Individual at Lincoln

Investigation into the circumstances surrounding the death
of a man at HMP Lincoln in July 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2012
This is the report of an investigation into the circumstances surrounding the death of
a man at HMP Lincoln in July 2008. At about 2.00am that day, he was found
hanging in his single cell in the Vulnerable Prison Unit by a member of staff. He was
24 years old.
I offer my sincere sympathy and condolences to the man’s family and friends for their
sad and untimely loss. I also offer them my apologies for the length of time it has
taken to produce this report. I recognise that this will have added to their distress.
The investigation was conducted on my behalf by an investigator. I would like to
thank the then Governor of Lincoln and his staff for their help and co-operation. I
owe especial thanks to the investigation liaison officer, whose contribution was
exemplary.
I commissioned a clinical review of the management of the man’s health needs while
he was in custody at HMP Lincoln. This was conducted by the clinical reviewer on
behalf of the local PCT. I am grateful to her for her significant contribution to this
report.
I am also grateful to Lincolnshire Police for their invaluable assistance in sharing
important information with my investigator.
The man had a long history of harming himself both before he came into prison and
in 2006, generally by cutting himself and only once by using a ligature. During 2006
the prison opened their suicide monitoring procedures no less than six times. My
investigation was delayed whilst allegations about the conduct of a prison officer
were considered. Neither I nor the prison or the police have found any evidence that
the officer’s misconduct was the cause of the man’s untimely death.
In general terms, I believe that the man’s health needs were met at Lincoln and that
his risk of self-harm was managed satisfactorily. Nevertheless I make 11
recommendations that I hope will help to prevent a similar tragedy occurring at
Lincoln or elsewhere in the Prison Service. I also offer two commendations with
regard to the actions taken by staff on the night he died.
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.
Nigel Newcomen CBE
Prisons and Probation Ombudsman January 2012
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CONTENTS
Summary
The investigation process
HMP Lincoln
Key events
Issues
Family concerns
Principal conclusions
Recommendations
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SUMMARY
The man was a 24 year old man. He had a troubled family background and began
using cannabis at the age of 14. He left school with no qualifications and spent most
of his short life thereafter unemployed. On two occasions in 2000, he attempted to
take his own life, once by taking an overdose of pain relief tablets and, on another
occasion, by attempting to hang himself. By his own admission, he frequently
harmed himself by inflicting multiple minor cuts to his arms as a means of relieving
his tension.
In February 2001, the man pleaded guilty to a serious assault on a woman and an
attempted theft for which he was sentenced to seven years imprisonment. He was
released on parole licence in July 2005 and was required to live at an approved
premises (also known as a probation hostel). The licence was revoked the following
October after he had returned to the approved premises under the influence of drink
or drugs. He returned to custody until he was released in February 2006. Two
months later, on 23 April, he attempted to kidnap a young girl. He was arrested
during the early hours of the following day and was subsequently recalled to prison.
The man was held in police custody between 24 and 26 April, when he was taken to
Magistrates’ Court. He was remanded in custody and ordered to appear for trial at
Crown Court on 2 August 2006. A Prisoner Custody Officer who escorted him to
court completed a suicide/self-harm warning form because he had seen comments
on the Prisoner Escort Record (PER) suggesting that he had made threats to take
his own life.
After his court appearance on 26 April, the man was taken to Lincoln prison. During
the reception procedures, he was not assessed as at current risk of self-harm or
suicide. Although he made it clear that he was unhappy at being returned to prison,
he told staff that he thought he could cope. However, the day after his arrival, he
applied to be separated from other prisoners because of the nature of his offence.
Thereafter, the man’s mental state deteriorated and he began to commit frequent,
but minor, acts of self-harm by cutting his arms. As a consequence, formal self-harm
monitoring procedures were put in place on six occasions during 2006. He was
given medication for depression and anxiety. In September of that year, he was
sentenced to life imprisonment with a recommendation that he serve not less than six
years before he could apply for parole.
In 2007, the man’s state of mind seemed to improve. He refrained from deliberate
self-harm throughout the year. Although he continued to have frequent mood
swings, he was no longer considered to be at risk of self-harm or suicide and so was
not subject to any additional monitoring procedures. His medication was regularly
reviewed and adjusted where necessary.
However, in June, the man’s uncle, who was in the community, was found hanged
after having gone missing. He appeared to take this news quite well and also
appeared to cope reasonably well when told he would not be allowed to attend the
funeral. In October, he began work as a wing cleaner, a job that enabled him to
spend longer periods out of his cell.
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The year 2008 began well for him. On several occasions during the year, he was
reported by staff as having a good attitude and being a good worker on the wing
cleaning party. However, on 17 April, he was placed on report for failing a
mandatory drugs test. He disputed the charge against him and asked for an
independent drugs test. His case was remanded to enable an independent drugs
test to take place. The final hearing was eventually scheduled to take place in July,
on the day that he died.
Earlier in June and July, information was given by prisoners that a prison officer was
trafficking in drugs and mobile telephones with prisoners, including the man, in E
wing. The information was taken seriously by managers who took measures to
monitor the activities of the officer concerned who was suspended on 16 July.
Thereafter, the Prison Service conducted an investigation into the claims of
corruption made by various sources and the officer was dismissed the following year.
The investigation found strong evidence to suggest that he may have been coerced
by the officer. However, no evidence arose from either the internal Prison Service
investigation or from the subsequent police investigation to show that there was a
provable connection between his conduct and his death.
On 10 July, the man was told by the prison chaplain that his grandmother, to whom
he had been especially close, had died. He was so distressed at this news that he
cut his arms. Consequently, an Assessment, Care in Custody and Teamwork
(ACCT) plan was opened for the first time since November 2006. (The ACCT plan is
a process by which prisoners considered to be at risk of self-harm or suicide are
monitored and supported with the aim of helping them to reduce the risk they
present. It can be initiated by any member of staff working in a prison.) He asked to
be allowed to attend his grandmother’s funeral but this was refused as she was not
considered to be a close relative and had not acted in place of his parents. He was
upset at this refusal but told staff he could cope. The ACCT plan remained open until
21 July.
At 11.00pm on 28 July, the man’s mother telephoned the prison to say that her son
had called a friend and said he wanted to join his uncle and grandmother, both of
whom were dead. The night orderly officer took the call and decided to go to see him
in his cell. He was surprised to be told of his mother’s telephone call but admitted
saying that he wanted to be with his uncle and grandmother. However, he told the
officer that he “was not going to do anything silly” (meaning harming himself). The
officer found nothing in his demeanour to suggest that he was at risk of self-harm or
suicide. Nevertheless, as a precautionary measure, he decided to open another
ACCT plan there and then. He instructed the operational support grade (OSG) on
duty in the wing to observe him at half hourly intervals. These instructions were
carried out, but at regular and predictable intervals. At 2.05am the OSG saw him
hanging in his cell.
An officer cut the man down and commenced cardio pulmonary resuscitation despite
the fact that he believed him to be dead. Further attempts to revive him were made
for approximately 30 more minutes by other officers and healthcare staff until an
ambulance crew arrived. However, he was pronounced dead at 2.44am.
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The investigation found that, overall, the man’s general health needs were met at
Lincoln and that, with some exceptions, the assessment, monitoring and
management of his risk of self-harm and suicide was satisfactory.
The investigation also found that, although an ambulance was requested promptly
after the man had been found hanging, the paramedic crew who responded were
unaware of the nature of the emergency until they arrived at the prison. As their
journey to Lincoln started some 21 miles away, they did not arrive until about 30
minutes after the original request for an ambulance had been made.
There was a delay of about six hours in informing the man’s next of kin of his death.
I am satisfied that, however unpalatable, the delay was not due to any insensitivity or
negligence on the part of the staff involved.
There was no evidence of proper prisoner support in the immediate aftermath of the
man’s death and no immediate debrief was held for the staff involved in handling the
emergency.
I make 11 recommendations to the Governor about ACCT procedures, self-harm
reduction measures, record keeping and the management of a death in custody. I
offer two commendations with regard to actions taken by staff during the night of
28/29 July 2008.
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THE INVESTIGATION PROCESS
1. The investigation was opened by my colleague on 1 August 2008. The
Governor and his staff produced the man’s core record and a number of other
documents for examination. Notices were displayed around the prison to
inform both staff and prisoners of the investigation.
2. The investigator conducted the initial stages of the investigation until,
unfortunately, he became ill. In February 2010, another investigator assumed
responsibility for completing the investigation. Both investigators interviewed a
number of staff and prisoners at Lincoln.
3. On 16 September 2008 one of my family liaison officers contacted the man’s
mother in order to explain the purpose of my investigation and provide her with
an opportunity to raise any questions or concerns about the care he received.
She raised a number of points of concern with the family liaison officer. These
are summarised as follows:
• Why was he not subject to more frequent observations once the prison
staff were aware of the telephone call he made to his friend in which he
spoke of wanting to be with his uncle and grandmother, both of whom
had recently died?
• Why was he not placed in a safer cell once he had been put on a
‘suicide watch’?
• Why were there unexplained marks on his body?
• He had been concerned about a possible transfer to a prison on the Isle
of Wight or to a secure hospital in Rampton. Was a transfer being
considered and what had been communicated to him?
• Why was there a delay of over six hours before the family were informed
of his death?
I have done my best to address these issues. I hope the findings of my
investigation and report help the family better understand the events leading to
his untimely death.
4. The investigator met representatives of Lincolnshire Police to discuss matters
of joint interest, with especial reference to the conduct of the officer at Lincoln
prison who had allegedly involved the man and other prisoners in trafficking.
5. I commissioned a clinical review of the management of the man’s health needs
while he was in custody at Lincoln. The review was conducted by the clinical
reviewer on behalf of the local PCT.
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Final report
6. The circulation of this final report has been significantly delayed and we
apologise to the man’s family, HM Coroner, the National Offender Management
Service (NOMS) and other interested parties.
7. In this report the NOMS has accepted ten of the recommendations and partially
accepted a further recommendation. Their responses to those
recommendations are noted on pages 63 to 65. The NOMS noted three factual
inaccuracies, amendments have been made in paragraphs 34 and 47. An
officer’s name had been removed from paragraph 53.
8. The family liaison officer spoke to the man’s mother following the circulation of
the draft report. Some of the responses she made have been dealt within the
draft report however, his mother asked this report to note her ongoing
concerns. I summarise those in the following paragraphs.
9. On reading the report, the man’s mother said that she agreed with the findings
and recommendations made and hoped that it would lead to improved practice
at the prison in assisting the prevention of further deaths.
10. The man’s mother had several points that are still of concern to her. Those
points are as follows:
• That the telephone call she made to the prison on the evening of 28 July
raising her concerns over her son’s mental well being, were not taken
seriously. Whilst acknowledging that an officer spoke to her son following the
call and he denied any thoughts of self harm, she felt he should have been
moved to a safer cell as a precaution.
• The quality of the psychiatric assessment that her son underwent shortly
before his death.
• Finally, she wished to know if any further legal action had been taken against
the officer dismissed from the Prison Service for corruption, whose actions
she believes to be responsible for her son’s death.
11. We note the three points raised by the man’s mother, but are unable to add any
further comment or information. However, we reflect her ongoing anxieties and
distress from her son’s death.
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HMP LINCOLN
12. HMP Lincoln was built in 1872 and is a category B prison holding male
prisoners. New prisoners are risk assessed and given a category based on
their offence and the risk that they pose to the public should they escape.
There are four categories: A, B, C and D, with category A prisoners being the
most dangerous. Category B are prisoners for whom the highest security
conditions are not necessary but for whom escape must be made very difficult.
The prison’s design is typical of the times, with galleried wings spreading out
from a central core. All cells have integral sanitation. It serves the nearby
courts of Lincolnshire, Nottinghamshire and Humberside. The prison holds
remand prisoners and those serving short sentences or waiting to be moved to
another prison. It holds a maximum of 738 men, which includes a small
number of remanded young offenders.
13. There are four main residential units. A wing consists of the first night centre
and holds prisoners on induction. B wing holds sentenced prisoners and C
wing holds remand and convicted prisoners. D wing is the segregation unit and
E wing is the vulnerable persons unit. J wing holds prisoners on short duration
drug treatment programmes.
14. Healthcare at Lincoln is commissioned by NHS Lincolnshire and is provided by
Lincolnshire Community Health Services. There is inpatient accommodation.
Her Majesty’s Inspectorate of Prisons
15. Prior to the man’s death, the most recent inspection of Lincoln by Her Majesty’s
Chief Inspector of Prisons for which a report has been published was in
December 2007. In the introduction to that report the former Her Majesty’ Chief
Inspector wrote:
“Lincoln prison has gone through a difficult period, but this
inspection found that normality had returned, with both
accommodation and staff morale repaired following the
disturbances. In effect, the prison had successfully turned a
particularly unfortunate page in its history. The new governor
still has plenty of work ahead to develop a fully effective local
prison, particularly given the poverty of purposeful activity, but
there are some solid foundations now in place”.
16. In the section of her report headed ‘Suicide and Self-harm’, the Inspector wrote:
“A total of 350 ACCT documents (Assessment, Care in Custody
and Teamwork plans, used in the management and monitoring
of prisoners considered to be at risk of self-harm or suicide) had
been opened in 2007 to date, and there were currently 15 open
ACCT documents, the standard of which was good. There had
been 183 incidents of self-harm in 2007 to date, although there
were a significant number of repeated incidents by the same
few prisoners. There had been one death by self-harm that was
9
still under investigation by the Prisons and Probation
Ombudsman. There was a full-time SASH [suicide and self-
harm] coordinator. Listener suites had recently been
refurbished and introduced. Listeners, who are prisoners
trained by the Samaritans to help and support other prisoners in
distress, felt supported in their work. A multi-disciplinary
committee met regularly to monitor trends."
17. The Inspector wrote about the vulnerable prisoners unit (where the man was
located and where he died) as follows:
“The vulnerable prisoners unit was located on E wing. About
60% of the population of the wing were sex offenders or
prisoners who for various reasons were likely to attract adverse
attention from other prisoners. The remainder were a mixture of
those who had been assaulted or claimed to have been in debt
in the main prison. There was evidence that some of the latter
group acted in a predatory or aggressive fashion towards the
others on the wing. There was no clear protocol on how to
decide whether a prisoner could be accepted onto the wing.
Prisoners who were sex offenders claimed that there were
examples of name calling and kicking of cell doors by others on
the wing when they were locked up. There were persistent
claims that meals were being adulterated and that alien items
had been found in the food. There was no compact to regulate
expected behaviour. Between 40% and 50% of the bullying
incidents reported each month emanated from E wing, and this
had been the case for several months before the inspection.
However, at the time of the inspection there were no prisoners
on E wing on the basic level of the incentives and earned
privileges (IEP) scheme, and none were being monitored under
the anti-bullying strategy.
