Individual at Preston

Investigation into the circumstances surrounding the
death of a man
at HMP Preston in January 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
January 2008
This is the report of an investigation into the apparently self-inflicted death a man at
HMP Preston on Monday 29 January 2007. I pass on my sincere sympathies to his
family and friends both in the UK and overseas for their loss.
I appointed a colleague from my team to investigate the circumstances surrounding
the man’s death on my behalf. She received excellent and timely support from the
prison’s Deputy Head of Reducing Reoffending. I would also like to thank the
Governor for the support and time that he and his staff gave to the investigation
process.
Despite repeated attempts to contact the man’s family, my office only communicated
with them at the beginning of the investigation process. Regrettably, they have not
had the opportunity to comment on the draft report before its finalisation.
I am also grateful to the clinical reviewer for his examination of the man’s medical
care while in prison. The clinical review was commissioned by Central Lancashire
Primary Care Trust (PCT) and makes five recommendations.
The man had lived illegally in the UK for two years with friends and his brothers.
Following a police raid on his home, he was arrested and questioned for a number of
days. The man appeared in court and was remanded to Preston on Thursday 25
January. During his five days at Preston, he appeared to suffer from anxiety and
was found in a state of panic on three occasions. He seemed confused as to why he
was in custody. Staff submitted two referrals to the mental health team for an
assessment, but he was not seen by a member of the mental health team before he
died.
I was pleased to find staff so keen to settle prisoners into HMP Preston, and
identifying their needs at an early stage to see if they could be addressed. However,
as in many prisons, I am concerned at the level of primary care mental health
resources available. Although I recognise that this is an area that is currently being
developed as a matter of priority, I have made a recommendation to reinforce this.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2008
Anonymous Report March 2008 2
CONTENTS
Summary 4
The Investigation Process 6
HMP Preston 7
Key Events 8
Issues 20
Recommendations 29
Anonymous Report March 2008 3
SUMMARY
The man was arrested suddenly following a police raid on his home. He was
questioned by the police and immigration services for several days, before being
remanded to HMP Preston on the evening of Thursday 25 January.
Throughout the reception and induction process, the man appeared to be confused
by his situation and concerned about the charges he was facing. He told staff that it
was his first time in prison and he appeared apprehensive.
Staff made efforts to explain his position to him, to put him in touch with his family
and to make him feel more comfortable. On three occasions, he was found in an
anxious state under his bed. Healthcare staff attended his cell promptly and
succeeded in calming him down by talking with him about his problems. A mental
health referral was made. Arrangements were made for him to speak with the imam
and attend Muslim prayers on the Friday afternoon.
The man displayed “bizarre behaviour” and his cellmate raised concerns about him
with the officers on duty. In his heightened state of anxiety, the man stood in his cell
shaking or pacing. An officer took him to one side to see if he was okay and the man
said that he was concerned about his legal representation. The officer explained
that nothing could be done over the weekend but that he could contact his solicitor
on Monday morning. The officer made a further mental health referral.
The weekly referral meeting was held by the mental health team on the afternoon of
Monday 29 January. They discussed both of the man’s referrals and agreed that the
problems with which he was presenting were anxiety related. With that in mind, they
referred him to the Primary Care Mental Health Worker who was on leave at the time
of the referral.
The man moved to the induction wing. His new cellmate raised concerns about
sharing a cell with the man after spending less than an hour with him at lunch time.
The cellmate was moved and he was left in the cell by himself. Prisoners
complained about him after they returned from their afternoon exercise period. They
reported to staff that he was making threatening comments. Officers on the wing
tried to get someone from the mental health team to see the man urgently.
Eventually, the medical response nurse, who was not mental health trained, agreed
to go to his cell after he had finished dispensing treatments. The man was
discovered hanging in his cell before the nurse attended.
When the man was found hanging, staff acted promptly. With the help of a prisoner,
they entered the cell and untied the ligature knot to lower him to the ground. At that
point, the nurses arrived, found no signs of life and commenced cardio-pulmonary
resuscitation (CPR). No one had brought a defibrillator to his cell, although it would
probably have been of limited use in any case. The man was pronounced dead by
the prison doctor at 4:55pm.
Although we had contact with the man’s family at the beginning of the investigation
process at the beginning of our investigation, my Family Liaison Officer has been
Anonymous Report March 2008 4
unable to contact his family or their representative since. Therefore, the man’s
family has not seen the draft report in order to make their comments.
