Individual at Pentonville

Investigation into the circumstances surrounding the
death of a man at HMP Pentonville
in April 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2009
This is the report of an investigation into the death of a man at HMP
Pentonville in April 2008. He was found suspended by a ligature in his cell in
D Wing. A post mortem examination carried out the same day confirmed the
cause of death as hanging.
I offer my sincere sympathy and condolences to the man’s family and friends
for their tragic loss.
The investigation was conducted by an investigator.
I also commissioned a clinical review of the management of the man’s health
needs while he was in custody. This was conducted by a clinical reviewer on
behalf of the local Primary Care Trust. I should like to thank her for her
invaluable contribution to the investigation.
My thanks also go to the Governor and his staff at Pentonville for their help
and co-operation during the investigation. I pay particular tribute to the liaison
officer for his help.
On 1 May, one of the Family Liaison team made contact with the man’s
mother over the telephone to enquire as to whether any family members
wished to meet her and the investigator to express any matters of concern
about her son’s time in prison and his death at Pentonville. She explained
that she and her husband were too distressed to speak to anyone at that
stage. My heart reaches out to them: there is surely no worse pain that
parents can suffer than that caused by the loss of their child. The family
liaison officer later wrote to them to reinforce that that she would be more than
happy to hear from them if they changed their minds. Although no further
contact was made, this report will be sent to them.
My report is critical of some aspects of the use of the suicide and self-harm
monitoring forms for the man. The clinical review draws attention to a number
of deficiencies in the management of his mental health and of his drug
misuse.
The Ombudsman’s office has investigated a number of previous self-inflicted
deaths at Pentonville. As with some of those cases, I make recommendations
in this report about ACCT procedures and about healthcare issues.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Jane Webb
Deputy Ombudsman March
2009
CONTENTS
Summary
Investigation process
HMP Pentonville
Key events
Issues
Conclusions
Recommendations
SUMMARY
The man had a history of dependency on alcohol, poly-substance misuse and
possible personality disorder. He was well known to the Mental Health
services, having had numerous admissions as a psychiatric inpatient up to
and during 2004, with one subsequent admission in 2007.
He was remanded into custody at HMP Pentonville for a week in August
2007, during which period he received opiate and alcohol detoxification.
Following a breach of bail, he was remanded again on 6 November 2007. He
was taken to HMP Wormwood Scrubs that day. Upon his arrival, he was not
considered to be at risk of self-harm. On 8 November, following an
appearance at Crown Court, he was taken to Pentonville. During his time in
the custody of the staff who escorted him between the court and the prison,
he said he was withdrawing from drugs and would kill himself if he did not get
the drugs he wanted. A suicide warning form was completed to alert prison
staff to this risk. The form was not signed by anyone at Pentonville. Although
he was assessed by a nurse and a doctor soon after his arrival, his records do
not make clear whether his risk of self-harm or suicide was considered.
During his time at Pentonville, the man once again required alcohol
detoxification. He was under the care of the Mental Health in-reach team and
was admitted to the healthcare centre on three occasions. On one occasion,
he was taken to hospital after experiencing hypotension. He was discharged
the same day.
On 20 December, an Assessment, Care in Custody and Teamwork (ACCT)
form was opened after the man deliberately cut his arm. This form is used by
the Prison Service to monitor and support those prisoners considered to be at
risk of self-harm or suicide. The form was closed on 7 February and re-
opened two days later after a further minor act of self-harm. There was no
evidence to show whether any case reviews were conducted thereafter or
whether this form was closed.
In January, he made voluntary contact with the Counselling, Assessment,
Referral, Advice and Throughcare service (CARATs). Despite this positive
development, there were unsubstantiated reports that he continued to use
illicit drugs.
After he threatened to hang himself on 12 March, he was admitted to the
healthcare centre and a new ACCT form was opened. This was his last
admission and the final occasion on which an ACCT form was used. A
psychiatrist who saw him nine days later considered that he could be
discharged to a wing but needed “the highest level of observation” in a shared
cell and said that the ACCT form was to remain in place. He was discharged
on 21 March. The psychiatrist arranged for him to be reviewed again a week
later. However he was not assessed again.
On 1 April, the man was taken to hospital after apparently experiencing an
episode of hypotension. He was discharged to the prison the same day. Five
days later an ACCT review panel met to consider his current risk of self-harm.
He was thought to be well balanced with no concerns. He was getting on well
with his cellmate. His risk was judged to be low.
A few days later, the man’s cellmate left the cell to talk to friends on another
landing, leaving him alone. Shortly afterwards, he left his cell to telephone his
girlfriend. She was extremely angry with him for allegedly lying to her about
the length of sentence he was likely to receive at a pending court hearing.
She told him she did not love him any more. He returned to his cell. An
officer who saw him thought he appeared to be alright. At 3.40pm, he was
found hanging in his cell. The determined attempts by healthcare and
discipline staff and by the paramedics to save his life were unsuccessful. He
was pronounced dead at 4.26pm.
My report is critical of some aspects of the ACCT procedures. I question the
wisdom of discharging the man from the healthcare centre on 21 March when
his risk was such that he was considered to require the highest level of
observation in the wing. I express my concern at the fact that he was left
alone in his cell on the day of his death, despite the fact that he was on an
open ACCT form. The clinical reviewer draws attention to a number of
deficiencies in the standard of mental healthcare offered to him.
However, I commend those staff who were involved in the discovery of the
man hanging and in the attempts to save his life in very harrowing
circumstances. I make special mention of one member of staff who gave
mouth-to-mouth resuscitation without a protective face mask regardless of the
risk to his own health.
The clinical reviewer and I make a range of recommendations that I hope will
reduce the risk of a similar tragedy occurring at Pentonville or elsewhere in
the Prison Service.
INVESTIGATION PROCESS
1. The investigation was opened on 14 April 2008 when an investigator
met the Governor, Deputy Governor, a member of the Independent
Monitoring Board and the secretary of the local branch of the Prison
Officers’ Association. He briefed the meeting on the terms of reference
for the investigation. On the same day, notices were issued to staff
and prisoners announcing the investigation and inviting anyone with
information or concerns relating to the man’s death to make
themselves known. Three prisoners came forward.
2. The investigator also commissioned a clinical review of the
management of the man’s health needs while he was in custody. This
was conducted by a clinical reviewer on behalf of the local Primary
Care Trust. Shortly after the man’s death, an internal review of the
quality of medical and nursing care given to him was conducted at
Pentonville in order to identify any lessons that could be learned and to
implement any necessary improvements. It is much to Pentonville’s
credit that such a prompt and thorough review was carried out. In
conducting her independent clinical review, the reviewer took account
of the findings of the internal report.
3. Nine members of staff and two prisoners were interviewed during the
course of the investigation.
4. On 1 May 2008, one of the Family Liaison team contacted the man’s
parents to ascertain whether they wished to express any concerns for
the investigation to address. They chose not to become engaged with
the investigation at that stage. However, they will be given an
opportunity to receive the draft report and can decide to become
involved with the investigation at any stage.
HMP PENTONVILLE
5. Pentonville is a local prison serving courts in north east London. At the
time of the investigation, it could hold up to 1152 prisoners. The
accommodation comprises the following seven units:
A wing - First Night Centre
B,C,D and G wings - hold convicted and remanded prisoners
G wing – holds convicted and remanded prisoners with
enhanced privilege status
E wing - Detoxification Unit
Segregation Unit
Vulnerable Prisoner Unit (VPU)
Healthcare centre
R wing which is currently closed.
6. Healthcare at Pentonville is provided by the local Primary Care Trust.
The healthcare centre has beds for up to 22 inpatients.
7. The establishment was last inspected by Her Majesty’s Chief Inspector
of Prisons in June 2006. In her report of that inspection, the Chief
Inspector pointed to improvements in some areas since her previous
visit in 2005. However, she reported that throughout her prisoner
survey, responses to most questions were significantly worse than the
comparator for other locals.
8. Where safer custody was concerned she wrote,
“Last time, we had a particular concern about the support
of prisoners in the early days of custody: especially as
five out of six recent deaths had taken place within days
of arrival. Though the physical environment for first night
prisoners had improved somewhat, the arrangements to
support them did not work effectively, and more prisoners
than in 2005 said they felt unsafe on their first night. This
important area was outside the remit of the new safer
custody arrangements.”
9. In the concluding paragraphs of her report, she said,
“We do not underestimate the problems faced by
managers at Pentonville. Its population, always
transitory, had become even more so with a 10 per cent
increase in remanded and unsentenced prisoners, who
accounted for over 60 per cent of the population.
Overcrowding, old buildings and inadequate facilities
severely inhibited the prison’s ability to deliver a safe,
decent and purposeful environment for its prisoners.”
10. In the executive summary of their annual report for the period 1 April
2006 to 31 March 2007, the Independent Monitoring Board at
Pentonville wrote as follows:
“It has again been a difficult year for Pentonville Prison.
The unprecedented national pressure on prison places
was reflected in conditions at local level. We have seen
staff struggling to cope daily demands of managing a
virtually full to operational capacity prison with no real
opportunity to devote time or energy to longer term
objectives.”
11. The Board pointed to some positive aspects of the establishment’s
operation as well as to some shortcomings. Their report drew attention
to the fact that there had been no self inflicted deaths in the prison
during the year. They believed this reflected the increasing priority
given to safer custody. However, the Board said there was no room for
complacency. There were two areas that stood out as sources of
serious risk: the poor reception facilities and the continuing problems
with cell bells being unanswered. The Board also recorded that there
had been 393 acts of self-harm, of which 58 were attempts at hanging.
They also reported that 643 ACCT documents had been opened during
the year.
12. Where reception facilities were concerned, the Board wrote,
“We are greatly concerned about the inadequacy of the
reception facilities. Pentonville has a high level of
receptions and discharges and the building now in use
for these purposes is quite simply not large enough, nor
is it sufficiently well equipped. This is a critical function
for the prison. If the reception of new prisoners is not
dealt with properly there are adverse implications for the
entire regime. In particular there will be a serious danger
that prisoners at risk of self-harm are not identified.”
KEY EVENTS
Background
13. The man was remanded in custody at HMP Pentonville on 13 August
2007 on a charge of criminal damage. He was identified as having a
history of poly-substance misuse, requiring an alcohol and opiate
detoxification, of low mood and at risk of self-harm. He had been
admitted to a psychiatric hospital on several occasions, the most recent
of which was in 2004.
14. During that brief period in custody at Pentonville, he was referred non-
urgently to the mental health in-reach team and to the substance
misuse service. He was transferred to the substance misuse unit the
day after his reception and assessed by a doctor. His alcohol
detoxification continued and a methadone detoxification programme
was commenced.
15. After a week, the man was released on bail. However, on 4 November,
he was arrested for breaching his bail conditions. He was kept in
police cells overnight.
16. The next day, he was taken to a Magistrates Court At about 1.30pm,
whilst in court cells, he was examined by a doctor who recorded his
findings as follows:
“Complains of shakes. Feeling anxious and sweating -
alcohol withdrawal symptoms. Has been given valium in
police cells. Drinks a bottle of vodka daily. History of
alcohol withdrawal seizures. No known allergies. Not on
any regular medications. Stable. Alert. Undistressed.
Orientated. Plan: 10mg valium, monitor regularly.”
17. Another doctor saw the man at 9.00pm that day. The doctor too noted
that he was experiencing shakes and prescribed Diazepam. The
doctor assessed him as being fit to be transported by cellular vehicle.
