Individual at Leeds

Investigation into the circumstances surrounding the
death of a prisoner
at HMP Leeds in January 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2011
This is the report of an investigation into the death of a prisoner at HMP Leeds. On
31 January 2010 the man was found hanging in his cell by a ligature attached to the
window, despite every effort, he could not be revived. The man was 39 years old.
I offer my sincere condolences to the man’s family and friends. The death of a loved
one is always difficult, and that can be made so much more so when the death
happens in custody. I hope my report addresses the questions the family may have.
I apologise for the delay in issuing this report and any additional distress this may
have caused.
The investigation was undertaken by one of my senior investigators. Both he and I
would like to thank the then Governor of Leeds and his staff for their participation in
the investigation. A doctor was asked by Leeds Primary Care Trust (PCT) to
undertake a review of the man’s clinical care. I appreciate his assistance throughout
the investigation process and his final report.
The clinical reviewer found that although the man had received a high standard of
care for his physical needs, the healthcare team at HMP Leeds failed to act on
correspondence received from his community General Practitioner in relation to a
recent suicide attempt and his drug and alcohol use.
I make five recommendations. Four of these are to the head of healthcare
concerning the effective use of information provided, the identification and treatment
of substance misusers and recording of cardio pulmonary resuscitation. The other is
to the Governor and also concerns the effective use of key information provided to
the prison. The National Offender Management Service have accepted three of
these recommendations, and partially accepted the remaining two. The man’s family
have indicated that they have no comments to make on the draft report.
Nigel Newcomen
Prisons and Probation Ombudsman October 2011
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CONTENTS
Summary 4
The investigation process 6
HMP Leeds 9
Key events 12
Issues 18
Conclusion 24
Recommendations 25
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SUMMARY
1. The man was remanded to HMP Leeds on 24 December 2009.
2. Healthcare staff requested medical records from the man’s community
General Practitioner, which were faxed to the prison on 29 December. These
showed a history of substance misuse and a recent suicide attempt. The
information in the document was not acted upon. Records show that the
man’s initial health screening did not give rise to any concerns, and the man
was not referred for a mental health assessment or assessed in relation to his
risk of suicide or self-harm.
3. The man had complex physical issues which were well addressed by the
healthcare staff at Leeds. He was receiving medication for sciatic nerve
damage and depression. Following a blood test, he was also found to be
positive for hepatitis C, which was due to be treated.
4. The man appeared at Bradford Crown Court on 28 January and was
sentenced to six years and six months imprisonment for robbery. Pre-
sentence reports completed for the court showed that the man had expressed
thoughts of taking his own life, had said that he had attempted to take his own
life after being released from a previous prison sentence, had no contact with
family or friends since being arrested and was in a “low mood” due to the
recent breakdown of his relationship. Although the report assessed his risk of
self harm as “medium” the offender manager suggested that “any emotional
crisis would escalate the risk of self-harm and suicidal thoughts”.
5. A probation report on the man also highlighted his vulnerability and assessed
his emotional state as “fragile”. Despite both the pre-sentence report and
probation report being amongst the documentation provided to the
investigator by the prison, neither appear to have been acted upon.
6. The man was worried about being bullied after details of his offence were
published in the local press on 29 January. The next evening the man
approached a wing officer and asked to be moved to another wing because
he was being threatened by other prisoners. As it was lock-up time and the
man was not worried by his cellmate, they agreed to deal with the move in the
morning. Unfortunately in the early hours of 31 January the man apparently
took his life using the crepe bandage from the dressing on his leg.
7. The man was discovered by his cellmate at 4.30am. Officers and healthcare
staff provided a good quality of emergency response and paramedics were in
attendance quickly and took over efforts to resuscitate the man. Sadly he
could not be revived and paramedics confirmed he had died at 5.04am.
8. I consider the healthcare the man received whilst at Leeds and the
emergency response on the day he died. I also consider the lack of effective
use of information that might have triggered a mental health assessment,
substance misuse treatment and crucially suicide prevention measures. I
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make five recommendations, four to the head of healthcare and the other to
the Governor of HMP Leeds.
5
THE INVESTIGATION PROCESS
9. My investigator formally opened the case at HMP Leeds on 4 February 2010.
During the investigation he visited Leeds and spoke to staff and prisoners who
had come into contact with the man during his time there. He interviewed four
members of staff. These interviews were recorded and transcripts are
annexed to this report. He also spoke to two other members of staff, and to
the man’s cellmate. The investigator told the Prison Officers Association, the
Independent Monitoring Board, and the chaplaincy about his visit, but they did
not ask to see him.
10. The investigator spoke to the Detective Superintendent who was leading the
police investigation into the man’s death. A thorough investigation had been
undertaken at the prison at the time, and the police had found no evidence to
suggest that the man’s death involved anyone else.
11. Notices were posted to staff and prisoners about my investigation, inviting
them to contact the investigator with any information they thought might be
relevant. None was received. The investigator looked at all relevant prison
records relating to the man. These include his main prison record, medical
records, statements made by staff, and some of the man’s personal papers.
12. Leeds Primary Care NHS Trust asked a doctor to carry out a review of the
man’s clinical care. I am grateful to him for undertaking this review. My
investigator discussed aspects of the man’s treatment both with healthcare
staff at Leeds and with the reviewer.
13. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and request a copy of the post mortem report.
Upon completion, my report will be sent to the Coroner to assist in his
enquiries into the man’s death.
14. One of my Family Liaison Officers (FLOs) contacted the man’s sister, his
listed next of kin. She told her of my investigation and invited her and the
man’s family to ask any questions or raise any issues for consideration. The
family asked if my investigation could consider:
• Why did the man’s cellmate not hear anything?
• How long had the man had hepatitis?
• As the man was disabled, why was he not on a hospital wing?
• What treatment was he receiving for his drug addiction?
• Why was there a few hours delay in the family being told of his death?
15. The man’s family have considered the draft report and have not made any
comments. I hope that my investigation will provide the man’s family with a
better understanding of his time in custody and the circumstances of 31
January.
6
HMP LEEDS
16. HMP Leeds is a Category B local prison, serving the courts of West Yorkshire.
It has capacity to hold just over 1000 male prisoners. The prison has four
Victorian wings and two modern wings; one of the wings is the vulnerable
prisoners’ unit. (Prisoners are most often deemed vulnerable due to the
nature of their offences but may also include those who are less able to cope
on the main prison wings for other reasons. Vulnerable prisoners are kept
separate from other prisoners.) Cells are either single or shared by two
prisoners. All wings have both prisoners who are on remand and convicted.
17. There is 24 hour healthcare cover at Leeds: the prison has its own in-patient
healthcare centre, operated by the local Primary Care Trust (PCT). In
daytime hours a doctor is in the prison, and there is nursing cover at all times.
Nursing staff are not based in the healthcare centre, but are allocated to
wings. Although they work on other wings on occasions when staffing levels
require it, they are usually based on their own wings.
18. Facilities available to prisoners include a gym and education which is
contracted out to The Manchester College. There are approximately 30
voluntary and community service organisations working within the prison.
These include the Samaritans, Prison Visitors, Bereavement Counselling and
minority interest groups.
Assessment, Care in Custody and Teamwork (ACCT)
19. ACCT is the prison service-wide process for supporting and monitoring those
prisoners thought to be at risk of harming themselves. An ACCT plan can be
opened by anyone working in the prison if they have any concerns that a
prisoner might have tried, or, in the future, might try to harm himself. The
purpose of ACCT is to try to determine the level of risk posed, the steps that
might be taken to reduce this and the extent to which staff need to monitor
and supervise the prisoner. Levels of supervision (where staff must check the
prisoner) and interactions (where staff must have a conversation with the
prisoner) are flexible and can be set according to the perceived risk of harm.
If staff believe the risk of harm to be very high, the prisoner may be constantly
supervised, with a member of staff positioned outside their cell at all times.
Where the perceived risk is lower, the level of supervision may be several
times an hour or day. Supervision can also take place during the night. As
part of the process a CAREMAP (plan of care, support and intervention) is put
in place and there should be regular multi-disciplinary review meetings.
Wherever possible, the prisoner at risk is also included in review meetings.
Night state
20. When prisoners are locked up for the night, the prison is in night state.
Staffing levels are at a minimum. The officer in charge of the operation of the
prison is the Night Orderly Officer (NOO), and has keys to access all cells.
Other officers on duty have cell keys in sealed pouches, only to be used in an
emergency. They are free to use their discretion when deciding to enter cells,
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including the ratio of how many members of staff to the number of prisoners in
the cell. But in doing so they must take into account security, including their
own safety. The radio operates on an open network, so that all staff on duty
are able to hear any message sent out.
Cell Sharing Risk Assessment (CSRA)
21. The CSRA assesses the risk a prisoner poses to other prisoners and whether
they are suitable for sharing a cell. The assessment considers a range of
factors including the prisoner’s past offences, whether they have displayed
bullying or violent tendencies in the past, any substance misuse or mental
health problems and whether they might try to harm themselves while in
prison. The prisoner is asked whether they have any concerns about sharing
a cell and this is also taken into account. One part is completed by a
discipline officer and one part by a member of healthcare staff. The staff
conducting the assessment must decide whether the prisoner poses a low,
medium or high risk to other prisoners. Those assessed as high risk will
generally be placed in a single cell, and the risk assessment should be
reviewed frequently. The prisoner may be required to work on those factors
that make them high risk.
Previous deaths in Leeds
22. The death of the man was the fifth self-inflicted death at HMP Leeds since the
start of 2008. Since the man died there has been one further self-inflicted
death. I draw the Governor’s and head of healthcare’s attention to previous
recommendations made concerning effective management of medical and
individual risk information.
Her Majesty’s Chief Inspector of Prisons
23. The most recent inspection report published by Her Majesty’s Chief Inspector
of Prisons, was following an unannounced inspection in March 2010. The
report noted that whilst prisoners did not report high levels of victimisation by
other prisoners, systems to investigate and monitor alleged incidents were
weak. Reporting of violence-related incidents and potential bullying had
improved, with a more focused strategy, but there were still no effective
procedures to ensure that investigations took place promptly and that alleged
bullies and their victims were monitored. The Chief Inspector also comments
that a great deal of attention had been given to suicide prevention strategies
and procedures, following a large number of self-inflicted deaths, and in
general support arrangements had improved.
24. The inspectorate report commented on the in-patient facility. It recommended
that it should not be used to accommodate prisoners with disabilities unless
there was a need for clinical inpatient care.
