Individual at Wandsworth

Investigation into the circumstances surrounding
the death of a man at HMP Wandsworth
in March 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2010
The man was 31 years old when he died in March 2010, in his cell at HMP
Wandsworth. He was found hanging. Originally imprisoned in December 2002, he
had been released on licence on 16 July 2007. However, he was deemed to have
broken the conditions of his licence and was recalled to prison on 11 September.
Since then he had been to a number of prisons before finally transferring to HMP
Wandsworth on 19 October 2009. For the purpose of this report, I have
concentrated in the main from the time when the man arrived at Wandsworth.
The investigator and Family Liaison Officer join me in offering our sincere
condolences to his family and friends for their sad loss.
I wish to thank the Governor of Wandsworth for making the necessary facilities and
information available to the investigator. I also thank the prison Liaison Officer for
his assistance.
In the course of the investigation, I asked for a clinical review to be carried out into
the medical care and treatment the man received in custody. A clinical reviewer was
appointed by the Chief Executive for the Primary Care Trust to undertake a clinical
review on my behalf. He has not made any recommendations.
I make four recommendations. All four recommendations relate to suicide
prevention procedures at the prison. Although the issues identified had no direct
bearing on the man’s death, they are matters which require attention and include one
matter regarding post closure reviews for ACCT documents which needed to be
addressed urgently.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Deputy Prisons and Probation Ombudsman November 2010
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CONTENTS
Summary
The investigation process
HMP Wandsworth
Key events
Issues
Conclusion
Recommendations
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SUMMARY
The man was originally imprisoned on 20 December 2002 after being found guilty
of a serious offence. He was sentenced to eight years imprisonment. In July
2007, he was released from prison on licence, but broke the conditions of that
licence and was recalled to prison custody in September 2007.
On 19 October 2009, he was taken to HMP Wandsworth. He was allocated to
the Onslow Unit (which holds vulnerable prisoners), which is where he lived until
his death. In the meantime, arrangements were being made for him to be
released in March 2010 to accommodation away from his original home area,
something he said he was looking forward to.
The man had, on several occasions, been monitored by the Prison Service as a
potential suicide or self harm risk. At the time of his death, he was not
considered to be at risk and therefore he was not being monitored.
However, this investigation has identified a number of concerns regarding suicide
and self harm procedures at Wandsworth. There is evidence of managers
routinely not carrying out daily checks and of others not following written
instructions. Additionally it has been identified that well embedded procedures
have not been carried out. As a result I make four recommendations relating to
those procedures, including one which, at the time of the investigation, required
urgent attention.
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THE INVESTIGATION PROCESS
1. When the Ombudsman’s office was notified on 1 March 2010 of the man’s
death, the investigation was allocated to a senior investigator. He contacted
the prison and arranged to open the investigation on 4 March.
2. On 4 March, the investigator met the prison liaison officer and Deputy
Governor. Following the meeting, he went to the cell where the man had been
found. He was able to view the inside of the cell and see where the ligature
had been attached. After viewing the cell, he arranged to return at a later date
to continue with the investigation.
3. Before leaving the prison, the investigator briefed a senior manager about the
investigation process and the issues he had identified as the Governor was
not available. He followed up the feedback in writing to the Governor.
4. On 29 March, the investigator returned to the prison to continue the
investigation. On this occasion he carried out a number of interviews, some of
which were informal, whilst others were recorded. Those recorded are
attached as annexes to this report.
5. Two days later and before leaving the prison, the investigator met the
Governor and Deputy Governor. At that meeting, he gave feedback on what
he had identified at that stage, some of which he believed required urgent
attention. He told the Governor that it was likely that there would be four
recommendations in the draft report. The Governor welcomed the feedback
and agreed to keep him informed of progress.
6. The Senior Family Liaison Officer spoke to the man’s sister by telephone on
25 March. His sister explained that Wandsworth had been very supportive
and described them as ”brilliant”. There has been no further contact prior to
the issue of this report.
7. On 14 July, the clinical reviewer forwarded his clinical review to the
investigator. The doctor did not make any recommendations.
8. The investigator left the Ombudsman’s office in July 2010, having completed
an initial draft version of this report. The report has been completed by an
Assistant Ombudsman.
9. Following the issue of the draft report, a prisoner at Wandsworth approached
another investigator to provide some further information about the man and
several other prisoners. The prisoner said he had spoken to the man, who
had told him that officers had picked on him. The Assistant Ombudsman
asked the prisoner to provide more detail about his allegations, but, some two
months later, the prisoner has still not provided this information. In the
circumstances, I feel that I am not able to investigate further. However, I have
sent a copy of the letter to the Coroner in case it will assist with his enquiries.