18. The magistrates remanded him in custody and ordered him to appear
at Crown Court on 8 November. He was taken to HMP Wormwood
Scrubs.
HMP Wormwood Scrubs: 6-8 November 2007
19. When the man arrived at Wormwood Scrubs, he told reception staff he
was born on 27 February 1970 and was single and unemployed. He
said he had been living at an address prior to his arrest. He confirmed
that his father was his next of kin and disclosed his address.
First reception health screen
20. As soon as a prisoner arrives in a prison he should undergo a first
reception health screen and a cell sharing risk assessment. The
purpose of the health screen is to enable medical staff to establish
what the prisoner’s immediate physical and mental heath needs are so
that appropriate action can be taken to meet those needs.
21. The purpose of the cell sharing risk assessment is to assess the risk a
prisoner presents of harming another prisoner if he shares a cell. This
has to be balanced against his risk of harming himself if he is placed in
a cell on his own. The assessment is normally undertaken by a prison
officer as well as a nurse.
22. During the first reception health screen, conducted by a nurse, the man
said he had a doctor in the community and disclosed the doctor’s name
and surgery address. However, he said he had not seen a doctor
during the previous few months. He said he had no outstanding
medical appointments of any kind. He disclosed that he had been
taking Diazepam 5mg (for relief of anxiety) each day and Olanzapine
10mg (an anti-psychotic drug) each morning. He had not received any
physical injuries in the previous few days. Although he did not suffer
from asthma, diabetes, tuberculosis, sickle cell disease or any
allergies, he claimed to have experienced an epileptic fit as recently as
the previous evening. He also said he was experiencing some chest
discomfort.
23. The man told the nurse he was used to drinking a bottle of vodka and
ten strong lagers daily but claimed he had not had any alcohol for two
days. He also admitted he had used amphetamines during the
previous week.
24. As far as his mental health was concerned, he disclosed that he had
received psychiatric treatment four weeks earlier, specifying that he
had been an inpatient at a psychiatric hospital in. However, he said he
did not have a psychiatric nurse or care worker in the community. He
repeated that he had been prescribed Olanzapine.
25. The man said he had tried to harm himself outside prison, claiming to
have run in front of a car six months earlier. The nurse was required to
ask him if he currently felt suicidal now that he was in prison. He
wrote,
“Withdrawing from alcohol abuse, evidence of
withdrawal. States suffers from depression. States
mood is low but denies any self-harm thoughts or suicidal
intentions.”
26. Although the nurse did not make clear whether the man wished to
consult a doctor, he did record that a referral was made for him to be
assessed by a doctor because of his alcohol abuse. He was not
screened for drugs but an alcohol detoxification programme was
commenced.
General health assessment
27. The man underwent a general health assessment the next day. His
height was recorded as 172cm and his weight 84.7kg. He said he
smoked but wanted to give it up. He said there were no illnesses in his
family. No matters of particular concern arose during this assessment.
Cell sharing risk assessment
28. An officer conducted the cell-sharing risk assessment. The following
table shows the questions asked of the man and the answers he gave:
Questions Answers
Have you ever abused alcohol or drugs? Yes
Are you currently dependent on drugs or alcohol? Yes
Are you subject to a current ACCT form? No
Have you been subject to an ACCT form in the past? Yes
Do you have any concerns about sharing a cell? No
Would you describe yourself as a person that gets No
angry or frustrated quickly?
29. The officer made a separate note of the fact that the man had told him
he was dependent on alcohol and suffered from depression.
30. The nurse completed the healthcare element of the assessment and
confirmed that no concerns had emerged about any risk of self-harm.
The man was assessed as presenting a low risk of harming others and
was therefore deemed suitable for sharing a cell. This conclusion was
countersigned by a manager.
31. He was taken to the First Night Centre where no events of any
significance were recorded.
Court appearance and transfer to HMP Pentonville
32. On 8 November, the man was taken from Wormwood Scrubs to Crown
Court, where he was once again remanded in custody. The Prisoner
Escort Record (PER) for the journey from the prison to the court carried
no notation of any risk of self-harm or suicide but did mention that he
had a “mental condition”. After his court appearance, he was
transferred to HMP Pentonville as this is the local prison in London
which serves the Crown Court.
33. During his time in the custody of the escorting staff, the man told a
Senior Prisoner Custody Officer (SPCO) that he was withdrawing from
drugs. He said that if he did not get his drugs, he would kill himself.
The SPCO therefore raised a suicide/self-harm warning form. The
purpose of this form is to draw the attention of prison staff to any risk of
self-harm or suicide so that appropriate steps can be taken to monitor
and manage that risk. The form should be signed by reception staff as
soon as the prisoner arrives in a prison. His warning form was not
signed upon his arrival at Pentonville.
HMP Pentonville: 8 November 2007 - 9 April 2008
November
34. The man was seen by a nurse and a doctor upon his arrival in
reception at Pentonville on 8 November. He told staff he had been a
psychiatric inpatient with a possible severe mental illness. He
complained of auditory hallucinations. As a result, an urgent referral
was made to the Mental Health in-reach team. Receipt of this referral
was not documented until 14 November, six days after it was made.
His alcohol detoxification was continued. However, he was not
screened for drugs. There is no notation in his records showing
whether his risk of self-harm or suicide was assessed and no ACCT
form was opened.
Admission to the healthcare centre
35. Three days after his arrival at Pentonville, staff became concerned that
the man seemed to be suffering from hallucinations. They therefore
asked for him to be assessed by a member of the healthcare team.
The nurse who saw him decided to admit him to the healthcare centre
as an inpatient.
Mental health review by a doctor
36. On the day following his admission to the healthcare centre, the man
was assessed by a doctor, who wrote as follows in his medical record:
“Patient interviewed on healthcare (E Wing). Was
admitted over the weekend due to experiencing
distressing hallucinations. Was initially on A Wing –
required alcohol detox following admission 3 -4 days ago.
Not clear why he was not on detox wing. Admits to using
at least 8 cans of strong cider/day and has dependence
syndrome - begins drinking in the morning. Also claims
that has been self-medicating and has been taking his
girlfriend’s Olanzapine for many months as she doesn’t
take it. He estimates that he uses approximately 10 -
20mg a day. He claims that since stopping it he is
experiencing distressing auditory and visual
hallucinations, his mother screaming at his dad and when
he closes his eyes he can see photo negatives of people.
He told me that he has been admitted to a psychiatric
hospital on numerous occasions and may have a
diagnosis of schizophrenia. He was under a doctor. He
lives with his girlfriend. He is on a charge of ABH but
was put into custody due to breach of bail conditions.
“On mental state, he presents as unshaven and is visibly
tremulous. He was slightly agitated and appeared to be
in a state of withdrawal. He immediately complained that
he was hearing voices and needs more medication.
There was a limited rapport but he remained cooperative
and was non-threatening. His speech was increased in
rate and volume. He appeared anxious in mood and
described feeling low. He was pre-occupied by his
hallucinatory experiences and though he said he felt
suicidal he was quite suggestible and couldn’t tell me of
any specific plans to harm himself. He denied any
homicidal urges. He had no abnormal thoughts but
described hearing his mother screaming but could not
make out specific words and visual disturbances as
described above. Cognitive function was intact.
“He certainly presents with symptoms of alcohol
withdrawal and it is difficult to ascertain whether he has
underlying symptoms of mental illness whilst in this state.
I have prescribed a small dose of Olanzapine due to his
level of distress. I will request some collateral from the
psychiatric hospital and in the meantime he should
remain on healthcare.”
Mental health review by a psychiatrist
37. On 16 November, the man underwent a further mental health review,
this time by another psychiatrist, who made the following entry in his
medical record:
“I saw the man on the Healthcare Unit. He was admitted
on 11 November. He was initially referred by the detox
team as he was complaining of both auditory
hallucinations as well as visual hallucinations. He was
initially on A wing and was undergoing an alcohol detox.
“He stated that he began experiencing these unusual
disturbances on arriving at Pentonville prison over one
week ago. He has both second and third person auditory
hallucinations he hears in the external space. They can
also be commanding in nature. However, he is adamant
that these commands are not in any way dangerous to
himself or others. He also describes some unusual
visual hallucinations of barking dogs and other images he
finds very uncomfortable. He describes these visual
hallucinations as being photo negatives on closing his
eyes. They mostly only come on whilst he is in his cell by
himself trying to go to sleep.
“He also complained of feeling quite low with fleeting
suicidal thoughts. These suicidal thoughts are in the
form of wanting to hang himself. Again, he said he looks
around the cell room for places to hang himself from.
“He has a long history of alcohol dependence and mental
and behavioural disorder secondary to alcohol abuse.
He was last admitted and discharged in September 2007
from the psychiatric hospital. He has in the past had
several admissions for similar reasons. This particular
admission only lasted a couple of days and was in the
context of an argument he had with his girlfriend.
“His current offence is breach of bail. However, he has
been convicted of ABH against his girlfriend who he says
is now back with him. This particular breach of bail
incident was when he visited his girlfriend after the
assault, saying that they have now sorted things out and
are back together. It is important to note that in the past
he has also had an order to stay away from his parents
due to harassment.
“Past psychiatric history: As already mentioned, he has
been admitted on several occasions for short periods of
time with a diagnosis of mental and behavioural
disturbance secondary to alcohol. He has also five years
ago taken a serious overdose. However, he does admit
to fleeting suicidal thoughts even since then. Although
he was prescribed anti-depressant medication a few
years ago, he is not prescribed any medication currently
apart from 10mg Diazepam from his GP. He does
however say that he takes his girlfriend’s Olanzapine
approximately 20mg-30mg a daily. He also said that he
takes venlaxafine (again his girlfriend’s medication). I
informed him of the dangers of taking medication that
was not prescribed for him. He has also experienced
delirium tremens on numerous occasions. He currently
drinks 6-8 cans of strong cider per day, saying that this is
quite low for him as he normally also drinks vodka.
“Current social history: He said he is staying with a friend
in Southend. However, one of the reasons for his breach
of bail conditions was that he visited his GP in Harrow on
the Hill. He receives benefits. He has been unemployed
for the last six years. He has been drinking heavily for
the past ten years. He also admitted to snorting 1g of
amphetamines 3-4 times per week.
“Mental State Examination: Appearance and behaviour.
Anxious, reasonably well-kempt Caucasian man who
looked older than his years. He provided good eye
contact and was pleasant and appropriate throughout the
assessment. There were no unusual gestures or
movements. He was not tremulous. He was not tearful
or agitated. He was not obviously responding to any
perceptual abnormalities. Speech: Normal in rate,
rhythm and volume. Spontaneous and coherent.
“Mood: Subjectively ‘low’ objectively anxious with a
reactive affect. He did complain of poor sleep over the
past five days. He says he has been unable to sleep at
all because of the perceptual abnormalities he has been
experiencing. His appetite has been good. He said he
has always had problems with his concentration but
denies any problems with his energy levels. He said that
he has fleeting thoughts of wanting to harm himself, in
particular looking for places where he can hang himself
from. However, there does not seem to be any real
intent as he also says that he has plans for the future in
terms of getting back with his girlfriend and sorting out his
life. I did not feel that there were any negative
cognitions.
“Thoughts: No formal thought disorder. No thought
interference or passivity phenomena. He was
preoccupied with his sleep and constantly asked me to
prescribe him a higher dose of olanzapine. He spoke in
detail how he would self-medicate. Eventually, he
calmed down when I offered him zoplicone for the next
three nights in the evenings. I feel it is important to note
that in the previous discharge summary it was stated in a
past psychiatric history that he has said “if you don’t
admit me I will kill myself”.
