive illness
characterised by chronic low mood) …
“… I have discussed [the man’s] case with [an RMN] who will enquire as to
whether he could be transferred … to another wing. He will also explore the
possibility of [him] sharing a cell and being able to attend education or the
music group.
19
“… [the RMN] will inform the Safer Custody Team of [the man’s] recent
attempt at ligaturing and his ACCT observations should be increased as
necessary.
“… I have recommended that [he] is prescribed Zopiclone [for sedation at
night] for one week. [He] did not want to take any anti-depressant
medication at present but I will review the situation when I review him again
in two weeks time.”
61. Following the consultation, the Specialist Psychiatric Registrar spoke to the
RMN about what the man had said about his attempt to use a bed sheet as a
ligature. The RMN gave her the man’s ACCT form and asked her to make an
entry about the comment. Her entry, which filled almost a complete side of
paper, included:
“… admitted that he had attempted to use sheet as ligature in the last 2
weeks. Continued to state he was ok and denied planning to self harm
although contradicted himself later on in interview by stating he always
wanted to kill himself.”
62. The RMN told my investigators that following a consultation with a prisoner by a
visiting psychiatrist, it is good practice for the psychiatrist to report back to the
mental health team. The RMN said that the Specialist Psychiatric Registrar did
this on 12 May when she spoke to him about the man. She told him that the
man’s mood had improved but he had also told her about making a ligature.
The RMN ensured that the Specialist Psychiatric Registrar made an entry in the
ACCT form. He said that he did not speak to the safer custody team about
what she had revealed as no one from the team was available. He said,
however, that he went to D wing and handed the ACCT form to an officer and
informed her about what the Specialist Psychiatric Registrar had written. He
asked the officer to pass on the information to one of the wing managers.
63. The officer told my investigator that she had no recollection of the RMN
speaking to her about the Specialist Psychiatric Registrar’s entry in the ACCT
form and asking her to pass on that information to the senior officer on duty.
Nor could she recall having seen the Specialist Psychiatric Registrar’s entry
before the interview with my investigator. She assumed, however, that she
must have done as she made the very next entry in the ACCT form and her
practice when making entries was to read the preceding one. The officer made
her entry in the ACCT form at 4.40pm. She said that at that time of day all the
cells would be locked so she had spoken to the man through the door hatch.
Had it not been a ‘lock-up’ period she would have gone into the cell to ask him if
it were true that he had been making ligatures. But that was not a question she
would ask through a locked door as other prisoners would be able to hear the
remark from their cells. She added that the Specialist Psychiatric Registrar’s
entry about the ligature did not accord with her own assessment of the man.
From the discussion she had had with him earlier that day she believed that
thoughts of his partner and his parents would prevent him from doing anything.
Her shift ended at 5.00pm and that was the last time she saw the man.
20
64. The wing manager told my investigator that the officer did not speak to him
about the entry that the Specialist Psychiatric Registrar made in the man’s
ACCT form. Nor could he recall having seen the comment before my
investigator showed it to him.
65. On the morning of 13 May, the CPN made the following entry in the man’s
clinical records:
“Seen by CPN for review. [The man] presented as low in mood. He denied
feeling suicidal, but admitted to having self harmed, although staff were not
aware of this, did find a razor blade in his cell ... We looked at the
consequences of this action, such as possibly being declined a guitar in his
cell. [The man] could not see the problem and stated he would not use the
strings to self harm. I contacted … Chaplaincy who [are] unsure whether
security would allow the guitar at the present time, but he was near the top
of the list for lessons. As he finds music therapeutic, I suggested that he
buys a CD player and … see if the library have any CDs for loan. [The man]
was fairly negative towards this and other suggestions. I arranged for him to
go to the library this [morning]. We looked at what else could help. This
included the gym and moving wings. I have encouraged him to put in
[applications] for gym induction and work, but he did not appear bothered …”
66. The CPN made further entries elsewhere following her consultation with the
man. In his ACCT form she made an entry in which she referred to his low
mood. She also noted his denial of current thoughts of self-harm or suicide as
well as his plans to engage in more activities. In the wing observation book, the
CPN referred to the man’s visit to the library. She also wrote that he was
interested in buying a CD player as he: “finds music therapeutic”. (The CPN
dated this entry 14 May; it should, however, have been dated 13 May.)
67. A senior officer on duty on D wing on 14 May told my investigators that,
although she was primarily based on E wing, she also worked on other wings to
cover staff shortages. This was why she was on D wing that day. She said that
one of her first tasks at the start of a shift is to check the open ACCT forms and
whether any case reviews are due. She saw that the man was due for a case
review. She did not realise at that time that this was the same person she had
met for an ACCT review ten days earlier on E wing. When the man came to the
review the senior officer remembered him from their previous meeting. She
said he appeared to be a lot better. He was able to hold a conversation and
was making eye contact. The man denied having thoughts of suicide or self-
harm. He was also making plans for the future: he had applied for work, he had
asked for a guitar from the Chaplain, and he talked about visits from his family.