“In group discussions, the vulnerable prisoners were the most
negative group in regard to feeling that they were ignored by the
establishment. They were the most critical of the personal
officer scheme, and wing files examined on this wing showed
the least evidence of entries made by staff about prisoners. On
some days during the inspection, none of the staff on duty on E
wing were regulars”.
18. A further inspection took place in May 2010, but the report of that inspection
has not yet been published.
Independent Monitoring Board
19. Each prison has an Independent Monitoring Board (IMB). IMB members are
lay members of the public and are unpaid. They monitor day-to-day life in the
prison to ensure that proper standards of care and decency are maintained. In
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the IMB annual report which covers the period February 2008 to January 2009,
the Chairman wrote in conclusion:
“This report details a variety of concerns and good practice and
recognises that the staff in general are well motivated, carry out
their duties with professionalism and care, which augurs well for
the future.
“The Board’s overall conclusion is that the prison is well run and
many of the previous deficiencies reported by this Board and
other Statutory Agencies who have a reporting function rather
than monitoring, have been successfully remedied”.
Investigation of previous deaths at Lincoln
20. I have investigated ten other apparently self-inflicted deaths at Lincoln, the
report of one of which has yet to be published. In respect of the other nine,
none of the recommendations made are relevant here.
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KEY EVENTS
21. On 23 April 2006, two months after the man came out of prison and his licence
expired, he attempted to kidnap a young girl. He was arrested during the early
hours of the following day and was subsequently recalled to prison for failing to
adhere to the conditions of his licence.
22. The man was held in police custody between 24 and 26 April, when he was
taken to Magistrates’ Court. He was remanded in custody and ordered to
appear for trial at Crown Court on 2 August.
23. A Prisoner Custody Officer (PCO), who escorted the man from the police
station to court, completed a suicide/self-harm warning form because of the
following comments he had seen on the Prisoner Escort Record (PER):
“DP (detained person) whilst on remand was on suicide
watch. Has made threats to his flatmate that he will take his
own life.”
The PER also indicated that he was considered to present no known medical or
security risk. No signature appears on the PER to show who made the above
comments.
24. At section 4 of the suicide warning form, the PCO made the following
comments:
“Over 4 years ago. States he is ok. He knows he is going to
prison today and is not happy about it. But can deal with it.”
Reception at Lincoln
25. The man arrived at Lincoln at approximately 2.30pm on 26 April 2006. The
PER was signed by a member of the reception staff at Lincoln but the signature
is illegible. Nurse A, who conducted the initial health screen, signed the
suicide/self-harm warning form. She ticked a box on the form to indicate that
no Assessment, Care in Custody and Teamwork (ACCT) plan was opened at
that stage.
Health screen
26. The man told Nurse A that he had no medical problems or concerns and had
not seen a doctor within the previous few months. He admitted to binge
drinking and using cannabis. When asked about his mental health, he said that
he saw a psychiatrist regarding depression in 2004 and had attempted to
overdose in 2000. She recorded her impression of his behaviour and mental
state as follows:
“Has a history of self-harm. However, states it was
something he did a long time ago, issues now resolved.
Previous inmate of Lincoln, states can cope with being here.
Good eye contact, cheerful and open in manner.”
12
27. At interview, the nurse was asked why she did not refer the man for a mental
health assessment. She said:
“Because it would have been based on the individual and
how he presented at that moment in time, from what I can
see of the document. He didn’t show any problems to me.
He maintained good eye contact. He was cheerful, open in
his manner from what I’ve documented. And we can only go
on how the individual presents at the time.”
Secondary health assessment
28. The following day, the man was seen for a secondary health assessment. (The
purpose of this assessment is to assess a prisoner’s longer term physical and
mental health needs.) He raised no medical or mental health concerns then,
although he did say he had suffered with depression for most of his life but had
learned how to cope with it. He said he had not taken any medication for
depression since 2004.
Cell sharing risk assessment
29. An officer conducted a cell sharing risk assessment (CSRA – the assessment is
made to determine the level of risk a prisoner poses to other prisoners in a
locked cell) as part of the normal reception procedures. The officer noted that
he had seen the man’s PER, his warrant, and a closed F2052SH (the
predecessor of the ACCT plan). He told the officer that he had never abused
alcohol or drugs and was not currently dependent on these substances. He
said he was not currently subject to self-harm monitoring procedures and had
never been subject to them. He was not concerned about sharing a cell and
the officer concluded that he presented only a low risk of harming others if he
shared a cell.
30. The nurse completed the healthcare element of the cell sharing risk
assessment. She agreed that the man’s risk of harming others if he were to
share a cell was low. She noted on the form,
“Denies any thoughts of suicide or self-harm. Only left
Lincoln in February 06.”
Request to be separated for own safety
31. That same day, the man asked to be separated from other prisoners for his own
safety because of the nature of his offence. He was located in J Wing, a unit
that was used as a temporary overspill facility for prisoners in need of
separation when there were no spaces in the Vulnerable Prisoner Unit.
Complaint about being depressed
32. On 2 May, the man attended the healthcare centre complaining of depression.
He explained that he had previously been prescribed clomipramine, dothiepin
and Seroxat (which are types of anti-depressant medication) for three years
prior to 2004. He said he had been experiencing broken sleep and difficulty
13
waking up in the mornings. He denied having any thoughts of harming himself
and it was felt that his mood was due to his current situation. He was
prescribed fluoxetine, another anti-depressant, which was to be reviewed three
weeks later.
Counselling, Assessment, Referral, Advice and Throughcare (CARATS)
assessment
33. On 17 May, the man asked to speak to a member of the local CARATs team.
(CARATs is a community based agency which supports and advises drug or
alcohol misusers both in the community and in prisons.) The following day, a
CARATs worker interviewed him and completed an initial Drug Intervention
Record (DIR) to assess his substance misuse needs. During his interview, he
confirmed that he had used alcohol and cannabis since he was 14. He told her
that he had taken an overdose of painkillers whilst in the community and had
cut his arms four years ago. She noted that further intervention with him was
both needed and accepted by him. A further appointment was scheduled for 1
June at which a care plan was to be agreed.
Review of medication
34. The man’s fluoxetine prescription was reviewed, as planned, on 23 May. He
complained that he was depressed and “stressed out”. He admitted to having
occasional fleeting thoughts of self-harm but said he had put that behind him.
Two weeks later 10mg of buspirone (normally prescribed for the treatment of
anxiety) was added to his prescription.
CARATs care plan
35. On 1 June, as planned, the CARATs worker saw the man again and drew up a
CARATs care plan. This was as shown in the following table:
Date Objective How will What has to Who will do What is the
objective progress be be done to the work? timescale for
set measured? achieve the the work?
objective?
1 June 06 Discuss Successfully Refer to Chaplaincy Two weeks
alcohol engage with chaplaincy The man
related issues Alcoholics and AA AA
Anonymous
(AA)
1 June 06 Community Successfully Send DIR to The man DIR sent 18
based help engage with CJIT in area CJIT May 06. Letter
and support Criminal of residence received 30
upon release Justice May 06. Visit
Intervention prior to release.
Team (CJIT)
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Further review of medication
36. The man complained on 15 June that the fluoxetine was still not working and
asked to change to clomipramine (another form of anti-depressant medication).
This happened on 23 June when he was seen in the mental health clinic. It
was written in his medical record that he “appears to have an underlying
depression, exacerbated by situation. Denied any thoughts of self-harm”.
Recommendation for enhanced privileges
37. On 27 June, the man was recommended for enhanced privileges under the
Incentives and Earned Privileges scheme. (The IEP scheme aims to
encourage good and constructive behaviour among prisoners.) This was
approved three weeks later, with the result that he could benefit from having
more visits, spend more of his private cash and have more of his own property
in his cell.
Complaint about being stressed
38. The man complained to a nurse on 14 July that he was feeling stressed.
Arrangements were made for a doctor to see him later that day. At 3.00pm, the
doctor who saw him made the following note in the medical record:
“Says he is feeling low and depressed for the last three
weeks. Says he is very agitated and angry. Also complains
of poor sleep. In court in two weeks to be sentenced.
Expecting a long sentence. [In fact he was not sentenced
until 29 September.] Trouble getting to sleep and also early
morning awakening. Denies self-harm or suicidal ideas.
Various options discussed. Increase clomipramine to 100mg
tomorrow and 150mg by night. Zopiclone [a mild sleeping
tablet] for three days. For mental health review please.”
Disengagement with CARATs
39. When The CARATs worker went to see the man on 20 July, he told
her that he no longer wished to engage with CARATs. No reasons
for his decision were recorded in his CARATs file and he signed a
service withdrawal disclaimer.
First Assessment, Care in Custody and Assessment (ACCT) plan opened
40. Two weeks later, on 31 July, a nurse was called to E Wing at about
9.15pm to see the man after he had made several minor cuts to his
right arm with a razor blade, some of which required the application
of steristrips (adhesive strips which can be used in place of stitches
to close wounds). A form F213SH (report of a self-inflicted injury
sustained by a prisoner) was completed, indicating that no further
treatment was needed. He told the nurse that he had thrown the
razor blade he had used out of the window.
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41. Prison Service policy is that whenever, a prisoner harms himself, an ACCT
(Assessment, Care in Custody and Teamwork) plan must be initiated. At
9.40pm on 31 July, an ACCT plan was opened for the man by Senior Officer
(SO) A, who was the night orderly officer at the time.
42. When an ACCT plan is initiated, the following procedures must be carried out:
• A Concern and Keep Safe form must be completed as soon as possible
after the initial risk has been identified.
• An Immediate Action Plan must be compiled within one hour of the risk
being identified.
• An assessment interview must also be completed within the same time
scale.
• A first case review must be held within the same time scale. At this
review a Care and Management Plan (or Care Map) must be agreed with
the at-risk prisoner. Subsequent reviews must also be planned if it is
decided that the ACCT plan must remain open. When it is considered
appropriate to close the ACCT plan, a post closure review must be held
within seven days of closure. Case review panels must be multi-
disciplinary and must make judgements as to the level of risk the
prisoner presents and how often he/she needs to be observed and
engaged in conversation.
43. The Concern and Keep Safe form for the man was completed by the SO at
9.40pm on 31 July. He wrote as follows:
“He had made numerous cuts to his right upper and lower
arm. He was in a calm mood when we opened his cell and
he was just sitting patiently. He stated he had no intention of
committing suicide and that he had cut himself because he
felt low. I offered him the ‘phone’ [ie the Samaritans
telephone] but he said he could and would talk to his cell
mate. I told him I would have him observed during the night
and that he could ring his bell if he felt upset at any time.”
44. The Immediate Action Plan, also compiled by the SO, recorded that the man
was happy to remain in his current cell so that he could talk to his cell mate. He
did not feel any need to telephone the Samaritans. The SO decided that he
should be observed four times during the night.
45. An officer conducted the man’s assessment interview at 3.00pm the next day, 1
August. During the interview, he said he had a lot on his mind after speaking to
his solicitor about his impending court appearance and about himself.
However, he insisted his act of self-harm was not an attempt to take his life.
Rather, it was a means he had often used in the past to relieve tension. He told
his assessor he had done this since he was 13. Finally, he said his reason for
wanting to live was his mother, to whom he was very close.
46. The first case review was held at 4.40pm on 1 August in E wing where the man
was living. The panel comprised the Unit Manager, a SO and the officer who
had completed the assessment interview with him, and a student on placement.
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No-one from the healthcare department was present. The record of the review
makes no mention of whether the man was present. The review was
summarised as follows:
“He is punishing himself inside at the moment and needs
support. His cell mate is supporting him at the moment
whilst in his cell. Listeners, Samaritans, KW, [Key worker]
staff, Chaplaincy all offered as support. Positive goals set.”
The panel decided that, although his risk of harming himself was thought to be
low, he should be observed at hourly intervals during the day and night and that
staff should engage in a conversation with him once in the morning, once in the
afternoon and once during the evening period. The ACCT plan was to remain
open and the next case review was scheduled to take place on 5 August.
47. The panel also set out a Care and Management Plan which included the
following goals for the man to achieve:
• Seeing a mental health nurse
• Writing to his mother
• Telephoning his mother to arrange a visit to him in the prison and at
court.
48. The record indicates that the second and third goals concerning contact
between the man and his mother were achieved on 3 and 4 August
respectively. However, the following entry was made in his ACCT ongoing
record shortly after 3.00pm on 3 August:
“Was expecting a visit from his mother this afternoon but
whilst he was waiting on the 1s landing to go, visits called to
say the visit had been cancelled by her. Seems
disappointed by this in his body language. Spent the
conversation picking at arms and old self-harm scabs and
not always making eye contact. When asked if he was more
anxious and thinking of further self-harm, he replied no.
Hopes to call his mother tomorrow.”
No further mention of this matter was made in the ACCT ongoing record.
Court appearance
49. The man appeared at Crown Court on 4 August. The hearing was adjourned
so that a Pre-Sentence Report could be compiled. A note in his medical record
that day shows that he was considered to be “fit and well” upon his return to
prison. Entries made in his ACCT ongoing record while he was out at court
also suggest that he managed to cope relatively cheerfully throughout the day.
50. However, at 8.45pm that day, the following entry was made in his medical
record by a member of staff whose signature is illegible:
17
“Called to see this man who had several cuts to left arm.
Steristrip required for only one wound and micropore
dressings to arm applied. Said he felt better after cutting but
had been promised a mental health nurse last week but still
hadn’t seen one. He had also stopped taking citolapram
(anti-depressant) tablets a week ago.”
Change of medication
51. An entry made in the medical record the next day, 5 August, by Registered
General Nurse (RGN) A shows that a decision was made to change the man’s
medication to Cipramil (another anti-depressant) following a review by the
mental health team. The record does not make it clear whether this was a
formal mental health review with him present.
Mental health review
52. However, two days later, the man saw a member of the mental health in-reach
team. The following entry was made in his medical record:
“Still not sleeping - looks awful. Things have improved
slightly - mum visited yesterday. Concern - bored quickly,
easily distracted. Some elements of OCD [Obsessive
Compulsive Disorder] - straightening things. Gets worse
when feels stressed. Would benefit from zoplicone every 3rd
night for the next two weeks. To see in clinic in four weeks.
He has agreed to approach me sooner if he begins to feel
worse.”
First ACCT plan closed
53. On 7 August, a further ACCT case review took place. The review was chaired
by a SO and attended by an officer. The man was present but again no
members of the healthcare team attended. The review was summarised as
follows:
“More positive now had good visit from mother on 6 August.
She is supporting him and will be there for him when he gets
out. He aims to live with mother when released.”
The summary does not categorically state that the ACCT was to be closed but
the case review form does contain a note showing that a post closure review
was to take place on 14 August. This review did not materialise as a further
ACCT plan was opened on 12 August.
Further act of self-harm
54. Nurse A went to the man’s cell at 6.30pm on 10 August at the request of wing
staff who noticed that he had “old multiple superficial cuts” to both arms from
the previous day. The nurse applied gauze to both sites. He told the nurse he
was alright and was not thinking about harming himself.