Independent Monitoring Board
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25. Each prison in England and Wales is also monitored by an Independent
Monitoring Board (IMB) formed of volunteers from the local community. IMB
members have full access to every prisoner and all parts of the prison. The
Board produces an annual report, the report for 2010 notes that “staff are now
strongly encouraged to report all incidents of violence, which includes
bullying”. The report goes on to say that staff are now recording “more
thoroughly acts of indirect violence, being the victim of gossip for example”.
26. The report also raises the issue of improved communication between the
prison and outside agencies, particularly in relation to cell sharing risk
assessments, where outside agencies have had “knowledge of a person’s
violent tendencies, strong racial views or mental health issues” but not shared
these with the prison.
9
KEY EVENTS
27. Following an offence on 17 December 2009, the man was arrested on 23
December and charged with robbery. When prisoners are moved between
different areas of custody, they are accompanied by a Person Escort Record
(PER). The man’s PER when he was transferred from police custody, his
PER notes physical health risks as “injuries to right leg” and mental health
risks as “depression”. His risk assessment additionally notes an infection to
one of his toes.
28. He was remanded to HMP Leeds on 24 December. A cell-sharing risk
assessment (CSRA) carried out that day noted no concerns at the man
sharing a cell, simply noting that he was a smoker. The assessment noted
that the man should be allocated a cell on the ground floor. In answer to the
question as to whether he was currently dependent on drugs or alcohol, the
man said that he was. He said that he had previously had mental health
problems, and the assessment shows that while he had previously harmed
himself, he had no such thoughts of doing so again.
29. The man’s reception health screening was carried out by a Staff Nurse. The
man said that he had been seen by his General Practitioner in the last few
months and was receiving medication for sciatic nerve damage and
depression. The Staff Nurse noted that the man had reduced mobility and
used crutches due to his fractured right hip and an ulcer and cellulites (non
contagious spreading bacterial skin infection) on his right foot. It was also
noted that he was waiting for an operation on his right hip. The man was
found to be positive for hepatitis C (a serious viral infection of the liver). It is
not clear from the records whether the man was aware of this previously or if
this was the first time he had been diagnosed. He said that he had seen his
doctor in recent months both to receive medication for damage to his sciatic
nerve, and for depression. He denied any drug or alcohol issues.
30. Later the same day the man was seen by a prison doctor. The man
confirmed that he been prescribed medication by his General Practitioner, and
had brought this in with him. This included a low dose of amitriptyline.
Amitriptyline is sometimes used as an anti-depressant, but the clinical
reviewer notes that the low dosage prescribed to the man suggests that it was
prescribed primarily for pain relief, with perhaps some small potential benefit
for depression. The medication was confirmed by the doctor. The doctor also
prescribed other medication to the man for his physical health issues,
including pain relief and antibiotics.
31. Between 25 December and 4 January 2010, healthcare staff regularly dressed
the man’s foot and another prison doctor, reviewed his medication.
32. On 4 January 2010 the man appeared at Bradford Crown Court. He was
convicted of robbery, but not sentenced at that stage. The man returned to
HMP Leeds.
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33. Regular dressings of the man’s foot continued over the next two weeks, this
included the application of a crepe bandage for protection and to keep the
dressings in place. When changing the dressing on his foot on 19 January,
the nurse noted a rash on the man’s face and abdomen, as a consequence
he saw another prison doctor later that day. The doctor confirmed that the
rash had become infected, and he prescribed erythromycin (antibiotic),
flucloxacillin (antibiotic) and loratadine (anti-histamine, for treatment of
allergies).
34. The man did not require 24 hour in-patient care (had he been outside prison
he would not have been in hospital) so remained on a normal prison wing. He
did, though, continue to be seen by healthcare staff on a regular basis to
redress his foot and review his medications. On 25 January, the man was
seen by the doctor concerning the best way to treat his hepatitis C, further
blood tests were requested and the doctor was to review treatment once the
results were received.
35. On 27 January the man’s foot was redressed, no signs of infection were
noted. In common with previous treatments, the dressings were held in place
by a crepe bandage.
36. The man appeared in court on 28 January and was sentenced to six years
and six months imprisonment.
37. Pre-sentence reports completed for the court show that the man had
expressed thoughts of taking his own life when he was received into custody.
He also said that he had attempted to take his own life after being released
from his previous prison sentence. The report also says that the man had no
contact with family or friends since he had been arrested, due to the nature of
the offence and he was in a “low mood” due the recent breakdown of his
relationship. The report assesses the man as “medium risk” of self-harm,
however the offender manager suggests that any “emotional crisis would
escalate the risk of self-harm and suicidal thoughts”. There is no evidence to
suggest that this important information was passed to the prison via the court
or probation service on the day the man was sentenced.
38. As a sentenced prisoner, the offender assessment (known as OASys) which
was completed on the man by his offender supervisor (probation officer)
which informed the court report should have been provided to the prison. It
describes the man as isolated, with a low opinion of himself. The report
confirms the man said that he had attempted to take his own life by taking an
overdose shortly before he committed his latest offence. He also said that he
had thoughts of killing himself on the day he committed the offence, and again
when remanded into prison. He said that he had been prescribed anti-
depressant medication. He felt disgust at his offence, although he claimed he
was no longer overwhelmed with thoughts of wanting to harm himself or end
his life. The assessment judges his emotional state at that time as fragile, but
concludes that although there had been self-harm issues in the past, there
were none at the time the OASys report was completed.