He did not complain about feeling intimidated on D wing.
68. The senior officer said that she discussed the man with an officer also present
at the review and they agreed that the ACCT should be closed. The senior
officer said she had briefly reviewed the ACCT entries from the previous day
and the day before. She saw the entry made by the CPN who noted that,
although the man was still feeling low, he was making plans for the future and
was not going to harm himself. The senior officer felt that was sufficient mental
21
health input for the review and that there was no need to invite someone from
healthcare to join the panel. She said that, as far as she was aware, there was
no set procedure at that time about having a healthcare representative on a
panel that might be considering the closure of an ACCT form. (Since the man’s
death, local procedures have changed. Healthcare must now be involved if a
panel is to consider closing an ACCT where the person has received significant
healthcare input.)
69. The senior officer told my investigators that she did not see the entry in the
ACCT form made by the Specialist Psychiatric Registrar on 12 May. Having
read the entry during her interview, the senior officer was not certain that it
would have made any difference had she seen it on 14 May. She accepted that
the decision to close an ACCT should be based on more than just how the
person presents on the day of the review. But she reiterated that the man’s
mood had improved markedly compared to how he had been ten days
previously and the entries she read in the ACCT gave her no cause for
concern.
70. At interview, the officer who was also at the review and who agreed about the
ACCT being closed, described D wing as a very hectic and noisy wing holding a
lot of young men in their early twenties to early thirties doing “a lot of running
around”. She said that although she had not been approached personally by
prisoners complaining about being bullied, she was aware of incidents where
prisoners had complained about their medication being stolen.
71. The officer confirmed that she had not met the man until the day of the ACCT
review on 14 May. She said that the senior officer had had dealings with the
man on E wing and she commented on how much better he now seemed. The
man agreed that he was feeling much better in himself, but also said that he
was bored and would like to get out of his cell a bit more. The officer had
collected a labour form from him that morning, and she told him that she had
dealt with that application along with his request to attend education classes.
He also said that he would not mind sharing a cell at some point, but did not
want to share a cell on D wing as he did not want to be involved with prisoners
receiving drugs.
72. The officer said that the senior officer asked the man whether he was having
any thoughts of suicide or self harm and he denied such thoughts. She told my
investigators that the man engaged fully in the conversation; he was not
withdrawn and he made good eye contact. Once he had left the room the
senior officer said that she thought the ACCT form could be closed and asked
the officer for her opinion. The officer agreed. She told my investigators that
she was content that that was the correct decision based on how the man was
on that day.
73. The officer also told my investigators that she thought she had attended around
a dozen ACCT reviews, and on only one of them had a mental health nurse
been present. Nor did she know if a telephone call was ever made to the
mental health team for their views. She said that, as far as she was aware, no
thought was given to asking a healthcare person to attend the man’s review.
22
74. On the morning of 15 May, the man told an officer that he wanted to speak to a
Listener. One of D wing’s Listeners went to see him. The Listener told my
investigators that the man told him that he would harm himself and he
explained why he intended to do so6. He also said that he wanted to move
back to healthcare and agreed that the Listener could speak to an officer on his
behalf. The Listener said that he alerted the senior officer and accompanied
him back to the man’s cell. He remained present while the senior officer spoke
with the man. However the man denied to the senior officer that he was
thinking of harming himself although, according to the Listener, he did ask to
move to healthcare. The senior officer told the man that he could not go to
healthcare but told him that he would arrange a transfer to C wing.
75. The senior officer confirmed to my investigator that he went to speak with the
man after being alerted by the Listener. The man said that he was frightened
and had not been collecting his meals. He did not cite any specific incidents of
bullying, however, nor did he name any individual prisoners. The senior officer
told my investigator that he would arrange to transfer him to a different wing.
He told him that F wing, which held full time workers, was the wing he should
ultimately aim for. In the interim, the senior officer said he would move him to C
wing which was a much quieter wing than D wing. He told the man that he
would arrange to transfer him as soon as possible, although it would probably
not happen until the coming Monday. The man said he was content to wait until
then. The senior officer told my investigator that there was nothing about the
man’s demeanour to indicate that he was desperate to move. He could not
recall either the man or the Listener mentioning a move to healthcare.
76. On the same day, the senior officer wrote on a ‘cell sharing risk minimisation
plan’ that the man would like to share a cell provided a suitable prisoner could
be identified. He also wrote that the man was: “… A nervous individual who is
not engaging with the regime as he appears to be afraid.”
77. The senior officer told my investigator that his practice at meal times was to
stand by the servery. He said that the man’s cell was near to the serving point
and on 15 May he escorted him to the servery to collect a meal. The senior
officer said that he was on duty throughout that weekend, and he had made a
point of unlocking the man’s door at most of the meal times. He thought that
the only meal the man missed was on the Sunday evening when he said that
he was not hungry. He said that, in addition, he arranged for the man to
shower alone on the Saturday (16 May) and offered him the same option the
following day. He also asked the landing officer to “keep an eye” on him.