“Perceptions: as already mentioned, he has been
experiencing second and third person auditory
hallucinations. These seem to be derogatory in nature,
which are mainly of his mother screaming at him.
However, he also describes his mother speaking to his
father about him. He also experiences occasional
command hallucinations, but not dangerous to himself or
to others. He also described visual hallucinations which
may be more pseudo-hallucinations. On closing his
eyes, he sees quite uncomfortable images of animals in
the photo negative detail. There are no tactile
hallucinations.
“Cognition: He was oriented in time, place and person.
However, a full mini mental state examination was not
undertaken.
“Insight: He seems to have very good insight into his
illness. He realises that these perceptual abnormalities
are not real and it seems as though it has already been
discussed with him that these are secondary to his long
term alcohol abuse.
“Impression: A 34 year old gentleman with a long history
of alcohol dependence syndrome. He has undergone
alcohol detox for the past ten days, but is currently taking
Olanzapine 5mg b.d. He does have a history of DTs and
these perceptual abnormalities are not unusual. He says
that he experiences these every now and then and
requires admission. His main complaint at the moment is
of a lack of sleep, and I felt that his mental state will
improve once he has a few nights of restful sleep on the
healthcare unit.
“Plan:
1. To remain on healthcare until Monday 19 November when
I will review him.
2. I will prescribe three days’ worth of zoplicone (to assist
sleep).
3. To continue with Olanzapine 5mg twice daily.
4. To consider starting an ACCT for the short term once he
is fit for transfer to ordinary location.”
38. The man was discharged from the healthcare centre on 19 November
with no documented review but was reviewed four days later by the
psychiatrist, who noted that he was in a state of anxiety and
‘withdrawal’. The psychiatrist prescribed a five day course of
Diazepam.
39. The man presented in a state of anxiety and withdrawal on 23
November. He told the doctor his mood was low and he was
experiencing thoughts of self-harm. The psychiatrist prescribed a five
day course of Diazepam. There is no evidence that the option of
opening an ACCT form was considered.
40. On 27 November, the man told the duty doctor that he had collapsed.
It was found that he had suffered a bout of diarrhoea and vomiting. He
asked the doctor to prescribe Diazepam. An appointment was made
for him to consult a doctor the following morning but he did not attend.
December
41. On 1 December 2007, staff suspected that another prisoner had
passed the man illicit drugs. The investigation found no evidence to
show what action was taken by staff.
42. Four days later, the man complained that he was suffering from
anxiety. He was assessed by a doctor, who diagnosed
benzodiazapine dependency in view of his recent history and because
of his use of prescribed and non-prescribed of drugs in the community.
The doctor raised the issue of persistent unconfirmed drug use whilst in
custody but did not document this. The doctor prescribed Diazepam 5
mg twice daily. He reviewed him on three further occasions in
December in relation to his drug dependency and on one further
occasion after the episode of self-harm described below.
ACCT form opened
43. On 20 December, after the man had made a superficial cut to his arm
in his cell, an ACCT form was opened. This is a document used by all
grades of staff to monitor those prisoners considered to pose a risk of
self-harm or suicide and to assist him to reduce that risk. Whenever an
ACCT form is opened, staff are required to undertake the following
tasks:
- Complete a Concern and Keep Safe form
44. This form is designed to assist staff to identify the main reasons why
the prisoner has become at risk of self-harm or suicide. The man’s
form was completed by an officer at 1.45pm on 20 December. He
recorded the following information:
“He is not aware of self-harm due to the panicking
behaviour. He is panicking and has a strong shaking
behaviour. At the moment he is very slow in walking and
talking. This caused by fear of being locked up in a cell.
He is worried about his family and self whereabouts.”
- Draw up an immediate action plan
45. The function of the immediate action plan is to record the most
appropriate environment and regime required to support the at-risk
prisoner prior to the first case review. Prison Service Order 2700 sets
out the requirement that the plan should be drawn up within one hour
of the Concern and Keep Safe form being raised. The form was not
completed until 5.20pm on 20 December, three hours beyond the
required time limit.
The man’s plan is shown in the following table:
Immediate action Action By whom Completed
required
Location To remain in shared cell By staff Existing
Frequency of staff Hourly obs. By staff Ongoing
support
Phone access Given phone call to family By staff 20 Dec 07
Listener access He is aware of Listener Ongoing
scheme and staff support.
Other immediate To be referred for mental Staff
interventions health assessment and day
care classes.
- Complete an assessment interview
46. This interview should also take place within 24 hours of the initial
concern being raised. The aims of the assessment are:
• to draw out the prisoner’s perceptions of the problems related to
his current distress
• to measure his mental state and his current suicidal thoughts
and intentions
• to identify what coping mechanisms can be utilised to help him
manage and reduce his risk.
47. The man’s assessment interview was conducted by an officer at
4.20pm on 21 December, approximately three hours beyond the time
limit set out in Prison Service Order 2700. The officer wrote as follows:
“The man suffers from severe panic attacks and during
one of these he made cuts to his arms. He says he has
no real issues that would cause him to harm himself. He
just can’t help it at times. He has self-harmed before
because of the same issues. He has no control over his
actions. He also mentioned his mental health issues that
might need to be addressed. He does take regular
medication. He stated he has no intentions of suicide but
he could he could not state whether he would cut again
during a panic attack. He says he is close to his mum and
dad and that he has regular visits from them. At present
an officer has allowed him to help out with the cleaners.
He says he is very happy on C wing. He should continue
to help cleaners when possible.”
- Undertake a first case review
48. The purpose of this review is to assess the immediate level of risk. The case
review should bring together a multi-disciplinary team in order to consider the
needs of the individual and the care required. The first case review should take
place within 24 hours of the initial concerns being raised.
49. The man’s first case review was conducted at 4.35pm on 21
December, approximately three hours beyond the required time limit
set out in Prison Service Order 2700. The review took place in an office
on C2 landing. The review panel comprised a senior officer and an
officer. The man was present.
50. The review was summarised as follows:
“Only hurts himself when having a panic attack to take his
mind off it. He has been offered a job assisting the
cleaners. He is feeling much better now. He says he
likes to keep busy. He is looking forward to getting a visit
from his parents. An officer offered to assist him in
booking his visits should he have any difficulty.”
51. The panel considered that the man’s risk of further self-harm was low
and made a routine referral for a mental health assessment to be
conducted. The next case review was scheduled for 24 December. A
note made at the front of the ACCT form shows that he was to be
subject to “one hour obs”. However, it is not clear from the record
whether this entry refers to this case review.
- Draw up a Care and Management Plan (Care Map)
52. The purpose of the Care Map is to identify what actions can be taken to
disable any suicide plan, to link the at-risk prisoner to people who can
provide support, to build on any strengths or interests the prisoner may
have and to encourage alternatives to self-injury. The Care Map
should be drawn up at the first case review. The man’s Care Map was
drawn up by a senior officer.
53. The following table shows the details of the Care Map:
Issues Goals Action By whom and Status of
required when action
Gets bored To keep Assist cleaners - An officer Ongoing,
busy or voluntary began 21 Dec
work 07
Visits- Get visits Send out visiting The man and an Ongoing
wants orders; officer
regular telephone
contact family; to book –
with his an officer to
family assist
Wants to Education Apply for The man Started
get classes education education
education English
classes
ongoing 25
January 08
Concerns To contact To be allowed Staff/the man
over court solicitors an office call to
case his solicitors on
Monday 28
January 2008
Second ACCT case review
54. The next case review took place as planned at 3.00pm on 24
December, again in the office on C2 landing. On this occasion the
review panel comprised a senior officer and an officer. No member of
the healthcare team was present. The review was summarised thus:
“The man states that he feels very low at present. He
feels a great pressure building inside his head and does
not really know how to express himself at present. He
feels that this was the cause of his previous act of self-
harm. He states that he still feels this way. He also has
not yet received a visit from his parents with whom he is
in contact. He has concerns that his level of medication,
recently increased, will soon be decreased. Showing
signs of anxiety and distress. Aware of staff/Listener
support. Given phone call to family. Observation level to
increase to 2 hourly interventions.”
A note made at the front of the ACCT form shows that he
was to be subject to “2 hourly obs”. However, it is not clear
from the record whether this entry refers to this particular
case review.
55. The panel considered that his risk of further self-harm was raised. The
next case review was scheduled for 1 January. The case review
record contains no reference to the objectives set in the care map.
January 2008
Third ACCT case review
56. The man’s third review took place on 2 January 2008, a day later than
planned. A senior officer chaired the review and an officer attended.
The man was present. The senior officer recorded the following
summary:
“He is feeling more occupied now he is working as a wing
cleaner and likes keeping busy during the day. He said
his medication has again been reduced by half which he
is finding very difficult to cope with. He is to see the
doctor on Friday about this but would like sooner if
possible. He finds night time the hardest period. Has not
harmed himself but has had thoughts of self-harm which
he has, with help of cell mate, talked himself out of.
Observations lowered during the day but remain 2 hourly
at night until medication review.”
57. The panel considered his risk of further self-harm remained raised and
set the next review for 12 January.
Contact with Counselling, Assessment, Referral, Advice and
Throughcare service (CARATs)
58. On 3 January the man had an appointment with a CARATs worker.
The purpose of the appointment was to assess what level of support he
needed both in prison and in the community to reduce his substance
misuse.
59. He agreed the following care plan with his CARATs worker:
Objective Method of Work to By whom When Comments
measuring be done on
progress completion
Provide Liaise with Refer CARATs, Immediate Referral
support in Drug direct to client and made
prison and in Intervention DIP team DIP team
the Programme
community. (DIP).
Offer further
treatment
and advice
upon
release.
Develop Liaise with Refer CARATs Immediate Referral
client’s client. client to and client made
awareness alcohol
of the risks group.
of alcohol
abuse.
Learn coping
skills,
relapse
prevention
and harm
minimisation.
60. The CARATs worker summarised the man’s main issues and key
achievements prior to release as follows:
“He has used a variety of drugs during his lifetime. These
include amphetamines, methadone, heroin, crack and
cannabis. At present, in the community, he uses
amphetamines as well as drinking heavily on a daily basis.
He drinks on average 10 cans of strong cider a day. He
stated that he started drinking at these levels at the age of
23. He stated that he previously attended AA meetings in
the community for six weeks and was sober during this
period. He also attended the James Cook House, Barking
in 2000. “
Further mental health review
61. On 10 January 2008, the man underwent a further mental health
review by the psychiatrist, who made the following record in his
medical file:
“I have reviewed the consultations below and admit that I
was unaware of his benzodiazepine dependence. The
man told me that he would use other people’s
prescriptions and never had an actual prescription of his
own for valium on the out. He also used his girlfriend’s
prescription for Venlaxafine (for treatment of depression)
and was never actually prescribed it by his own GP.
Initially during the assessment, he began requesting
sleeping tablets and even warned me not to reduce his
valium. His sleep has been much the same since I last
saw him on the Healthcare Unit. He mainly complains of
initial insomnia with broken sleep throughout the night.
There does not seem to be any early morning wakening,
although he does not feel he has a restful night. He does
participate in education on a daily basis and said he
enjoys studying maths and English. He said he is
particularly good at maths. He is also speaking to his
girlfriend on a regular basis, who is currently living in his
own flat.