18
Second ACCT plan opened
55. A second ACCT plan was initiated at 10.40am on 12 August, this time by SO B.
In the Concern and Keep Safe form, the SO wrote:
“Self-harmed on 9 August. Says he has self-harmed
because he is stressed out at the moment. Says he has
mood swings and he would like to see the doctor.”
This act of self-harm is not mentioned in the man’s core prison record or in his
medical record.
56. The 2006 calendar shows that 9 August, when the man harmed himself, was a
Wednesday and that 12 August, when the ACCT was opened, was a Saturday.
My investigators were presented with no evidence to show why there was a
delay of three days between his act of self-harm and opening the ACCT plan.
57. The SO also compiled an Immediate Action Plan. He recorded that the man
was once again content to remain in his current cell with the same cell mate.
He was to engage in four conversations with staff during the day and be
observed at hourly intervals when locked in his cell during the day. At night, he
was to be observed four times. The SO also noted that he had spoken to his
mother the previous day. He agreed to use the Listeners if necessary.
58. During the assessment interview the same day, the man said he was feeling
low and did not know how to lift his mood. He thought his low morale may have
been due to his inability to forgive himself for the offences he had committed in
the past. He said he saw his acts of self-harm as a means of punishing himself.
Although he said he did not value himself and felt worthless, he reiterated that
he did not wish to die. He said he had support from his mother and family. He
agreed with the plan for him to be assessed by the mental health review team
and for his medication to be reviewed.
59. The first case review for this second ACCT plan was held at 10.10am on 13
August in E wing. SO C chaired the review. The Unit Manager for the day and
an officer attended, as did the man, but the healthcare department was not
represented. The review was summarised as follows:
“The man attended the review stating he felt okay at present
but did feel a little low in mood earlier. His medication was
changed approximately a week and a half ago and he feels
his mood has deteriorated since this time. The Board
suggested a review of his medication and he will be put
forward for this. He has had a contact with a mental health
worker and feels comfortable speaking with her. Ongoing
support from mental health team is required as per care
map. He was advised as to all support mechanisms
available. The Board agreed the level of observations and
conversations should remain the same at present.”
19
60. The panel judged that the man’s risk of self-harm or suicide was raised and
scheduled a further review for 21 August. An invitation was to be sent to a
Registered Mental Nurse (RMN) of the mental health team to attend.
61. A care and management plan agreed by the panel with the man set two
principal goals:
• His medication was to be reviewed by a doctor.
• Ongoing support was to be made available by the mental health team.
62. Four days later, on 14 August, the man again told staff that he felt stressed. He
was seen by a nurse (whose signature in the medical record is illegible) who
decided that he should see a member of the mental health team as well as a
psychiatrist. The nurse discussed him with another nurse who had apparently
seen him during the previous week. This nurse, who had altered his
medication, took the view that the new prescription had not yet been given
enough time to take effect. She felt she could not do any more for him until she
could assess the success of the medication. She therefore felt no need to see
him at that point. It is not clear from his medical record whether he saw a
psychiatrist.
63. At 11.00pm that day, another nurse was asked to see the man as he had made
a number of fresh cuts in his left arm. The nurse applied steristrips to four cuts
and left the other wounds to dry. The nurse made the following entry in his
medical record:
“States feels stressed. On ACCT already. Declined
Samaritans phone.” Signed Nurse.
64. A further case review was held at 3.15pm on 15 August, earlier than planned,
as a consequence of the man’s further act of self-harm the previous day. Once
again, SO C chaired the review and was joined by an officer and RMN. The
review was summarised as follows:
“The man attended the review stating he felt okay today.
Case review held due to self-harm incident last night. He
has seen the doctor who has referred him to a psychiatrist.
A referral to mental health has been made and a nurse will
see him next week. He is due back in court on 11th
September and has set his mind on the worst case
scenario.”
The panel judged that his risk was still raised. No changes were made to the
observation levels set previously. A further case review was scheduled for 22
August.
Second ACCT plan closed
65. The next case review was held as planned on 22 August. SO B chaired the
review which was attended by an officer and the man. The healthcare
20
department was not represented. The record of the review does not show what
level of risk was assessed but the SO summarised the review thus:
“States he is okay. Says his medication is working very well.
He is less agitated. The nurse says that he has improved a
lot since Thursday. He says that if he is feeling down he will
speak to a member of staff and not bottle it up.”
The record of the review does not explicitly state that a decision was made to
close the ACCT or for what reasons, but the form does indicate that a post
closure review was scheduled for 5 September. In the event, no post closure
review took place as a new ACCT plan was opened on 4 September.
Third ACCT plan opened
66. At 8.40pm on 4 September, the man’s cell mate rang his cell bell to alert staff to
the fact that the man had inflicted a number of minor cuts to his right arm. His
wounds were treated by a nurse both in the cell and in the wing treatment room.
No stitches were required. As a result of this act of self-harm, an ACCT plan
was opened by the Night Orderly Officer (NOO).
67. The NOO completed a Concern and Keep Safe form shortly after 9.00pm and
then drew up an Immediate Action Plan. The man told him that he had cut
himself to release pressure and he felt better as a result. He said he had no
intention of harming himself again. The NOO decided to remove his razor
blades from his cell in order to prevent any further attempts. (Razor blades are
issued to prisoners to allow them to shave each day. If a prisoner uses them to
self-harm they can be removed.) The NOO also decided that the man should
engage in conversations with staff during the morning, afternoon and evening
periods and be observed at hourly intervals during the night.
68. At his assessment interview, held at 4.00pm on 5 September, the man
reiterated that his acts of self-harm were a means of relieving tension within him
and were not related to any desire to kill himself. On this occasion, he said, he
had not taken his medication for a week. He told his assessor that he was due
to see a mental health nurse but he became frustrated whilst waiting for the
appointment to take place. He said he had been experiencing mood swings but
did not want to die. He said the main issue was to see a member of the mental
health team so that his medication could be reviewed.
69. The initial case review was held at 4.15pm that day. The review was chaired by
a SO and attended by an officer who had conducted the assessment interview.
The man was present but the healthcare department was not represented. The
review was summarised as follows:
“After speaking to the man, his main issue and reason for
cutting himself is that he has stopped taking his medication
as it was giving him severe headaches. He becomes easily
frustrated and has used cutting his arm since he was 13 as a
way of releasing stress and as a coping mechanism. He is
21
waiting to see mental health team about a review of his
tablets.”
The care and management plan drawn up at the review included two goals for
him to achieve with the support of staff. They were to stabilise his mood with
appropriate medication and to re-establish contact with his mother (who had
recently moved house). The panel considered that his risk of further self-harm
was low and made no changes to the frequency of observation set by the NOO
when he opened the ACCT plan. They scheduled a further review for the
following day, 6 September.
70. The review took place as planned, at 3.00pm. The panel comprised a SO, the
case manager for the day, an officer and a mental health team member referred
to only by his first name. The man was present. The review was summarised
thus:
“He appears to be having problems with sleeping and
medication. Both are linked. Therefore the medication will
be re-assessed with a view to changing it. No other
problems.”
The panel considered that he presented a low risk of further self-harm and
directed that he should be observed at hourly intervals by day and by night and
that he should engage in conversations with staff during the morning, afternoon,
evening and night time periods. A further case review was scheduled for 13
September.
71. A nurse, whose signature is illegible, made the following entry in the man’s
medical record on the same day::
“Seen in ACCT review. Immediately prior to this episode of
self-harm, had not been taking his citolapram for one week
as was having nausea/vomiting as side effects. States mood
very low, anxiety high and sleep poor. To discuss with MO
(Medical officer, the prison doctor) re possibility of change to
Mirtazapine. No change to ACCT.”
72. On 7 September, a member of the healthcare department, whose signature is
illegible, noted in the man’s medical record that he did not appear for an
appointment with the doctor. There is no evidence to show whether anyone
checked why this was the case. However, the following two inter-related
entries in his ongoing record the next day suggest there may have been a
misunderstanding about the timing of the appointment:
9.35pm 7 September – “Must see doc in morning to get med
script” [prescription].
9.00am 8 September – “He was under the impression that he
was down to see the doctor this morning. Has now been told
that nursing staff are sorting his medication with the doctor
without the need for him to be present.”
22
Third ACCT plan closed
73. On 13 September, a further ACCT case review took place as planned, chaired
by a SO and attended by an officer. The man was present but no-one from the
healthcare department attended. The following is the summary of the review:
“Attended review and stated he felt ok and no problems.
Medication now sorted and sleeping a lot better. No
thoughts of self-harm and has not attempted it since this
book was opened. Stated he feels he can cope on his own
and will approach staff members if he becomes frustrated in
the future. Aware of Listener scheme and Samaritans
scheme and how to access. Happy to close ACCT book at
this time.”
The panel scheduled a post closure review for 20 September. In the event, this
review did not take place as a new ACCT plan was initiated on 15 September.
Nurse called to cell during the night
74. At 2.20am on 15 September, a nurse was called to see the man in his cell
because he was feeling stressed. The nurse, whose signature is illegible,
made the following entry in his medical record:
“Complains of feeling stressed and unable to relax. States is
feeling the effect of no medication today (to commence
fluoxetine tomorrow). Advised that mirtazapine has a long
half life and will therefore still be in his system. Given
reassurance. Will ask staff to speak to MO re anxiolytic [a
drug used for the treatment of anxiety].”
Fourth ACCT plan opened
75. The man made more superficial cuts to his right arm at about 11.30pm on 15
September in his cell. His wounds were cleaned and steristrips applied. No
further treatment was necessary. As a consequence of this act of self-harm,
the Night Orderly Officer, SO A, initiated a new ACCT plan.
76. The SO completed a Concern and Keep Safe form just before midnight. The
man told the SO “his head was in a mess” following an interview with a
psychiatrist (for the purpose of compiling a psychiatric report to court). He said
that during that interview, “he went over all the events that had happened to him
and the offences”. He told the SO he would not be “doing anything else”
(meaning harming himself) as he felt he now “had it out of his system”. He said
he wanted to see a doctor as soon as possible. The SO’s concluding remarks
on the Concern and Keep Safe form were, “After a discussion with the nurse,
we felt that he was a low risk for further action”.
77. The SO also completed an Immediate Action Plan on 15 September, in which
he recorded that the man wanted to see a doctor on the following Saturday (ie
the next day, 16 September) if possible. The SO directed that the man should
23
be observed at hourly intervals by day and night and should engage in four
conversations with staff during the day.
Further act of self-harm
78. At 2.30pm on 16 September, the man was found to have inflicted minor cuts to
his right forearm. A nurse covered the wound with a dry dressing and
steristrips.
79. At 10.30am on Sunday 17 September, Officer A conducted an assessment
interview with the man. During the interview, he said he was experiencing
anxiety and depression and felt his medication was insufficient for his needs.
He told the officer he was “coping with prison life in general”. He reiterated that
his act of self-harm had been brought about by talking to a psychiatrist which
brought back memories of his childhood. He explained that he used cutting as
a release valve. He confirmed that his act of self-harm was not an attempt at
suicide and that he had no intention of dying.
80. The officer recorded that the man experienced regular mood swings and
disturbed sleep patterns. He communicated in a positive manner throughout
the assessment. He said he was close to his mother with whom he had regular
contact. He told the officer that he needed to live for his mother because of the
support she gave him. His main concern was his need for his medication to be
sorted out. A note was made in the record of his assessment interview that he
was due to see a doctor later that day. The record of the assessment ended
with an agreement that he should try to remain with the same cell mate and
with an assurance that he should see a doctor. (There is no evidence that he
saw a doctor later that day. See also paragraph 80 below.)
81. The initial ACCT case review was convened at 10.45am on 17 September,
immediately after the assessment interview. The review was chaired by a SO
and attended by an officer and the man. The healthcare department was not
represented. The review was summarised as follows:
“He is more settled especially now that he is on the right
treatment but not strong yet. Awaiting sentence on 29
September at Crown Court. He feels he can now handle his
situation especially if we remove razors other than for use.”
82. The panel considered that the man’s risk of further self-harm was low. He was
to be observed at hourly intervals during the day and that staff were to have
four conversations with him. He was also to be observed at hourly intervals by
night. The next ACCT case review was scheduled to take place on 21
September.
83. The review panel set out a care and management plan for the man in which two
goals were agreed. His medication was to be improved by seeing a doctor and
his razor blade was to be handed back after use.
24
Appointment with doctor
84. The man’s medical record shows that he was due to see doctor during the
morning of Monday 18 September, but that he did not keep the appointment.
However, an entry made three days later shows that he was seen by a doctor
that day. The following information was recorded:
“Seen on E wing.
“Depression. Says was on fluox 40 on the out. But has not
taken it for six months. Advised starting dose is 20mg and
will increase as needed after two weeks.
“Stress. Works at the charity shop and is fine at work. But
finding association very difficult/stressful. Self - harms on
association/nights. F35 done: two weeks no association.
Review two weeks regarding fluox.” .
(The term ‘F35’ refers to a Prison Service form used by managers to give
written advice or instructions to another person. See also paragraphs 183-185
below.)
ACCT case review
85. The case review scheduled for 21 September took place as planned. The
panel comprised a multi-disciplinary team including a healthcare representative
and the man. The review was summarised as follows:
“Appears settled at this time. Gets stressed up after
association. Saw doctor 21.9.06 not given medication. Does
feel like cutting up now and again. Cuts up on out. Lots of
scars on arms done over past two months. At court in next
few weeks. Will then be able to cope better possibly.”
The panel made no changes to the frequency of observations and recorded that
his level of risk was considered to be low. The ACCT form was to remain open.
The next case review was scheduled for 28 September. A nurse was to be
invited to attend.
86. At that review, it was decided that, although the man felt alright, the ACCT plan
should remain open until after his court appearance the following day. The next
review was therefore set for 3 October.
Appearance in court
87. On 29 September, the man appeared at Crown Court for sentencing. He was
given a sentence of life imprisonment and told that he would have to serve a
minimum of six years before he could apply for release on parole. The Prisoner
Escort Record (PER) for the journey to and from the court indicated that he was
at risk of self-harm or suicide. He was checked regularly during the journeys
and whilst in the court cells. He arrived back at Lincoln at about 2.20pm. An
entry was made in his core prison record to reflect the fact that he had been
25
given a life sentence and that he was already subject to ACCT procedures. It is
clear from the entries made in the ACCT ongoing record that, in keeping with
Prison Service policy, the ACCT plan was taken with him. He told reception
staff upon his return that he felt alright. The following entry was made in his
ACCT ongoing record at 4.00pm that day by an E wing officer:
“Had a chat on return to E wing. States that he expected an
indeterminate sentence but was hoping for a shorter
recommendation but was not surprised with 6 years. Says
he has begun to accept it and has no thoughts of self-harm
at present. Advised that I am on all weekend if he needs a
chat.”