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39. The man’s cellmate, told my investigator that on his return to prison on 28
January, the man had been suffering some anxiety over the length of his
sentence, and “some of the other lads were giving him a hard time when they
found out what he was in for”.
40. The man’s cellmate said that after being locked into their cell on the evening
of 29 January, he and the man talked into the early hours of the morning. The
man’s cellmate told the investigator that apart from being dejected over the
length of his sentence, the man showed no signs of being depressed or at risk
of harming himself.
41. Several local newspapers printed reports of the trial on Friday 29 January,
including details of the offence. The man’s cellmate said that the man was
concerned about other prisoners knowing these details. Staff later received
information that a prisoner had put a copy of one of these newspaper stories
on the wing notice board, it is not clear whether this was on the Friday or
Saturday, but it appears to have been quickly removed by another prisoner. It
is also not clear whether the man was aware of this, but the possibility must
exist that if he did, this was part of the reason he felt he was being bullied.
42. At weekends prisoners are locked into their cells for the night at 5.00pm.
Shortly before being locked up on the evening of Saturday 30 January, the
man asked to speak with a Senior Officer (SO). The Senior Officer took him
into an office on the wing where they could speak privately. The man then
told the Senior Officer that he had been threatened by another prisoner (who
he identified) on the wing and he asked to be moved to another wing. The
Senior Officer asked if the man was asking to be segregated for his own
safety, but the man said he was not. He said that had been threatened by
another prisoner on the wing, and just wanted to move to another wing but
wanted to stay on normal location.
43. The man confirmed to the Senior Officer that he had no problems with his
cellmate and did not feel unsafe with him. The Senior Officer spoke to the
man’s cellmate, who said that he knew about the threats. He said that he did
not have a problem with the man or with continuing to share a cell with him,
despite the man’s offence becoming common knowledge and despite the
threats the man had received. The Senior Officer then told the man that he
would deal with the request to move first thing in the morning. Prisoners were
just about to be locked into their cells for the night, and the man had said he
felt safe until the morning, when the Senior Officer would deal with securing a
move for him. The man said that he was content with this course of action.
44. The Senior Officer said in interview that he had convinced himself that the
man was safe from the prisoner who had threatened him, was safe with his
cellmate, and was himself content for the matter to be addressed the following
morning. The Senior Officer said that the man gave no indication that he
might harm himself during the night, and therefore he saw no need to open an
ACCT document to ensure special monitoring and support measures were in
place. The man therefore returned to his cell and the prisoners were locked
up for the evening.
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45. The prison officer on duty on D wing that night was an Officer serving the sixth
of seven scheduled consecutive night shifts. The Officer said that when on
night duty he patrolled each of the three landings for which he was
responsible once or twice per hour. The man and the man’s cellmate’ cell
was only two doors along from the wing office, so each time The Officer left
the office he passed close by the cell. He said that throughout the previous
week he recalled hearing the man and the man’s cellmate talking to each
other fairly late into the night. On the 30 January, this continued and the two
men were talking into the early hours of Sunday morning. When speaking to
my investigator, neither the man’s cellmate nor the Officer could be specific
about the time, but both agreed it was approximately 2.30am when the two
prisoners stopped talking in order to go to sleep.
46. Because of his disability, the man occupied the lower bunk bed in the cell, and
the man’s cellmate the upper. Shortly before 4.30am, the man’s cellmate said
he awoke and decided to smoke a cigarette. As he looked around the cell, he
saw the man leaning back against the wall, suspended by a something
attached to the bars on the cell window. The man’s cellmate said ran to the
door, pressed the cell’s emergency call bell, then ran back to the man and
tried to support his weight, all the while shouting for help. He told the
investigator that the man was cold to the touch, and although the man’s
cellmate has no medical training, he did not think that he was alive.
47. At this moment, the Officer was just leaving the wing office in order to check
on another prisoner. He heard the man’s cellmate call for help, and was at
the cell door in a matter of seconds. He looked through the observation
panel, and saw the man’s cellmate with his arm around the man at the
opposite end of the cell. He saw that the man was hanging by a ligature and
immediately put an emergency call across the radio. The Officer used the call
sign Code Blue. This is the emergency code indicating that a prisoner is not
breathing, with the possibility that this might be due to a ligature. The
emergency call went out at 4.30am.
48. When the Officer’s emergency call went out, the Senior Officer and the Night
Orderly Officer were in the office on B wing, which is only a few yards from the
entrance to D wing. They immediately went to assist, reaching D wing in what
the Senior Officer estimated to be approximately 15 seconds. Having put the
emergency call out over the radio, the Officer had decided to go into the cell.
He was in the process of breaking the seal on his cell key pouch when the
Senior Officer arrived. Through the observation panel, the Senior Officer
could see the man suspended by a ligature, his weight being supported by the
man’s cellmate, who was visibly upset. He opened the cell, and the three
officers went in. The man was suspended by a bandage which he had taken
off his foot, and whilst the other two officers supported the man, another
Officer used his anti-ligature knife to cut him down, cutting the bandage
between the ligature point and the man’s neck. The Officer told my
investigator that the man was cold to the touch, and his initial impression was
that the man was already dead.