I found evidence that staff had tried to engage and find ways to calm the man’s state
of unease. Two members of staff were sufficiently worried about his mental state to
submit mental health referrals. However, I am concerned about the primary care
mental health resources available at Preston and this report includes two related
recommendations. Of the eight recommendations in total, five derive from the
clinical review. Three are my own.
Anonymous Report March 2008 5
THE INVESTIGATION PROCESS
1. This investigation was conducted by my colleague, on my behalf. Notices were
issued to staff and prisoners offering them the opportunity to contact the
investigator with any information they thought relevant. No staff or prisoners
responded to these notices.
2. On 7 February 2007, the investigator visited Preston to collect copies of the
man’s prison records. During this visit, my investigator met with the Chair of the
Independent Monitoring Board. She also met with a member of the Prison
Officers’ Association (POA) and the Head of Healthcare to explain the purposes
of the investigation and give them the opportunity to raise any concerns about
the investigation process. At the end of her visit, the investigator had a brief
meeting with the Governor who undertook to co-operate fully.
3. I would like to thank the Governor and his appointed investigation liaison officer
for their assistance during this investigation. The investigator returned to
Preston several times to interview staff and prisoners. She also contacted the
Border and Immigration Agency and the man’s solicitor.
4. I am grateful to the clinical reviewer for conducting a thorough examination of the
man’s medical care.
5. The man’s elder brother spoke to my Senior Family Liaison Officer on a number
of occasions. My Senior Family Liaison Officer, accompanied by the
investigator, met with the man’s other brother on 13 March 2007 to explain the
investigation process and to give him the opportunity to raise any concerns. I
hope that this report goes some way to answering the questions that the man’s
family might have about his death.
Anonymous Report March 2008 6
HMP PRESTON
6. As a local prison, HMP Preston faces the pressures of overcrowding on a daily
basis. The population is always close to the prison’s operational capacity of 690
prisoners. Preston is expected to increase its operational capacity over the next
year.
7. In her most recent inspection, Her Majesty’s Chief Inspector of Prisons found
that, despite the threat of overcrowding to a healthy regime, Preston managed to
operate “impressive first night arrangements”, although reception procedures
were not as good. The inspection team found that there was “evident mutual
respect between many staff and prisoners”. However, minority ethnic prisoners
did not feel that they were effectively looked after, despite an improvement in the
race relations policy. That said, the prison imam spoke highly of management at
the prison and said that there were no difficulties that he was aware with Muslim
prisoners integrating with other prisoners on the wings.
8. There is a mental health inreach team at Preston and an inpatient mental health
facility for prisoners with acute mental health needs within the North West Prison
Service Area. However, there is only one primary care mental health worker
dealing with day to day mental health needs such as depression or anxiety. (I
am pleased that this appointment has been made since a previous investigation
in which I criticised the lack of primary care mental health resources at the
prison. I understand that further work is ongoing, in partnership with Central
Lancashire PCT, to address this important area of healthcare.)
9. The man’s death was the first of two apparently self-inflicted deaths in 2007 at
HMP Preston.
Anonymous Report March 2008 7
KEY EVENTS
10. The man appeared at a local Magistrates’ Court on 24 January, facing five
counts of possession of a document with intent to deceive. He was refused bail
and remanded into custody. His younger brother also appeared in court with
him and was facing the same charges. Both were remanded to prison until their
next court appearance, which was yet to be scheduled.
11. At the time that the man was remanded, the prison system was struggling with
significant overcrowding issues. As a result, he was not remanded to the closest
prison, but instead transferred to Preston after spending a night in court cells.
His younger brother was under 21. Prisoners under the age of 21 are kept
separately from the adult population in Young Offender Institutions (YOIs), with
additional facilities for young people. He was therefore transferred to a nearby
YOI.
12. On arrival at Preston, the senior officer in reception checked that the man had all
of the appropriate paperwork. The senior officer completed section one of the
cell sharing risk assessment (CSRA) and passed the part completed risk
assessment and paperwork to the duty reception officer. (The cell sharing risk
assessment is used to determine whether it is safe for a prisoner to share a cell
with another prisoner, or if it would place the prisoner or his cellmate at risk.)
That officer interviewed the man and asked him if he should have any concerns
about locating him in a cell with another prisoner. The man said that he was not
aggressive, had no thoughts or history of self-harm and no history of substance
misuse. The duty reception officer concluded that the man could safely share a
cell with another prisoner. The officer particularly remembered that the man
asked whether he could be deported, rather than serve a custodial sentence in
the United Kingdom. The duty reception officer advised the man to speak to his
solicitor about deportation and his sentence, because he was not qualified to
help him. The officer said that it was unusual for a prisoner to ask to be
deported. In his experience, prisoners are usually anxious not to be deported.