Fourth ACCT plan closed
88. At 6.45pm on 29 September, the duty manager noted in the man’s ACCT
ongoing record the need for staff to watch for any change in his demeanour, in
view of his sentence. Thereafter, he appeared to settle to the extent that, on 3
October, his ACCT plan was closed after a final case review that day, at which
a representative of the healthcare department was present. A post closure
review was scheduled for 16 October. However, that review did not take place
as a new ACCT plan was opened on 9 October.
Fifth ACCT plan opened
89. The man only managed to avoid harming himself until 8.20am on 9 October
when he made a number of minor cuts to his left arm, none of which required
any significant treatment. SO B initiated an ACCT plan immediately. In the
Concern and Keep Safe form, the SO recorded that the man had told him that
he had thought of self-harm and therefore cut himself. In the Immediate Action
Plan, the SO recorded his decision that the man should be observed at hourly
intervals during the day and night and should be engaged in conversations with
staff four times during each 24 hour period.
90. SO D completed the assessment interview with the man that evening. In the
record of the interview, the SO wrote:
“The life sentence is playing on his mind and he is wondering
if it is all worth it. Has a recommendation of 6 years but
knows he will do more than that. Says he feels ok at the
moment but his mood changes quickly. This happens on a
daily basis.
“Mental state fluctuates sometimes quite rapidly. Says he
has a poor sleep pattern and some days a poor appetite.
Saw a psychiatrist for a pre-sentence report who diagnosed
a personality disorder. Says he can’t sleep as his mind is
racing, lots of thoughts about his past, his current offence
and feelings of remorse.
26
“States that he does not want to die, but part of him does.
Wants to use this sentence as a way of starting afresh.”
The box in the form entitled ‘agree what is to happen now with the interviewee’
was left blank.
91. The first case review was conducted at 7.30pm that evening. Present were two
SOs and the man. The healthcare department was not represented. The
review was summarised as follows:
“Says part of him wishes to be alive but part of him not. Self-
harm is a way of coping with life stresses. Wants to stop
self-harming. Observations to remain at hourly, 4 x
conversations per day (am/pm/evening/night).”
92. The panel judged that the man presented a raised risk of further self-harm. And
noted that a routine referral was to be made for a mental health assessment. A
further case review was scheduled for 13 October. A mental health nurse was
to be invited to attend.
93. The care and management plan included two goals for the man to achieve with
the support of staff. The first was for him to explore ways of coping with past
problems (i.e. those stemming from his childhood). A referral was to be made
via the chaplain for him to see a counsellor to help him achieve this goal. The
second was for him to explore any mental health issues or problems with the
help of the mental health team. The record does not make clear whether he
saw the chaplain or a counsellor.
94. The next case review took place on 13 October as planned. The panel
comprised a SO and an officer but a mental health nurse was not present. The
review as summarised as follows:
“He states he’s feeling ok at the moment. He is on
medication which is stabilising his depression. However, he
is still getting mood swings that he cannot stop. He knows
his trigger points but has no coping strategies in place. He is
waiting to see Mental Health Team about this and in view of
that we feel the document should remain open on same
obs.”
The panel judged that his risk of further self-harm was low and scheduled a
further case review for 20 October. A mental health nurse was to be invited to
attend.
95. That review took place as planned but the mental health nurse was not present.
The review was chaired by a SO and attended by an officer, with the man
present. The comment was made that he was now unemployed but was
hoping to join education classes. The panel judged his risk to be low but kept
the ACCT plan open. The next review was to take place on 26 October with a
nurse present.
27
96. The next review took place on 26 October. It was chaired by a SO and
attended by an officer. No member of the healthcare team was present. The
review was summarised as follows:
“Medication has been changed, needs a while to take effect.
Family ties with mother have improved. Still waiting for
education interview. Same obs. No feelings of self-harm.”
The panel considered that his risk was low but kept the ACCT plan open. A
further review date was set for 1 November. No comment was made in the
record of the review as to whether a member of the mental health team was to
be invited to attend.
Fifth ACCT plan closed
97. The review took place as planned but again, no member of the healthcare
department was present. The review was summarised as follows:
“He says he is still wanting to go on education. I have
spoken to them and a member of the education department
will come and see him on Monday. Family ties with mother
is still good. He and the board feel that this booklet can be
closed. He says he has no thoughts of self-harm.”
The ACCT plan was closed. A post closure review was scheduled for 15
November but actually took place a day later than planned, on 16 November.
The following comments were recorded:
“His attempt at self-harm was purely an act of frustration
because his mother had not turned up for a visit. He now
realises that it was a silly thing to do and it will not happen
again. He has no thoughts of self-harm.”
Sixth ACCT plan opened
98. During the evening of 11 November, the man cut his left arm in his cell shortly
after 10.00 pm. He told the NOO that he had done so because he had been
refused his medication. The NOO opened an ACCT plan that evening and
recorded his comments in the Concern and Keep Safe form. The NOO also
drew up an Immediate Action Plan in which it was agreed that he should remain
in shared accommodation and be observed at half hourly intervals through the
night and at hourly intervals by day. The NOO reminded him of the availability
of Listeners and the Samaritans.
99. The ACCT ongoing record shows that the man was observed at 30 minute
intervals in keeping with the NOO’s instructions. My investigator noticed that
the observations were carried out on a predictable basis. He managed to
achieve a restful night without further incident.
100. At 3.00pm the next day, an assessment interview was conducted by Officer A.
The man told the assessor he had become stressed because his mother had
not booked a visit the previous day. As a consequence, he had asked the
28
nurses for extra medication to calm him down. He said the nurses told him his
medication could not be changed without first seeing a doctor. He therefore cut
his arm later that evening. He emphasised that there were no other reasons for
his self-harm and he did not wish to kill himself. He also confirmed that he had
since been able to contact his mother and now felt better.
101. The man also told the officer he had regularly self-harmed both in and out of
prison and had twice attempted to take his life in the community. He said he
had suffered from depression for many years and was currently taking anti-
depressant medication. He told the officer that he felt disappointed that he had
self-harmed again as he had managed to avoid doing so for nearly two months.
He said he wanted to “come off the ACCT book to put this behind him”.
102. The assessment interview was followed by an initial ACCT case review, chaired
by a SO. Also present were Officer A and the man. The review was
summarised as follows:
“The man admits that he only self-harmed because his
mother didn’t visit him. He has agreed to ask his mother to
contact the prison if she thinks she will not be visiting him
when previously agreed. We will then let him know that she
is not coming thus preventing al the stress caused. All
agreed on closing book. No thoughts of self-harm.”
103. The ACCT plan was closed. According to the front cover of the ACCT plan, a
post closure review was set for 25 November. However, the record of the initial
(and only) case review, signed by the SO, shows the same date and time as
the post closure review. This is clearly a mistake on the part of the SO. In the
event, a post closure review was held on 29 November. The review was
conducted by the SO who recorded the following summary:
“He has settled down. He is now unemployed but at ease
with himself and still in contact with his mother. He has no
thoughts of self-harm.”
104. The last entry made in the man’s medical record in 2006 was on 15
December. It read as follows:
“Not sleeping and this is making him angry in day. When
had mirtazapine was given at 4pm (sic). Was asleep by 6pm
but awake from midnight. Would like to try mirtazapine again
but nocte [nightly] and reduce fluoxetine to 10mg for five
days and then start mirtazapine.”
Key events in 2007
105. The man’s records show that 2007 was a very different year for him. He
refrained from deliberate self-harm throughout the year. Although he continued
to manifest frequent mood swings, he was not considered to be at risk of self-
harm or suicide and no ACCT plans were opened. His medication was
regularly reviewed and adjusted where necessary.
29
106. In June, the man’s uncle, who was in the community, was found hanged after
having gone missing. He appeared to take this news quite well. He also
appeared to cope reasonably well when told he would not be allowed to attend
the funeral. During this period, he had frequent contact with his mother.
Nevertheless, as a precaution, his razors were removed from his cell after use.
The entries made in his core record show that he was given appropriate care
and support by wing and healthcare staff.
107. On 10 October, the man began work as a wing cleaner, a job that enabled him
to spend longer periods out of his cell in constructive activity. A week later, his
cell sharing risk was reviewed. It was decided that he should remain in a
shared cell with the same cellmate.
108. In December, an entry made in his core record shows that the man adhered to
wing and prison rules and got on well with other prisoners.
Key events in 2008
109. The year 2008 also began well for the man. On several occasions during the
year, he was reported by staff as having a good attitude and as a good worker
on the wing cleaning party. Although his record shows that he applied in March
to become a Listener although it is not clear what happened to his application.
Failed Mandatory Drug Test (MDT)
110. However, on 17 April, the man was placed on report. It was alleged that he had
administered buprenorphine to himself between 24 March and 7 April. (This is
a drug used to replace heroin during the treatment of drug addiction.) He
disputed the charge and asked for an independent drugs test. His case was
adjourned to allow that to happen. On 12 May and again on 10 June, his case
was further adjourned to be heard by an independent adjudicator. (This
hearing was eventually scheduled to take place in July on the day he died.)
111. As a result of the fact that a drugs related charge had been raised against him,
the man was referred back to the local CARATs team. On this occasion, was
the CARATs worker assigned to him. The following is an extract from the note
the CARATs worker made on 20 May in the man’s Drug Intervention Record
(DIR):
“He has no drug issues. He admits to having some cannabis
in the past, but never caused problems. This current MDT
positive is being challenged by him. He did not/does not
take drugs. Signed service withdrawal suspended for now.”
No further entries were made in his CARATs file.
112. An entry made in the man’s core record in mid-May shows that he was
regarded by staff as “mixing with the wrong element on the wing”.
30
Allegations of trafficking by a prison officer
113. In June and July, information was given by prisoners that an officer was
trafficking in drugs and mobile telephones with prisoners in E wing, where the
man lived. The information was taken seriously by managers and a corruption
information log was opened.
114. On 15 June, an entry was made in the man’s core record showing that the
appropriateness of introducing him to a new cell mate was assessed. The
record shows that, as they knew each other, both he and the other prisoner
were happy to share the same cell. The new cell mate was interviewed by my
investigator. The following are extracts from his interview:
“As you may be aware, there is an Officer currently
suspended for an investigation of corruption of bringing drugs
and mobile phones into the prison.
“The man was in a cell with [a prisoner – name withheld] who
was due to be released. He asked me to go into his cell with
him. One of the first things that he said to me was, ‘If you
want anyone contacted, let me know and I will sort it for you’.
I said, ‘What do you mean?’ He said, ‘I have got an officer in
my pocket. I am not going to tell you who but I have got a
phone, he has brought me a phone in.’
“On this mobile phone, he rang his mum…He made other
calls to his brother … On one phone call to one of his
brothers he asked his brother that if he goes to this funeral
[that of his grandmother] if he was allowed, to have his
brother bring along some cannabis for him. Obviously I
heard his brother speak and he was absolutely not going to
do that.’
“And then I noticed his state of mind deteriorate rapidly and
his use of heroin substitute – subutex – he started to take a
lot of that, snorting up his nose. He was taking heroin which
I was obviously against.”
115. My investigator asked the prisoner whether he knew where the man was getting
the drugs from. The prisoner replied:
“I do know where he was obtaining that from but I am not
prepared to tell that at the moment, but he was getting it from
an inmate on the wing who I believe was having it supplied
by the officer that was suspended.
“Things then came to a head. Obviously I knew a lot about
this suspended officer. I knew what he was getting up to …
and he was coming into the cell regularly, very distressed,
stating that this officer had threatened him because he had
apparently owed him money for mobiles but he couldn’t get
31
any money from anywhere. People that were on the wing
that were ordering the mobile phones, he was the go-
between basically. They were ordering the phones and he
was going to the officer who bought them in but the others
weren’t paying up and the buck stopped with him. He was
getting increasingly distressed that this officer had
threatened violence against him if he didn’t pay the debt.
They knew where his family lived, all that sort of stuff. Like I
say, his intake of drugs increased, his self-harming
increased. He would not seek any help from the nurses
whatsoever because he didn’t want to go on the book [the
ACCT document].
“So it was about this time [about 10 July] that I thought
enough is enough. Drugs were being brought in, he was
self-harming, he was scared for his safety, scared for his
family and he was in debt with the officer so I then took it
upon myself to report the officer.”
116. The officer was suspended from duty on 16 July 2008. Thereafter, the Prison
Service conducted an investigation into the claims of corruption made by
various sources. The officer was dismissed from the Prison Service the
following year.
Seventh ACCT plan opened
117. On 10 July, the prison chaplain told the man that his grandmother had died. He
asked to be allowed to speak to his mother. At 6.20pm that day, Officer B,
seeing how upset he was, opened an ACCT plan. In the Concern and Keep
Safe form, he wrote:
“The man had heard that one of his grandparents had died
today. On talking to him to see how he was he informed me
he had cut his arms this afternoon.”
118. At 6.45pm, a SO completed an Immediate Action Plan. The SO commented
that the man felt safe and comfortable with his cell mate and did not wish to
move to another cell. The SO decided to place him on hourly observations and
instructed that staff should engage in conversations with him four times during
the morning, afternoon and evening periods. The record shows that Officer B
was to arrange for him to have a telephone call to his mother the next day, 11
July.
119. The officer conducted an assessment interview with the man the following day
at 10.30am. He recorded his concern at the news of his grandmother’s death
and an apparent deterioration in his relationship with his mother with whom, he
said, he had not spoken since February. He also told the officer that the last
time he saw his mother, she told him she thought more about her boyfriend
than about him. He said he had also lost contact with his father. He told the
officer he had self-harmed by cutting his arms as a means of stress relief and
that he had behaved in this way several times in the previous three months. He
32
also said he had been self-harming by one means or another over a 12 year
period. He told the officer he would most likely cut his arms again if necessary
to relieve his stress and would do it secretly. However, he said he did not feel
suicidal. The officer recorded his view that the man needed to regain contact
with his parents.
120. An initial ACCT case review was held immediately upon the officer’s completion
of the assessment interview, at 10.45am on 11 July. The review was chaired
by a SO and attended by Officer B and the man. No-one from the healthcare
department was present and neither was a chaplain. The review was
summarised as follows:
“The man attended his review and actively participated in a
constructive and positive manner. Having been advised of
his gran’s death, he was accepting of this news and states
he has now come to terms with it. He uses self-harm as an
anger management tool and dresses his own cuts as
appropriate. He states he has no intention to take his own
life and understands the facilities available to support him.
He declined a copy of the care map. Board agreed to reduce
obs. To provide support as required.”
121. The panel judged the man’s risk of further risk behaviours to be low and
decided that a further case review should be conducted on 16 July. The panel
also decided that he should be observed at hourly intervals and that he should
be engaged in conversations with staff once during each of the morning,
afternoon, evening and night time periods.
122. The panel also drew up a care and management plan. This set out a number of
goals or targets for him to achieve with the help of staff in order to reduce his
risk. The targets included reviewing the cell activities in which he could
engage, continuing to share a cell, restoring contact with his mother and
making use of Listeners and/or the Samaritans if necessary. However, there
was no mention of any plan to remove razors from him.