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HMP WANDSWORTH
10. The prison is situated in South West London. Originally built in 1851, the
prison has undergone extensive refurbishment and modernisation. It is the
largest prison in the United Kingdom and provides accommodation for adult
remand and sentenced males.
Her Majesty’s Chief Inspector of Prisons
11. Her Majesty’s Chief Inspector of Prisons reports on all prison establishments.
Inspections are either announced in advance, which allows the prison being
reported on to prepare for inspection, or unannounced, when the inspection
team arrive with no prior warning.
12. In the introduction to her latest report on Wandsworth, following an announced
inspection conducted in June 2009, the Chief Inspector made the following
comment which is relevant to this investigation:
“the suicide prevention policy, while comprehensive, focused on
process rather than the specific needs of prisoners at the
establishment … there were good support resources available for
some prisoners at risk … but there were weaknesses in the
assessment, care in custody and teamwork (ACCT) process”.
Independent Monitoring Board
13. Each prison has an Independent Monitoring Board (IMB) made up of
members of the public and their role is to monitor the prison and to report any
concerns that they have regarding the prison, or how prisoners are treated.
Board members are able to visit any area of the prison at any time and have
direct access to any prisoner who they wish to see, or who requests to see
them. The Board holds regular meetings in the prison, with the Governor
attending for part of the meeting. The Chairperson of the Board produces an
annual report to the Secretary of State for Justice.
14. In their latest report covering the period June 2008/May 2009, the Board said:
“It is very encouraging to be able to report that Wandsworth has
continued upwards in performance improvement. There are
significant improvements in a number of areas compared with last
year and overall it is a better place than it was this time last year”.
Under the heading “Suicide prevention”, the Board said that, although much
improved, the quality of ACCT recording remained variable. They also said
the immediate action plans were not always completed within an hour of the
ACCT being opened.
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Prison officer grades
15. There are three levels of uniformed prison officer grades. Prison officers are
the front-line supervisory staff and, in the majority of cases, prisoners have
first and most contact with them.
16. Senior Officers (SOs) are the first grade of managers and act as a reference
point for prison officers. SOs are responsible for the day-to-day management
of their area, supervising staff and dealing with issues raised by prisoners.
17. Principal Officers (POs) were the highest rank of the uniformed staff. They
supervise other uniformed staff and have operational responsibility for the
prison.
18. In addition to prison officers, there are a group of staff known as Operational
Support Grades (OSGs). OSGs wear prison uniform and carry keys (but not
cell keys) and do not carry out the same function as prison officers. Their role
is to support the areas of the prison that have little or no prisoner contact, for
example, the front gate to the prison. Additionally, they carry out night patrol
duties. These duties often mean they have indirect contact with prisoners,
which is limited to seeing and talking to them through a hatch in a cell door.
Prison Service Orders (PSO)
19. Prison Service Orders contain long term instructions which are intended to last
for an indefinite period. Any mandatory instructions to Governors or Directors
of contracted prisons are written in italics. Each PSO is given a title and
unique reference number.
Assessment, Care in Custody and Teamwork (ACCT)
20. ACCT monitoring requires staff to identify any concerns, take action, and
document those actions for prisoners identified as at risk of suicide or self-
harm. The ACCT document should be available to all staff where the prisoner
is located. Within 24 hours of the document being opened, the prisoner will be
seen by a trained ACCT assessor and have a case review meeting, which is a
multi disciplinary meeting. The meeting draws up a care and management
plan, known as a Caremap, and a member of staff is nominated as the case
manager. Wing managers are specifically trained to take on the role of case
manager, oversee the management of the ACCT document and attend case
reviews.
Anti Ligature Knives
21. Staff in contact with prisoners are issued with specially designed knives to use
in an emergency to remove a ligature. The knives have a concealed blade
which is placed against a ligature and which can be pushed forward to cut it
without harming the prisoner.
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Emergency response codes
22. In the event of urgent medical assistance being required, a number of prisons
have chosen to adopt codes to alert medical staff to particular incidents. The
most common code used is code red and code blue, although some prisons
have opted for code one and code two. At Wandsworth, “code one” is used to
alert staff to incidents involving prisoners with breathing difficulties. This
includes any prisoner found hanging.
23. In prisons where codes are used, healthcare departments have created
emergency response bags which contain the necessary equipment to deal
with the particular incident. This ensures that medical staff takes the correct
emergency equipment with them and helps provide the necessary medical
care as quickly as possible.
Police investigations of deaths in custody
24. With all deaths in prison custody, the police are notified by the prison as soon
as the death has been discovered. In the first instance, the police treat the
area where the person is found as a potential crime scene and, as part of their
investigation, note the names of everyone involved and those who have been
in contact with the body. Additionally, they note the identity of all those
entering and leaving the cordoned area. It is only when the police are
satisfied that the death is not suspicious that the Ombudsman’s investigators
begin their own investigations.