78. In his discussion with my investigator, the senior officer acknowledged that D
wing, given its purpose, could be chaotic at times and that it was not an
appropriate environment for a person such as this man. Nevertheless, nothing
occurred during that weekend to cause him to feel concerned for the man’s
safety.
6 Due to the principle of confidentiality under which the Listener scheme operates, the Listener could
not reveal to my investigators the explanation given by the man.
23
79. My investigator observed the available CCTV recording taken on D wing. This
covered a 24 hour period from 8.00am on 17 May to 8.00am on 18 May.
During this period the man came out of his cell on four occasions. Three of
these occasions were to collect his three meals of the day. The other occasion
was to attend a family visit in the early afternoon. The only time that a prisoner
appears to be attempting to converse with him while he was in his cell was in
the middle of the afternoon. The prisoner remained at the door for almost a
minute. On two occasions the prisoner can be seen crouching down and it
appears that he might be trying to speak through any gap between the cell door
and frame. However, the CCTV recording is silent so it remains unclear what is
occurring. Around 15 minutes after this the man came out of his cell to collect
his final meal of the day.
80. The man’s father, grandmother and partner visited him the day before he died.
His father told my Family Liaison Officer that his son could hardly talk because
his mouth was so dry. He said that his son’s mouth would dry when he was
worried or upset. His father said that another difference that day was that,
when the family were leaving, his son stared him straight in the eye and he
waved. This was different to the norm as ordinarily it was difficult to catch his
son’s eye at the end of a visit.
81. An Operational Support Grade (OSG) staff member told my investigators that
he had been responsible for patrolling D wing on the night of the man’s death.
At night he carries an anti-ligature knife and a cell key held in a sealed pouch.
The seal must only be broken in the case of an emergency. At around 5.30am
he was carrying out a cell check. When he looked into the man’s cell he saw
him lying face down on the floor. There was a ligature around his neck, tied to
the bed frame. He said that he banged on the door and shouted to try to get a
response from the man. Getting no reply, the OSG called for assistance from
the Night Orderly Officer7 (NOO) and the first response nurse. He broke the
seal of the key pouch and stood ready by the cell door. He said that the
assistant NOO arrived in around 20 seconds followed by two nurses. When the
assistant NOO was a few feet away the OSG unlocked the door and they went
into the cell. They cut the ligature from the man’s neck. As nurses were
present by this time, the OSG left the cell. He confirmed that he was aware of
Durham’s contingency plans about entering a cell at night time. He said that he
would have entered the cell before the arrival of support if it was clear that the
man was hanging. However, the situation was not clear which was why he
decided that he should wait for support to arrive.
82. A Registered General Nurse (RGN) was the first response nurse. She arrived
at the cell just after the ligature had been cut away. She examined the man
and found no signs of life. She recorded that rigor mortis was established and
so resuscitation was not attempted.
7 The Night Orderly Officer is the person in operational charge of a prison at night time.
24
After the man’s death
83. A hot debrief was held for the staff who responded following the discovery of
the man’s death. A member of the care team was present to offer her support.
84. One of Durham’s Family Liaison Officers, along with a colleague, travelled to
the home of the man’s parents at around midday to break the news. His father
was at home but his mother was at work. The staff informed the man’s father of
his son’s death and asked him whether he wanted to contact his wife. He said
that he thought it best to wait for her to finish her day’s work and to come home
before telling her. They asked if he had any support available to him in the
meantime, and he told them that his mother-in-law lived nearby.
85. In the early afternoon the man’s mother telephoned and asked if she and her
husband could come into the prison. They came in that afternoon and
attended an initial meeting with the prison Governor and the Family Liaison
Officer. The man’s mother told my investigator that her husband said at the
meeting that he did not want his son to be subject to a post mortem
examination. The Family Liaison Officer said that such an examination had
already been carried out, although the family later discovered that the post
mortem examination was not carried out until later that afternoon. The man’s
mother said that she and her husband asked to visit D wing. They were told
that it was the association period and were asked to return after prisoners had
been locked in their cells. She said that she and her husband accepted this,
but said they were not offered any where to wait inside the prison so they
waited in their car outside. They went back to the prison around 45 minutes
later and were able to visit D wing. They were not able to visit their son’s cell,
however, as it had been sealed and the police had not given permission for its
release. The man’s parents were informed that Durham would contribute to the
costs of the funeral arrangements in line with national policy. That evening, the
man’s parents and his partner visited the local hospital to view his body. The
man’s mother said that they found Durham generally unhelpful unless pushed
for information.
86. My investigator asked the Family Liaison Officer about the man’s mother’s
complaint that the family were misled about the timing of the post mortem
examination. The Family Liaison Officer denied commenting on the post
mortem.