13. The nurse on duty in reception on 25 January found that the man had a partially
completed first reception healthscreen with him from his overnight stay in the
court cells. (The first reception healthscreen is an interview by healthcare staff
that takes place when a prisoner arrives at the prison. It should determine any
physical or mental health conditions that require treatment, any substance
misuse matters that need to be addressed and any risk that the prisoner may
pose of harming himself or attempting suicide.) The nurse told my investigator
that, instead of starting a new healthscreen, she checked the details on the
existing form were correct and added to it. She asked the man a series of
questions about his physical and mental health. She also assessed his
behaviour and considered his likely risk to himself and others. The man told the
nurse that he had never tried to harm himself before. Nonetheless, she noted:
“feeling anxious about first time in prison, confused over what he is charged
with but stated he had no plans to harm himself at present.”
Anonymous Report March 2008 8
14. When the nurse asked the man whether he had any specific questions for
reception staff, he asked about his sentence. She recorded the following in his
medical record:
“worried about sentence has 10 yrs in head, advised to speak to officer on
wing, try to contact solicitor.”
15. The man described how the police had found lots of identification with his details
on them in his flat, but said that he was not involved in any deception. The
nurse told my investigator that she knew the nature of the charges that he was
facing but was not in a position to give him legal advice. She made a record of
the man’s confused presentation. She said that, although he was confused
about being in prison, he was fully aware of what had happened to him in the
previous few days. He told her that he had never received psychiatric treatment
outside of prison, had never taken medication for psychiatric problems and had
never self-harmed. He said that he had no thoughts of self-harm at that time.
The nurse did not think that he was at risk of self-harm and therefore did not
open an ACCT document. (ACCT - Assessment, Care in Custody and
Teamwork - is the system used to monitor and support prisoners considered to
be at risk of suicide or self-harm.) Based on her findings, she did not make a
referral for a mental health assessment. During her interview, the nurse made it
clear that the man was not having a panic attack in its truest sense, because he
was in control of his breathing. She completed the medical section of the cell
sharing risk assessment, indicating his confusion, before giving it to the officers
to ensure that it accompanied the man to the wing.
16. During the healthscreen, the nurse asked another reception officer to speak to
the man about his charges. The second reception officer took the man to one
side of the reception area after his healthscreen and went through his court
documentation with him. During interview, the officer remembered that the man
was anxious to contact his friend and get his flat sorted out. He reassured him
that staff on the first night centre would help him to get in touch with his solicitor
and contact his friend. The man was given some food and was later escorted to
the first night centre.
17. He was located in a shared cell on the first night centre with another prisoner.
The first night officer then took him to a small interview room on the wing to
complete the ‘Immediate Needs’ checklist, a form designed by staff at Preston to
highlight any matters that are particularly troubling a prisoner who has just
arrived. Some prisoners may not have been expecting to go to prison and
officers help them put their affairs in order. The man initially indicated that he
could not speak English at all. As the interview progressed, he began to
understand what was being said to him and spoke to the first night officer. He
said that he was “frustrated” because his mobile telephone had been confiscated
by police so he had no contact numbers and he wanted to speak to his friends.
In particular, he wanted to call someone abroad but the first night officer said
that he could not authorise an international telephone call. The officer explained
that prisoners have to make an application for an international call to the
Governor.
Anonymous Report March 2008 9
18. The first night officer suggested that he write to his friends, but the man said that
he had no addresses with him. When the officer suggested that his friends
would visit him in due course, the man said that they were unlikely to because
they would be fearful of arrest. He told the first night officer that he had never
been depressed or treated as such. The officer did not think that the man was at
risk of self harm. He described him as being “angry” during the interview
because he could not understand why he was in prison. The officer again
explained the charges that he was facing but the man still seemed to be
confused. As an experienced officer on the first night centre, the officer said that
a lot of prisoners are confused and angry when they first come into custody and
the man did not give him any particular cause for concern.
19. At 7.30am the following morning, the man was seen lying on the floor under his
bed, apparently having a panic attack. The officer covering the early morning
shift before prisoners were unlocked radioed for assistance from healthcare
staff. He handed over to another first night officer who arrived for the main shift
and explained that he was waiting for healthcare to visit the man.