Care team
25. Each prison has its own care team. Care team staff are drawn from all areas
of the prison and trained specifically to help and support prison staff.
Following any serious incident, they provide an invaluable role to any member
of staff who requires support.
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KEY EVENTS
26. The man was originally imprisoned on 20 December 2002. He had been
found guilty of a serious sexual offence and was given an eight year prison
sentence.
27. Due to the nature of his offence, he was monitored under the Multi Agency
Public Protection Arrangements (MAPPA), which are designed to manage
high risk offenders in the community. There are three levels of MAPPA and
he was monitored under level three:
• Level one MAPPA is normally managed by a single agency and
is the lowest monitoring procedure available under the MAPPA
system.
• Anyone identified as falling into the level two heading would be
managed by more than one agency, very often probation and
the police, and possibly more if the circumstances warrant it.
• Those subject to level three are considered as being the highest
risk cases, where more than one agency will take responsible
for the management of the person concerned.
28. In July 2007, the man was released from prison on licence (the licence sets
out certain conditions that the prisoner must comply with, or risk being recalled
to prison). He breached the conditions of that licence and, on 11 September,
was taken back to prison to continue his original sentence.
29. From then on, the man remained in prison custody and as part of the normal
sentence progression he went to a number of prisons. On 19 October 2009,
he was taken from HMP Belmarsh, which is where he had been imprisoned
while pending a transfer, to Wandsworth. When he arrived at Wandsworth he
was allocated to Onslow Unit as a vulnerable prisoner because of the nature
of his offence. (Vulnerable prisoners are often segregated from other
prisoners for their own protection.)
30. The man’s Offender Supervisor is based at the prison. One of her
responsibilities was to act as the link between the prison and his Offender
Supervisor in his home area. She told the investigator that as part of the
preparation for the man’s release from prison, which was scheduled to take
place 19 March 2010, arrangements were in place for him to be housed at a
Trust in another part of the country. The Trust offers specialised
accommodation for ex offenders with mental health problems. She said the
reason for allocating him to the Trust was because of a MAPPA condition
which said he could not return to his home area.
31. During the informal meeting with the investigator, the Offender Supervisor said
the man had been fully aware that he would be going to the Trust at the end of
his sentence. She said he had been looking forward to going there and had
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said he did not want to return to his home area. She added that he told her
that his family would visit him at the Trust.
32. From what has been gleaned from his prison record, the man settled in well at
Wandsworth and was employed as a wing cleaner, a job he enjoyed. The
investigator has spoken to a number of people about him and they all describe
him as a friendly man but “obsessed” with cleaning.
33. At 3.10pm on 31 December, Officer A opened an ACCT document as she was
concerned about the man. In the concern and keep safe section of the form,
the officer said he felt low and had attempted suicide several times in the past.
She added that he had been emotional and unsure as to whether or not he
would harm himself.
34. The document was passed to the wing manager who then completed the
immediate action plan. Shortly after an ACCT assessment was carried out,
followed by an “Action Following Assessment” review meeting.
35. In the case summary, the manager completing the section, SO A, said the
man had a number of frustrations because of his OCD (obsessive compulsive
disorder, an anxiety disorder often characterised by repetitive behaviour
patterns). He also made a note that the man had been concerned about his
mother’s health. The SO recommended that a referral should be made to the
prison in-reach team (the team providing mental health services in the prison),
although he added that this was not urgent. The level of observation was set
at three times during the day and hourly both at night and during the times he
was locked in his cell.
2010
36. On 1 January, the first case review meeting was held. The case manager, SO
B, was the chair of that meeting and the ACCT record shows that it was just
him and the man who attended. The SO made a note that the man said he
felt unsupported and that he had been hitting his head against a wall. He
added that the man had “let out his aggression” and “felt better”. However,
there appeared to have been no exploration of why he was hitting his head, or
whether any injury had resulted. The SO made an entry in the review that a
member of the in-reach team should be invited to the next case review
meeting. The level of observation remained unchanged.
37. Four days later, on 5 January, the second case review meeting took place.
On this occasion, three members of prison staff, the man and a member of the
in-reach team all attended the review.
38. The chair of the meeting, SO C, summarised the meeting. In the summary,
the SO said the man had been upset about his mother’s health. He also had
a hospital appointment for a wrist injury which he wanted to ensure took place.
It was further noted that he was keen to work and was possibly working too
hard. The level of observation remained unchanged.
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39. That day, despite the ACCT document being opened for six days, the first
daily management check took place. The check sheet shows that the
manager concerned had reminded prison staff that a photograph of the man
still needed to be attached to the ACCT document.