“Although he said that he felt low, this seems to be more of
a fleeting mood throughout the day. He finds he is at his
lowest during the evening when locked in his cell. He even
told me that he understood that partly the reason was that
he was in prison. He said that he did not feel as bad
during the daytime. However, he did want to discuss
antidepressant medication with me and said that in the
past he has been on zispin (mirtazapine) and that he was
at his best when he was taking zispin which was whilst he
was in Pentonville Prison.
“Regarding the self-harm incident two weeks ago, he said
that he had not planned to harm himself during the day and it
was only during the evening when he became extremely
frustrated and angry at himself. He went on to say that he
felt like banging his head on the walls but did not call for help
from the officers. He then proceeded to cut his left forearm
‘close to the veins’ with the intent to kill himself. He said that
he was quite frightened once he had done the act and then
added that it was more of a cry for help “like my other
attempts”. He was happy that the wound had healed quickly
and did not have any more thoughts of DSH (deliberate self-
harm)/suicide.
“There were certainly no psychotic symptoms elicited
during this assessment and he was happy continuing
taking Olanzapine10mg by night. He is also currently on
5mg valium in the morning plus 10mg of Valium in the
evening. This is a reducing regime looked over by his
GP…
“…I went on to give him advice on sleep hygiene.
Although I reassured him regarding his daily attendance to
education, I asked him to increase his activity during the
daytime.
“I do not feel like he has a major depressive illness at
present. For this reason I do not feel he warrants any anti
depressant medication on the basis of this assessment. I
had not made any changes to his prescription chart. He
does appear quite stable currently and was happy with the
consultation.
“Plan: Review again in 4 – 6 weeks.”
62. A doctor reviewed the man on two further occasions in January about
his benzodiazepine prescription but did not make any entries in the
ACCT form. On 18 January, the psychiatrist reviewed him as a result
of an urgent referral because of his increased agitation. On this
occasion, he prescribed a three day course of Zoplicone and made a
corresponding entry in his ACCT ongoing record. On the same day,
his CARATs worker made a note of the fact that his client was now
engaged in maths and English classes and “had no further concerns”.
Fourth ACCT case review
63. The man underwent a fourth ACCT case review as planned at 11.10am
on 12 January. A senior officer chaired the review with an officer and
the man present. No member of the healthcare team was present.
The review took place in the office on C4 landing. It was summarised
as follows:
“He stated he has had his medication issues addressed
and feels much better. He is happy with his current cell
mate but still requires support from landing staff. Due to
this we have decided to leave him on his current
observations for 2 weeks.”
Fifth ACCT case review
64. The man’s fifth ACCT case review took place on 25 January. The
review panel comprised a senior officer and an officer. He also
attended. Once again, no member of the healthcare team was
present. The senior officer summarised the review thus:
“Says he feels low and likes the support of staff and the
ACCT process. Gets on well with his cell mate. Says he
is not going to hurt himself. Says he does not want
ACCT closed. Offered phone call to Sols ref court case
on 18 February which he declined. Says he is not going
to kill or harm himself. He insists he feels low but well.
He knows how to get help if needed.”
65. The panel judged that his risk of further self-harm was low. A further
review was set for 7 February. It is not clear what level of observation
was set.
February
Application for enhanced level of privileges
66. The man applied for enhanced status under the Incentives and Earned
Privileges (IEP) scheme on 6 February. This scheme is in place in all
prisons and is designed to reward good behaviour with increased
privileges. Those on the enhanced level are normally given extra
visits, letters and telephone calls. He wrote on his application form,
“I’ve been here for three months now and I get on well
with all the staff. I show courtesy to them. I comply with
the wing regime. I’m in full time education and am
getting on very well there too.”
67. In response, his landing officer wrote that the man had been on C wing
for some time and was polite to staff and other prisoners. The officer
felt that he deserved enhanced privilege status. His record does not
clarify whether his application was approved.
68. The following day, he failed to appear for a review by a psychiatrist
from the mental health team.
Sixth ACCT case review - ACCT closed
69. The man’s sixth ACCT case review took place as planned on 7
February. The review was chaired by a senior officer. An officer and
the man were present. However, no member of the healthcare team
was present.
70. The case review was summarised as follows:
“He is now attending full time education. He is bright and
cheerful in demeanour with relevant eye contact
throughout the interview. He is much happier and
settled. He is now on a maintenance script with his
medication. He states he has no intention of self-harm or
suicide and that if he has a change of mood/situation he
will approach staff. He is aware of all support services
available. ACCT document closed.”
71. Whenever an ACCT document is closed, a post closure review must
take place after an appropriate interval. The senior officer set 14
February as the date for the man’s post closure review.
Further act of self-harm - ACCT re-opened
72. Two days after the man’s ACCT form was closed, he made minor cuts
to his left arm. Consequently, his original ACCT document was re-
opened. A nurse examined him at midday in the C wing treatment
room and applied six sutures.
73. The following information was recorded on the Concern and Keep Safe
form by an officer:
“The man made a cut to his left lower arm using a razor
blade. He did this during the serving of lunch whilst staff
were on his landing. He said he felt he could not handle
it but would not say what he could not handle. He said
he has not been sleeping. He has previously been on an
open ACCT only being closed recently (2 days).”
74. The Immediate Action Plan was as shown in the following table:
Concern about No
cell sharing?
Immediate Action By whom Completed
action required
Location Already in double cell. Staff 9.2.08
Happy with cell mate
Frequency of Every 2 hours until Staff Ongoing
staff support assessment
Phone access As per regime Prisoner/staff Ongoing
Listener access Explained and understood Prisoner/staff Ongoing
75. As the original ACCT form had been re-opened, no new care map was
drawn up and no initial case review was conducted. My investigator
was presented with no evidence to show that any subsequent case
reviews were held. The front cover of the ACCT form indicated that it
was closed again on 14 February. My investigator was told that this
date was likely to have been the date of the planned ACCT post-
closure review rather than to date the form was closed. Numerous
entries were made in the ACCT ongoing record up to and including 23
February. The last entry was made on that day at 6.00pm. It said,
“Management check. Obs noted.” My investigator was unable to
ascertain whether or when this ACCT form was closed.
76. The entries made in the ACCT ongoing record between 9 and 23
February show that the man’s mood and behaviour varied. Some of
the more pertinent entries are repeated below.
2.35pm on 9 February:
“Prisoner has again self-harmed by cutting his left lower
arm. He has just received his canteen and got his
tobacco. This time he says he wants to go to D wing.
Taken to see nurse in B/G wing treatments.”
2.50pm on 9 February
“Has been seen by Dr in reception who has prescribed
him for more sleeping tablets. He also said that he is
happy on C wing and does not wish to move. Thanked
me for taking him to the doctors.”
4.00pm on 10 February
“His cell mate has been moved out due to the man self-
harming constantly. We have given him a chance to
find a cell mate of his choice but up till now no one
wanted to be located with him due to his self-harming.”
3.15pm on 11 February
“He told me that he was feeling particularly bad and that
he really felt like killing himself. He said he has suffered
depression for years but has never felt this bad. He is
unable to sleep at night and this is making him feel
worse. I took him to see a MH doctor at healthcare who
is going to adjust his medication to help him sleep.”
77. A doctor assessed the man on this occasion and prescribed a five day
course of Zoplicone and arranged to review him again three weeks
later. The doctor did not make a corresponding entry in the ACCT
form. His CARATs file shows that he attended an alcohol group on 11
February.
Suspected overdose - admitted to hospital
78. At 4.00pm the next day, the following subjective comment was made in
the ACCT ongoing record:
“He pretended to feel faint. Then when he saw medical
staff he decided to be sick by sticking two fingers down
his throat. He threw up in the bin next to the medical
hatch on the wing….”
79. The man was examined by a nurse. He appeared to her to be passing
“coffee ground vomit” and to be disorientated. Other prisoners
reported that he may have been taking illicit drugs. There was also a
suspicion that he may have bought medication from other prisoners in
exchange for tobacco. At 10.45pm, he was taken to hospital for
observation. During his stay in the hospital, he was placed on constant
observation. He became very aggressive towards the prison staff who
were guarding him and had to be restrained in order to prevent him
harming himself. At 9.00pm on 15 February, he was discharged from
the hospital and admitted to the healthcare centre as soon as he
arrived back at Pentonville.
Admission to healthcare centre
80. The following entry was made in his medical record:
“Admitted healthcare inpatient unit. For assessment of
mental health. Admitted to HCC (healthcare centre) from
reception after being discharged from hospital after a
suspected overdose – unknown substance on 12
February. On speaking to him he denies taking any other
than his prescribed medication, stating that he ‘felt funny’
after drinking large quantities of water. He says he
doesn’t recall anything. Given hot water and zoplicone.
Settled 23.30hrs and has slept through.”
Appearance in court and discharge from the healthcare centre
81. The man was taken to Crown Court during the afternoon of 21
February. The ACCT form accompanied him. The Prisoner Escort
Record for the journey to and from court also noted that he was at risk
of self-harm and indicated that he was vulnerable. He returned to the
prison shortly before 6.00pm. An entry was made in his medical record
indicating that he was fit to be discharged from the healthcare centre
and to be placed in an ordinary wing on his return. His ACCT form
contains no evidence that a case review prior to discharge from the
healthcare centre was convened. No follow-up medical appointment
was made.
Review by doctor
82. On 25 February, a doctor reviewed the man’s case after he had
become agitated and anxious because he said he had not received any
Diazepam for four days. The doctor prescribed a slowly reducing
regime of Diazepam and arranged for a further review in due course.
83. The man’s CARATs worker recorded the following information in his
CARATs file on 29 February:
“He stated he is feeling somewhat depressed at the
moment. He stated that he has seen the doctor who is in
the process of sorting out his medication. He stated that
he does not want to do any group work at present. No
further issues.”
March
84. A doctor reviewed the man again on 3 March and noted that he
remained anxious.
New ACCT form opened
85. Shortly before midday on 12 March, the man’s cell mate told an officer
in D wing that he was crying. The officer spoke to him straightaway.
He said he was going to hang himself because he did not want to live
any more. The officer consulted a nurse in the wing treatments room
with the aim of arranging an appointment for him to be seen by
someone from the mental health team. He was told that no-one was
available. However, the nurse arranged for the locum doctor to assess
him that afternoon. The officer asked the cell mate to keep an eye on
him during the lunch period. At about 12.45pm, the cell mate pressed
his cell bell to alert staff to the fact that the man had made a rope and
said he was going to hang himself. Both a doctor and a nurse
assessed him straightaway. They decided to admit him to the
healthcare centre and place him on constant observation. He
remained subject to this level of observation until mid-morning the
following day. Meanwhile, the officer decided to open a new ACCT
form.
Concern and Keep Safe form
86. The officer completed the man’s concern and keep safe form straight
away. He told the officer he wanted to hang himself because he could
not cope on the wing. The officer described him as nervous and
shaking, with slow speech. He thought his mood was “quiet”.
Immediate Action Plan
87. The man’s immediate action plan was not drawn up until 7.45am on 13
March, some 18 hours beyond the required time limit set out in Prison
Service Order 2700. The following table shows the plan’s details:
Concern about No
cell sharing risk?
Immediate Action By whom Completed
action required
Location Admitted to healthcare Doctor Done 12 March
centre by locum doctor
for assessment. He is
happy as this is what he
wants.
