Individual at New Hall

Investigation into the circumstances surrounding the
death of a young woman at HMP New Hall
in May 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
May 2007
This is the report of an investigation into the death of a young woman in May 2006 at
HMP New Hall. She was found hanging in the toilet area of her shared dormitory.
She was just 22 years old.
I wish to offer my sincere condolences to the young woman’s family and friends for
their sad loss.
The investigation was conducted by two of my investigators. I would like to extend
my thanks to the Governor and her staff at New Hall for their help and co-operation
throughout this investigation.
A clinical review was undertaken by the relevant Primary Care Trust into the medical
care that the young woman received while in custody. I am grateful to the clinical
reviewer for his timely and comprehensive report. Indeed, it has meant that my own
report can be abbreviated given that so much is covered in the clinical review. All
the more so, given that the young woman had offered no indication either to staff or
to fellow prisoners that she might be considering harming herself.
I understand that, despite her young age, the young woman had already spent eight
previous periods at New Hall. On each occasion, she had undergone detoxification
from drug abuse. Her offences all seem to have involved acquisitive crime to fund
her drug habit.
This pattern is characteristic of very many women prisoners I have met at New Hall,
Styal, Holloway, and elsewhere. Their offending should not be trivialised at it has
real victims. And its repeated nature seems to leave the courts feeling they have few
alternatives but to impose custodial remands or short sentences of imprisonment.
Nevertheless, the women themselves are amongst the most vulnerable in our
society, and the crimes they commit are manifestly at the less serious end of the
spectrum. They are the group of prisoners for whom the rather old fashioned term
‘diversion from custody’ really should have some meaning.
I make four recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman May 2007
CONTENTS
Summary
The Investigation Process
Key Events
Issues
Recommendations
HMP New Hall action plan
SUMMARY
The young woman arrived at HMP New Hall on 8 April 2006. She was medically
assessed during the reception process and placed into the Substance Misuse Unit
where she began a methadone detoxification programme.
The time she spent on the unit passed without incident. However, on 18 April, the
young woman asked in a written note not to be moved to E wing when she
completed her detox. She wrote that she had had some trouble outside of prison
with two of the women on E wing. When she was eventually discharged from the
Substance Misuse Unit on 28 April, she was moved to Residential block 1.
The young woman shared a two roomed dormitory with three other women. It
appears that she settled in well and was liked by her room mates.
Just after 1 am on 1 May, one of the young woman’s room mates found her hanging
in the toilet area. She was suspended by a bed sheet ligature from a water pipe over
the sink. The cell bell was rung and officers responded swiftly.
Staff entered the dormitory and she was cut down. Cardio pulmonary resuscitation
was commenced immediately. A defibrillator was attached to the young woman but
it indicated not to shock. Paramedics arrived and took over the resuscitation
attempt, but pronounced her dead at 2.10 am.
The young woman had given no indication, either to staff or to her fellow prisoners,
of any thoughts about self harm or suicide. In fact, she was annoyed that the police
had ticked the self harm box on the Prisoner Escort Record, saying ‘it shouldn’t be
on the paperwork, I’ve done nothing’.
1
THE INVESTIGATION PROCESS
1. The investigation was opened by two of my investigators. The Governor and
her staff produced the young woman’s medical record and a large number of
other documents for examination. Notices were distributed around the
establishment, notifying staff and prisoners of the investigation. A number of
prison staff and prisoners were subsequently interviewed.
2. My investigators liaised with the police officers investigating the death on behalf
of Her Majesty’s Coroner. They confirmed that they were treating the death as
a probable suicide and had ruled out the involvement of anyone else. My
investigators were given copies of the police statements to assist with my
investigation.
3. Her Majesty’s Coroner was contacted to inform him of the nature and scope of
my investigation. Upon completion, this report will be sent to the Coroner to
assist with his enquiries into the young woman’s death.
4. One of my Family Liaison Officers contacted the young woman’s mother to
inform her of my investigation. Her mother said that she was happy with the
contact she had had with the prison. She also said that she would wait to read
our draft report before meeting with a member of my team.
5. In line with our standard procedures, the Primary Care Trust (PCT) was
informed of the woman’s death. A clinical review was undertaken, looking into
the medical treatment and care received by the young woman whilst at New
Hall.
2
HMP NEW HALL
6. HMP New Hall is a closed female prison holding adults, young offenders and
young people. There is also a 40 bed semi-open unit for adult women.