40. It was a further three days before the next daily management check was
carried out. Once again, it was noted by the manager that a photograph was
required. Similar entries appear in the check sheets on 9 and 10 January.
41. On 11 January, the third case review meeting took place. On this occasion,
the man and SO C attended along with the chair of the meeting, SO D. They
agreed that the ACCT document should remain open. Once again, it was
recommended that a member of in-reach be invited to the next meeting.
There was no change to the level of observation.
42. The next entries on the daily management check sheet were 15 and 16
January. On both occasions the manager concerned has noted that a
photograph of the man still needed to be added to the document. There are
no further management checks recorded after 16 January and no photograph
attached.
43. Eight days later, on 19 January, the final case review meeting took place. In
addition to the case manager SO D and the man, there was a representative
from the prison chaplaincy team, a crisis counsellor and a member of the
prison CARATs team (CARATs - Counselling, Assessment, Referral, Advice
and Throughcare services – provide substance misuse treatments in prisons).
It was noted that his outlook appeared to have sufficiently improved for the
meeting to agree the ACCT document could be closed. A post-closure
interview was arranged for 26 January, but there are no records confirming
that this took place.
44. On 11 February, the Offender Supervisor met with the man as part of her
normal routine for prisoners who will soon be discharged from prison. At that
meeting she explained the rules of the Trust and also the conditions of his
release licence to him. She explained to him that, whilst at the Trust, he
would only be allowed out of the building for three hours each day, and that he
would be escorted at all times. She said he was unhappy about the restriction
and had become tearful and angry. The meeting ended shortly afterwards.
45. At about 8.30pm, Officer B opened an ACCT document for the man. Under
the heading “Concern and Keep Safe”, the officer wrote:
“He made attempts to cut himself on the neck. He reckons that he is
not being treated fairly by staff on the wing and probation staff as well,
considering the work he puts in on the landing daily”.
[In the wing history sheet, Officer B wrote that “the man was standing in his
cell with a razor blade in his hand. He made threats to cut himself in the neck.
The razor was taken off him”].
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46. Officer B told the investigator that after opening the ACCT document, he made
an entry in the Wing Observation Book to alert staff that an ACCT had been
opened. In addition he telephoned the prison control room to tell them the
ACCT had been opened and obtained a log number [921/10]. After being
given the log number, he telephoned a manager to explain what he had done
and to pass on the log number. (I understand that whenever an ACCT
document is opened at Wandsworth, the centre manager is informed. The
reason for this is so that the manager can add the information to a daily
briefing document, which is prepared for the Governor. There is no
requirement for that manager to do anything other than record the
information.)
47. Once Officer B had completed the telephone call, he left the prison, as it was
the end of his working day. In response to the draft report, he has stated that,
as standard, when he finishes a shift he hands over any ACCT documents to
night staff.
48. The following morning, Officer C, one of the prison’s ACCT assessors,
interviewed the man. At interview he told the investigator that, the man had
been “very upbeat” when he saw him and had said he was not going to hurt
himself.
49. Whilst completing the assessment, the officer noticed that the “Immediate
action plan” section had not been completed the previous evening. Realising
that it was meant to have been completed within 60 minutes of the ACCT
being opened, he completed it, after which he handed it over to a manager in
preparation for a case review meeting to take place.
50. At interview Officer C said the man was not available to attend a case review
meeting that morning, as he was attending a “job club” interview. The officer
said the case review was arranged for the afternoon, but as he would be
unavailable, he had spoken to SO B about the assessment. He said he told
the SO that in his opinion the ACCT document did not need to be opened and
that the SO should consider closing it. The officer said he had no concerns
about the man’s safety and no concerns when he later learned that the SO
had closed the ACCT document.
51. At about 3.00pm, SO B carried out an ACCT case review, at which the man
was present. At interview, the SO said that before holding the review, he had
spoken that morning to Officer C about his assessment of the man. The SO
confirmed that Officer C had told him that the man was unavailable to attend a
review meeting that morning, as he was going to a “job club”, but that he
would be available in the afternoon. The SO said the officer told him that in
his opinion, the man did not need to be monitored under ACCT and that the
man wanted the document to be closed.
52. The investigator showed the SO the ACCT document and asked him why the
conversation with Officer C had not been recorded as part of the case
summary. The SO said it was a mistake on his part and that he should have
made a note of what he had been told.
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53. As part of the case review, SO B wrote a summary of his meeting with the
man, after which he closed the ACCT document. He arranged a post closure
interview for 16 February.
54. At interview, the SO told the investigator that once an ACCT document has
been closed and a date arranged for the post closure interview to take place, it
remains a live document. He said the normal routine is that the post closure
date is entered into a prison computer system, which diaries the information
and, on the scheduled date, it appears as a piece of work to do that day.