Immediate review of local procedures
87. A prison governor told my investigator that, as the man’s death was the fourth
at Durham in a fairly brief period of time, an immediate review was carried out
to consider if there were any procedures that needed to be changed. This
review resulted in the issue of a notice to staff to say that, where a case review
team is considering the closure of an ACCT plan, the review panel must include
a member of staff who knows the prisoner well. In the case of a prisoner who
has had mental health support, the panel must include an appropriate member
of healthcare staff.
25
88. Another issue discussed by my investigator and the prison governor was how
significant entries in ACCT forms, such as the Specialist Psychiatric Registrar’s,
become submerged within the form as further ACCT entries are added. The
governor’s suggested solution was the introduction of a new section in the
ACCT form in which reference is made to significant entries elsewhere in the
ACCT. Such references are then ‘struck through’ when the issue of concern is
resolved leaving it easy for the reader to identify potentially unresolved issues.
Thematic review of the last three deaths at Durham
89. As I have said, the man’s death was the fourth self-inflicted death in Durham
within a period of just ten weeks. A common theme amongst the last three
deaths was that all the prisoners had been subject to support and monitoring
through the ACCT procedure up to, or close to, the time of their deaths. The
Safer Custody Advisor for the North East region reviewed the three ACCT
forms. His findings on reviewing the man’s ACCT forms included that:
• There should have been a case review each day for the first 72 hours
after the man was placed on constant observation. Reviews were not
held on 30 March and 31 March.
• The post-closure review scheduled for 21 April did not take place.
• When the ACCT form was re-opened an assessment interview was not
held.
• Some daily entries in the second ACCT indicated good interaction
between staff and the man but most entries merely recorded brief
exchanges with him.
• There was no healthcare representation at the case review on 14 May
when the second ACCT was closed. Nor did the panel refer to the
ACCT entry made by the Specialist Psychiatric Registrar on 12 May.
90. The Safer Custody Advisor was also critical of the level of management checks
carried out on the ACCT forms for all three prisoners.
26
THE MAN’S JOURNAL
91. After the man’s death, two documents were found in his cell. One was a
goodbye letter to his family. The other was a document totalling six sides of A4
paper in which he recorded his thoughts during the final days of his life. He
also noted a series of complaints about things that had happened and were
continuing to happen. Problems that he listed included a cell mate who had
stolen items from him; that food had been stolen from him; that when on E wing
his sink had been blocked for more than two weeks; that social visits had been
foreshortened; that mistakes had been made with canteen and catalogue
orders; that association periods had been at irregular times; that evening meals
were served at irregular times and on occasions he was overlooked for
breakfast; and that he had not received prescribed sleeping tablets. He also
complained about the prison failing to arrange education classes, and failing to
arrange visits to the library, the church and the gym. The man’s major
complaint, however, was his fear of the other prisoners on D wing who he noted
kept coming to his cell to make threatening demands for medication and
tobacco. He wrote that he complained to an officer about being fearful of other
prisoners but that the officer had told him not to worry as they were only “hollow
threats”.
92. The man also referred in the journal to his conversation with a senior officer on
15 May (Friday). He noted that he had previously been told that he would be
transferred back to healthcare if he was “struggling”, but when he asked the
officer about that he was told he could not be transferred. He added, however,
that the officer did say that he would hopefully be able to transfer him to a
different wing on the following Monday. The end of the fourth side and the
whole of the fifth side cover the events of Friday 15 May. The sixth and final
side is annotated “Saturday”8 and includes the following commentary:
“It’s going to have to be tonight, I have no other choice … I’ve had a
[prisoner] banging on my door threatening me if I don’t give him [tobacco].
I’ve already given him a pouch. Why could none of the guards see him
shouting and banging on my door? He went away eventually and then came
back! I was so scared I refused to go out for lunch … this morning I actually
had hope, I thought ‘I can get through this.’ The straw that broke the
camels back was today … having some fucking crazed smack-head
demanding [and] threatening … It’s 4.00pm, he’s been back again … If I
don’t give him [tobacco and cigarette paper] apparently my life’s gonna be
made hell in here … I can’t take this anymore.”
93. In accordance with standard protocols, the two documents left by the man were
seized by the police investigators. From his journal, the police extracted 31
issues that they put to Durham seeking the prison’s responses.
8 NB: The man took his life at some time between the final roll check on Sunday evening and the early
morning roll check on Monday morning. This may mean that he changed his mind about taking his
life on Saturday night but made no journal entries for Sunday. Otherwise, it means that he made no
journal entries on Saturday and then incorrectly annotated the final page “Saturday” when in fact it
should have been annotated “Sunday”.