20. The nurse who had assessed the man on reception was on duty again that
morning. When she arrived on the wing, she found the man in his cell under the
bed breathing rapidly. After speaking to him, the nurse discovered that he was
“very anxious about being in prison and stated he had never been in this
situation before”. She spoke with him for some time. After a short while, she
asked the prisoner who shared the cell to leave them alone for some privacy.
The nurse asked the man what was wrong and he said he did not know why he
was in prison. She reminded him that she had spoken with him the previous day
and what he had told her about the circumstances of his arrest. The nurse
thought it was “bizarre” that he appeared to have completely forgotten their
previous conversation. It was at this point that she decided that she would
“definitely have to refer him to mental health inreach”. As the conversation
progressed, his breathing became normal. The nurse suggested that officers
contact the chaplaincy team to see if the imam could encourage the man to
settle into the prison routine. Following this episode, she also asked the doctor
to visit the man’s cell. The nurse thought that the man was particularly worried
about being locked in the cell and speculated as to whether he had suffered a
previous traumatic experience that had made him claustrophobic. Staff agreed
to keep his cell door open as much as possible, security permitting.
21. The first night and induction wing principal officer wrote in the observation book
that the man was “having a possible panic attack, although I do believe he was
exaggerating a little”. Nevertheless, a message was left at the gate so that the
imam, who was due that morning, would make his way to see the man as soon
as he arrived in the prison.
22. When the imam in Preston’s chaplaincy team arrived at the prison at 9.00am
that day, he immediately received a message at the gate to come to the first
night centre and see a prisoner. The imam said that he thought it must have
been urgent for a note to be left at the gate. Normally it would just be left in the
chaplaincy office. The imam made his way to the first night centre where an
officer directed him to the man’s cell. He found the cell door open. The man
Anonymous Report March 2008 10
was standing in his cell and shaking, as if he had just had a panic attack. The
imam took him to a glass-walled room just behind the wing office so that they
could talk privately. The man said that he had come from a nearby city and had
no family members in England but lived with a friend. The man asked if he had
contacted his friend, but the man said that he could not because his friend had
also been arrested. He asked the imam where his friend was. The imam told
him that he did not know but that, due to overcrowding, there was a chance that
his friend had not been brought to Preston. (The imam asked an officer on the
wing to find out what had happened to the man’s friend after he finished talking
with him. The officer said that they were already in touch with the police about
his whereabouts.)
23. The man asked the imam where he was. The imam was surprised that he did
not know but explained that he was in prison in Preston. He then asked why he
had been arrested and the imam said that the police should have told him this.
The man finally said that he was charged with five counts of deception. The
imam told him that he needed to calm down and wait for his solicitor who would
be able to advise about the nature of the charges he was facing. The man said
that his solicitor had scared him by suggesting that he was likely to get two years
for each count of deception, and it was likely that he would serve a ten year
prison sentence. The imam explained that solicitors are obliged to advise their
clients as to the absolute maximum sentence they could receive and that the
advice did not mean that he would necessarily be sentenced to ten years.
24. During this meeting, the imam asked the man if he had any thoughts of self-
harming. He told my investigator that he asks every prisoner, especially those
who are in prison for the first time, whether they feel at risk of self-harm. The
man said that he had no such thoughts and the imam was satisfied with this
answer. The imam said that if the man had said he was thinking of self-harming,
or if he had thought that he might be at risk, he would have opened an ACCT
document. At the end of their discussion, which lasted around thirty minutes, the
man asked the imam to say a short prayer for him, which he did. The imam
invited the man to attend the weekly Muslim service that was taking place that
afternoon and he agreed. The imam escorted the man to his cell but left the
door open, as he had found it, to avoid making him feel anxious or
claustrophobic.
25. Shortly afterwards, the duty first night centre officer completed the follow-up
assessment to the immediate needs checklist which had been completed by
another first night officer the evening before. The duty first night centre officer
told my investigators that the man spoke good English but would sometimes
exaggerate his language difficulty to his advantage. The officer particularly
remembered that the man was anxious about retrieving his telephone contacts
from his mobile telephone. The officer told him that he would speak to the police
to try to recover the telephone, but when he spoke to the police they said that
the telephone had been confiscated by the immigration service. The duty first
night officer spoke to the immigration service who said that they were not in
possession of any of the man’s personal property.
Anonymous Report March 2008 11
26. The man also asked the duty first night centre officer if arrangements could be
made to telephone his father overseas. The officer explained that international
telephone calls were allowed, but that an application had to be made to the
Governor. The officer filled out the necessary application form on the man’s
behalf. Following the interview, the officer wrote that the man was still “very
concerned” about being in prison and needed help with legal aid. However,
according to the follow-up assessment checklist, the man did not ask for
information about deportation, visits, letters or telephone calls.