However, he told the investigator that although he made a note in the ACCT
document of the post closure date, he had not entered into the computer
system.
55. In the meantime, the man had met his Field Offender Supervisor and Offender
Supervisor. He mentioned his concern at the restriction placed on him relating
to leaving the Trust, but at that time he was more concerned at not being able
to carry his own money. The Offender Supervisor said the Field Offender
Supervisor explained the reasons to him, which were to do with ensuring other
residents could not take his money from him. He appeared to accept this.
The man was told that he would be taken to another prison and from there he
would then be taken to the Trust. She said he was happy with the
arrangements.
56. Operational Support Grade (OSG) A told the investigator that she had met the
man on a number of occasions. She described him as always being friendly
and that he would often speak to her about his mother. She remembered him
telling her that he was due to be released and that he would be going to
Lancashire. He told her that he was not going to return to his home area in
Kent and that he was looking forward and excited about making a fresh start
in a new area.
57. The following day, the man spoke to his Offender Supervisor again. She said
that on this occasion he was “worrying” about not being allowed to have his
mobile telephone whilst at the Trust. She said this and other conditions had
been explained to him during the meeting about the rules in place at the Trust
and that he understood what was required.
58. On 25 February, OSG A was in the Onslow Unit. During an informal meeting
with the investigator she said the man had noticed her and had then run
towards her. She said he grabbed her hand and said he wanted to say
goodbye and that she thought he must have been told he was moving. The
OSG said she did not have any concerns about him and described him at
being very happy at that time.
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1 March
59. At about 8.15am, the Offender Supervisor was in the Onslow Unit and had
spoken to the man. She said the conversation was a general chat with him.
She remembered asking him how he was and him saying he had felt better,
but had not explored what he meant. The investigator asked her whether she
had been concerned about the man’s safety. She said that she was not.
60. Shortly after speaking to the Offender Supervisor, the man collected his
medication from the Onslow Unit dispensary. Registered General Nurse
(RGN) A told the investigator that she had given him his ibuprofen (it is
unclear from the records why he had been prescribed ibuprofen) and that he
appeared fine. She said she had no concerns about him.
61. At the time of this investigation, and due to the lack of available cells in the
main prison, a number of cells on the Onslow Unit were being used to
temporarily hold some prisoners from the main prison overnight. To ensure
vulnerable prisoners were not at risk from the other prisoners, they would be
temporarily locked up whilst the relocated prisoners moved from the unit into
the main prison.
62. At about 8.40am and because prisoners from the main wing were moving out
of their temporary cells on the Onslow Unit, the vulnerable prisoners were
locked up for a short while. Officer D was one of the officers locking prisoners
up to allow the movement to take place. At interview, she told the investigator
that when she went to the man’s cell he questioned why he was being locked
up. She said he was upset and had told her that on the previous day he had
been warned by an officer about pressing his in cell emergency call button.
She said that after assuring him that he was not in any trouble he smiled at
her. The officer told him he would be unlocked once the other prisoners had
left the wing. The investigator asked the officer if she had any concerns at
that stage about his safety. She said that she did not.
63. Once the relocated prisoners had left the Onslow Unit, wing officers began to
unlock the remaining prisoners to allow them to leave their cells. At about
9.30am, Officer D looked into the man’s cell through the door observation
panel to ensure she would not hit him with the door when she opened it.
When she looked inside the officer saw him hanging by a ligature which had
been attached to the cell window bars. She told the investigator that his feet
were on the ground and that his body was slumped forward. The officer said
she immediately went into the cell and attempted to lift him up as she wanted
to take the pressure off of his neck. Unable to lift him, she shouted for
assistance.
64. Officer D said Officer E was the first person to arrive and that he had used his
whistle to alert other staff that assistance was required. Officer E went into
the cell and whilst he lifted the man, she used her anti ligature knife to cut the
ligature just below where it had been attached to the bars. Having cut the
ligature they laid him onto the cell floor. As they did so, Officer F arrived and
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when he went into the cell he saw that the ligature was still around the man’s
neck. Using his own anti ligature knife, he cut it away.
65. Once the man was on the floor, Officer D checked for signs of life, but did not
detect any. She said his skin colour was blue and so she began chest
compressions. At the same time, SO A, who had also arrived, began mouth
to mouth breathing.
66. In the meantime, Officer F left the cell and, using his prison radio, asked for
urgent medical assistance. Although there is a radio code to be used in this
situation (code one), he could not remember if he had used it or simply asked
for assistance. He said that soon after asking for medical assistance,
healthcare staff arrived and took over from Officer D and SO A.