123. The following entry was made in the ACCT ongoing record at 2.15pm on 11
July, by a member of staff whose signature is illegible:
“The man has been in contact with his mum. Had a long talk
to her. This seems to have upset him as his father was there
and his dad blanked him and doesn’t want anything to do
with him. Positive out of this his mum has told him she is
going to visit him next week. Learned that his gran’s funeral
is next Wednesday and he wants to look at the possibility of
going. Says he is stressed at present. States he is not
suicidal and has no thoughts of suicide. States he feels like
cutting his arms to release the stress but is going to try and
be strong for his mum.”
124. Shortly after 3.00pm the next day, the following further entry was made:
33
“Had a long chat with the man about his history of self-harm,
his relationships with his parents and his gran dying. Very
upset about his gran dying and hopes to go to the funeral to
grieve and be of support to his mum. He believes that going
to the funeral will help him stop thinking about dying and will
also help him grieve for his gran. Also by going he will be
able to banish some feelings of helplessness as he will be
there to support his mum.”
125. On 13 July, the man handed in a formal application to attend his grandmother’s
funeral. One of the prisoners interviewed by my investigator said that he told
him that if he were not allowed to attend the funeral he would kill himself. The
investigation found no evidence to show whether that information was passed
on to staff. During her interview with my investigator on 30 April 2010, the
Deputy Governor said she could not recall whether she personally dealt with his
application. However, she explained that the Prison Service’s policy for
prisoners’ attendance at funerals was that they were normally only allowed to
attend if the deceased was a close relative such as parent, sibling or
son/daughter. In the case of other deceased relatives, including grandparents,
a prisoner would only be allowed to attend the funeral if it could be shown that
the person concerned had acted as a parent. She said that her understanding
was that his grandmother had not acted in this way which would explain why he
was not allowed to attend her funeral.
126. The following entry was made in the ACCT ongoing record at 8.30am on 16
July, the day of the funeral of the man’s grandmother:
“Spoken to briefly. Stated no current problems or thoughts of
self - harm. Is upset he cannot go to his nan’s funeral today.
However, states he is coping. All methods of support re-
explained and offered to him.”
127. My investigator was told by two members of the chaplaincy team that prisoners
who had suffered a family bereavement but had not been allowed to attend the
funeral could apply for permission to attend a ‘parallel funeral’ in the prison
chapel. The investigation found no evidence that the man applied for this
facility.
128. At 7.00pm on 16 July, a further ACCT case review was conducted as planned.
The panel comprised two members of staff from E wing together with the man,
but without anyone from the healthcare department. The review was
summarised as follows:
“He appears settled and states he no longer wishes to harm
himself. Will review on Sunday with a view to closing book.
States knows how to ask for help and who to ask. Has made
contact with mother and family which he has found
reassuring.”
34
The panel considered that he presented a low risk of further self-harm and
made no changes to the frequency of observations set at the review held on 11
July.
Seventh ACCT plan closed
129. The same panel met in the man’s presence at 9.15am on 21 July, to review his
risk. The panel concluded that the ACCT plan could be closed. They
summarised the review thus:
“Is waiting for a move to a therapeutic environment. Has a
long history of self-harm. States is on cleaners and can
approach staff if feeling low. Is waiting for assessment.
Would consider other units. He states if he feels like
harming himself will speak to staff.”
A post closure review was scheduled for 28 July but there is no evidence that it
took place.
130. No entries were made in the man’s core prison record or in his medical record
between 21 and 28 July. However, one of the prisoners interviewed by my
investigator said that on an unspecified date – almost certainly during this
period – staff decided to move the cleaners down from the fourth to the ground
floor of the wing. According to this prisoner, he was told that he was to move
but he said, “I’m not having any pad mate [cell mate] down there.” As a result,
he moved into a single cell, where he remained until his death. The
investigation found no evidence to show whether any assessment was made of
his suitability to be in a cell on his own despite the number of times the support
of the ACCT procedures was required and the support which his cell mate
gave.
131. Another prisoner volunteered the following information to my investigator during
an interview:
“… The next night [the evening of 28 July] he had had his
hair cut, which was very unusual for him. He had had a
shave, again which was very unusual, he used to have a little
beard, very rarely shaved. He had shaved, had had his hair
cut, put clean clothes on because normally he wore the
same clothes for a few days. He was unusually happy. He
was very friendly with people, very chatty.
“This was on the night he took his life. I saw him. He was
speaking to an officer. I believe you should talk to her as
well because he got on very well with her. (This officer was
not interviewed by the first investigator. She resigned from
the Prison Service in September 2009 and was not
interviewed by the second officer either.)
“Looking back now, and obviously hindsight is a wonderful
thing, he seemed to be as though it was an acceptance that
35
something was going to happen. He just wasn’t the person
that people were used to. He was totally different.”
Events during the night of 28/29 July
132. Among those on duty in the prison during the night of 28/29 July were an
Operational Support Grade (OSG) and the NOO. In a statement he later gave
to the police, the NOO said that, at about 11.00pm, he was patrolling the prison
when he received a message from the Control Room to move to a place where
he could take a telephone call. He went to an office in J Wing and took the call
which was made by the man’s mother. She explained to him that she was
concerned about her son’s mental state because a member of her family had
received calls from him in which he had expressed a wish to be with his
grandmother and his uncle (both of whom were dead). He told her that he
would go and speak to her son to assess his mood.
133. He and two colleagues went to the man’s cell and found him sitting on his chair.
The SO told him about the call he had just received from his mother. He
appeared to be surprised by what he told him but admitted to making the calls.
He said that he had done so at a time when he felt low but now told the NOO
that he felt fine. The NOO asked him if he was considering “doing anything
silly”, meaning harm himself. He replied that he was not. The NOO asked him
to remove his t-shirt so that he could check whether he had harmed himself
recently. He saw no fresh cuts or blood on his upper torso or on his arms.
After replacing his t-shirt, he told the NOO he felt fine. The NOO said he had
no reason to believe that he presented any risk to himself.
Eighth and final ACCT plan opened
134. Nevertheless, having consulted his colleagues, the NOO decided to take the
precaution of opening an ACCT form and to place the man on half-hourly
observations. These commenced at 11.20pm.
135. The ACCT form shows that the OSG checked the man at 30 minute intervals
from 11.20pm in keeping with the NOO’s instructions. He made the following
entries in the ongoing record:
“2320 Stood in cell. Said he was ok.”
“2350 Walking round in cell.”
“0015 Still up and about in his cell.”
“0045 Walking round his cell.”
“0115 Stood in his cell.”
“0140 Walking in his cell.”
136. At interview, the OSG confirmed to my investigator that “most of the time”, he
did not say anything to the man. The OSG said:
“I looked through the observation flap but didn’t say anything,
as far as I can remember. The light was on in his cell and I
could see him clearly. I could see he was ok. I know I made
my first entry in the ACCT form at 11.20pm on 28 July 2008
36
but I cannot recall the event. I know I wrote, ‘stood in cell,
says I’m ok’. I therefore may have spoken to him on that
occasion. I next made an entry at 11.50pm and recorded
that he was walking around in his cell. The light was on. He
did not look agitated or anything. He seemed alright. I made
other entries recording that he was stood up in his cell or that
he was walking around. I did not regard this sort of
behaviour as odd because prisoners often spend long
periods during the night moving around their cell. So I didn’t
think his behaviour was unusual. He gave me no indication
he was contemplating taking his own life. An officer on duty
and the NOO both thought he was pretty normal when they
saw him at about 11.00pm.”
137. In a statement he gave to the police, the OSG wrote that at 1.30am on 29 July,
he switched on the night light in the man’s cell and saw him standing towards
the right side of the cell. The OSG thought he was “fine”. He therefore
switched the night light off. He said he did not engage in any conversation with
him as he was not requested to do so. He said he was only expected to
“observe that he was ok”.
The man found hanging
138. At 2.05am, the OSG approached the man’s cell in order to conduct a further
check. When he looked through the observation panel in the cell door, he could
see his silhouette against the window. He was facing the cell door. The OSG
therefore switched the cell light on and could clearly see him hanging from the
window frame. He told an officer who was stationed outside another prisoner’s
cell about 15 feet along the landing that the man was hanging.
139. The officer joined the OSG, took his emergency keys from him and went into
the cell. (For security reasons, staff on duty at night carry keys in a sealed pack
which they may only open in an emergency.) Meanwhile, the OSG raised the
alarm by transmitting a Code One message over the radio. (The code system
alerts staff to a life threatening emergency in the prison without the use of
language or terminology that could cause distress to other prisoners within
earshot.) After raising the alarm, he had no further involvement in the
emergency.
140. When the officer went into the cell, he saw that the man appeared lifeless. He
described his face as having a “greeny/brown” colour. The officer cut him down
from the window from his suspension point with a specially issued knife.
141. As the officer was on his own he could not prevent the man’s body dropping to
the floor. He positioned him on the cell floor on his back with his head towards
the cell door and his feet towards the window. He then cut the ligature away
from his neck. The officer felt for a pulse in the neck but found none. He later
told the police:
“The man’s teeth were clasped around his tongue and I tried
to open his jaw but I was unable to and could not move his
37
tongue. I then decided to attempt CPR [cardio pulmonary
resuscitation] although I was convinced he was dead. I
started to apply chest compressions over his t-shirt. I had
only been doing this for a short while when another officer
entered the cell. He then took over doing chest
compressions and I went to the cell door and saw the nurse
coming down the stairs. I re-entered the cell with the nurse
who had her green medical kit with her. At this time the
officer was still applying chest compressions. The nurse
then took over the chest compressions and asked me to
apply a face mask to the man. I started to do this and the
officer took over. At this time, another nurse, a Healthcare
Support Worker (HSW), came into the cell and the two
nurses took over the medical duties. I then stepped out of
the cell and after speaking with the OSG I returned to my
previous duty.”
142. The NOO made his way to E wing as soon as he heard the Code One message
on his radio. In his statement to the police, he wrote:
“I entered the cell and I could see that a man was laying on
his back on the floor with his feet towards the window ad his
head towards the cell door. Two officers were in the cell.
“I requested an ambulance over my personal radio.”
143. The foIlowing are extracts taken from the statement the HSW gave to the
police:
“… At approximately 0200hrs the following morning, Tuesday
29 July 2008, we [HSW and nurse] received a radio message
over our personal radios of a ‘Code One’ … The message
gave a location of E Wing but it did not give any indication as
to the precise nature of the medical emergency. This is
normal practice.
“… I took the green coloured medical bag containing the
oxygen and ambu-bag [a device that enables oxygen to be
squeezed into a person’s lungs from a bag] and the nurse
took the orange coloured bag which contains the airways
equipment, drugs and medicine. I then opened up my sealed
key, which is contained in a pouch that I carry and the seal
should only be broken in an emergency situation to allow us to
exit the Healthcare Wing. As it happened, my key had not
been sealed in the pouch correctly and I had to cut it with a
fish knife [an anti-ligature knife] to get it open.
“… I remember that on entering the cell one of the officers, I
don’t remember who it was, was applying chest compressions
to the man lying on the floor and the other officer appeared to
be clearing the man’s airway. As soon as I had arrived in the
38
cell she told me to collect the defibrillator machine which is
kept in the treatment room in E wing. [A defibrillator is a
portable electronic device which automatically diagnoses a life
threatening disorder of the heart rhythm.] As a precaution,
earlier in the evening I had left the treatment room door
unlocked on E wing which houses vulnerable prisoners and
poor copers, in case there was a medical emergency on that
wing and we had to gain quick access to the treatment room.
I went with an officer to the treatment room which is located
on the next floor up from the ground floor. After locating the
defib machine, the officer ran back down the stairs with the
machine as he was quicker than me and he probable returned
to the cell in just less than a minute after he had left the cell to
collect the machine.
“… Because the work was so exhausting and it was very hot
in the cell, myself and the nurse and two other officers…took it
in turns to perform chest compressions on the man and
attempt to ventilate him using the ambubag but there were no
signs of life and the defib machine repeatedly advised not to
shock in its analyse phases.
“… We carried on repeating this procedure until two
paramedics … arrived at the cell. I think from memory they
logged this on the sheet as 0244hrs.”
144. Later that day, the HSW wrote a memorandum to the Governor in which she
drew attention to the problem she had encountered opening her sealed key
pouch. She wrote:
“At approximately 0205 hrs on 29 July 2008, I arrived on E
wing ground floor to a Code One. I was then asked to collect
the defib machine from E wing treatment room. I was unable
to gain access at first as I was unable to open my key pouch
as the key pouch was sealed incorrectly. This put vital
minutes on to gaining access to equipment. I feel this could
have been avoided if the pouch was correctly sealed.”
145. The Lincolnshire police took a statement from one of the paramedics who
responded to the prison’s request for an ambulance. The following are extracts
from that statement:
“At approximately 0200am on Tuesday 29 July 2008, whilst
at Horncastle Ambulance Station, having just finished a
break, we received a job via our personal airwaves terminal
from the Lincolnshire Control Room ... The job was to attend
HMP Lincoln …
“There was no detail at this time as to the nature of the job
and I was informed via my airwaves radio that they would
attempt to find out more details of the job while we were on
39
route. It was treated as an emergency response. Having
arrived at HMP Lincoln at around 0230am we called up ‘on
scene’.
“During the journey from Horncastle to Lincoln [a distance of
approximately 21 miles] my assistant in the ambulance had
attempted to find out more information as to the nature of the
job but this information had not been obtained.
“On arrival at the prison and reporting at the main gate, all
mobile telephones were taken from us and we were then
escorted through the prison in our ambulance by a prison
officer to E wing.
“As we approached the wing I actually asked the prison
officer why we were there and he replied that it was for a
hanging.
“… Having arrived at the cell … my assistant fixed the heart
monitoring leads to the man’s chest area. While she was
doing this, I attempted to cannulate the man on the inside of
his left elbow but this was unsuccessful. [A cannula is a tube
inserted into the body in order to administer medication or to
remove fluid.]
“Whilst my assistant had placed the heart monitoring leads
on the chest area she was also engaging in performing chest
compressions, alternating with ventilations at the rate of thirty
chest compressions to two ventilations. She then informed
me that the reading from the heart monitoring machine was
asystole, meaning that there were no signs of life. She
continued the CPR and ventilations for about another four to
five cycles which lasted about five minutes approximately,
before stopping. After this time, the reading was still
asystole. The medics [the nurse and HSW] had informed me
that they had been carrying out CPR on the man for about 30
minutes prior to our arrival and so the decision was made to
cease any further action. The man’s face had cyanosed [a
bluish discolouration of the skin], his lips were blue and his
pupils were fixed and dilated. The man’s extremities had
hypostasis, which indicated that life was extinct. I was able
to say that life was extinct and pronounced this at 0244hrs.”