Frequency of Initially on constant Unit staff Ongoing
staff support observation until review
by MHT
Phone access Has PIN number/credit Unit staff Done 12 March
Listener access Aware of Listeners Unit staff Done 12 March
Other immediate Given TV Unit staff Done 12 March
interventions
88. The plan also records that a case review was to be organised and a
further assessment of the man was to be made. Healthcare staff were
briefed about him and an entry was made in the unit staff observation
book.
Assessment interview
89. The man’s assessment interview was conducted by an officer in the
healthcare centre at 3.15pm on 14 March over 48 hours after the initial
concerns had been raised. It should have been completed within 24
hours of the initial concerns being raised. He told the officer he had
once tried to hang himself and had also tried to jump in front of a car.
He said he began to self-harm whilst in custody approximately four
months earlier in order to ”alleviate his issues”. With regard to his
physical state, the officer described him as “shambolic”. He apparently
looked ill and as if he had not been eating. The officer said he kept
crying during the interview and could not stop shaking. He told the
officer he was hearing voices and could not concentrate.
90. As far as the man’s current mental state was concerned, the officer
recorded that he told him he “wanted to end it all”. He was fed up with
living but gave no further information about how he might take his own
life. He also said he had in the past made an attempt to overdose
which resulted in his hospitalisation. However, when the officer asked
him about what coping resources were available to him, he said he had
a very supportive family and he had a flat.
91. The officer’s concluding remarks in the record of the interview were
that the man wished to see a doctor to discuss medication.
First case review
92. The man’s first case review was held in the healthcare centre very
shortly after his assessment interview. The case review panel
comprised a senior officer, who is trained to work in support of
healthcare staff, and a nurse. The man was also present.
93. The case review was summarised as follows:
“He says he is feeling so depressed he says he cannot
sleep and is having nightmares and anxiety attacks. He
also says he is hearing voices (his mother). His mother
doesn’t tell him to self-harm but is very judgemental. He
feels more settled and safer in the healthcare centre. He
has been seen by the mental health team doctors but has
not been prescribed any more meds. He has requested
a phone call to his mother. I believe he is using the
ACCT as a manipulation tool to remain in the healthcare
centre and manipulate his medication, even though his
risk of self-harm is still real.
Observations: one hourly.”
94. The panel judged the man’s risk of further risk behaviour as “raised”.
They decided he should be reviewed again one week later.
Care Map
95. The man’s care map was drawn up by a senior officer at the case
review. The details are shown in the following table:
Issues Goals Action By whom and Status of
required when action
Family contact Phone call Landing staff Ongoing
and Governor’s
authority
Ongoing MHT To keep in MHT informed Healthcare Ongoing
(Mental Health touch with staff
Team) MHT
To locate on C Maintain Relocate C4- Officer 20/21 March
Wing with support from 02
friends friends
Complaints of black-outs
96. The man was assessed by a doctor and a nurse manager during the
lunch period on 13 March as he had complained of blackouts and
trembling, which was thought to be due to benzodiazepine withdrawal.
He made a full recovery. No drug screen was conducted. A doctor
also assessed him as being depressed. Again no drug screen was
performed and his medication was unchanged: he remained on
Olanzapine 10mg once daily and Diazepam 7.5mg once daily.
97. On 18 March, the locum Trust doctor met the man for the first time.
She documented that he was feeling low and was experiencing suicidal
thoughts. This was in contrast to the views of other staff who reported
in the ACCT document that he was sleeping and eating normally, was
mixing with other patients and appeared to be “fine”. She did not make
a corresponding entry in the ACCT form.
Court appearance
98. The man appeared at Crown Court on 19 March. He was convicted of
his offence of Actual Bodily Harm and remanded in custody to appear
for sentencing on 23 April.
Mental health review by psychiatrist and further ACCT case review
99. The locum doctor reviewed the man again on 20 March. Afterwards,
she made the following entry in his medical record:
“He said that he is feeling very low/depressed and is not
sleeping at all. It was discussed that he would be
discharged from the healthcare wing today and will be
reviewed in the clinic. He mentioned that if he was
discharged he would hang himself. There has been no
evidence of depressive symptoms during his period of
stay here. He has been observed to have adequate
biological functions.
“Discussed with doctors. Plan:
- To discharge him back to the wings from healthcare
today
- To prioritise him going to a shared cell in view of the
risk of him, trying to harm himself
- To have highest level of observation in the wing
- Clinic appointment end of next week for a doctor to
review.”
100. He did not see a psychiatrist thereafter.
101. He underwent a further ACCT case review in the healthcare centre at
3.30pm the same day. The purpose of the review was to assess his
readiness for discharge from the healthcare centre. The review panel
comprised a principal officer and an officer. He was also present. The
review was summarised as follows:
“Spoke about issues, talked about length of sentence and
that he would be out in 5 weeks. He also stated that he
couldn’t go to B Wing as he owed 6 pks of tobacco.
Changed to C Wing and he was happy with that. Needs to
keep in touch with MHT.”
102. His risk was considered to be raised. A Principal Officer (PO) told my
investigator she made this judgement because she was aware that he
was about to be transferred from the “nurturing environment” of a
healthcare centre to a different environment in which the staffing level
was lower. She decided that he should be observed hourly by day and
night. She wrote the instruction on the front cover of the ACCT form so
that it was clear to all staff. The next review was scheduled for 24
March. There is no evidence that the staff present at the review knew
of the comments made by the locum doctor in his medical record about
the need for him to have “the highest level of observation”.
103. The man was discharged from the healthcare centre on 21 March. No
follow up appointment took place. He was allocated to a shared cell in
C wing.
Further ACCT case review
104. The next case review took place as planned on 24 March at 10.30am
in an office in C wing. This was attended by a senior officer, an officer
and the man. No member of the healthcare team was present. The
review was summarised as follows:
“Good eye contact and body posture. He states he is
happier on C Wing – he knows people on the unit and is
supported by the wing Listener. He gets on ok with his
new cell mate and enjoys getting out onto the landings
and mixing with others. He had a telephone call to his
family yesterday that went well. However, he states he is
still depressed which he puts down to being in prison. No
new issues raised. Aware of all support networks
available.”
105. His risk of further self-harm was assessed as low. It was decided that
he should be observed once during the in the morning, once in the
evening and every three hours by night. The next review was
scheduled to take place on 4 April.
106. On 26 March, a doctor reviewed him regarding his Diazepam
reduction. The doctor did not formally assess his mental state as he
considered that he was under the care of the mental health team and
would soon be assessed at a follow-up appointment. However, as
another prisoner had died in the prison on 30 March, all those on an
open ACCT form at the time were reviewed. This was in line with
Prison Service policy. He was seen by a senior officer at 11.15am in
the office on C2 landing.
107. The officer made the following record of the review:
“Following a death in custody this morning, the man was
interviewed to see how he was. He said that it was the
last thing he wanted to hear and it had upset him a lot
due to his own suicidal tendencies and impulses. He is
having more medication issues and I feel he is getting
into debt with tobacco. He has asked for a phone call to
his mother. Otherwise says he is okay and thanked me
for our chat.”
108. The officer considered that his risk of further self-harm was ”raised”.
No record was made of the frequency of observations required.
April
Episode of hypotension
109. On 1 April, the man experienced an episode of hypotension
(abnormally low blood pressure) and hypoxia (shortage of oxygen) in C
wing. He was attended by a nurse, who referred him to the duty
doctor. The doctor made a full assessment apart from a drug screen
and, in view of his hypotension, sent him to the accident and
emergency department at hospital. Here he was given fluids
intravenously and blood tests were made. The results of these were
normal. He was therefore discharged the same day.
110. The following day, he was transferred from C wing to D wing. The
reasons for this move are not clear. That day, he was attended by a
nurse after he had complained of shaking and feeling unwell. He
asked to be given Diazepam. There is no evidence to show whether
he was given any. His temperature and pulse were taken. These
showed no abnormalities. He was reassured and he quickly settled
thereafter.
Final ACCT case review
111. The man’s last ACCT case review took place on 6 April. This time, the
panel comprised of a senior officer and an officer. No member of the
healthcare team attended. However, the man was present. The
review was summarised thus:
“Spoke at length with him, who states he is ok and enjoys
D Wing. Gets on well with cellmate and has no major
concerns at present. Seems quite well balanced at the
moment. However, I did say I would contact H/care for
him to check on his psychiatric report for court.”
112. The panel considered that the man’s risk of further self-harm was low.
No record was made of the frequency of observations required. A
further case review was scheduled for 14 April. The senior officer later
told my investigator that during the review, he asked him when he was
going to close the ACCT form because he was feeling fine. He said he
was reluctant to close the form at that point because he wanted to
gauge his behaviour over a longer period. He knew that the man had
only just come onto the wing and he needed more time to settle. He
therefore set a date for the next review to take place eight days later.
He knew this was a Monday, when more staff could be involved in the
review if that was necessary. He said he told him that he would
consider closing the ACCT at that review of it was appropriate to do so.
Day of Incident
113. My investigator spoke to the man’s cell mate about his knowledge of
the man and about the events of the last day of his life. He said,
“I came to this prison on 26 January 2008. I think I met
him towards the end of March. This was when I was in
cell D4-31. He had been moved from C wing and he
joined me in my cell. He said he had been having
difficulties with his cell mate in C wing. He was therefore
moved across to this wing. I’m not sure why he couldn’t
have been given another cell in C wing. He spent about
three weeks with me before he died.
“On one occasion he went to court. He was returned to
my cell the same day. He talked a lot about his court
case. He had an outstanding charge of ABH. He
pleaded guilty to the charge and was committed to the
Crown Court. He had just completed an 18 month
sentence. He was worried about having to do yet more
time. He knew he would have to serve over 12 months.
He was depressed about his court case but his biggest
worry was his girlfriend. He would often call his parents
in order to talk to her. He loved her very much and
couldn’t stop talking about her.
“He didn’t seem to be withdrawing from alcohol but he
used to tell me he couldn’t wait to get out of prison so
that he could have a drink. He had issues. I knew he
was a self-harmer because I could see scars on his
arms. He told me he had overdosed and had not long
come from hospital. He said he had overdosed on the
drugs he was taking. He said he had drunk too much
water. He was sometimes hard to live with. He was
always wanting something. You can only help so much.
But he was a peaceful lad.
“He was treated well by staff. He didn’t depend on them.
He kept himself to himself. He never talked to me about
wanting to kill himself. I thought that when he did harm
himself he was crying out for help. He didn’t want to be
in prison but he couldn’t control this. So he took it upon
himself to harm himself. I had no reason to believe he
was going to hang himself. It was only after he died that
alarm bells began to ring in my mind. I began to blame
myself. On the day he died, he kept asking me if I was
going to education. When they called out for exercise at
about 10.00am, I stayed in the cell with him. He was just
lying on his bed, facing the wall. He was very quiet. He
did ask me why I didn’t go to education. I would not have
known why he asked me that question.
“During the lunch time lock up, he asked me if I was
going to education that afternoon. He wasn’t tearful. He
was concerned his phone credit hadn’t been put on. I
told him to wait until the afternoon. It might have been
put on by then. He wanted to get hold of his mum so that
he could speak to his girlfriend. He didn’t take his lunch
meal.”
Telephone call
114. At 2.05pm, the man left his cell to telephone his girlfriend. A transcript
of his telephone call was made available to my investigator. It revealed
that his girlfriend thought he had been lying to her about the length of
sentence he was likely to receive when his trial was completed. She
was very angry and screamed at him several times during their
conversation. She ended by telling him she did not love him.