7. A dedicated safer custody team has been set up to drive forward the Safer
Prisons agenda. The strategy has been to adopt a ‘whole prison approach’, to
the management of those prisoners identified as being at risk of suicide or self
harm. This work includes a multi-disciplinary Substance Misuse Unit (SMU),
which provides stabilisation and maintenance through clinical interventions,
heat therapy, auricular acupuncture and a ‘Return to Fitness’ programme.
8. New Hall also runs enrichment activities, designed to enhance self-esteem,
such as hand pampering and nail art, as well as offending behaviour
programmes, educational and work opportunities.
9. The prison’s healthcare provision is split between general primary healthcare
run by the PCT and the SMU which is run by another PCT.
10. There have been six previous deaths at New Hall since I assumed the
responsibility for investigating all prison deaths in April 2004. Five of those
deaths were apparently self inflicted, although the circumstances and issues
were not directly equivalent to those raised by the death of the young woman
who is the subject of this report.
3
KEY EVENTS
11. The woman was remanded to New Hall on Saturday 8 April 2006, having been
arrested for theft the previous day.
12. A nurse saw the young woman during the reception process and completed a
First Reception Health Screen form. She noted that the Prisoner Escort Record
(PER), completed at Queens Gardens Police station the previous day, had a
tick in the box marked ‘suicide/self-harm’. When the reception nurse asked the
young woman about that, she replied, ‘It shouldn’t be on the paperwork, I’ve
done nothing’. The nurse wrote, ‘behaviour appropriate – withdrawing from
drugs’, on the health screen form. During interview she said that she had no
concerns about her having thoughts of self-harm. She said that was based on
what the young woman had said in answer to her questions, the way the young
woman presented herself and her own training and experience.
13. The young woman said that she was using £100 worth of heroin and ‘crack’ a
day, and that she had last used the drugs during the previous day. She told the
nurse that she felt that she was withdrawing and wanted counselling in relation
to her drug abuse.
14. The nurse ticked the boxes on the health screen form for the young woman to
be referred to the Detox Unit (meaning the SMU) and the CARATS team, and
for her to be admitted to the Detox Unit. (CARATS (Counselling, Assessment,
Referral, Advice, and Throughcare Services) work within the prison and can
provide one to one counselling, ongoing care and support plans and links with
external treatment services in preparation for release.)
15. The young woman was admitted to the SMU and started on a methadone
detoxification, beginning with a seven day stabilisation programme. It was
noted in her medical record that, during her first night, she was screaming in
her sleep sounding very distressed, although she did not wake.
16. The following few days passed without incident. On 14 April, an entry was
made in her history booklet stating, ‘[The young woman] keeps her head down
and gets on with things, is no problem on the wing.’ (History sheets are used to
record noteworthy events relating to a prisoner’s time in custody.)
17. On 15 April, the computer record does not show a dosage of methadone being
dispensed to the young woman, although the administration record chart for
that day shows 25 mg of methadone was issued to her. The clinical reviewer
having discussed the matter with a number of staff was satisfied that the reason
for there not being an entry on the computer system was that some of the staff
were unfamiliar with the new ‘Methasoft’ system.
18. In response to the issue of our draft report the prison have replied that the
clinical SMU staff were trained in the use of the ‘Methasoft’ software in March
2006 and that a systems failure was the reason for the lack of an entry.
4
19. The young woman wrote a request on 18 April asking not to be moved onto E
wing when her time on the SMU finished. The reason she gave was that she
had had some trouble outside of prison with two women who were now on E
wing. She believed that she would get into fights.
20. On 24 April, the young woman was given a reward slip for always being polite
and no trouble on the wing. It was attached to her file.
21. On 28 April, the young woman was moved to Residential block 1 and housed in
dormitory 1, room 2. This was a multi-bedded cell, consisting of two rooms and
a toilet area. She shared the cell with three other women. A note on her
history sheet states that ‘[the young woman] has been on Res 1 before; she
knows what happens and is happy to be on the unit.’
22. As noted, the SMU is managed by the Primary Care Trust and the general
prison healthcare facility by another Primary Care Trust. When the young
woman moved from the SMU, there was no clinical handover evident in her
medical record, although as highlighted in the clinical review there was a
continuity of care plan put in place by the CARATS team. The lack of clinical
handover was mentioned by one of the other women who shared the dormitory
with the young woman. This issue will be addressed by the phased
introduction of the Integrated Drug Treatment System (IDTS) which began in
July 2006.