27
ISSUES
Reopening of the ACCT form on 3 May
94. The man’s original ACCT form had been closed on 14 April when he was
deemed no longer at risk. A new ACCT form was opened on 3 May when he
was found underneath his bed in a distressed and tearful state. The officer who
discovered him sought advice from the safer custody team and was told that,
because the original ACCT form had been closed only recently, there was no
need for a further initial ACCT assessment interview and no need for a new
caremap. My investigator spoke with the training delivery and operational
adviser for issues related to Prison Service Order (PSO) 2700 which gives
instruction and guidance on the ACCT process. My investigator was advised
that although PSO 2700 is silent on the matter, staff at Durham acted
appropriately in deciding that there was no need in this man’s case for a further
ACCT assessment interview and new caremap.
I recommend that the Prison Service consider revising the instructions
given in PSO 2700 to include explicit mention about the action to be taken
when an ACCT plan is reopened.
Communication following the man’s consultation with the Specialist
Psychiatric Registrar on 12 May
95. During his consultation with the Specialist Psychiatric Registrar on 12 May, the
man disclosed that at some stage in the previous two weeks he had made a
ligature from a bed sheet and tried to use it on himself. Following the
consultation she spoke to an RMN. He advised her to make a relevant entry in
the man’s ACCT form (which she did), and he also told her that he would pass
the information on to the safer custody team.
96. However, the RMN’s evidence is that there were no members of the safer
custody team available that afternoon for him to pass on the information.
Instead, he spoke to one of D wing’s landing officers when he handed her the
ACCT form. The RMN said that the officer agreed to pass on the information to
the senior officer on duty.
97. The officer could not recall the RMN telling her about the Specialist Psychiatric
Registrar’s entry in the ACCT form, nor could she recall passing the information
on to the senior officer on duty. (The senior officer confirmed that the officer did
not speak to him about the man.) It seems clear to me, therefore, that the
officer did not alert the senior officer on duty to the Specialist Psychiatric
Registrar’s entry: both of the discipline officers are in agreement on that point.
What is unclear, however, is the content of any conversation between the RMN
and the officer. Their accounts are at variance with one another and it is not
possible for me to conclude which of the two is the correct version.
98. Interestingly, however, it was the same officer who made the next entry in the
ACCT form immediately following the Specialist Psychiatric Registrar’s entry.
She told my investigator that her practice was to read the previous ACCT entry
28
when making an entry of her own. That said, she had no recollection of seeing
the Specialist Psychiatric Registrar’s entry before being shown it by my
investigator.
99. I further discuss the Specialist Psychiatric Registrar’s entry in the ACCT plan in
the following section.
Closure of the ACCT form on 14 May
100. There were just two members of staff at the ACCT review on 14 May, neither of
whom knew the man well. This is despite the fact that a case review team
should be comprised of a minimum of three staff. The case manager was also
the case manager at the man’s previous review on E wing on 4 May. However,
it seems that her attendance at the 14 May review was more coincidental than
planned. The other panel member had not met him before. The case manager
told my investigators that she did not read the man’s ACCT form in any depth.
She said that she read the CPN’s entry from the previous day, but did not read
back to 12 May and so did not see the Specialist Psychiatric Registrar’s entry.
Having been asked by my investigators to read the entry, the case manager
was not certain that it would have made any difference to her thinking had she
seen the entry at the time. She said that the man’s mood had improved
markedly compared to how it had been at the previous ACCT review a week
earlier. This day he gave her no cause for concern.
101. The case manager said she had not thought it necessary to invite a healthcare
representative to the review given the meeting the day before with the CPN.
102. The other panel member gave similar evidence about the man’s presentation
that day. She confirmed that as with the case manager she had not read the
Specialist Psychiatric Registrar’s entry either.
103. It is of concern that two members of staff, neither of whom knew the man very
well agreed to close the ACCT without familiarising themselves with the daily
entries made since the previous case review.
The Governor should remind staff about the importance of familiarising
themselves with the daily entries made in ACCT plans to assist their
decision making at case reviews.
104. Following the man’s death the Governor issued a notice to staff about the
structure of a review panel that might consider closure of an ACCT. In this
man’s case, that would have meant attendance of a member of the safer
custody team, a member of staff who knew the man well, a member of
healthcare staff and perhaps an additional attendee, such as a member of the
chaplaincy team. There is no doubt that a review panel strengthened in both
size and experience in this way is likely to make more reliable decisions on
whether or not to close an ACCT. I am pleased that Durham has acted so
promptly in revising its local procedures on the make up of ACCT review
panels.
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105. It does not follow that a strengthened panel would necessarily have kept the
man’s ACCT open. Nor does it follow that the decision made by the case
manager and the other panel member to close the ACCT was necessarily
wrong. However, the review did seem to focus on how the man was on that
particular day rather than how he had been managing in general since the last
review. There were several aspects connected with the man’s circumstances
to suggest that it might have been prudent to have kept the ACCT form open.