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49. Two other officers also heard the emergency call and made their way to D
wing. On arrival, one of the Officers began to keep a log of events. A Nurse
was the emergency response nurse on duty on 31 January. At 4.30am she
heard the Code Blue call from D wing across the radio network, and
immediately made her way to the cell. She arrived just as the officers were
going in. The prison’s log shows that she arrived at 4.31am.
50. The officers assisted the man’s cellmate out of the cell. Operational Support
Grade (OSG) was on duty with an Officer on C wing when she heard the
Code Blue call over the radio. They made their way to D wing. On arrival, the
OSG found the man’s cellmate outside the cell in a distressed state, so she
began to talk to him. She took him aside and offered him support.
51. The officers laid the man on the cell floor. The Officer began to feel the
effects of shock, so handed his anti-ligature knife to the Senior Officer who
managed to cut the bandage away. He radioed through to the
communications centre to request an emergency ambulance. He also asked
that the duty governor be informed. The Nurse and the Senior Officer began
to perform cardiopulmonary resuscitation (CPR) while the Officer held the
oxygen tank.
52. Another Nurse was on duty in the healthcare centre and, hearing the
emergency call, made his way to D wing. The log shows that he arrived at the
cell at either 4.36am or 4.38am (the log gives both times). He took over from
The Senior Officer. The Officer had heard the emergency call on the radio
and made his way to D wing, and one of the nurses asked him to collect the
resuscitation bag from the treatment centre. The nurses attached a
defibrillator (a machine which detects whether there is any activity in the heart
and, if so, will advise a shock to assist the heart back into rhythm). The
defibrillator did not detect any activity in the man’s heart and did not advise
them to deliver a shock, so they continued with CPR.
53. The ambulance arrived and the crew were escorted to the cell by an Officer
arriving there according to the log at 4.47am. They took over from the nurses.
54. The paramedics worked to try to resuscitate the man until 5.04am, when they
confirmed that he had died.
55. The OSG was still talking to the man’s cellmate, who was visibly upset. He
told the OSG that two nights previously the man had said that he felt suicidal,
and that if anything should happen to him the man’s cellmate should tell his
daughter that he loved her. However, after the man spoke to the wing Senior
Officer, he thought that he had seemed to be more relaxed, so he didn’t tell
anyone. He also said that the man had appeared to be fine that night before
the man’s cellmate had fallen asleep. The man’s cellmate then indicated that
other prisoners had “started getting on at him and making his jail time hard. I
think it pushed him over”. The OSG told the man’s cellmate that he could
request counselling if he wished and this appeared to calm him down.
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56. The OSG supported the man’s cellmate until approximately 5.30am. At this
point the man’s cellmate was taken to another cell, with a Listener (Listeners
are prisoners trained by the Samaritans to offer confidential emotional support
to fellow prisoners in distress).
57. A hot debrief was held for staff (a hot debrief is held as soon as possible on
the same day after a death in custody. They are held to ensure that all staff
involved have an opportunity to discuss any issues arising). Support was
offered for any who felt that they needed it.
58. The Governor posted notices to staff and to prisoners informing them of the
man’s death, and letting them know how to obtain support should they feel it
would be of benefit to them.
59. A debrief session was held on 2 February, chaired by a Governor. All
available staff who had been involved on 31 January attended.
60. A note from the man to his sister was found in his diary a few days after his
death which although not clear, seems to indicate his intention to take his own
life.
Breaking the news to the man’s family
61. The man had listed his next of kin as his sister. The prison Governor, and a
Sister from the chaplaincy went to the address given to inform the family of
the man’s death. However, when they arrived at the address the man’s sister
was not at home. They spoke to her son, and decided it was not appropriate
to break the news to him. He did, though, provide an address for another
sister (his aunt), and the Governor and the Sister then travelled to this
address and broke the news to the man’s sister.
62. The family commented that they were grateful for the contact they had had
from the prison’s family liaison officer, who they described as helpful.
Post mortem
63. A post mortem was held on 31 January. The cause of death was given as
hanging.
15
ISSUES
Healthcare
64. The clinical reviewer says:
“the healthcare team at HMP Leeds afforded him [the man] a high
standard of physical health care but missed the clear opportunity to
explore his mental state and drug issues as they failed to react to
correspondence from his GP or recognise from his presentation that these
were important issues.”
65. The man’s reception health screen confirmed that he suffered from
depression but, despite him saying that he was dependent on them in his
CSRA, also showed that he denied any drug or alcohol issues. The prison
healthcare sought information from the man’s community General
Practitioner, which was provided on 29 December 2009. This clearly
documented a recent overdose and attempted suicide, treated at the local
hospital accident and emergency department. The community General
Practitioner also described injected heroin use, the use of crack cocaine, poly
drugs and excessive alcohol.
66. The clinical reviewer confirms that the issues of “injecting drug use and self-
harm through overdose are not considered subsequently by the healthcare
team at HMP Leeds”. There was also “no evidence of exploration or follow-up
of the documented depression at HMP Leeds”.