27. During the morning of 26 January, the man approached the first night officer and
said that he was unhappy with his solicitor and wanted details of another
solicitor. That officer thought that the man approached him particularly because
he was a familiar face from his first night in prison, he is also a trained legal aid
officer. He suggested that the man contact the Immigration Advisory Service,
who would be able to advise him about his immigration status. He wrote the
address down and reassured him that, in his experience, they were quick to visit
prisoners who contacted them. The officer also explained that it would be
inappropriate for him to recommend a lawyer, but gave him a directory of
solicitors. He said that the man should write to the solicitor that he wanted to
represent him with the details of his case and see if they would take him on as a
client. The man asked the officer how long his sentence was likely to be, given
the nature of his charges. The officer told him that he could not advise about
that because it depended on the circumstances of the offence and the judge’s
decision in court.
28. By coincidence, that day the imam was the member of the chaplaincy team
detailed to work on the first night centre. This meant that he would speak to all
of the new prisoners who had arrived the previous day. He said that, at some
point later that morning, he walked past the man’s cell and he was standing in
the far left corner of the cell, shaking and looking out of the window. The imam
said that the man appeared to be “internally not feeling well”. The imam
suggested that he calm himself down and sit on his bed, but the man insisted
that he was okay standing.
29. At 12.45pm, healthcare staff were called to the man’s cell again after he was
found collapsed on the floor of his cell. The same nurse as had seen the man in
reception attended his cell and found him under his bed, breathing heavily. He
began breathing normally again when he sat up and spoke to her about his
anxiety. He told the nurse that he was having problems coming to terms with
being in prison and was troubled by the effect that it would have on his mother’s
health. He told her that speaking with the imam had helped him calm down.
The nurse explained to the man that he had to be locked into his cell over the
lunchtime period, but that this would be an opportunity for him to calm down and
rest. Two senior officers were waiting outside in case the nurse needed
assistance. The nurse locked the door when she was finished and was
accompanied by the senior officers as they made their way off the wing together.
Before they had left the wing, an officer on the wing called for assistance
because the man had again got under his bed and was shaking. One of the
senior officers unlocked the door and both resumed their position outside the
cell. The nurse calmed the man down again and explained that he had to be
Anonymous Report March 2008 12
locked in his cell over the lunchtime period. He was in the cell on his own at the
time, but the senior officers explained that new prisoners would arrive before the
end of the day and he would have someone else in the cell later on. She
advised the man to see the imam again because it seemed to have helped him
before. The man asked her to find him a copy of the Quran. Officers told her
that this would be arranged. Eventually, he calmed down and the nurse was
able to leave him.
30. The nurse described the man as suffering from “genuine panic”. She said he
was in control of his breathing and therefore was not having a panic attack.
However, he was not in full control of himself and, in his anxious state, fell off his
chair. She made the mental health referral at this time. After seeing him that
afternoon, she spoke to the doctor and the doctor agreed to go and see him in
his cell in order to give him something to help him sleep over the weekend.
31. The mental health team meets every week, on a Monday, to discuss all of the
mental health referrals and decide whether the prisoner should be seen by the
in-reach team or the primary care mental health worker. The nurse said that she
was concerned that the man would have to wait over the weekend, but she did
not know what else to do for him. There are no primary care mental health
services available at Preston over the weekend period.
32. At some point during the afternoon of the 26 January the doctor on duty that day,
went to see the man. She remembered him being particularly anxious about his
family and his mother’s health. Following her visit, the doctor made the following
entry in his medical record:
“Not sleeping. Coping poorly with incarceration. Needs MHT (Mental Health
Team) referral. Review after he has had a few nights rest. Prescribed
Zopliclone in possession for five days.” [Zopiclone is a drug commonly used
to treat sleeplessness.]
During interview, the doctor said that she was concerned about the man’s
anxiety. She said that it was not unusual for someone who has not been in
prison before to suffer from such reactive anxiety. The doctor said that the
prescription was written on the inside of the prescription chart, which meant that
nurses would give him the sleeping tablets daily on the wing. In January 2007,
there was no policy at Preston for risk assessing new prisoners on arrival at the
prison as to whether they should have medication in possession in their cell.