67. At the time when the whistle was blown, RGN A was in the Onslow Unit. She
told the investigator that she heard the whistle and, although she was not sure
why it had been blown, she went to offer assistance. She said an officer
shouted to her telling her that it was the man and that he had no pulse.
68. When RGN A arrived at the man’s cell, she saw him on the floor with two
officers carrying out CPR. The nurse said she went into the cell and checked
for signs of life, but did not detect any. She said his lips were blue and his
skin colour pale. She asked for additional medical assistance after which she
assisted with cardio pulmonary resuscitation (CPR) by taking over the chest
compressions from Officer D. The nurse told the investigator that CPR was
carried out at a rate of 30 chest compressions to two breaths.
69. In response to her request for additional medical assistance, another nurse
and Doctor A arrived. They had responded to the first radio message and had
taken emergency medical equipment including oxygen and a defibrillator to
the man’s cell. (A defibrillator can restart the heart in some cases of cardiac
arrest by giving an electric shock. It detects the electrical activity in the heart
and gives automated instructions to the rescuer.)
70. Doctor A told the investigator that when he arrived at the cell, RGN A and an
officer were carrying out CPR. He said the man’s skin colour was pale and
blue. The doctor said he took over mouth to mouth resuscitation and that
CPR continued for a further 15 minutes. He said that although the defibrillator
pads had been attached to the man’s chest, it had not advised shocking him,
which he said meant there was no cardiac output.
71. At 9.45am, the doctor checked the man’s condition. He said the pupils were
dilated and fixed and there was no pulse. At that point he stopped any further
attempt to resuscitate him and pronounced him dead.
72. The doctor said that once he had pronounced death, he and the nurses left
the cell. He said he met a paramedic who had arrived in response to an
emergency call and told him the man had died. He said the paramedic then
left the prison.
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Following the man’s death
73. After it had been confirmed that the man had died, the prison’s Family Liaison
Officer travelled to the man’s home town to break the news to his family.
When he arrived there was no one in and so he telephoned the man’s father
who at that time was at work. Unfortunately he had to break the sad news
over the telephone, after which the man’s parents returned home to meet him
74. I understand the man’s parents asked the Prison Chaplain to carry out the
funeral service for their son. Additionally the prison offered assistance with
funeral costs and offered them the opportunity of visiting the prison, something
they decided they did not want to do at that time. At the request of the man’s
parents, the prison’s Family Liaison Officer was asked to contact their
daughter in the first instance.
75. On 29 March, after speaking to the man’s sister the previous week, the
Ombudsman’s Family Liaison Officer wrote to her summarising their
conversation. In that letter the Liaison Officer said she had been told by the
man’s sister that the prison hade been “brilliant and extremely supportive” and
that her brother had kept in regular contact and had been helpful. The Family
Liaison Officer also noted that his property had been returned to his family.
76. In addition the man’s parents had said they had received a letter from the
prison which described their son as hardworking and polite, which they had
found comforting. The Family Liaison Officer said the man’s parents had
spoken highly of the help and support provided by the Prison Service.
77. During the conversation with the Family Liaison Officer, the man’s sister told
her that her brother had telephoned his parents on three occasions the week
before his death, which she said was unusual. However, although this was
unusual, she said he had given no indication that anything was wrong. She
said he told his parents he loved them and that he was looking forward to
being released and that he had given up smoking.
78. I understand that all prisoners who were being monitored under the ACCT
procedure were reviewed. This is normal practice and done to ensure they
are properly supported following a death. In addition, prison staff received
support from the prison care team and their own line managers.
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ISSUES
Assessment Care in Custody and Teamwork (ACCT)
Immediate action plan
79. Once an ACCT document has been opened, and the concern and keep safe
section completed, the next action is for the unit manager to complete the
immediate action plan section. As a reminder, and at the beginning of the
immediate action plan, the following mandatory instructions tell the manager
completing the form what to do:
“The immediate action plan should be done by the unit manager
immediately following concerns and keep safe have been raised. This
plan must be in place within 60 minutes.
“The purpose of this immediate action plan is to keep the vulnerable
prisoner safe until a full assessment of the prisoner’s risks has been
made, then reviewed in “Action Following Assessment”, and
CAREMAP has been started”.
80. The Governor at Wandsworth also issued a revised local “Suicide Prevention
Policy Strategy Document” in September 2009. At section nine of that
document, the Governor stressed by writing the following in bold letters:
“The immediate action plan needs to be put in place within one hour of
the ACCT plan being open ... ”
81. On this occasion and contrary to both the ACCT instructions and local policy
document, the immediate action plan was not completed on 11 February, but
on the following morning, some 12 hours later. It was completed by Officer C
after he realised during the ACCT assessment that it had not been done the
previous evening.