67. This is a serious omission by the healthcare team at Leeds. Although we will
never know whether this lack of action on the man’s substance misuse issues,
depression and recent overdose contributed to him taking his own life, these
issues should have been considered key indicators of risk and followed up
accordingly. I therefore agree with the clinical reviewers concerns and make
the following recommendations:
The head of healthcare must ensure that a system is put in place so that
correspondence from a patient’s community General Practitioner is
routinely shown to the prison doctor. Also that the records are
appropriately endorsed to confirm that the information has been read
and will be responded to appropriately.
The head of healthcare should ensure that the healthcare team are more
vigilant in identifying drug users and more confident in taking
substance misuse histories and that all healthcare staff are trained in
the Integrated Drug Treatment System to an appropriate level.
68. Instructions and guidance to the Prison Service are contained in Prison
Service Orders (PSOs) and Prison Service Instructions (PSIs). PSO 3550
addresses clinical services for substance misusers, and contains a mandatory
requirement to provide a service for the management of alcohol misusers,
which includes identification during reception screening of alcohol
16
dependency and those at risk of developing withdrawal symptoms and
provision of managed and supervised treatment. Although I accept that the
man may not have admitted his excessive use of alcohol during the reception
screening, this clearly became apparent from the documentation faxed by the
community General Practitioner (29 December) and from the OASys report. I
am therefore disappointed that although he saw a number of healthcare
professionals, in addition to the lack of action in relation to the man’s drug
dependence and depression, there was also an apparent lack of action in
relation to his alcohol issues.
69. Unsupported withdrawal from drugs and/or alcohol can have a serious affect
on someone’s state of mind. It is impossible to say whether the outcome
would have been different if the man had received appropriate support and
medication, but the possibility must exist that his state of mind at the time of
his death may have been affected.
Mental health issues
70. The man clearly stated during his reception health screen on 24 December
that he suffered from depression, this is indicated on the reception checklist.
Also noted in his medical records is, that along with a number of other
medications (relating to his physical health issues) he is prescribed the anti-
depressant amitriptyline. Amitriptyline is, though, also used to relieve pain,
and the low dosage prescribed to the man suggests that this may have been
the primary reason he was prescribed. The records do not make this clear.
71. On 29 December (more than a month before he died), the prison received
faxed documentation from the man’s community General Practitioner which
clearly shows that he had been treated in accident and emergency at the local
hospital for a recent overdose, which was considered a suicide attempt.
72. I am very concerned, that despite these two key indicators of risk that the man
was not referred to the mental health team for an assessment, and make the
following recommendation:
The head of healthcare should ensure that there are processes in place
to capture and act upon all relevant information in relation to the
physical and mental health of prisoners.
Offender Assessment System (OASys) Report
73. The OASys report was completed by the man’s offender manager on 29
January and subsequently sent through to the prison. Although primarily
designed for the management of risk to the community and sentence
planning, the document clearly sets out the man’s history of depression, self
harm and his recent suicide attempt. The offender manager assessed his
emotional state as ‘fragile’. I accept that the report was completed just two
days before the man’s death, however it is not clear whether the OASys
report was ever read by any member of prison staff. It is apparent that it was
17
not acted upon and had it have been so the man might very well have been
more closely monitored or at least spoken to.
74. PSO 2700 addresses suicide prevention and self harm management. It
covers “Other sources of risk information or assistance concerning prisoners”.
This makes clear that agencies and individuals outside of prison can help with
warnings, assessment and referral. The document states:
“Establishments must have in place robust systems for receiving and
recording, and passing to the area of the prison where the prisoner
resides, information coming into the establishment from families, agencies,
Offender Managers/Supervisors and other parties outside the
establishment who have a concern for a prisoner who may be at risk of
self-harm or suicide”.
75. There is no evidence that HMP Leeds has in place any system that ensures
OASys reports are swiftly read and acted upon. Such a report can be
invaluable especially if it contains information that might prove vital to protect
a prisoner from harm and I suggest that it should be considered a source of
key information and treated accordingly:
The Governor should ensure that OASys documents are reviewed upon
receipt, and staff should be reminded that they might contain valuable
information about a prisoner’s state of mind and risk of self harm or
suicide.
76. It is recognised that prisoners may be more vulnerable at times surrounding
court appearances. This can be particularly heightened at times of conviction,
and sentencing, especially if the sentence is for a long period. The man was
sentenced to six years and six months imprisonment on 28 January, just three
days before he apparently took his life. There is no note on the electronic
Person Escort Record (PER) which accompanied the man back from court on
28 January to suggest that there were any concerns at his state of mind. The
pre-sentence report (PSR) prepared for the court, however, makes clear that
the man was in a “low mood” and any “any emotional crisis would escalate the
risk of self-harm and suicidal thoughts”. There is no evidence to show that
this important information about the risk to the man’s well being was passed
on to the prison as a matter of urgency either by the court or probation
service. The PSR was in the papers provided by the prison to my
investigator, but it is not clear when this arrived at the prison or if it was ever
read by prison staff – it is clear however, that it was not acted upon. This was
another missed opportunity to consider the man’s state of mind and risk of
suicide.
77. Despite this prison staff should be aware that a change of status can increase
the vulnerability of a prisoner and the Governor may wish to remind staff to be
particularly vigilant when a prisoner returns from court with a significant
change of status.