115. The cellmate said to my investigator:
“At 2.00pm, we were unlocked for education. I was
supposed to go but I stayed on the wing chatting to my
mates on another landing. I saw him on the phone at the
time. He seemed to be having an argument. He was
distressed and talking loudly. I think he was talking to his
mum.
“I noticed before I left the landing that the staff had
already locked the cell door. They would have had to let
him back in. I didn’t see him go back into his cell.”
116. An officer who was on duty on landing at the time told my investigator
that the man’s cell door would have been unlocked to allow his cell
mate to report for education. He said it was likely that the door
remained open whilst he was making his telephone call and that he
would have let himself back in the cell and shut the door afterwards.
He said he seemed alright to him at the time. He acknowledged that
he was likely to have been the last person to see him alive.
The man discovered hanging
117. A senior officer (SO) told my investigator that at approximately 3.40pm,
he was talking to prisoners on D3 landing when two prisoners called to
him to go to cell D4-31.
118. One of those prisoners, Prisoner A, told my investigator that another
prisoner, Prisoner B, shouted to him and said he thought something
was wrong in the man’s cell. He explained,
“…He asked me to see if the guy was ok. I said he’s
always acting funny. Prisoner B said, ’I don’t think he’s
alright’. He didn’t say why he couldn’t see inside the cell
very well. When he shouted to me he was near the cell
and I was very close to him but on the opposite side of
the landing. In order to join him at the cell I had to go to
the other end of the landing and back as there was no
bridge across the landing at the end nearest the man’s
cell. It took me a matter of seconds to get to the cell.
When I looked in the cell I saw him hanging. I shouted,
‘Gov, gov’ to the SO who was on the landing below. I
used those words because I didn’t want to alarm other
prisoners.”
119. The SO approached the cell and looked through the observation panel
in the door. As he did so he saw the man hanging by a ligature from
the window bars. He entered the cell and took his weight until two
more officers, who were next to arrive, cut him down. The SO then
raised a whistle alarm and shouted “fours” to indicate that help was
needed on the fourth landing.
120. At the same time, an officer used his radio to summon help from the
healthcare staff, indicating that this was a “level one”, a code indicating
a life threatening emergency. An ambulance was called at that point.
Two officers administered cardio-pulmonary resuscitation (CPR) until
two members of the healthcare team arrived and relieved them. The
SO told my investigator that, despite the fact that fluids were
discharged from the man’s mouth, he continued to administer mouth to
mouth resuscitation without having the benefit of a protective face
mask.
121. Nurse A, who was in reception at the time, heard the whistle alarm. As
he left to attend the emergency, the call was repeated as a level one
emergency on D4 landing. He therefore asked Nurse B, who was also
in reception, to accompany him. She agreed to go straight to D wing
while he collected the emergency first aid bag. A defibrillator was not
collected. (A defibrillator is a portable electronic device that
automatically diagnoses potentially life threatening cardiac
irregularities.) At this stage, neither knew that a prisoner had been
found hanging. Nor did they know the exact cell in which the
emergency had occurred. However, upon their arrival in D wing, they
were directed to the cell by a governor.
122. Nurse B could see a group of officers outside the cell. An officer was
recording staff movements in and out of the cell. She then saw the
man on his back in the cell with his head adjacent to the door and his
feet towards the cell window. CPR was in progress. An officer was
administering chest compressions and the SO was applying mouth to
mouth resuscitation.
123. Nurse B could find no signs of life. There was no pulse and no
respiratory effort. She found that copious amounts of clear fluid were
draining from the man’s mouth. There was evidence of cyanosis (ie
the colour of his skin was grey/blue). She found no recordable blood
pressure. His pupils were fixed and dilated. There was a ligature mark
on the right side of his neck. As she assessed him, the SO told her
what had happened. He wanted to apply two further chest
compressions but she advised against this in view of the amount of
fluids in his airway. She asked for the full level one emergency
equipment, including the defibrillator, to be brought to the cell. Nurse A
fetched the defibrillator from the healthcare centre. Meanwhile, she
used an instrument to withdraw fluids form his mouth, inserted an
airway and applied oxygen. The officer continued with chest
compressions. Nurse A attached the defibrillator pads to his chest. At
about 3.50pm, the defibrillator advised to shock. He delivered a shock
but the rhythm analysis showed asystole (i.e. no cardiac electrical
activity). Consequently, CPR was recommenced.
124. At this point, a doctor arrived and asked for the cell to be cleared of
some furniture so that more space could be created. This was done.
An attempt was made to insert a breathing tube but this was
unsuccessful. Nurse B re-inserted a guedel airway (a device inserted
to help clear a patient’s airway) and applied further oxygen. CPR was
continued throughout. The doctor attempted to insert a tube through
which life saving drugs could be administered, but did not succeed.
The man remained in asystole. At the doctor’s request, adrenalin was
administered at 4.00pm and again two minutes later. Paramedics
arrived at that point and a full ambulance crew reached the cell six
minutes later. At 4.09pm, the ambulance crew took over CPR and
asked staff to clear the cell. Approximately one minute later, all staff
except Nurse A and the ambulance crew left the cell. The paramedics
intubated the man. The doctor remained outside the cell for about ten
minutes. At about 4.22pm he entered the cell to discuss developments
with the paramedics. At 4.25pm, an agreement was made to cease
CPR. Death was pronounced at 4.26pm. No note was found in the
cell.
125. The cellmate concluded his interview with my investigator as follows:
“When I found out that he had died I was shocked and
distressed. I had been told that two prisoners saw him
hanging and they alerted staff. I think they were probably
looking for me. He wasn’t sociable. He didn’t have many
friends. I believe he should not have been banged up on
his own, especially because he was on an ACCT form.”
Informing the man’s next of kin
126. Shortly after the man’s death had been pronounced, another prisoner
at Pentonville set fire to his cell in the segregation unit. The Governor
and his staff therefore had to deal with that incident as well as with the
aftermath of this death. As a result, the Governor asked the police to
inform the man’s next of kin of his death. Essex police officers did so
at his parents’ house at 9.45pm, some five hours after his death.
Support to the family after the man’s death
127. A letter of condolence from the Governor was sent to the man’s family
by courier at 2.00pm the next day. On that day, the Governor
telephoned the family and offered to arrange for the prison’s Family
Liaison Officer to visit them.
128. The funeral took place on 22 April. The Family Liaison Officer attended
on the Governor’s behalf. The full costs of the funeral were offered to
the family. The Governor extended to the man’s father an invitation to
visit the prison in order to view the cell in which his son died.
129. On 14 April, the man’s parents were offered an opportunity to visit the
prison so as to view their son’s cell and talk to staff.
Support to prisoners and staff
Prisoners
130. The Governor also issued a Notice to Prisoners in which they too were
informed of the man’s death and offered support by Listeners, the
chaplaincy, Independent Monitoring Board and any other member of
staff. Arrangements were made to review all those for whom an ACCT
form was currently open.
Staff
131. The staff involved when the man was discovered hanging and who
attempted to save his life went to the treatment room on D2 landing in
order to support each other. At 5.00pm, the Governor chaired a debrief
of those staff.
132. The clinical review draws attention to the fact that there was no clinical
debrief by appropriate healthcare managers.
133. On the same day, the Governor issued a Notice to Staff announcing
the man’s death and offering the support of the prison care team and
the chaplaincy. He also announced that a critical debrief would be
arranged.
ISSUES
134. Here I examine:
• Whether the man’s health needs were adequately met while he was
in custody.
• Whether his risk of self-harm or suicide was appropriately identified,
monitored and managed.
• Whether the response when he was found hanging was prompt and
effective.
• Whether appropriate courtesies and support were offered to the
man’s family in the aftermath of his death.
Were the man’s health needs adequately met while he was in custody?
135. Here I rely heavily on the findings and conclusions reached by the
clinical reviewer in her clinical review of the management of the man’s
health needs. It should be noted that her methodology included an
overview of a document entitled, “Death in Custody Clinical Review:
Interim Report: 27.2.1970 – 9.4.2008”. This report was produced by a
member of healthcare team at Pentonville.
136. The interim report by the member of the healthcare team and the
clinical review by the clinical reviewer should be read in conjunction
with my report. However, for ease of reference, the following table
shows the recommendations made in the interim report together with
corresponding comments from the clinical reviewer.
Referrals
Interim report findings Comments by the clinical reviewer
Recommendation 1.
There should be a review of the The investigation revealed an absence of a
referrals process to the Mental robust system for handling urgent referrals.
Health Team involving triage of This does not appear to have adversely
urgent referrals. A clear auditable affected the man’s care.
protocol of then system should be
produced.
Drug testing
Interim review findings Comments by the clinical reviewer
Recommendation 2.
There should be a written policy The man was known to have substance
regarding drug testing for all misuse problems. He was detoxified from
psychiatric patients on admission to heroin during a stay at Pentonville in August
the healthcare unit which should be 2007 and there were several mentions of this
part of the initial nursing in his subsequent medical records as well as
assessment. This should be a documented suspicion that he was
subject to regular audit, obtaining illicit drugs in prison which may
have caused collapse and admission to
There should be an agreed policy hospital. However, he was not tested for
for requesting healthcare performed illicit drugs at any time during his stay.
drug screening on patients in HMP
Pentonville where clinically This omission may have led to an incomplete
indicated e.g. suspected withdrawal, or inaccurate diagnosis of his intercurrent
unexplained collapse etc. physical and mental health problems during
his stay and his clinical management may
have been suboptimal as a result.
Induction of doctors
Interim review findings Comments by the clinical reviewer
Recommendation 3.
The induction of new doctors should It appeared that the members of the
be should be reviewed. psychiatric team who saw the man were
Consideration should be given to either unaware of, or untrained in, the
training relevant to working in a possible effects of his poly substance
prison environment with its misuse. I did not find anything in the written
increased risk of self-harm and medical record to suggest that medical staff
suicide and high levels of substance lacked the skills to asses risk of self-harm or
misuse. Induction should include suicide. At least one junior doctor on the
formal ACCT training and psychiatric had not been trained in ACCT
appropriate training from the procedures.
Substance Misuse team. The
importance of thorough
documentation should also be
highlighted.
Joint working
Interim review findings Comments by the clinical reviewer
Recommendation 4.
There should be a review of joint Despite his previous history of poly
working between primary care, substance misuse and suspicions of current
secondary MHT care and the misuse, the man was not assessed by the
Substance Misuse service within Substance Misuse Service during his stay.
HMP Pentonville. Monthly or twice Joint working between the services would
monthly meetings to discuss shared have facilitated improved diagnosis and
patients would facilitate improved management of his problems.
interdisciplinary communication and
patient care.
Documentation of substance misuse
Interim review findings Comments by the clinical reviewer
Recommendation 5.
Where there is a history of drug use The documentation of the man’s previous
within the prison this should be drug misuse in his medical record was
documented, especially as it may haphazard, although there was mention of it
provide important information for in free text in a number of consultation
further consultations e.g. entries made and it was fully READ coded
unexplained collapse/persistent during his previous stay in August 2007.
hallucinatory symptoms. Notably, the junior psychiatrist who saw him
on 10 January 2008 for a mental health
review documented that he had previously
been unaware of his benzodiazepine
dependence, even though he had seen him
twice before.
(The READ coding system enables On 12 February 2008, a nurse documented
staff who make entries in the that other prisoners said he had been buying
electronic medical record to medication from other prisoners, on which he
highlight a medical problem so that may have overdosed, thus precipitating his
it is highly visible to the reader.) admission to hospital. This does not appear
to have been followed up or referenced
prominently in his medical record.