23. According to the young woman’s cell mates, she was happy to be in the
dormitory with them. Neither they, nor the staff, saw any indications of her
intention to self harm.
24. During the evening of Sunday 30 April, the young woman was apparently in
good spirits. She sat and watched television and smoked with the others. One
of her cellmates said that she woke up twice during the night. The first time she
saw the young woman lying on the bottom of a set of bunk beds, not her own
bed. On the second occasion, the young woman was getting herself a bowl of
cereal. Her cellmate did not speak to her on either occasion and she does not
think the young woman noticed her being awake.
25. About 1 am on Monday 1 May, the second cellmate woke the third cellmate,
who was snoring loudly. The third cellmate got out of bed and went into the
toilet area. There she saw the young woman hanging by a ligature, fashioned
from a green prison-issue bed sheet. The ligature was attached to the water
pipe above the sink. She walked back into the sleeping area and said, ‘[third
cellmates name] It’s [the young woman], she’s done something stupid and is
hanging.’
26. The second cellmate pressed the cell bell to summon help. Two officers went
to answer the bell and the assist Night Orderly Officer followed close behind, as
cell bells were unusual during the night. The Night Orderly Officer radioed for
further assistance as she made her way to the dormitory, but halfway through
her transmission the radio battery ran out of power. Luckily, the nurse in
healthcare had heard the part message and made her way to the dormitory.
5
27. The assist Night Orderly Officer opened the cell with her key, the officers and
the Night Orderly Officer, who had joined them, entered the cell. The Night
Orderly Officer immediately lifted the young woman to relieve the pressure on
her neck, with assistance from a third officer who had just arrived. One of the
initial attending officers cut through the ligature with a ‘fish knife’ (a specially
supplied safety knife used to cut ligatures). The young woman was lowered to
the floor and the third officer then used his knife to cut the sheet from around
the young woman’s neck.
28. The assist Night Orderly Officer had left the dormitory to call for an ambulance.
She returned to the centre office and rang the control room. When they
answered she was put through to the ambulance control room. As the call was
not answered immediately, she passed the phone to another officer who was in
the centre office. The ambulance was requested at 1.12 am according to the
clock in the control room. The ambulance service logged the call as being
received at 1.25 am.
29. A nurse arrived at the dormitory as the young woman was being cut down and
asked for her to be moved out of the toilet area to give her more room to work.
She and one of the initial attending officers began cardio pulmonary
resuscitation (CPR) whilst the Health Care Assistant (HCA) was called to bring
the resuscitation bag from healthcare. The nurse noted that the young
woman’s pupils were fixed and dilated and she could not detect a pulse.
30. The HCA arrived shortly after with the equipment and the nurse attached a
defibrillator to the young woman. It indicated ‘no shock’, so she continued CPR
now using the ‘ambubag’ to supply oxygen.
31. The paramedics are noted to have arrived at the dormitory at 1.46 am. CPR
continued until 2.10 am, when they pronounced the young woman dead.
32. At 3.45 am, the prison chaplain telephoned the woman’s mother and informed
her of her daughter’s death. Her mother was not at home and the chaplain was
given the mobile number to reach her.
33. At 4 am, the staff involved were brought together for a ‘hot debrief’, to discuss
the response and handling of the situation. Two issues were raised. The first
was that there was not a key available in the sealed pouch to enter the young
woman’s dormitory cell. However, as the assist Night Orderly Officer was
present on the wing with the keys it caused no delay. (My investigators were
informed during their investigation that the key issue has now been rectified,
with a key available should it be needed in the future.) The second issue was
that staff found that the papers in the Death in Custody Contingency Plans
lacked a check list and that there were multiple copies of some papers.
34. Staff were generally happy with the way the establishment took care of them
after the young woman’s death. However, the assist Night Orderly Officer
thought it insensitive that on her first two shifts back at work she was assigned
6
a ‘special watch’ (watching a prisoner at risk of self harm). After she raised the
issue, she was reassigned for the first shift.
35. The young woman’s mother has said that she was very happy with the way the
prison has handled her daughter’s death and felt that the news was broken to
her sensitively. She has visited the prison and spoken with some of the officers
who tried to resuscitate her daughter. The establishment paid for her
daughter’s funeral. The young woman’s mother is now a regular visitor at the
prison, speaking with other prisoners to give them support.