First, there are the issues very specific to his immediate circumstances: a
young man who had no previous experience of the criminal justice system and
was in prison for the first time, and who was charged with a very serious
offence. In addition, he was a man who, as the Specialist Psychiatric Registrar
explained, suffered from chronic dysthymia (chronic low mood). He told her
that for a long time he had wanted to kill himself (and he had made similar
remarks to community mental health staff prior to his apparent index offence).
This aspect of his personality made him an unusually difficult person to keep
safe.
106. However, PSO 2700 does contain specific advice on dealing with prisoners who
present a chronic risk of suicide. It highlights two particular groups who can be
said to be at chronic risk. One group are those who experience short-term
suicidal crises repeatedly. The PSO advises that opening and closing ACCT
plans many times in one period of custody, with no supervision or support in
between times, is not safe. The PSO explains that such individuals need a
long-term care plan, ideally one that provides some continuity of care:
“They may have an ACCT plan [kept] open long-term over many months.
During periods when the risk of suicide is considered to be very low … the
ACCT plan merely requires that a member of staff interacts with them once a
day and they have reviews once a month. But when (by means of the daily
interaction) staff identify that risk is increasing ... an assessment interview
and case review is immediately held and additional support put in place.
“The … ACCT plan is closed every time the immediate crisis is over …
However, the ACCT plan is filed on the wing and one member of staff is
tasked with interacting with the prisoner daily and making a note in the wing
record. All staff are made aware of the signs that mean that this particular
prisoner is becoming more distressed … When risk is seen to be rising, an
ACCT is opened and an assessment interview and case review carried out
…”
107. It is not possible for me to say whether such arrangements would have been
successful in keeping this man safe. But it might have been a more prudent
approach especially given that these were still early days for him and he was
still waiting for his case to come to court.
The Governor should ensure that the safer custody team are reminded of
the advice in PSO 2700 on dealing with those at chronic risk of suicide so
that they can provide appropriate advice to wing staff on managing such
prisoners.
30
The man’s time on D wing
108. The man came to D wing through a slightly circuitous route. On his initial arrival
in Durham he went to E wing for induction. However, due to concerns about his
risk of self-harm or suicide, he was moved to healthcare. He remained in
healthcare for a month. By the end of that time he was much more settled and
his risk of self-harm or suicide was believed to have diminished. As a result, he
was transferred back to E wing in order to complete his induction. Once
induction was over, he needed to be allocated to one of Durham’s residential
wings as is the case for all prisoners. At this time he was considered high risk
for cell-sharing purposes. This assessment was based on his alleged index
offence and suspected mental health issues. It meant that he had to be located
in a single cell. There is no information on record to explain why he was moved
to D wing. However, the likely explanation is that, when he was transferred
from E wing on 7 May, the only single cell available in Durham was on D wing.
There was no particular reason at that time to think that he should not go to D
wing, and therefore this move was reasonable.
109. D wing at Durham is primarily used for prisoners being maintained on the IDTS
(Integrated Drug Treatment System) programme. All of the evidence points to
the man being a timid and insular person, and that he tended to avoid crowds
and avoided confrontation. Local information gathered within Durham about
reported incidents of bullying shows that the number of incidents on D wing
during the first half of 2009 was largely the same as on Durham’s other main
residential wings. However, most staff interviewed by my investigators agreed
that D wing was a busy and lively wing, and that that it would have been an
unsuitable environment for someone like him.
110. Indeed it is clear from his journal that the man found his time on the wing very
difficult. This is hardly surprising given his personality and the nature of D wing.
He wrote that other prisoners on the wing demanded from him drugs and
tobacco. He wrote that he was scared to come out of his cell, and that resulted
in him not collecting some of his meals. He noted in his journal that it should
have been obvious to staff when one particular prisoner was shouting and
banging on his door. He also made two references in his journal about
apparently reporting problems to staff. In the first entry he wrote “I’ve
mentioned the bullying, and put in a [complaint form] yesterday”. In the second
entry he wrote that when an officer asked him why he had not come out of his
cell to collect his lunch he replied that he was too scared to do so. He noted
that the officer’s response was to say that they were “only hollow threats”.
111. Unfortunately, little of what the man wrote in his journal can be corroborated as
he largely kept matters to himself. Moreover, despite his reference to having
submitted a written complaint about bullying, Durham has not been able to
locate this document. Nor is there any other record that he complained formally
about being bullied. The one established occasion when he did speak to a
member of staff was on Friday 15 May: he spoke to a Listener who in turn
called the senior officer on duty. The man told the senior officer that he was
fearful of the other prisoners on the wing. The senior officer told him that he
would arrange to transfer him to a wing to which he would be more suited. He
31
also advised him though that the transfer would probably not happen until some
three days later, on the following Monday. The senior officer told my
investigator that the man seemed accepting of that timescale. The senior
officer had no reason to suspect that the situation might have been more
pressing, and I conclude that his proposed plan for dealing with the man was
reasonable.