Bullying
18
78. The man told his cellmate that he was worried that if the nature of his offence
was revealed he would be subject to bullying from other prisoners. On 29 or
30 January pages from local newspapers were posted on notice boards on
the wing. These identified the man and gave details of his offence. It is not
known whether the man knew about this, I understand they were swiftly
removed by another prisoner. However if he did it could clearly have added to
his feelings of concern.
79. The man identified an individual who he believed was threatening him to an
officer on the night that he died. He spoke to the Senior Officer in private and
asked to be moved to another wing. This was around 5.00pm on Saturday 30
December, the time that prisoners are locked up for the night at the weekend.
Having checked with the man that he felt safe for the night and had no issues
with his cellmate, the Senior Officer and the man agreed to deal with the issue
the following morning. Unfortunately during the early hours of the following
morning the man apparently took his life.
80. The Senior Officer ensured that spoke to the man in private, so he would have
been able to voice any concerns he had out of earshot of other prisoners.
However the man did not give any indication to the officer that he would feel
unsafe locked up overnight. He also confirmed he was happy with his
cellmate, indeed they had been heard chatting into the early hours by wing
staff over the previous few nights. I am satisfied that the Senior Officer did all
he could to ascertain that the man was safe overnight, with a view to
arranging a move to another wing the following morning. The Senior Officer
also considered and decided against opening at ACCT. In making such a
decision, staff must consider how the individual prisoner is currently
presenting, as well as other information. Given the information available to
him – and we cannot say whether the Senior Officer would have made a
different decision even had all the information been available to him - I am
able to understand why he made this decision. Indeed, even if the man had
been subject to special monitoring, there is no way of knowing if this would
have prevented what happened.
81. However it is clear that none of the information that had been available (from
the community General Practitioner, PSR and OASys) on the man’s drug and
alcohol issues, mental health and previous suicide attempt had been
effectively managed and acted upon. If the Senior Officer had been in
possession of this key information, he may have made a very different
decision. It is impossible to say whether a different decision would have
prevented the man from taking his own life, but being without the information
referred to above, the Senior Officer was clearly prevented from making
informed decisions on both moving the man immediately and opening an
ACCT plan by the earlier failings discussed in this report. Indeed a full
assessment of the man’s risk of self-harm of suicide might very well have
already been carried out if the information available had been acted upon.
Events on 31 January 2010
19
82. Following the discussion with the Senior Officer, the man and his cellmate
were locked up at approximately 5.00pm on 30 January. They were heard
talking to each other into the early hours of the next morning. The Officer who
was on duty that night said that he had both men talking to each other until
fairly late throughout the previous week.
83. Around 4.30am, the man’s cellmate got up for a cigarette and discovered the
man suspended from the window. He pressed the cell bell and then tried to
support the man whilst calling for help.
84. The Officer responded immediately, he looked through the observation panel
and saw that the man was hanging by a ligature. The Officer put an
emergency call out over the radio, using the call sign Code Blue. This
effectively informs others that a prisoner is not breathing and that a ligature
might be involved. It is good practice to use such codes as this ensures the
correct response from staff (such as bringing the right equipment).
85. Officers entered the cell quickly and the ligature was cut using an anti-ligature
knife (a tool designed for that specific purpose). The man had used the
bandage used to dress his leg wound as a ligature.
86. As already stated earlier in this report, the man’s physical health needs had
been well addressed and the use of a crepe bandage to protect his wound
and hold the dressing in place, would not have been seen as a risk by
healthcare staff. However if the information available from the community
General Practitioner, PSR and OASys report had been acted upon, a full
assessment of the man’s risk of self-harm or suicide should have taken place.
If the result had been to open an ACCT, the risk of using a crepe bandage
may have been considered.
87. CPR was started by a nurse and the Senior Officer, also assisted by another
Nurse. A defibrillator was also used, which advised not to administer a shock.
The paramedics arrived at 4.47 am and despite continued attempts to
resuscitate the man, he was confirmed dead at 5.04am.
88. The Clinical Reviewer notes that there is no information as the use of an
airway, oxygen or resuscitation drugs. He also notes that there are no
records of the man’s condition such as colour, pulse, respirations or blood
pressure. It is important to effectively record vital signs, equipment and drugs
used when administering CPR and I endorse The Clinical Reviewer’s
recommendation:
The head of healthcare should ensure that a detailed record of CPR is
kept including a description of the patient’s vital signs and the
equipment and any drugs used.
Support for Staff and Prisoners
89. According to staff, the man’s cellmate, the man’s cellmate, was clearly upset
and visibly shaken. The man’s cellmate was assisted out of the cell and was
20
clearly well supported by the OSG, including advising him that counselling
was available for him. The OSG stayed with the man’s cellmate until 5.30am.
He was then supported by a Listener.
90. I am pleased to see that the man’s cellmate told my investigator that he was
well supported on the evening.
91. Staff were satisfactorily supported through a hot debrief held on the day,
ensuring that all staff involved were able to discuss any issues arising. In
addition support was offered to anyone who felt they needed it.
92. Also notices were posted to both staff and prisoners informing them of the
man’s death and indicating how to access support if needed.
Issues arising following the death of the man
93. Cell sharing risk assessments (CSRAs) had been carried out on both the man
and the man’s cellmate, both were assessed as low risk and suitable for a
shared cell. The police have investigated the man’s death and there is no
suggestion that the man’s cellmate was involved in the death of the man.