146. My investigator asked one of the prisoners he interviewed whether he had an
opinion as to why the man might have taken his life. The prisoner replied:
“I believe it was two things. One, the death of his
grandmother because he made it quite clear to me that if he
couldn’t go to the funeral to be there for his mum, not so
much for his nan, he would commit suicide, that was what
40
he told me. I had a discussion with him and he sort of
came around a bit and said he was being daft.
“The other one I believe [the corrupt officer - name
withheld] had a lot to answer for because he [the man] was
very scared of him. [The officer] threatened him a lot. He
was in debt with [the officer]. [The officer] knew about him,
threatened him and his family.”
147. An officer who was in charge of the wing cleaning party of which the man was a
member, told my investigator:
“I cannot speculate as to why the man took his own life. I
cannot comment as to whether he did so because on the day
of his death he was due to face a disciplinary hearing for
failing a Mandatory Drug Test. I know that, had he been
found guilty of this charge, he would have lost his job as a
cleaner with the result that he would probably have had to
spend long periods locked in his single cell.”
Letter found in the man’s cell
148. After his death, a letter addressed to his mother was found in the man’s cell. In
it he wrote:
“I hope you understand why I have had to do this and I’m
sorry that it is in close proximity to Nan’s … Mum, this has
been on the cards for years. I think deep down you know
that my head has been f*****d for years and though I’ve
battled through this long I can’t do it any longer. Mum, I’m so
f***ing depressed. I go to bed every night hoping I will die
and feel cheated every morning when I awake. I’ve got so
much pain inside me it hurts every time I close my eyes so
this is the answer to my suffering. I don’t know why I’m like
this. I don’t know why I’m so messed up. To be truthful I
don’t think I can take being away from you as long as I have
and I have lost hope of ever seeing anything other than bars
and razor wire and in a way it’s an escape from prison as
well as the demons which plague me.”
Informing the next of kin
149. At interview the duty governor explained that he was contacted at home at
about 3.00am on 29 July and told that the man had been found hanging. He
left for the prison as soon as he could and arrived at about 3.30am. He said he
went straight to the orderly officer for a briefing about what had happened.
Afterwards he went to E wing. He told my investigator that he considered
notifying the man’s family of his death immediately but decided not to do so.
He said:
41
“I was aware that the mother was concerned and I had to
think about her feelings and I didn’t think that was the sort of
news she would want to receive at 3.30am – 4.00am,
particularly when I wasn’t aware of the situation at home. I
also had other matters, operational issues that I was trying to
resolve. So I was trying to sort that out. I needed to try and
get everything back to normal by 7.30am when the rest of
the prison was opened up. I had, as I’ve mentioned earlier,
at least two members of staff that were quite adversely
affected by the incident that night. So I was dealing with
those issues as well. And I was trying to get the coroner in
and trying to establish all the facts and make sure the area
was sealed off. But I think the main reason was the feelings
of the mother, and I didn’t think it was appropriate at that
time in the morning, particularly as it was only two to three
hours before daybreak anyway, when the family liaison
officer would be able to make the contact.”
150. My investigator asked the duty governor whether, in similar circumstances, he
would do anything differently in the future. He said he felt he made the right
decision and would do the same again if the circumstances were to be
repeated.
151. A prison family liaison officer was appointed. At her interview she told my
investigator that she was called by the prison at around 6.30am to 7.00am.
She confirmed that she was initially called by the control room to be told that
there had been a death. She could not recall whether she was told that the
person who had died was the man. She said she was next called by the
Governor just as she was leaving her house for the prison. Again, she could
not recall whether the Governor told her who had died.
152. She arrived at the prison at about 8.15am. Upon her arrival she was told by the
Governor that the man had been found hanging and had died. The Governor
also told her that the man’s mother had telephoned the prison at about 8.00am to
enquire how her son was following her telephone conversation with the NOO the
previous evening. My investigator was unable to ascertain who took the call at
8.00am. That person was unable to confirm to the man’s mother that her son
had already died. She told my investigator that she was thus aware of the need
to inform her of his death as soon as possible.
153. By 8.50am, she was equipped with sufficient information about the details of the
man’s death to ring the telephone number she had been given for his next of kin.
The man’s answered and she told her of her son’s death.
154. She asked the man’s mother if she and any other family members wished to
attend the prison in order to receive more detailed information in person. She
also offered to send a taxi to collect those who wished to make the journey. This
invitation was declined. However, that afternoon, members of the family visited
the prison and viewed the body at the mortuary under arrangements made with
the help of the family liaison officer. Later, his personal property was handed to
his family at different stages.
42
The man’s funeral
155. The man’s funeral took place on 11 August. The Governor offered to pay the full
costs.
Prisoner support
156. My investigator interviewed the prisoner who had been the man’s cell mate.
During the interview, the prisoner confirmed that early on the morning of 29 July,
the Governor personally told him of the death. However, beyond that, my
investigator was presented with no information to show what other support was
given to prisoners in the aftermath of the death.
Staff support
157. The duty governor on the day of the man’s death told my investigator that there
was no ‘hot debrief’ after he had been pronounced dead. (A ‘hot’ - or immediate -
debrief designed to allow staff involved in responding to an emergency to
express any distress they may have experienced.) He said:
“We had a debrief, a cold debrief, some weeks later. There
wasn’t actually a hot debrief. I went round and spoke to all
the staff that were on. I had some concerns with staff. The
Staff Care and Welfare team were in. Some staff had been
adversely affected by what had happened and I decided …
not to hold a debrief. It had been a long night for those
involved in the whole thing.”
158. According to the duty governor, a member of the Staff Care and Welfare Team
attended the prison on 29 July and spoke to all those staff who wanted to see
her. He believed that follow up contact was made with some staff who had
been particularly affected by the events of the previous night.
159. My investigator was told by one member of staff that when the debrief was held,
those present were limited in what they could contribute because they were “not
allowed to talk about operational matters”. The member of staff concerned said
he did not have a chance to discuss “how things might have been done
differently”.
43
ISSUES
160. Here I examine whether:
• The man’s health needs were adequately met while he was in custody at
Lincoln.
• His risk of self-harm or suicide was properly assessed, monitored and
managed prior to the night of 28/29 July 2008.
• His risk of self-harm or suicide was properly assessed, monitored and
managed during the night of 28/29 July 2008.
• He was subject to any form of bullying or coercion and, if so, whether
this was linked to his death.
• The response to the discovery of him hanging was prompt and effective.
• The family were promptly and sensitively informed of his death and
whether they were given appropriate follow up support.
• Prisoners and staff were appropriately supported after the death.
I also provide responses to the additional specific concerns raised by the man’s
mother.
Were the man’s health needs adequately met while he was in custody at
Lincoln?
161. Here I rely heavily on the findings of the clinical review conducted by the clinical
reviewer on behalf of the local PCT. The following are key extracts from her
report.
History of events
162. “The man was received into custody at HMP Lincoln on 24 April 2006. At
reception, a history of depression and repeated attempts at self-harm were
documented. During his period of custody at HMP Lincoln, he frequently
sought help and advice for mental health issues and there were multiple
documented episodes of self-harm. During the night of his death on 29 July
2008, he had been placed on 30 minute observations in his cell due to
concerns that he may harm himself. At 1.40am he was reported to be walking
around in his cell. At 2.05am he was found hanging with a blanket ligature
around his neck. He was cut down by prison staff and resuscitation
commenced. The attending ambulance paramedics arrived at around 2:40am
and he was pronounced dead at 2.44am.”
Medical history
163. “The man received a First Reception Health Screen at HMP Lincoln on 26 April
2006. There was no declaration of physical health problems. He declared a
family history of type 2 diabetes and heart disease. There was a declared
44
history of drug abuse with use of cannabis in the past and within the preceding
month. He admitted to binge drinking of alcohol and a smoking habit of ten-15
cigarettes a day. He stated that he had received treatment from psychiatric
services in 2004 for depression. He admitted to an attempted overdose in 2000
and a history of self-harm. He denied any current feelings of self-harm and
was assessed as cheerful and open in manner with good eye contact.”
Background information
164. “The man was seen by a Consultant Psychiatrist on 15 and 26 September 2006
at the request of a firm of solicitors. In the report produced following these
interviews and taking into account background information, the psychiatrist
concluded that he was not suffering from a mental disorder as defined in Part 1
of the Mental Health Act 1983. It was the psychiatrist’s view that he was
suffering from a personality disorder of antisocial type as defined in
International Classification of Diseases 10th Edition. His depressive symptoms
were described as dysthymia, a term used to describe low grade depressed
mood that is not severe enough to be classified as depressive illness. His
dysthymia, put in the context of ongoing personality disorder and offending
behaviour was felt to put him at odds with the society in which he lived and in
turn made him worthless, hopeless and subjectively helpless.”
Recommendations and opinion
165. “There is clear evidence that the man received timely and appropriate response
to his physical and mental health needs and the healthcare staff involved in his
care should receive recognition for the level of care provided.”
166. “Frequent requests for changes of medication by the man were inappropriate
but were carefully considered by the medical officers concerned in an
appropriate manner with full documentation of any changes made.”
167. “There is no documentation of any psychotherapeutic intervention being
offered. This may have been helpful in addressing the man’s persistent self-
harming behaviour and should be considered in any prisoner who presents with
mental health issues that are not responding positively to medication.”
168. The clinical reviewer concludes that “Overall, the standard of healthcare
received by the man during his period of custody was exemplary” and I agree
with his judgement.
Was the man’s risk of self-harm or suicide properly assessed, monitored and
managed prior to the night of 28/29 July 2008?
169. When the man was first received at Lincoln on 26 April 2006 from court,
included in the accompanying documentation was a self-harm/ suicide warning
form which highlighted concerns about his history of self-harm. However, the
nurse who conducted the first reception health screen and who read the
comments on the warning form judged that he did not present as being at a
current risk of self-harm. Therefore, reception staff did not consider it
45
necessary to open formal self-harm monitoring (ACCT) procedures at that
stage.
170. As it happens no harm befell the man on this occasion. However the Governor
will wish to consider whether it would have been a sensible precaution to have
opened the ACCT proceedings in the light of the concerns expressed by court
staff.
Involving healthcare staff in ACCT case reviews
171. Although the records of the 22 ACCT case reviews held in respect of the man
do not always make clear the disciplines of those staff in attendance, it appears
that healthcare staff were only present on four occasions. On at least three
occasions, no mental health team representative attended despite having been
invited to do so.
172. Whilst I acknowledge the demands placed upon staff in busy local prisons such
as Lincoln, especially where healthcare staff are concerned, I would urge the
Governor and PCT to give due weight to the involvement of healthcare staff in
ACCT case reviews, especially where the at risk prisoner is a prolific self-
harmer, as was the case with the man, and when healthcare are providing
treatment.
The Governor and PCT should remind their respective staff of the need
to involve appropriate healthcare staff in ACCT case reviews, where
possible, in keeping with the provisions of Annex 8G of PSO2700.
Record keeping
173. The investigation found several examples of poor record keeping:
• No comment was made in the man’s medical record or in his core prison
record after he had self-harmed on 12 August 2006.
• The record of the ACCT case review that took place on 22 August 2006,
does not explicitly state that the ACCT plan was to be closed.
• The record of an assessment interview conducted on 9 October 2006
after he had self-harmed contains no entry in the box entitled ‘agree
what is to happen now with the interviewee’.
• Not all the signatures of staff who made entries in his ACCT plan or in
his medical record were sufficiently legible for the author to be identified.
As minor as these housekeeping points may seem, I believe that it is essential
for front line staff to achieve and maintain the highest standards of record
keeping, especially in relation to all aspects of self-harm risk monitoring.
Where the specific issue of the legibility of signatures is concerned, I make the
following recommendation:
The Governor and PCT should take steps to ensure that whenever
members of staff make an entry in a prisoner’s record, they should
46
always print their name clearly and legibly against the entry. It is
especially important for them to do so when making entries in ACCT
plans and medical records.
Prompt opening of ACCT plans
174. The ACCT procedures were initiated on six occasions between July and
November 2006 and on two occasions in 2008, on most occasions as a result
of the man’s infliction of minor cuts and scratches on his arms. On each
occasion bar one, they were opened in a timely fashion and appropriate support
was put in place.
175. However, it appears that there was a delay of three days between the man’s act
of self-harm on 9 August 2006 and the subsequent opening of an ACCT plan. I
make no formal recommendation on this matter as this was the only delay
discovered in a total of eight ACCT plans. However, I cannot overstate the
importance of initiating ACCT plans promptly after any act of self-harm by a
prisoner.
Closing the ACCT plans
176. The ACCT plan opened at 10.00pm on 11 November 2006 after the man had
self-harmed, was closed at 3.20pm the following day. Although a Concern and
Keep Safe form, immediate action plan, assessment interview and initial case
review were completed, no Care Map was drawn up before the decision to
close the ACCT plan was made.
177. PSO 2700 sets out the following provisions for the closure of ACCT plans:
“The ACCT plan can only be closed once all Care Map
actions have been completed and the Case Review Team
judges that it is safe to do so, i.e. that the problems that
caused the ACCT plan to be opened have been resolved or
reduced, the prisoner is able to cope with any remaining
difficulties.”
It is clear from the record of this particular case review that the staff in
attendance did not follow the correct procedures for closing an ACCT plan. As
this oversight was an exception, I make no formal recommendation but suggest
that the Governor draws the attention of the relevant staff to the policy set out in
Annex 8G of PSO 2700 for the closing of ACCT plans and to paragraph 9.14 of
his local suicide prevention policy document.
Post-closure ACCT reviews
178. After a decision had been made to close the man’s ACCT plan on 21 July 2008,
a post closure review was scheduled to take place a week later. However the
investigation found no evidence that this review took place. This apparent
omission has to be seen in the context of the fact that a further ACCT plan was
opened at 11.00pm on 28 July. I therefore make no formal recommendation on
the matter. However, I take the view that staff should ensure they schedule and
47
convene post closure ACCT reviews appropriately and in accordance with
guidance.
Predictability of ACCT observations
179. During the evening of 11 November 2006, the man cut his left arm in his cell
shortly after 10.00 pm. The NOO opened an ACCT plan shortly after 10.00pm
that evening, completed a Concern and Keep Safe form, drew up an Immediate
Action Plan in which it was agreed that the man should remain in shared
accommodation and should be observed at half hourly intervals through the
night and at hourly intervals by day. The ACCT ongoing record shows that he
was observed at 30 minute intervals in keeping with the NOO’s instructions.
However, my investigator noticed that almost all the observations were carried
out on a predictable basis.
180. This happened again during the night of 28/29 July 2008 when the night patrol
on duty was instructed to observe the man at 30 minute interviews. The list
below shows the times of the observations carried out and the comments
recorded.
“2320 Stood in cell. Said he was ok.”
“2350 Walking round in cell.”
“0015 Still up and about in his cell.”
“0045 Walking round his cell.”
“0115 Stood in his cell.”