Length of GP appointments
Interim review findings Comments by the clinical reviewer
Recommendation 6.
Review of GP appointments should GP clinics within Pentonville allow for 5-7
occur with regard to their time minute appointments. It would be extremely
length and equivalence with that in difficult to complete a consultation with a
the community. 10 minute patient with complex problems in this time,
consultations are considered usual particularly if the doctor had not seen then
practice and allow time for patient before. This short appointment time
appropriate documentation. was noted to have compromised making the
fullest possible entries in the man’s medical
record on occasion. In general practice in
the community it would be considered good
practice (and necessary) to offer such
patients more than the standard 10 minute
appointment if possible.
Benzodiazepine policy
Interim review findings Comments by the clinical reviewer
Recommendation 7.
The benzodiazepine policy It was apparent that the management of the
produced in December 2007 by a man’s benzodiazepine dependence was
Consultant, Substance Misuse suboptimal. There did not appear to be a
Service, should be reviewed, clear management plan or schedule for the
agreed and implemented through dose, or reduction in dosage of prescribed
clinical governance arrangements. benzodiazepines, so it was difficult for the
different doctors who saw him to manage his
treatment consistently. There was evidence
in his medical record that a too rapid dosage
reduction had caused him significant distress
at least once and could have had an ongoing
impact on his mental state. All doctors
working in the prison should be familiar with
current Department of Health guidelines on
the management of this condition and it is
hoped that any local policy is in line with
these guidelines.
ACCT documentation
Interim review findings Comments by the clinical reviewer
Recommendation 8.
\When patients are subject to an The documentation in the medical records of
ACCT this must be clearly opening and closing ACCTs on the man was
documented in the medical record haphazard and would have made it more
using READ codes and including difficult for health care staff to know what
opening and closure dates. level of risk of self-harm he was thought to be
Systems should be in pace to at any time.
ensure that this occurs routinely and
health care staff should make a The opening of his first ACCT was recorded
brief entry into ACCT documents at in his record on 20 December 2007 but not
the time of consultation. READ coded, so could not be highlighted as
a problem.
(The Electronic Medical Information
System - EMIS - record can capture It is my impression that a second ACCT was
important information by entering a opened early in 2008 but I cannot find any
diagnosis or event by its code, mention of this in his medical record.
known as READ code. Any READ
code entry can then be highlighted His third and last ACCT was opened on 12
as a problem.) March 2008, at which time he was
considered a high risk of suicide and
admitted to the healthcare unit. The intent to
open his ACCT was written in his medical
record but the act of opening the document
was not READ coded and it was not clear in
subsequent entries at what level of risk he
was being managed.
Good clinical care
Interim review findings Comments by the clinical reviewer
Recommendation 9.
The panel would like to commend None.
the actions of all those staff involved
with the man’s assessment and
admission to the healthcare unit on
12 March 2008. The clinical care
provided was safe and appropriate.
Supervision of psychiatric staff
Interim review findings Comments by the clinical reviewer
Recommendation 10.
Supervision of junior staff should be The psychiatrists in training were interviewed
reviewed so that it fulfils the as part of the internal review of the man’s
guidance of the Royal College of death. The transcripts of these interviews
Psychiatrists and is in line with the revealed poor induction processes for new
PCT’s Mental Health Trust policy. staff and inadequate supervision of their day
to day work and their training.
Follow-up post discharge of inpatients
Interim review findings Comments by the clinical reviewer
Recommendation 11.
There should be a review of how Following discharge from his second and
follow-up appointments are made third inpatient stays in health care on 21
post inpatient discharge with a view February and 21 March 2008 respectively,
to ensuring a robust system that is there was no arrangement for the man to
not single person dependent. have a follow-up appointment with the mental
health team, despite the complexity of his
case.
Case load and allocation in the psychiatric team
Interim review findings Comments by the clinical reviewer
Recommendation 12.
There should be some Despite the complexity of his case, the man
consideration of both doctor was never seen by a consultant psychiatrist
experience and complexity of during his five month stay at Pentonville,
patients’ case when allocating although a doctor’s opinion was sought on
patients’ for both inpatient one occasion by the Senior House Officer
assessment and outpatient follow- when the specialist registrar was unavailable
up post health care admission. in clinic on 20 March 2008. Apart from one
entry in his record by the specialist registrar,
all other entries were made by junior
psychiatrists in training.
137. The clinical reviewer makes the following additional comments:
Inadequate documentation in the medical record
“The EMIS medical record can capture important
information by entering a diagnosis or event by its code,
known as READ code. Any READ code entry can then
be highlighted as a problem. These problems then
appear as a problem list on the summary screen in the
record and are a valuable means of highlighting
important information, particularly to others using the
record who may be unfamiliar with the patient. I have
already commented on the shortcomings in respect of
adequate problem entries in relation to ACCT
procedures. There are two other important examples of
problems not being adequately documented.
“The man attempted self-harm on 20.12.2007 (cut to arm
requiring stitching). He was seen by the GP but this self-
harm was not documented in the record with a READ
code and so was not registered as a problem. He also
cut himself with a razor blade on 9.2.2008, requiring
further stitching. There is no mention in the medical
record at all on the day this occurred but it was noted by
the junior psychiatrist two days subsequently. Again, it
was not recorded as a problem with a READ code. It
would therefore not be easily apparent from the medical
record to others providing care that these episodes of
self-harm had occurred.
“He was seen at hospital on two occasions following
collapse – on 12.2.2008 (3 day admission) and 1.4.2008
(A and E assessment). These episodes were not READ
coded in his medical record. It appears the cause of
these collapses was not determined by the hospital
although the collapse in February was strongly suspected
by prison staff to be due to an overdose of illicitly
obtained drugs. It is not recorded whether a referral
letter was sent to the hospital with the patient on either of
these occasions giving his medical history, which might
have helped the hospital to reach a diagnosis. Another
collapse on 27.11.2007 was managed without referral to
hospital but again was not READ coded in the record.
Neither was a cause postulated. It would therefore not
be easily apparent from the medical record to others
providing care that these episodes of collapse had
occurred, nor what their cause was considered to be.
“I commend the use of a shared EMIS medical record
between primary care and mental health. However, in
the prison healthcare environment where many different
healthcare professionals may be seeing the patient and
making records, it is most important that the record is
used to the best advantage.
“I recommend that all staff using the EMIS record should
receive additional training in the use of READ codes and
problem management.”
Management of the man’s self-harm and suicide risk from time of
discharge from and his inpatient Health Care on 20. 3 2008 and his
death on 9.4.2008
“On discharge from Health Care on 20.3.2008 it was
noted on the advice of the consultant psychiatrist that the
man was to have ‘highest level of observation in the wing’
and a shared cell. He was supposed to have a clinic
appointment at the end of the following week with the
junior psychiatrist but there was no evidence that this
appointment had been made or kept, as he did not see a
psychiatrist again prior to his death.
“He was seen on 26 March and 2 April by the GP for
review of his benzodiazepine dependence but there was
no documentation of a mental state assessment. When
questioned for the internal review, the GP said he did not
formally assess his mental state as he considered he
was under the care of the mental health team and would
shortly be seen on a follow up appointment.
“His ACCT level of risk was reviewed after discharge
from Health Care by prison officers on 24 March and
considered to be low and his level of observations was
reduced. At the next review on 30 March, it was
considered raised but no mention made of any increase
in the level of observations. At the last review on 6 April,
three days before his death, his risk level was considered
to be low, but again with no record of the level of
observations.
”I endorse the recommendations made in the interim
report arising from the prison health care internal review.
Additionally, I recommend that all staff using the EMIS
record receive additional training in the use of READ
codes and problem management. Patients with a history
of poly substance misuse present a particular challenge
when being cared for in the prison setting.
Recommendations 2, 3, 4, 5, 6 and 7 in the interim report
should be taken very seriously in this context as his
substance misuse problems could have been managed
more appropriately.”
I endorse all the recommendations contained in the interim review
and in the clinical review.
Was the man’s risk of self-harm or suicide appropriately identified,
monitored and managed?
Suicide warning form
138. When the man arrived initially at HMP Wormwood Scrubs on 6
November 2007, he was assessed as not being at risk of self-harm or
suicide. However, when he was taken to court two days later, he told a
Senior Prisoner Custody Officer (SPCO) that he would kill himself if he
was not given the drugs he wanted. The SPCO raised a suicide
warning form so as to alert any agency responsible for his care and
safety to his risk of self-harm or suicide. Upon his arrival at HMP
Pentonville after his court appearance, the warning form should have
been seen and signed by a reception officer so that appropriate follow-
up action could be taken. However, the form was not signed. The
investigation found no evidence of any follow-up action in relation to
the risk related information on the form.
The Governor should ensure that suicide/self-harm warning forms
are always seen and signed during reception procedures and that
appropriate follow up action is taken in relation to the risk
information presented.
ACCT procedures
139. ACCT procedures were invoked for the man on the following three
occasions at Pentonville.
• The first ACCT form was opened on 20 December after he had cut
his arm. This form was closed on 7 February.
• The same form was re-opened on 9 February as a result of a
similar act of self-harm. It is not clear whether or when this form
was closed.
• A third and final ACCT form was opened on 12 March. This form
remained in place until his death in April.
140. I comment below on the quality of the procedures followed during each
of these three episodes.
First ACCT form
141. The man deliberately cut his arm on 20 December. His injury was not
serious but a number of stitches were required. The investigation
found evidence that the ACCT procedures followed during the currency
of this ACCT form were broadly in line with national and local policy.
142. However, although a Concern and Keep Safe form was completed on
time, the immediate action plan that followed it was completed
marginally (three hours) outside the required time limit set down at
paragraph 8 of Annex 8G in Prison Service Order 2700. The initial
assessment interview, too, was conducted outside the required time
limit by the same margin as was the initial case review.
The Governor should remind his staff of the importance of
adhering to the provisions of PSO 2700 where the timescales for
the completion of immediate action plans, assessment interviews
and initial case reviews are concerned. Appropriate training
should be provided where necessary.
143. The record of the case review that took place on 24 December
contained no references to the objectives set in the care map made out
for the man three days earlier. In my view, there is little to be gained
from drawing up a care map for an at risk prisoner if the objectives set
in it are not reviewed and updated.
The Governor should remind his staff that care maps are an
essential element of ACCT procedures and should be reviewed
and updated at all case reviews.
144. In the 18 day period during which this form was in force, six case
reviews were conducted. Comprehensive summaries were recorded at
the end of each review. The man was present on each occasion. In
my view, the decisions reached as to his risk were reasonable and the
level of observations appropriate. Although regular entries were made
in the ACCT ongoing record, it was, in some instances, difficult to
discern what frequency of observations had been decided upon.
The Governor should ensure that clear and visible records are
made in ACCT forms showing the frequency of observations
decided upon at case reviews.
145. Although the records showed clear evidence of the presence of a case
manager and a wing officer at each review, no other disciplines were
represented at any of the reviews held in wings. The absence of a
member of the health care team at any of the reviews was, in my view,
a significant omission, especially in light of the fact that the man
frequently expressed concerns about his medication. My investigator
was given a copy of the local suicide and self-harm prevention policy
which was in place prior to 1 April 2008 as well as a copy of the revised
version that came into force after that date. In both documents, the
requirement for healthcare staff to attend ACCT case reviews is clearly
set out.