36. During the investigation it was established that some entries on the young
woman’s paperwork relating to previous self harm attempts were incorrect.
They had been entered in error, instead of in the records of another prisoner
with a similar name. As noted in the clinical review, the prison acted swiftly to
remove the entries, provide staff training and ensure systems were put into
place to lessen the possibility of further human errors.
37. The three women with whom the young woman shared the dormitory were all
very complimentary about the staff at New Hall. Neither they nor any of the
staff who had any contact with the young woman throughout her time at New
Hall saw any signs to indicate that she was likely to self harm, let alone take her
own life.
7
ISSUES
38. There was no indication that the young woman was contemplating taking her
own life or harming herself. When she was found hanging and the alarm
raised, the staff reacted swiftly and professionally. However, as noted, there
were a few problems although, through luck and fortunate staff location, they
did not cause delay or hindrance to the response in this case.
Family notification
.
39. Best practice is for the sad news of a death in custody to be broken to the next
of kin in person by a representative of the prison or, in certain circumstances,
by the police. In this case, the young woman’s mother was telephoned by the
prison chaplain, and in fact it was then established that she was away from
home. A mobile number was given to the chaplain who was then able to make
contact and break the news.
40. The chaplain offered the young woman’s mother a personal visit, but she
decided to visit the prison herself the next day. My investigator has spoken to
the Governor who made the decision to telephone the young woman’s mother.
Her decision was based on the time of day and the concern to let her know of
her daughter’s death before the news broke in the media.
41. I am entirely satisfied that in this instance the decision about how to contact the
next of kin was taken for the right reasons, and I note that the young woman’s
mother felt she was told of her daughter’s death in a sympathetic manner.
However, in these tragic and unenviable circumstances, all prisons should aim
to notify next of kin in person wherever this is possible.
Radio batteries
42. When the Night Orderly Officer used her radio to summon medical assistance,
the battery died a few seconds into her transmission. The officer in the control
room had heard the part message and had telephoned to the healthcare unit to
pass on the request. The nurse had also heard the part message and in fact
arrived as the young woman was being cut down. I believe the nurse was
entirely right to make her way directly to dormitory 1, although if the radio
transmission had been completed she would have been able to arrive with the
resuscitation bag rather than having to send for it.
43. Radios that are working properly are especially important during the night time
lock-down, because of the reduced staffing levels and difficulty in moving
around the prison.
44. Faulty or poorly charged radio batteries have been mentioned in a number of
my investigations. Poor recharging practice and use of batteries beyond their
useful life have previously been cited as the causes of radio failure.
8
The Governor should consider an investigation into the quality of the
establishment’s battery stock and consider whether any additional
staff training into battery charging and rotation procedures is
required.
Methasoft computer system
45. On 15 April, according to the computer records, the young woman did not
receive her dosage of methadone. Yet the paper records confirm that she did
in fact receive her medication. The clinical reviewer identified during
conversation with staff that not all of the SMU staff were fully conversant with
the computerised ‘Methasoft’ system.
The prison health partnership should ensure that all relevant SMU
staff are trained in the use of the ‘Methasoft’ computer system.
Cell Keys
46. It was discovered during the investigation that the staff assigned to Residential
1 did not have a key to the dormitories available to them in their sealed
pouches. In this particular instance, the assist Night Orderly Officer was on the
wing and able to use the key that she carried. However, having to rely on the
close proximity of certain staff to a location is clearly not ideal.
47. Although my investigators were told that a key is now available, I would like the
new arrangement formalised in the local arrangements for patrol periods,
including night state.
The Governor should ensure the arrangements for accessing rooms
are included in the written arrangements for patrol periods.
Death in custody contingency plan
48. During the ‘hot debrief’, it came to light that the death in custody contingency
plan contained multiple copies of some papers and no check list, making
compliance less straightforward than it should be.
The Governor should review the death in custody contingency plans
and associated documentation, to ensure they are fit for purpose.
9
RECOMMENDATIONS
 The Governor should consider an investigation into the quality of the
establishment’s battery stock and consider whether any additional staff
training into battery charging and rotation procedures is required.
 The prison health partnership should ensure that all relevant SMU staff
are trained in the use of the ‘Methasoft’ computer system.
 The Governor should ensure the arrangements for accessing rooms are
included in the written arrangements for patrol periods.
 The Governor should review the death in custody contingency plans
and associated documentation, to ensure they are fit for purpose.
10