“0140 Walking in his cell.”
181. The fact that the man was awake and pacing or standing still in his cell
throughout the period of monitoring suggests that he was likely to have known
when he was about to observed. Paragraph 4 of Annex 8HH in PSO 2700
refers to the need for irregular observations. Paragraph 9.23 of the Governor’s
local suicide prevention policy document also refers to the same issue.
The Governor should remind staff of the need for observations of at-risk
prisoners to be carried out at irregular intervals, in keeping with the
provisions of paragraph 4 of Annex 8HH in PSO 2700 and of paragraph
9.23 of his local suicide prevention policy document.
182. That said I blame no-one for the fact that the man successfully hanged himself.
Removing razor blades
183. The investigation found that on some occasions, staff reduced the availability of
razors after the man had used them to cut himself, but that on many other
occasions, no such steps were taken. There was rarely any mention made in
the record of his ACCT case reviews of the question of the removal of razors,
despite the fact that the local suicide prevention policy directs that this must be
done.
184. My investigator was told that the formal removal of razors from the man could at
any time be undermined by the fact that he would have been able to borrow or
48
even steal such items from other prisoners, including cell mates. However, it
seems that there was an inconsistent approach by different staff to the difficult
task of minimising the man’s reliance on cutting himself as a means of relieving
his tension.
The Governor should remind his staff of the provisions contained at
paragraph 9.25 of his local suicide prevention policy for the removal of
items such as razor blades from at risk prisoners. He should ensure that
those provisions are followed consistently by all staff, especially where
the recording of decisions made in ACCT case reviews and care maps is
concerned.
Restriction of association
185. On 18 September 2006, an entry was made in the man’s medical record that
included the following comment:
“Stress. Works at the charity shop and is fine at work. But
finding association very difficult/stressful. Self-harms on
association/nights. F35 done: two weeks no association.
Review two weeks regarding fluox.”
186. The term ‘F35’ refers to a form used in the Prison Service by a manager
normally to give written advice or an instruction to another person. My
investigator was concerned that in this particular case, it seems that an
instruction may have been given by a doctor instructing that the man should not
be given association, a sanction normally enacted only as part of a punishment
awarded after a disciplinary hearing. My investigator was presented with no
evidence to clarify whether the comments on the form were to be taken as
advice or as an instruction.
187. I am concerned that the apparent restriction of the man’s association on this
occasion, however well intentioned, was, to say the least, unorthodox. Whilst I
make no formal recommendation on the matter, I suggest that the Governor will
wish to satisfy himself that decisions to prevent prisoners, especially those
considered to be at risk of self-harm or suicide, are made in keeping with
current national policy.
The man’s suitability to be in a cell on his own
188. One of the prisoners interviewed by my investigator said that on an unspecified
date – almost certainly between 21 and 28 July - staff decided to move the
cleaners down from the fourth to the ground floor of the wing. According to this
prisoner, the man was told that he was to move but he said, “I’m not having any
pad mate down there”. As a result, he moved into a single cell, where he
remained until his death. The investigation found no evidence to show whether
any assessment was made of his suitability to be in a cell on his own. It is
possible that his apparent refusal to share a cell on the ground floor suggested
to staff that there was no value in conducting a formal assessment. However, if
staff had studied his previous ACCT plans, they would have seen that central to
49
his management when at risk of self-harm was the need for him to be with a
cellmate.
The Governor should review his local suicide prevention policy so that
clear guidance is given to staff with regard to the need for continuous
assessment of the appropriateness of at-risk prisoners’ relocation from
shared to single cell accommodation. This factor, where it applies,
should be included on the agenda for post closure ACCT reviews.
189. Following the closure of the man’s most recent ACCT plan on 21 July, he was
supposed to have been the subject of a post closure review on 28 July but the
investigation found no evidence to show that this took place. This is a matter of
concern. This was not the first time a post closure review was not held but on
all other occasions the opening of a new ACCT plan negated the need for such
a review. In my view, there was no good reason for there to be no post closure
review in this instance. Had such a review occurred, it is possible that due
consideration may have been given to the appropriateness of placing him in a
single cell.
The Governor should remind his staff of the requirement for a post
closure review to take place whenever an ACCT plan is closed, unless in
exceptional circumstances, and should make regular management checks
to ensure that this requirement is met.
190. In assessing whether the man’s risk of self harm was properly managed, I have
found that his frequent acts of self-harm were demanding of healthcare staff
and wing officers. Nevertheless, I believe that decisions to open ACCT plans
were carefully and thoughtfully made and measures taken to support him were,
in the main, appropriate. It became clear to staff that he had developed a
propensity, if not a dependence, on cutting his arms as a means of releasing
and relieving tension. His risk of harming himself was constantly re-assessed
during periods when ACCT plans were in force.
191. Apart from the exceptions on which I comment in paragraphs 165-182 above, I
have found that ACCT procedures were carried out as set out in Prison Service
Order 2700 – Suicide Prevention and Self - Harm Management. I therefore
conclude that the assessment, monitoring and management of the man’s risk of
self-harm prior to the night of 28/29 July 2008 was satisfactory.
Was the man’s risk of self-harm or suicide properly assessed, monitored and
managed during the night of 28/29 July 2008?
192. A prisoner told my investigator that he thought the man was different that
evening. He had shaved, his hair had been cut, he was unusually happy and
talkative, and was wearing clean clothes, something he rarely did. In hindsight,
the prisoner wondered whether this was a sign that he had accepted that
“something was going to happen”. However, he gave no indications to staff that
he was actively contemplating suicide at any stage that day and so there were
no apparent grounds for any intervention.
50
193. The first significant event occurred at about 11.00pm that night, when the man’s
mother called the prison as she had received a telephone call from a third party
whom the man had rung to say that he wanted to be with his uncle and
grandmother, both of whom were dead.
194. The NOO took the call and reassured the man’s mother that he would go and
see him to assess his stage of mind. The NOO told the man about the call from
his mother and he seemed surprised but admitted making the call to the third
party. He said he had done so at a time when he felt low but he now felt fine.
The NOO asked him if he was considering “doing anything silly”, meaning harm
himself and he replied that he was not. The NOO asked him to remove his t-
shirt so that he could check whether he had harmed himself recently. He saw
no fresh cuts or blood on his upper torso or on his arms. After replacing his
shirt, he repeated that he felt fine. The NOO said he had no reason to believe
he presented any risk to himself.
195. Nevertheless, the NOO decided to take the precautionary step of opening an
ACCT plan there and then. He gave an instruction to the OSG to observe the
man at half hourly intervals and recorded this decision in the ACCT plan.
196. The man’s death followed very quickly after he had given an indication to a third
party outside the prison that he wanted to be with his two deceased relatives.
Although, when checked, he said he felt alright, the NOO made an intelligent
decision to open an ACCT plan. In keeping with the NOO’s instructions, the
OSG observed the man at the required intervals but on a predictable basis, as
described in paragraphs 173 - 175 above.
197. Prior to the night of 28/29 July 2008, I do not believe that the man gave any
indication that he was actively contemplating suicide. However, he gave an
indirect indication of suicidal ideas to a third party outside the prison shortly
before 11.00pm that night. That person called the man’s mother who relayed
her concern to the NOO, who checked him and assessed that he was not at
risk. Nevertheless, the NOO took the sensible precaution of opening an ACCT
plan there and then, and directing that the man should be observed at half-
hourly intervals.
198. I conclude that the measures taken by the NOO were in keeping with best
practice. Although I draw attention to the predictability of the observations
made of the man that night, I blame no-one for the fact that he was able to
successfully take his life. He did so using a method which he had not used in
prison before. It is generally accepted by pathologists that it possible for
unconsciousness to occur within seconds of the brain receiving no oxygen
when a prisoner hangs himself, and for death to occur within less than three
minutes.
I commend the NOO for having the presence of mind to open an ACCT
plan shortly after 11.00pm on 28 July as a precautionary measure, and for
deciding that the man should be observed at half hourly intervals.
51
Was the man subject to any form of bullying or coercion, and, if so, was this
linked to his death?
199. With the significant help of senior managers at Lincoln and of Lincolnshire
Police, my investigator was able to gather and scrutinise useful intelligence
about the claims made by prisoners that an officer in E wing at Lincoln was
trafficking mobile telephones and drugs with the man and others in 2008. The
claims were investigated by a Governor from another prison between February
and May 2009. That Governor recommended that disciplinary charges should
be laid against the officer for the following:
• Trafficking subutex to a prisoner (not the man) in or around May 2008.
• Trafficking codeine based medication to a prisoner (not the man) on an
unknown date in 2008.
• Trafficking veterinary medication to a prisoner (not the man) on an
unknown date in 2008.
• Conspiracy to undertake the trafficking of contraband to the man on an
unknown date in 2008.
• Entering into an inappropriate relationship with the man on an unknown
date in 2008.
• Assisting two prisoners (not including the man) in damaging prison
property namely a mobile telephone detector on an unknown date in
2008.
200. The charges were heard at a Prison Service disciplinary hearing on 16
November 2009. All the charges against the officer were proved and he was
subsequently dismissed from the Prison Service.
201. The investigation found evidence to suggest that the man may have been
coerced by a corrupt prison officer. However, no evidence arose from either
the internal Prison Service investigation or from the police investigation to show
that there was a provable connection between the conduct of the officer and his
death. In the letter found in his cell after his death, addressed to his mother, he
made no reference to these matters. I accept that any misconduct by the
officer had no bearing on his decision to take his life.
Was the response to the discovery of the man hanging prompt and effective?
202. The man was found hanging at approximately 2.05am on 29 July by the OSG
who immediately called for assistance from an officer, who was about 15 feet
away, outside the cell of another prisoner who was on constant observations.
The officer went into the cell and, single handedly, cut him down and removed
the ligature. At interview, the officer said he found him to be lifeless and his
face a greeny/brown colour. He could not find a pulse. The officer later told
the police that the man’s teeth were clasped so tightly that he could not move
52
the tongue. Nevertheless, he decided to attempt CPR, despite his belief that he
was dead.
203. The OSG raised the alarm over the radio, as a result of which other staff arrived
to give assistance. A request was also made to the emergency services for an
ambulance. Amongst those who first responded to the OSG’s request for
assistance were another officer, a nurse and the HSW. The NOO also
responded. The second officer assisted the first officer with the application of
chest compressions. The nurse and HSW applied advance resuscitation
techniques using emergency first aid equipment brought to the cell. They
continued to attempt to revive the man until two paramedics arrived at about
2.30am. Further attempts were made by the paramedics to revive him but he
did not respond. In view of the length of time unsuccessful attempts had already
been made to revive him prior to their arrival, the paramedics decided, at
2.44am, that he was dead.
I commend the two officers, nurse and HSW for their determined attempts
to save the man’s life.
Emergency service response
204. One of the two paramedics, who were tasked to respond, logged the time of the
incoming call as approximately 2.00am. Although this time is not consistent
with that logged by the prison, it is not unusual for slightly different times to be
recorded by different agencies in an emergency such as this.
205. The paramedic and her colleague did not arrive at Lincoln prison until
approximately 2.30am. In a statement given to the police, she disclosed that
when she and her colleague were tasked to respond to the request from the
prison for an ambulance, they had just come to the end of a break at Horncastle
Ambulance Station, some 21 miles away from the prison. Although I am
concerned at the length of time it was bound to take for the ambulance crew to
travel such a distance in response to a life threatening emergency at the prison,
there is no evidence that the 30 minute response time achieved affected the
outcome.
206. However, I am concerned that the ambulance crew were not aware of the
nature of the emergency. As a result, the control room staff at the Ambulance
Station made attempts, while the ambulance was on its way to the prison, to
acquire more details. Nevertheless, the ambulance crew did not discover that
they had been asked to respond to a suicide by hanging until they arrived at the
prison. (Despite the lack of information given to the crew when they were
deployed, they treated the task as an emergency from the outset.)
207. My investigator was unable to clarify whether anyone at the prison failed
properly to inform the emergency services of the reason for calling an
ambulance. No matter what caused the confusion, and no matter that the lack
of information did not seem adversely to affect the outcome, this must not be
allowed to happen again. The Governor must be satisfied that his contingency
plans for the management of a life-threatening emergency properly legislate for
the passage of essential information to the emergency services.
53
The Governor should review his contingency plans for the management of
life-threatening emergencies to ensure that proper information is passed
to the emergency services as to the nature of the emergency. If
necessary, appropriate staff training should be offered.
Withdrawal of mobile telephones from the ambulance crew
208. One of the paramedics wrote in her statement to the police that, upon their
arrival at the gate at Lincoln, she and her colleague were instructed to
surrender any mobile telephones in their possession. Although there is no
evidence that this delayed their progress into the prison, I am concerned that it
could do so in the future. I leave it to the Governor to judge whether, in the
circumstances, this was an unnecessary security procedure.
Incorrectly sealed key pouch
209. The HSW told my investigator she had difficulty gaining access to the
emergency keys in her sealed pouch when called upon to respond to the
emergency. She believed the difficulty occurred because her pouch had been
incorrectly sealed. She reported this to the Governor in writing the same day.
The Governor will wish to satisfy himself that her complaint has been
satisfactorily resolved and that steps have been taken to minimise the risk of it
happening again.
210. Notwithstanding the criticisms I have made above, I consider that the response
to the emergency was handled well.
Was the support given to the man’s family after his death appropriate?
Informing the next of kin
211. The investigation found that there was a lapse of time of about six hours
between the discovery of the man hanging and his mother being informed of his
death. This was a matter of concern to his family.
212. According to the protocols in place at the time, it fell exclusively to the person
appointed as the prison’s family liaison officer to inform the next of kin of the
death of a prisoner.
213. The duty governor that night was the first manager to be contacted, at about
3.00am, and told that the man had been found hanging. He left for the prison
and arrived at about 3.30am. He said he went straight to the orderly officer for
a briefing on what had happened. Afterwards he went to E wing. He
considered notifying the man’s family of his death immediately but chose not to
do so, primarily because he believed it would have been inappropriate to break
the news of his death at that time of night, especially when the family liaison
officer would be on duty within two to three hours. He also had urgent
operational duties to perform in the prison as a direct result of the death, as well
as gathering accurate information about what had happened.
214. The prison’s family liaison officer was called by the prison at around 6.30am to
7.00am, arriving at the prison at about 8.15am. Upon her arrival, she was told by
54
the Governor that the man had been found hanging and had died. The Governor
also told her that the man’s mother had telephoned the prison at about 8.00am to
enquire about his wellbeing following her telephone conversation with the NOO
the previous evening. Whoever took the 8.00am call may not have been aware
of the full details of events and may not have been in a position to report that her
son had died. She told my investigator that she was thus aware of the need to
inform the man’s mother of her son’s death as soon as possible. By 8.50am, she
was equipped with sufficient information about the details of his death to ring the
telephone number she had been given for the next of kin. The man’s mother
answered. She then told her of her son’s death.