112. From an entry that the man made in his journal it seems that he was under the
impression based on a conversation with Durham’s suicide prevention co-
ordinator that he might have been entitled to a transfer back to the healthcare
unit. His journal also indicates that he asked the senior officer on 15 May about
moving to healthcare, which accords with the evidence given by the Listener.
However, such a transfer would only occur in the case of clinical need and
there is no evidence to suggest that his clinical needs warranted healthcare
admission at that time.
113. Another of the man’s journal entries was about cell sharing. The entry indicates
a degree of despair that he might have to share a cell. However, the case
manager, the other panel member and the senior officer were all under the
impression from their conversations with him on 14 and 15 May that sharing a
cell would be a positive move for him, although not while he was on D wing. In
her response to the draft report, the man’s mother wrote that her son would not
have truly wished to share a cell but would have complied with whatever was
asked of him by staff.
Durham’s non-collusive (integrated) regime
114. Following an inspection of Durham in September 2006, Her Majesty’s Chief
Inspector of Prisons commented on the percentage of prisoners who reported
feeling unsafe at that time: 24 per cent said they felt unsafe at the time of the
inspection and 43 per cent said that they had felt unsafe in Durham at some
time. The Chief Inspector referred to Durham’s non-collusive (or integrated)
regime and recommended that consideration be given to options for the support
of vulnerable prisoners.
115. Many prisons locate their vulnerable prisoners on dedicated units. My
investigator spoke with Durham’s acting Governor about the option of setting up
such a regime at Durham. The acting Governor pointed out that there are
significant implications in running such units, however, as they require separate
regimes, separate visiting arrangements, separate arrangements for education
and so on. Moreover, the sad reality is that prisoner on prisoner bullying occurs
even within vulnerable prisoner units. It s also important to note that the man
may not have been located on a vulnerable prisoner wing even if there had
been such a facility at Durham. Prisoners are usually located on vulnerable
prisoner wings due to the nature of their offence making them vulnerable to
violence or threats from other prisoners. This man’s alleged offence did not fall
into this category.
116. A minority of prisons, such as Durham, operate an integrated regime with no
separation of potentially vulnerable prisoners. The acting Governor
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emphasised that Durham’s stated approach is to manage such a regime by
dealing robustly with bullying and violence. I was pleased to learn that the
Chief Inspector’s very latest inspection of Durham has shown a reduction in the
percentage of prisoners who reported feeling unsafe. The scores now show
that Durham is performing better on this measure than the average for
comparable establishments. I welcome this improvement since the previous
inspection in 2006.
Should staff have recognised the man’s ongoing risk?
117. The evidence from both discipline officers and clinical staff was that the man’s
mood improved in the weeks following his first reception into Durham. That is
hardly surprising given the extremely low point he would have been at in the
first few days after his arrest and remand into prison: it should be remembered
that he had no previous criminal convictions and was totally unused to a
custodial environment.
118. We know from the man’s journal that he was growing desperate during his final
days on D wing. Despite the journal entries staff did not recognise how he was
feeling and of course we cannot know how clearly he communicated any of his
fears with staff. Instead, the senior officer had every reason to believe that the
man might in fact have been growing more optimistic, not less so, given the
promise of an imminent transfer to a different wing. He took his life only hours
before he would have been transferred and at a time when he had a reason to
start feeling a little more optimistic than he had been for the past several days.
Concerns raised by the man’s family and partner
119. The man’s mother raised many issues of concern with my Family Liaison
Officer. Some of these were concerns raised or shared by other family
members and/or by the man’s partner. These included matters both before and
after her son’s death. Her main concerns before her son’s death largely
reflected the matters he itemised in his journal. The most significant of these
were probably the location of her son on D wing linked with the fact that
Durham does not have a vulnerable prisoners’ wing. His mother was also
concerned about the management of the ACCT process including that there
were only two members of staff at the panel that closed the ACCT on the
second and final occasion. I have dealt with these main issues within this
report. Other issues have been dealt with by letter directly with the man’s
mother.
120. As indicated, the man’s mother was also concerned about matters following her
son’s death, including the way the prison dealt with the family. This included
the family’s claim that they were misled about the time of the post mortem
examination. His mother also objected to certain comments made by the
prison’s family liaison officer including being told by him that he “understood
how she was feeling”. She responded to the remark by telling him that he had
“no idea” how she was feeling. On this point, the advice contained in Prison
Service Order (PSO) 2710 about breaking the news of a death in custody to a
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family member explicitly warns staff not to use the phrase “I know how you feel”
for the very reason the man’s mother has raised.
121. It is not possible for me to conclude with certainty what precisely was said at
this initial meeting, although there is no question that it has caused great and
continued upset to the man’s mother. The Family Liaison Officer role is an
extremely difficult one and the first meeting with a bereaved family will usually
be crucial in establishing a relationship with the family. PSO 2710 contains
many pointers on what prison staff should or should not do. As I have
mentioned, one is to avoid telling the family that “you know how they feel”. The
PSO also advises FLOs that they must be prepared to face “raw emotion” and
advises them not to “fill silences”.