82. The ACCT procedure is a long established, well embedded system throughout
the prison estate and helps provide a level of care which might otherwise not
be made available. Considering it is not a newly introduced procedure, there
is no excuse in my mind for basic failures such as the one identified here.
The Governor should carry out a review of ACCT procedures and satisfy
himself that the systems are robust and in line with PSO 2700 and his
own local policy.
Case review
83. On 12 February, SO B chaired an ACCT case review meeting, at which the
man was also present. It is clear from the interviews with the SO and Officer
C that the SO had spoken to the officer that morning about the man. Also
clear is that the SO did not record his conversation with Officer C in the ACCT
case manager summary.
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84. I have considered carefully the actions of SO B. I am satisfied that he had
spoken to the ACCT assessor, Officer C, in an effort to gain as much
information as possible for the case review meeting. He recognises that he
should have recorded that conversation in the ACCT summary and had made
a mistake by not doing so. I am concerned, however, that ACCT documents
are sometimes closed by an officer by themselves, and that on this occasion a
Care Review Team approach (in which more than one officer, or
representatives from other disciplines within the prison) was not taken.
Post closure interviews
85. Following the closure of the ACCT document opened 31 December 2009 (the
ACCT was closed on 19 January), a post closure interview was scheduled to
take place on 26 January. It is clear from the ACCT document and wing
computer system that it had been entered into the diary. However, there is no
evidence, either on the computer or within the ACCT document, to show that
the post closure review took place.
86. After taking the decision to close the ACCT opened on 11 February, SO B’s
next action was to arrange a post closure interview. Although he wrote into
the ACCT document that he had arranged for the post closure interview to
take place on 16 February, he failed to enter the information into the wing
computer system. This meant that there was no electronic record of the
review for the man which is why the post closure interview did not take place.
87. SO B is an experienced manager. He recognises that this was a serious error
and that he should have ensured the proper arrangements were in place to
protect the man.
88. I accept that, after the ACCT document was closed, the man did not end his
life immediately, but it is disappointing that the correct processes were not
followed to ensure the post closure review was completed. It concerns me
that on at least two occasions there is evidence to show that post closure
interviews were not held.
89. Clearly there is a problem which requires urgent remedial action to be taken.
Having identified the problem on 30 March, the investigator raised the matter
with the Onslow Unit Senior Manager and Unit Manager that day. They
accepted the finding.
The Governor should review and consider what action to take in relation
to the management of the man’s ACCT documents whilst at
Wandsworth.
Daily management checks
90. When an ACCT is opened, a “Management Quality Assurance Sheet” is
attached. Section one of the sheet is titled “Daily Wing Manager Check”. The
sheet lists certain quality checks that must be made. One of the checks is to
ensure that a photograph has been attached to the front cover, and another
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which states that a “Wing manager to quality assure all ACCT documents
daily”. Additionally it adds that the manager should note deficiencies and
rectify any deficiencies “immediately”.
91. The quality assurance sheet on the ACCT opened on 31 December shows
that management checks were not being carried out on a daily basis. There
were also numerous requests for a photograph to be attached, but these were
acted upon.
92. A new ACCT document has since been introduced into the prison. Section
J/K of the document is titled “Senior Officer’s Daily Management Check”. It
follows similar lines to the previous document in that it is a daily check, but
covers a number of key areas in greater detail including identifying whether
previous deficiencies have been rectified.
93. In addition to the daily wing management checks there is now a weekly check
of all open ACCT documents carried out by a member of the senior
management team. Section L has ten sections which are then broken down
into specific action points. One of the actions is that the senior manager
should check and confirm the daily management checks are being carried out.
94. As part of this investigation, on 31 March, the investigator examined two open
ACCT documents for prisoners who were living in the Onslow Unit. One of
the documents had been open for 19 days. During that period, there had
been 11 daily checks and each requested that a photograph should be
attached. Additionally there had been one senior management check. At that
check there was no mention of daily management checks not being carried
out, but it had been noted that a photograph was required.
95. The second ACCT document that the investigator examined had been open
for nine days. During that time there had been four daily management checks
and one senior management check. The senior manager had not commented
on the lack of daily checks.
96. From the evidence, there appears to be a lack of management accountability
and poor quality control. It is evident that instructions and guidance are
available, but are seemingly being ignored. It is important that the ACCT
procedure is robustly managed and that all staff do what is required.
Deficiencies need to be dealt with promptly and anyone not carrying out the
required piece of work challenged. In the two random checks, and in the case
of the man, there is evidence of a lack of management control which must be
rectified. If there is to be confidence in the ACCT procedure at Wandsworth,
there has to be strong management control.
The Governor must satisfy himself that the ACCT procedures at
Wandsworth are being effectively monitored and robustly managed.