146. I am also concerned that, in some instances, doctors who reviewed the
man at times when his ACCT was in force did not make any entries in
the ACCT ongoing record for the information of those in the wings in
which he was located. For example, the plan made by a doctor on 20
March was that, when he was discharged from the healthcare centre,
he should receive the highest level of observation in the wing. This
was not recorded in the ACCT ongoing record for discipline staff to see
and act upon.
The Governor should reinforce to wing and healthcare staff the
requirement for ACCT case reviews to be conducted as a multi-
disciplinary function, embracing the expertise of specialist staff
such as the healthcare team, chaplaincy and others. This is
especially important with prisoners like the man, who have
current and historical substance misuse and mental health
problems.
In order to promote effective communication between healthcare
and wing staff with regard to important information about at risk
prisoners, the PCT should ensure that doctors make appropriate
entries in ACCT ongoing records as well as in clinical records.
147. The ACCT form was closed on 7 February. A post closure review was
scheduled to take place a week later. However, the man cut his arm
again on 9 February. As a result, the original ACCT form was re-
opened.
Re-opened ACCT form
148. A new Concern and Keep Safe form was completed and a new
Immediate Action Plan was drawn up on this occasion. However, the
ACCT form contains no evidence that any case reviews took place.
Neither does it show whether or when the form was closed. I consider
that if it is the case that no reviews were held, there was a significant
systemic failure. The seriousness of this apparent failure is mitigated
by the fact that between 9 and 23 February, numerous entries were
made in the ACCT ongoing record indicating that the man was
observed at varying intervals wherever he was located. It is also
mitigated by virtue of the fact that another ACCT form was opened on
12 March. However, I take the view that, in this case, either record
keeping or the execution of ACCT procedures fell below acceptable
standards.
The Governor should make sure that staff of all grades and
disciplines are fully aware of the requirement for regular ACCT
case reviews to be conducted and for proper records to be
maintained. The Governor should ensure that appropriate
training is provided where necessary.
ACCT form opened on 12 March
149. At 11.45am on 12 March, it came to the attention of staff that the man
was crying in his cell and had threatened to hang himself. In response,
an officer opened an ACCT form. Very soon afterwards, he was
admitted to the healthcare centre.
150. A Concern and Keep Safe form was completed, an Immediate Action
Plan was drawn up and an initial assessment interview was conducted.
The fact that the man was admitted to the healthcare centre very
quickly and was placed on a constant watch straightaway mitigates the
delays that occurred in opening the ACCT form and in drawing up the
Immediate Action Plan. However, once again the assessment
interview did not take place within 24 hours of the initial concerns being
raised. A Care Map was drawn up. One of the targets set in the plan
was “to relocate him in C wing where he could be with friends”. Whilst I
make no formal recommendation on this matter, I believe staff should
be cautious about setting such a target so soon after his admission as
an inpatient following his threat to hang himself.
151. At the first case review, held in the healthcare centre at 4.25pm on 14
March, a nurse and an SO trained and deployed to the unit in support
of the healthcare team were present. A comprehensive summary of
the review was recorded. The man said he felt more settled and safer
in the healthcare centre. The panel thought he might have
manipulated his admission but acknowledged that his risk of self-harm
was nevertheless real. They judged his risk to be raised and decided
that he should be observed once an hour.
152. Only one subsequent ACCT case review was conducted in the
healthcare centre thereafter. This took place on 20 March. The
purpose of the review to assess the man’s readiness for discharge to a
wing. It was initially intended that he should go to B wing. However,
when he disclosed that he was in debt to some prisoners there, it was
decided that he should go to C wing instead. He told the panel he was
happy with this. Nevertheless, despite his risk of further self-harm
being considered to be raised, he was discharged.
153. I am concerned that the man was discharged from the healthcare
centre at a time when his risk was judged to raised. I make this
comment in the context of the concerns expressed by the clinical
reviewer in her clinical review on this issue. She draws attention to the
fact that a psychiatrist who assessed him on 20 March considered that
he required the highest level of observation after his discharge to a
wing. The investigation found no evidence that this requirement was
considered during the ACCT case review. I note that the case review
summary does not contain any mention of the level of observations
decided upon. Although a number of entries were made on the front
cover of the ACCT form about observation levels, it is not easy to
discern which, if any, refer to this particular case review. (That said, it
is clear from the ACCT ongoing record that he was observed once
hourly after being discharged.)
154. I question whether, if the man’s risk of self-harm or suicide was such as
to require the “highest level of observation” in a wing, it was wise to
discharge him from the healthcare centre. However, I note that the
psychiatrist took the precaution of arranging for him to be assessed
again a week later. Had this happened, a better professional eye could
have been kept on his state of mind. It is regrettable that no such
follow-up assessment took place.
155. In her clinical review, the clinical reviewer comments on this matter as
follows:
”In the context of a patient with complex substance
misuse and personality problems who self-harms
relatively frequently, it is difficult to know whether the
man’s death could have been prevented by closer
monitoring and the appropriate psychiatric follow-up after
discharge on 20 March. The NICE guidelines of July
2004 - ‘Self Harm: The short term physical and
psychological management and prevention of self harm
in primary and secondary care’ discuss in depth the
difficulty of making a quantitive assessment of suicide
risk in a person already recognised to be at increased
risk, as he clearly was, due to previous self-harm
attempts and other psychosocial factors. However, the
ACCT procedure alone appeared too blunt a monitoring
tool for a person with his problems.
“Recommendations 3, 8, 11 and 12 in the interim report
merit particular attention in relation to this finding.”
Should the man have been left alone in his cell on 9 April?
156. From the point of the man’s discharge from the healthcare centre on 21
March, he was considered to require shared accommodation so as to
minimise the possibility of self-harm or suicide. He spent time in B and
C wings before finally transferring to D wing on 2 April. He was in a
shared cell throughout.
157. The ACCT case review nearest to the date of his death took place on 6
April. The review summary shows that the panel thought he was well-
balanced. He was getting on well with his cell mate and had no
concerns. His risk of self-harm was considered to be low. He was
alone in his cell in D wing from about 2.10pm on 9 April. He was found
hanging at 3.40pm. Although his cell mate could hear him talking
loudly whilst on the telephone as if he were having an argument, he did
not see him return to his cell. An officer said he “seemed alright”.
Thus, he gave no obvious signs that he was actively contemplating
suicide.
158. My experience of other investigations has shown how common it is for
an at risk prisoner in a shared cell to wait for his cell mate to leave
before taking his own life. Ideally, no prisoner on an open ACCT form
should be left alone in his cell. The reality is that this cannot be
guaranteed. Staff are unable to require the cell mate of an at-risk
prisoner to remain in the cell.
The Governor should ensure that prisoners on open
ACCT forms who are deemed to require shared
accommodation, are observed at frequent intervals in
their cells during periods when their cell mate cannot be
with them.
Was the response to the discovery of the man hanging prompt
and effective?
159. The findings of the internal interim review, supported by the clinical
reviewer, are as follows:
“Both discipline and healthcare staff should be commended for the
attempted resuscitation of the man. Appropriate resuscitation, basic
and advanced life support were carried out according to national
resuscitation guidelines in a difficult physical environment. Discipline
and healthcare staff worked effectively as a team and tasks were
performed and handed over appropriately according to expertise.
“Recommendations
• Review availability of one way valve (protective face masks) for
staff who might be involved in resuscitation procedures.
• For all Hotel 9 the exact location must be stated. If CPR is in
progress, this information should be given as part of the level
one call. Healthcare and the prison should review current policy
around locked gates/wings and landing access during
resuscitation.
• Following any attempted resuscitation, there should always be a
short clinical debrief involving all the team members which
should be documented in the medical records.”
(Hotel 9 is the radio call sign allocated to any member of the healthcare
team assigned the responsibility for responding to a medical
emergency. ‘Level one’ is the term used to describe a life threatening
incident.)
160. I agree with the clinical reviewer’s conclusion. However, I believe the
SO deserves particular credit for administering mouth-to-mouth
resuscitation without a protective face mask regardless of any risk to
his own health.
Were appropriate courtesies and support offered to the man’s family in
the aftermath of his death?
161. Shortly after the man’s death, another prisoner set fire to his cell in the
segregation unit at Pentonville. The Governor and his staff had
therefore to deal with two major events simultaneously. Although it
would have been more appropriate for a representative of the prison to
inform his family of his death, I understand why the Governor chose to
ask the police to undertake this task. The five hour delay in informing
the family was, I understand, caused by the fact that two police forces
became involved in managing the task. In the circumstances, this
seemed unavoidable. Whilst I make no formal recommendation on this
matter, I believe that the news of a prisoner’s death should ideally be
communicated to the next of kin by the Prison Service, rather than by
the police, as soon as possible after death has been pronounced.
162. I am satisfied that appropriate support was offered to the family
thereafter.
CONCLUSIONS
163. The investigation found a number of deficiencies in the quality of
healthcare afforded to the man while he was in custody at HMP
Pentonville. Although his alcohol dependency was treated, he was not
tested for the use of illicit drugs at any time. The psychiatric team did
not seem to be aware of the possible effects of his poly substance
misuse and he was not assessed by the Substance Misuse Service.
This omission may have led to an incomplete or inaccurate diagnosis
of his physical and mental health problems.
164. So far as suicide prevention was concerned, the investigation found
evidence that some of the ACCT procedures followed fell below
acceptable standards. There were also occasions when the healthcare
team was not represented at ACCT case reviews.
165. However, the manner in which staff and paramedics attempted to save
the man’s life is worthy of commendation, as are the actions of the SO
who gave mouth to mouth resuscitation without the benefit of a
protective face mask regardless of any risk to his own health.
166. A number of recommendations are made about these and other issues.
It is essential that urgent action is taken to implement them.
RECOMMENDATIONS
Recommendations to the Governor
1.The Governor should ensure that suicide/self-harm warning forms are
always seen and signed during reception procedures and that appropriate
follow up action is taken in relation to the risk information presented.
2. The Governor should ensure that clear and visible records are made in
ACCT forms showing the frequency of observations decided upon at case
reviews.
3. The Governor should remind his staff of the importance of adhering to the
provisions of PSO 2700 where the timescales for the completion of immediate
action plans, assessment interviews and initial case reviews are concerned.
Appropriate training should be provided where necessary.
4. The Governor should reinforce to discipline and healthcare staff the
requirement for ACCT case reviews to be conducted as a multi-disciplinary
function, embracing the expertise of specialist staff such as the healthcare
team, chaplaincy and others. This is especially important in cases involving
prisoners like the man who are at risk of self-harm or suicide and have current
and historical substance misuse problems.
5. The Governor should make doubly sure that staff of all grades and
disciplines are fully aware of the requirement for regular ACCT case reviews
to be conducted and for proper records to be maintained. The Governor
should ensure that appropriate training is provided where necessary.
6. The Governor should ensure that prisoners on open ACCT forms
and deemed to require shared accommodation, are observed at
frequent intervals in their cells during periods when their cell mate
cannot be with them.
Recommendations to the Primary Care Trust
1. The PCT should consider implementing each recommendation listed in the
internal review and supported by the clinical reviewer in her clinical review as
well as those made by her herself.
2. In order to promote effective communication between healthcare and
discipline staff with regard to important information about at risk prisoners, the
PCT should ensure that doctors make appropriate entries in ACCT ongoing
records as well as in clinical records.
Commendations
1. The SO should be commended for administering mouth to mouth
resuscitation without a protective face mask regardless of any risk to
his own health.
2. All those staff involved in the discovery of the man hanging and in
attempting to save his life in very harrowing circumstances, should
also be commended.