94. However on a security incident report (SIR) filled out by the Senior Officer
after the incident, there is a note that the man’s cellmate has an “extensive
security file re bullying/drugs through visits”. During the investigation the
investigator also received a letter from another prisoner suggesting that the
man’s cellmate was “bullying” the man, although there was no other evidence
to support this.
95. At lock up on the night he died, the man told an officer that he wished to be
moved to another location because he was being bullied, he gave the name of
the prisoner concerned and also confirmed that he was happy to be in the
same cell as the man’s cellmate. The officer discussed his concerns and they
both agreed to follow up his request in the morning, as the officer and the man
felt he would be safe locked up overnight. Despite the SIR and letter received
from another prisoner, neither this investigation or that of the police found any
evidence that suggested the man’s cellmate was bullying the man or involved
in his death.
96. I am greatly concerned however that the security file referred to by the Senior
Officer cannot be located by the prison and that the CSRA on the man’s
cellmate cannot therefore be effectively updated. The Governor may wish to
follow up this issue.
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CONCLUSION
97. The man apparently took his own life at HMP Leeds on 31 January 2010. He
had been remanded in prison since 24 December 2009 and was sentenced to
six years and six months imprisonment on 28 January.
98. Although his physical health needs were addressed very well by the
healthcare department at Leeds, it is clear that he was failed in terms of his
mental health, and drug and alcohol issues. He was not referred for a mental
health assessment despite clear information about all three issues being
made available to the healthcare department by the man himself when he
arrived in the prison, then again by the community GP on 29 December, over
a month before the man died.
99. In addition, vital information concerning the man’s state of mind and previous
suicide attempt set out in the PSR provided to the court, and his OASys
record was not acted upon by prison staff. As a result there was no
discussion concerning his risk of self-harm or suicide. Also prison staff did not
appear to consider his increased vulnerability following sentencing.
100. The man was worried about being bullied by other prisoners, especially if
details of his offence became known. He asked to be moved to another wing
and named a prisoner who had threatened him. He confirmed to the wing
officer that he was not worried about spending one more night on his current
wing as he was about to be locked up, and he was not concerned about his
cellmate. Unfortunately during the early hours of the following morning, the
man took his own life. The officer made the decision to deal with the man’s
request the following morning based on the information he had available.
Should the full picture of the man’s vulnerable state been apparent the wing
officer may very well have made a different decision. I make no criticism of
the officer.
101. I make five recommendations, four to the head of healthcare and one to the
Governor, concerning the effective use of information provided to the
prison/healthcare department, the identification and treatment of drug users
and effective recording of CPR.
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RECOMMENDATIONS
1. The head of healthcare must ensure that a system is put in place so that any
correspondence from a patient’s community GP is routinely shown to the
prison doctor. Also that the records are appropriately endorsed to confirm
that the information has been read and will be responded to appropriately.
The National Offender Management Service (NOMS) has partially accepted
this recommendation. The service commented:
“The correspondence from the community GP is seen by a nurse every day
and triaged. All relevant correspondence is tasked to the GP on duty, and
they will respond appropriately”.
2. The head of healthcare should ensure that the healthcare team are more
vigilant in identifying drug users and more confident in taking substance
misuse histories and that all healthcare staff are trained in the Integrated Drug
Treatment System to an appropriate level.
The National Offender Management Service (NOMS) has accepted this
recommendation. The service commented:
“The first night reception screen includes a number of questions to identify
drug users when they first come in and those identified as drug users then
undergo further screening relating to their drug use.
All staff will complete IDTS awareness as part of their induction training.
All IDTS staff and other relevant healthcare staff working with drug users are
trained up to RCGP Part 1 or equivalent.”
3. The head of healthcare should ensure that there are processes in place to
capture and act upon all relevant information in relation to the physical and
mental health of prisoners.
The National Offender Management Service (NOMS) has accepted this
recommendation. The service commented:
“All information given in reception by the patient is used to determine if further
assessment is needed by primary care mental health, IDTS or long term
conditions team. Task referrals are made to the appropriate team via
Systmone (the electronic medical record system) by the healthcare reception
screening staff. This referral process negates the need for paper referrals and
provides a full audit trail of when referrals are made, received and actioned.
Correspondence requesting confirmation of medical history and any current
treatment or interventions is sent the next working day after reception to the
GPs and when returned is triaged by a nurse and the GP and any other
relevant team is tasked according to the information provided. Each team
responds accordingly.”
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4. The Governor should ensure that OASys documents are reviewed
immediately upon receipt, and staff should be reminded that they might
contain valuable information about a prisoners state of mind and risk of self
harm or suicide.
The National Offender Management Service (NOMS) has partially accepted
this recommendation. The service commented:
“West Yorkshire Probation currently use a 24/7 telephone/fax to ensure that
any information that they are in possession of (including OASys) is brought to
the attention of the Prison as soon as they are aware that a prisoner has been
remanded/sentenced to custody. This is acted upon immediately when
received.”
5. The head of healthcare should ensure that a detailed record of CPR is kept
including a description of the patient’s vital signs and the equipment and any
drugs use.
The National Offender Management Service (NOMS) has accepted this
recommendation. The service commented:
“All staff will complete training in record keeping as part of their annual CPR
training to include patients vital signs, equipment used and any drugs used.”
24