The Governor should consider how best to quality control and audit the
ACCT procedure.
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Family support
97. I have been pleased to learn how much the man’s family appreciated the
support received from the family liaison officer. As can be appreciated, it is a
difficult role and not one that can be given to anyone to do. The value of
having proper family support in place is self evident.
98. Prisons and prison staff do not always receive the credit for what they do. It is
clear from the family that they appreciated the help and support they received
from the prison. A simple letter of condolence containing a few details about
their son’s behaviour in prison meant a lot to them and gave comfort at a very
difficult time. Although I make no formal recommendation, I invite the
Governor to share my comments with his staff and to thank them for the care
and kindness shown to the family.
Clinical review
99. In his clinical review, the clinical reviewer has summarised his findings
regarding the man's medical history. He has not made any recommendations.
100. The clinical reviewer said that the man’s medical notes show that he had
previously suffered a scaphoid fracture (the scaphoid is a small bone in the
wrist). He said the injury had failed to heal and as a result he was awaiting
surgery to repair the damage.
101. The man told prison staff that he was suffering from Obsessive Compulsive
Disorder (OCD). The clinical reviewer was asked to comment on the condition
and its effect on him. In his report, the doctor said there is no evidence in the
medical notes of any formal diagnosis having ever being made. However, he
adds that whilst at HMP Rye Hill, which is one of the prisons he had been to,
he had been reviewed by both a psychiatric registrar and a psychologist. The
reviewer said the registrar felt OCD was in fact a self diagnosis by the man.
He adds the psychologist had suggested he had a personality disorder. The
reviewer went on to say the medical notes show there had been some
discussion as to whether or not he had some degree of learning difficulty. It
was thought that it may have been brought on following a head injury as a
child. However, he said that this was never confirmed.
102. The clinical reviewer said that throughout his time in prison, the man’s mood
had been variable and volatile and that his history of harming himself was an
ongoing pattern of behaviour. That behaviour led to him being monitored
under the ACCT procedure.
103. The clinical reviewer said it was clear from the man’s medical notes that when
he died on 1 March, his pupils were fixed and dilated and there was no
shockable rhythm detected by the defibrillator. This suggests that there was
little chance that he would be successfully resuscitated when he was found.
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Emergency response
104. When Officer D called for assistance on finding the man, she received
immediate help from Officer E. He then summoned further assistance by
using his whistle. Officer F attended and, after cutting the ligature from the
man’s neck, radioed for medical assistance.
105. Although Officer F cannot remember clearly whether the used the term “Code
1” when alerting staff to the emergency, it is clear that staff responded quickly.
I am therefore satisfied that he gave appropriate information to his colleagues.
While I do not make a recommendation on this issue, however, the Governor
might wish to remind staff of the relevant codes for use in emergency
situations.
106. The doctor also attended promptly and, after attempting CPR for 15 minutes
and using a defibrillator, he pronounced that the man had died. At this point,
paramedics arrived. It is unclear when they were called and by who, although
it is likely that this happened after Officer F’s radio message, and I would
suggest that the Governor might wish to assure himself that an ambulance
was called immediately. However, given that the doctor and other healthcare
staff attended very quickly, and with the correct equipment, I am satisfied that
the emergency response was appropriate.
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CONCLUSION
107. The man was recalled to prison and arrangements were in place for him to live
at the Trust once he was released. The evidence suggests he was looking
forward to moving to the Trust and making a fresh start. That said he was
concerned about the requirement for him to be accompanied outside of the
premises. Whether he fully understood the reason for the restriction is not
known, but from the evidence provided, he did.
108. His family have told me that he telephoned them on a number of occasions.
At no stage were they concerned about his welfare.
109. I am satisfied that he was settled at Wandsworth and that he had engaged
with prison staff and that they had engaged with him. He was approaching his
release date and so what made him take the decision to end his life is not
known. It may have been an impulsive act but that would be speculation.
110. It concerns me to learn of the failings in the ACCT procedure. It is a well
embedded procedure and in my mind there is no excuse for some of the poor
practices found during this investigation. I am satisfied that none of the
findings contributed directly to his death. However, they are matters which
require remedying quickly and which the Governor will wish to satisfy himself
have been properly dealt with.
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RECOMMENDATIONS
1. The Governor should carry out a review of the ACCT procedures and
satisfy himself that the systems are robust and in line with PSO 2700 and
his own local policy.
2. The Governor should consider and review what action to take in relation to
the management of the man’s ACCT documents whilst at Wandsworth.
3. The Governor must satisfy himself that the ACCT procedures at
Wandsworth are being effectively monitored and robustly managed.
4. The Governor should consider how best to quality control and audit the
ACCT procedure.
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