215. I have considerable sympathy with the concerns expressed by the man’s mother
in this regard. However, I am satisfied that the delay was not borne out of any
negligence or insensitivity on the part of the duty governor or family liaison
officer. They had considered other methods of breaking the news of the man’s
death to his mother. One such option was to ask the police to inform her in
person. However, the view of the duty governor and of the family liaison officer
was that this method was also likely to incur lengthy delays, such that the news
may not have been conveyed to her significantly earlier.
216. That said, I take the view that, following the death of a prisoner, the need to
inform the next of kin in an appropriate manner is paramount. I am aware that in
previous reports I have drawn the attention of the previous Governor to this
issue. The present Governor will wish to satisfy himself that the need to break
the news of a prisoner’s death promptly and, ideally, on a face to face basis is
clearly expressed in his local contingency plans.
The Governor should urgently review his local contingency plans for
informing the next of kin of the death of a prisoner so as to ensure that this
task is carried out promptly and, ideally, on a face to face basis, by an
appropriate person.
Were prisoners and staff appropriately supported after the man’s death?
Prisoner support
217. My investigator was told by the prisoner who had been the man’s cellmate that,
early on the morning of 29 July, the Governor personally told him of the death.
However, beyond that, my investigator was presented with no information to
show what other support was given to prisoners in the aftermath of the death.
218. Prison Service Order 2710 sets out the following provisions for the support of
prisoners following a death in custody:
“Friends, associates and cellmates of the prisoner who has
died or other prisoners who had been offering peer support or
acting as Listeners and any friends or relatives in other
establishments should also be offered support. Local
Samaritans will make themselves available to debrief
Listeners. Other peer support schemes can help, such as
prisoner group sessions. The Chaplaincy Team and, in
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particular, the Chaplain from the particular faith tradition of the
prisoner must always offer support to, and to pray with
prisoners and staff. This will include holding a memorial
service for the deceased’s family, prisoners and staff subject
to any faith specific considerations and the views of the family,
staff and prisoners. Some self-inflicted death in custody
statistics may be taken to indicate that there is a potentially
heightened risk of suicide and self-injury attempts following a
death in custody, with several prisons having experienced
“clusters” of deaths, sometimes with “copycat” features. Staff
should be alert to this possibility and be vigilant, particularly
with other vulnerable prisoners, especially known self-injurers,
other high-risk groups or recent “at-risk” prisoners and those
on recently closed or open ACCTs, which must be reviewed
and documented as soon as practicable and within 24 hours.
Applied psychology, probation and mental health in reach staff
should also be able to offer assistance to individual prisoners.”
I consider that the support offered to prisoners and staff in the aftermath of
the man’s death was not satisfactory.
The Governor should ensure that, following any death in custody,
appropriate support is offered to prisoners in keeping with the
provisions of PSO 2710.
Staff support
219. The investigation found that there was no debrief of staff after the man had
been pronounced dead in his cell. My investigator was also told by one
member of staff that when the full debrief was held some time later, those
present were limited in what they could contribute because they were “not
allowed to talk about operational matters”. The member of staff concerned said
he did not have a chance to discuss “how things might have been done
differently”.
220. PSO 2710 also makes it clear that there should always be a ‘hot’ debrief after a
death in custody has occurred.
The Governor should ensure that, in keeping with the provisions of PSO
2710, a ‘hot’ debrief takes place immediately after any death in custody.
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ADDITIONAL FAMILY CONCERNS NOT INCLUDED IN MAIN BODY OF REPORT
Consultation with psychiatrist:
221. The man’s mother asked why the psychiatrist who saw her son only spent a
short time with him and why he did not arrange a further referral. I am unable
to answer this question as there is no evidence in his medical record to clarify
this point.
Use of a safer cell
222. The man’s mother asked why her son was not put in a safer cell, especially on
28 July 2008. She took the view that had this been done, he would not have
been able to use his curtains as a ligature. (The ligature he used was made
from a torn piece of green bed-sheet and not from the blue curtain material
covering the windows of his cell.)
223. A safer cell is defined as one in which the opportunity for a prisoner to hang
himself is minimised. There are no safer cells in the Vulnerable Prisoner Unit
where the man died. Had there been any such cells it does not follow that he
would necessarily have been located in one during the night of 28/29 July. The
NOO took the sensible precaution of opening an ACCT plan and directing that
he should be observed at half hourly intervals through the night. I consider that
these measures were appropriate, particularly as the man had not harmed
himself with a ligature on any previous occasion whilst he was in custody.
Why were there marks on the man’s body?
224. The man’s mother expressed her concern that there were unexplained marks
on her son’s body when she viewed him in the mortuary. The pathologist who
conducted the post mortem examination listed the following old marks and
injuries on the body:
• A horizontal scar measuring 1.0cm just below the central aspect of the
lower lip.
• Numerous oblique, horizontal and vertical scars to the posterior and
anterior aspect of both forearms as well as to the back of both hands and
to the anterior aspect of both upper arms measuring up to 15cm.
• Irregular indistinct scarring to both anterior knees.
225. The pathologist also listed the following fresh marks and changes on the body:
• A very superficial abrasion measuring 1.5cm, 2.0cm to the left of the
midline, to the forehead.
• Two abrasions measuring 0.1cm to the forehead, 3.0cm right of the
midline.
• A ligature mark to the neck.
• Fresh and recent cuts to the anterior and posterior aspect of the left
forearm. These were measuring up to 8.0cm in length and were of
oblique orientation. There were at least 20 such cuts present.
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• A longitudinal band-shaped abrasion measuring 6.0 x 0.9cm to the inner
aspect of the right forearm.
• An abrasion measuring up to 0.9cm to the back of the left hand.
• A blue to purple bruise measuring 2.9 x 1.0cm to the left inner elbow.
226. The pathologist commented that none of these injuries (other than that caused
by the ligature) might have caused or contributed to the man’s death.
Transfer to a prison on the Isle of Wight or to Rampton
227. The man’s mother thought that her son had been considered for a transfer to a
prison on the Isle of Wight or to the secure hospital at Rampton. There is a
reference in his life sentence plan to his being “happy at the prospect of a move
to HMP Wakefield”. On 3 October 2006, a Governor submitted a request to the
Population Management Section at Prison Service Headquarters for him to be
transferred to HMP Wakefield on the grounds that it was “the only appropriate
allocation when considering his offence and length of sentence”. The
investigation found no evidence that he had been considered for a transfer to a
prison on the Isle of Wight.
228. The only reference to Rampton Hospital that my investigator could find was
contained in a psychiatric report to court by a doctor dated 28 September 2006.
In this report, he wrote:
“After his sentence it is also worth referring him to the
Dangerous and Severe Personality Disorder Unit (DSPDU)
in Rampton Hospital. Following his sentencing, if I am
informed about his whereabouts, I will be happy to refer him
to Rampton Hospital for an assessment and advice.”
Conduct of the prison family liaison officer
229. The man’s mother said that her son had told her that another prisoner in a
nearby cell had taken his own life. When she told the family liaison officer, she
said that the family liaison officer became annoyed.
230. At interview, the family liaison officer replied to this claim as follows:
“I have absolutely no memory of that conversation but I can
say 100% categorically that I wouldn’t be annoyed. It
wouldn’t be my place to be annoyed by that. And if that’s
been mis-communicated to her, then I’m really sorry but I
have no memory of that at all.”
231. The version of events given by the man’s mother differs from that given by the
family liaison officer. I consider that there has most likely been a
misunderstanding between the two parties but I note the family liaison officer’s
professionalism in offering her apologies.
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CONCLUSIONS
232. In her clinical review of the management of the man’s health needs at Lincoln,
the clinical reviewer concludes that, overall, the standard of healthcare he
received was exemplary. I agree. However, his frequent acts of self-harm
were demanding of healthcare staff and officers in E wing. Nevertheless,
decisions to open ACCT plans were carefully and thoughtfully made and
measures taken to support him were, in the main, appropriate. It became clear
to staff that he had developed a propensity, if not a dependence, on cutting his
arms as a means of releasing and relieving tension. His risk of harming himself
was constantly re-assessed during periods when ACCT plans were in force.
233. Apart from the exceptions on which I comment in paragraphs 167- 179 above, I
believe that the ACCT procedures were carried out as set out in Prison Service
Order 2700 – Suicide Prevention and Self - Harm Management. I therefore
conclude that the assessment, monitoring and management of the man’s risk of
self-harm prior to the night of 28/29 July 2008 was satisfactory.
234. Prior to the night of 28/29 July 2008, the man gave no indication that he was
actively contemplating suicide. However, he gave an indirect indication of
suicidal ideation to a third party outside the prison shortly before 11.00pm that
night. That person called the man’s mother who relayed her concern to the
NOO, who checked him and assessed him as being alright. Nevertheless, the
NOO took the sensible precaution of opening an ACCT plan there and then,
and directed that he should be observed at half-hourly intervals.
235. I conclude that the measures taken by the NOO were in keeping with best
practice. Although I draw attention to the predictability of the observations
made of the man that night, I blame no-one for the fact that he successfully
hanged himself.
236. The investigation found evidence to suggest that the man may have been
coerced by a corrupt prison officer. However, no evidence arose from either
the internal Prison Service investigation or from the police investigation to show
that there was a provable connection between the conduct of the officer and his
death. In the letter found in his cell after his death, addressed to his mother, he
made no reference to these matters.
237. I consider that the response to the emergency was in the main handled well.
However, there was a delay of about six hours before the news of the man’s
death was conveyed to his mother. I take the view that, following the death of a
prisoner, the need to inform the next of kin promptly is paramount. Local
contingency plans for informing the next of kin must reflect this.
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RECOMMENDATIONS
1. The Governor and PCT should remind their respective staff of the need to involve
appropriate healthcare staff in ACCT case reviews, where possible, in keeping with
the provisions of Annex 8G of PSO 2700.
Accepted – “There is currently a robust system in place to ensure either Lincolnshire
Community Health Services (where general health needs are concerned) or
Lincolnshire Partnership Foundation Trust (where mental health needs are
concerned) are integral to the ACCT process.”
2. The Governor and PCT should take steps to ensure that, whenever members of
staff make an entry in a prisoner’s record, they should always print their name clearly
and legibly against the entry. It is especially important for them to do so when
making entries in ACCT plans and medical records.
Accepted – “Accurate and legible completion of records are required under Nursing
and Midwifery Code of Conduct and Lincolnshire community Health Services Policy
All staff are required to work to this standard and information regarding this has been
circulated to all members of the healthcare team to ensure they are up to date and
aware of their requirements. A Governor’s Order has been issued that informs all
staff that anyone who makes entries into ACCT documents should always print their
name clearly and legibly against the entry and where applicable add their epaulette
number.”
3. The Governor should draw the attention of the staff concerned in the case review
conducted on 1 November 2006 to the policy set out in Annex 8G of PSO 2700 for
the closing of ACCT plans and to paragraph 9.14 of his local suicide prevention
policy document.
Accepted – “This is covered through ACCT training and the ACCT books give
guidance on how to conduct an ACCT closure.”
4. The Governor should remind staff of the need for observations of at-risk prisoners
to be carried out at irregular intervals, in keeping with the provisions of paragraph 4
of Annex 8HH in PSO 2700 and of paragraph 9.23 of his local suicide prevention
policy document.
Accepted – “ACCT observations are discussed at reviews. The wing managers also
carry out daily quality checks of all ACCT books. This is also raised at ACCT
training. Residential managers complete weekly management checks on all ACCT
books to ensure consistency.”
5. The Governor should remind his staff of the provisions contained at paragraph
9.25 of his local suicide prevention policy for the removal of items such as razor
blades from at-risk prisoners. He should ensure that those provisions are followed
consistently by all staff, especially where the recording of decisions in ACCT plans is
concerned.
Accepted – “The policy has been reviewed since 2008; this is covered in 9.32 of the
current policy. Staff do not routinely remove items in possession from prisoners at
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risk of self harm. Staff are reminded of this at ACCT training sessions. 10% quality
checks of closed ACCT books are completed by the Head of Safer Prisons.”
6. The Governor should remind his staff of the requirement for a post closure review
to take place whenever an ACCT plan is closed and should put in place regular
management checks to ensure that this requirement is met.
Accepted – “Regular management checks are carried out by:
• Daily wing SO managers checks
• Weekly Residential Governors checks
• 10% quality checks of closed ACCT books by Head of Safer Prisons,
Safer Prisons Admin manages the follow up of Post Closure reviews.”
7. The Governor should review his local suicide prevention policy so that clear
guidance is given to staff with regard to the need for continuous assessment of the
appropriateness of at-risk prisoners’ relocation from shared to single cell
accommodation. This factor, where it applies, should be included on the agenda for
post closure ACCT reviews.
Accepted - “This is covered through paragraphs 9.18 and 9.19 of our local policy.
The Post Closure form has been reviewed and this added to the agenda to ensure it
is discussed at the post closure review point.”
8. The Governor should review his contingency plans for the management of life-
threatening emergencies so as to ensure that proper information is passed to the
emergency services as to the nature of the emergency. If necessary, appropriate
staff training should be offered.
Partially accepted – “Basic life support training for officers is now being provided by
staff from Lincolnshire community Health Services as a rolling programme to
maintain knowledge and skills. Medical emergencies are notified to healthcare staff
via radio (Hotel 1) and healthcare staff communicate required information to external
emergency response via Control. It is reported that the ambulance control room
requests information that is not readily available at the time that ambulance is
requested. A Governor’s order will be issued on a annual basis reminding staff of the
reporting codes for medical emergency and the mandatory details that are required
in order for the control room provide information to the ambulance service.”
9. The Governor should urgently review his local contingency plans for informing the
next of kin of the death of a prisoner so as to ensure that this task is carried out
promptly and, ideally, on a face to face basis, by an appropriate person.
Accepted – “The death in custody contingency plan was reviewed in September
2010 and reiterates the process of who informs the next of kin and the risk
assessment process that is applied in considering any issues in informing the next of
kin in person.”
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10. The Governor should ensure that, in keeping with the provisions of PSO 2710, a
‘hot’ debrief takes place immediately after any death in custody.
Accepted – “The death in custody contingency plan was reviewed in September
2010 and highlights the requirement of the Duty Governor to arrange the hot debrief.”
11. The Governor should ensure that, following any death in custody, appropriate
support is offered to prisoners, in keeping with the provisions of PSO 2710.
Accepted – “The death in custody contingency plan was reviewed in September
2010 and highlights the requirement of the Duty Governor to arrange appropriate
support is offered to prisoners.”
Commendations
1. I commend the NOO for having the presence of mind to open an ACCT plan
shortly after 11.00pm on 28 July as a precautionary measure, and for deciding that
the man should be observed at half hourly intervals.
The Governor has written to the NOO, drawing attention to the commendation within
the report.
2. I commend the two officers, the nurse and HSW for their determined attempts to
save the man’s life.
The Governor has written to the staff concerned and drawn attention to the
commendation within the report.
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