I recommend that the Governor should ask his Family Liaison team to
review on a regular basis the guidance contained in PSO 2710 about
dealing with bereaved families.
The man’s cell-sharing risk assessment
122. When the man arrived in Durham the reception officer assessed him as being
medium risk for cell-sharing purposes. However, the healthcare worker and
locating officer assessed him as being low risk and therefore suitable to share a
cell with another prisoner. I am rather surprised at that assessment. It was
known that he been charged with murder and at that stage Durham knew
nothing else of his character and personality. Based on the information held on
that first day I consider that he should have been deemed as medium or high
risk until more information was known. The cell-sharing risk assessment
process has now changed so I make no further comment and make no
recommendation.
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CONCLUSION
123. The man was an unusual prisoner in several respects. In the first instance, he
was a young man from a stable family background who had not previously been
in trouble with the law. He was then arrested and remanded into Durham
charged with murder. Those two factors, his arrival into prison for the first time
and charged with a very serious offence, immediately meant that he was at high
risk of self-harm or suicide.
124. The other aspect of the man’s personality that made him different was his
apparent predisposed attitude towards suicide. Although he reported having
had a happy childhood, he informed psychiatric workers that from his early
teenage years he had had constant feelings of not wanting to exist. He
described having feelings of being different to others and of not being able to “fit
in”. He also said that for him, suicide had always been an option.
125. It is abundantly clear that the man found prison life very difficult. He had
described being bullied at school and being bullied at work, so it is hardly
surprising that he seems to have become a potential target for bullying within a
prison setting.
126. The man would most likely have had an easier time had he been located on a
wing other than D wing. It could also be argued that the second ACCT form
was closed prematurely. However, given the context of a busy local prison and
the limited time and opportunity available to staff in getting to know him, it is
open to question how much more they could reasonably have done to prevent
him acting as he did.
35
RECOMMENDATIONS
The following recommendations were made in the draft report. The Service
responses are contained in italics below each recommendation:
1. I recommend that the Prison Service consider revising the instructions given
in PSO 2700 to include explicit mention about the action to be taken when an
ACCT plan is reopened.
Prison Service response: Recommendation accepted. The management of
prisoners identified as being at-risk of suicide/self/harm and thereby subject to
ACCT procedures is set out in current instructions. The management of an at-
risk prisoner falls to the Case Manager and the Review Team throughout the
process, including closure and post closure reviews. The ACCT Plan can only
be closed once all the CAREMAP actions have been completed and the Case
Review Team judges that it is safe to do so, i.e. that the problems that caused
the ACCT Plan to be opened have been resolved or reduced and the prisoner is
able to cope with any remaining difficulties. If, at this time it is felt that there is
either a continuing or new risk to the individual the Case Manager can either re-
open, or open a new ACCT plan and based on the risks presented determine
the action to be taken to keep the prisoner safe. Target for completion:
Completed and ongoing.
2. The Governor should remind staff about the importance of familiarising
themselves with the daily entries made in ACCT plans to assist their decision
making at case reviews.
Prison Service response: Recommendation accepted. The Safer Custody team
and other relevant staff have been made fully aware of the need to comply with
the instructions given in Prison Service Order 2700 about the ACCT process.
Local refresher training remains ongoing in Foundation and, Case Manager
procedures ensuring compliance to the PSO. Target date for completion:
February 2010
Progress: ACCT refresher training given to all Senior Officers commencing from
19 May 2009 and completed by 30 June 2009. Discussed at ACCT Assessors bi
-monthly meetings. On going training for foundation.
Reviewed August 2011: ACCT training is identified at all close down days and,
as part of the monthly training programme.
3. The Governor should ensure that the safer custody team are reminded of the
advice in PSO 2700 on dealing with those at chronic risk of suicide so that
they can provide appropriate advice to wing staff on managing such prisoners.
Prison Service response: Recommendation accepted. The Safer Custody team
and other relevant staff have been made fully aware of the advice in PSO 2700
on dealing with those at chronic risk of suicide so that they can provide
appropriate advice to wing staff on managing such prisoners. Target date for
completion: February 2010
36
Progress: New Safer Custody Manager appointed in November 2009 and
attends Residential morning meetings on a daily basis. Also carries out daily
and weekly checks of ACCT documents and feeds back to wing managers.
New Safer Custody Manager appointed November 2010 and has continued to
provide support in this area.
4. I recommend that the Governor should ask his Family Liaison team to review
on a regular basis the guidance contained in PSO 2710 about dealing with
bereaved families.
Prison Service response: Recommendation accepted. Guidance contained in
PSO 2710 will be reviewed by the Family Liaison and Safer Custody Teams to
ensure the appropriate care is maintained when dealing with bereaved families.
Target date for completion: March 2010.
Progress: Both FLO’s aware of contents of PSO 2710.
Two further FLO’s trained in March 2011.
37