(Since that time, a policy has been introduced to manage this risk and
encourage an individual to manage their own clinical condition.) The doctor
agreed with the nurse’s decision to make a referral for a mental health
assessment. The man did not seem to be reacting well to custody and staff at
the prison did not have access to his past mental health history.
33. The Muslim service took place at about 1.30pm. The imam remembered that
the man attended and was supplicating and crying throughout the service. After
the service, prisoners have the opportunity to chat to each other before returning
to their wings. After the service on Friday 26 January, the imam was speaking
with several prisoners when the man approached him. The imam immediately
Anonymous Report March 2008 13
stopped talking to the others and asked him if he was okay. He asked the imam
what was going to happen to him. The imam reassured him that someone would
come and see him to explain what was likely to happen. The prisoners nearby
overheard this conversation and asked the man why he was in prison. He told
them that he was worried about his charges and concerned about his sentence.
The other prisoners reassured him that he was unlikely to receive as long a
sentence as he expected. The imam said the man appeared to be comforted by
the conversation. Since their morning meeting, the imam had learned that the
man’s friend (who he has since discovered was his brother) had been taken to a
nearby YOI. He reassured the man that he would have the same access to an
imam and the same support structure that he had at Preston. The imam
promised to come and see the man on Tuesday morning.
34. At 7.15am on Saturday 27 January, the man rang his cell bell and told an officer
that he was suffering from a headache. The healthcare centre was contacted
but no note was made on the man’s medical file as to whether he received any
treatment. Ten minutes later, the officer noticed the man lying on the floor,
positioned half way under his bed. After two or three minutes, the man got up
and started walking around his cell looking agitated. At this time, he was sharing
a cell with another remand prisoner. Staff were aware of the man’s anxiety and
the difficulty that some prisoners might have had sharing with someone who was
distressed. Staff told my investigator that they were pleased at the calming
effect that the man’s new cellmate appeared to have on him.
35. When he learned of the investigation process, the man’s cellmate contacted my
office to speak to the investigator. He wanted to express his concern at the
treatment that the man received when he was at Preston. The cellmate told the
investigator that the man had a good grasp of English but that staff would not
take the time needed to understand him. He said that officers in the first night
centre told the man that he would get around 20 years in prison for the charges
that he was facing. The cellmate said the man was particularly worried about his
sentence and the impact that it would have on his family. The cellmate said he
repeatedly asked staff for more information about the man’s legal case, but staff
ignored his many requests. The cellmate also asked about the man’s younger
brother in the YOI, but again he said that staff were not responsive.
36. The cellmate described the man as “decent”, but that staff and prisoners were
intimidated by him and did not treat him respectfully. The cellmate particularly
remembers an occasion on Saturday 27 January when a male and a female
officer were on duty. He found the man with a razor blade in an anxious state.
The cellmate persuaded the man to give him the razor blade and then handed it
to staff. The cellmate said that he made it clear to staff that the man was at risk
of attempting suicide. He said that he told staff repeatedly that the man should
be put on a ‘suicide watch’.
37. The investigator spoke to the officers who were working on the first night centre
over the weekend of 27 and 28 January. Neither officer recalled a prisoner
giving them a razor blade. However, the female officer remembered the man’s
cellmate approaching her on 28 January with concerns about his “bizarre”
behaviour. She passed on the concerns to the male officer who agreed to speak
Anonymous Report March 2008 14
to the man. The male officer took the man into the small interview room on the
wing and asked him what was wrong. The man appeared angry in their
exchange and the male officer said that he felt intimidated at times, but
established that the man’s main problem was with his solicitor. The male officer
explained that it was not possible to sort out his solicitor on a Sunday, but that it
could be dealt with the next day with the help of a legal aid adviser. The officer
was worried about the man because he seemed confused and kept repeating
the same question. He was also aware of the cellmate’s concerns. With this in
mind, the officer made a second referral to the mental health team. During
interview, he could not remember if he took it to the mental health team that
night or the following day and it was undated. He said that he took it to the
healthcare centre and handed it to a nurse, explaining his worry. He made the
following entry on the form:
“[The man] appears to be very distant and struggles to understand and take in
what is said to him. He has displayed odd behaviour, lying under his bed
awake! Sometimes he appears very agitated and ready to ‘blow’.”
38. The two officers said that they did not consider that the man was a risk to himself
that weekend. Both officers are trained in ACCT procedures which enable staff
to identify and support prisoners who are at risk of self-harm. They said that
they would have opened an ACCT document if they had been worried about
him.
39. On Monday 29 January, the male officer who was on duty over the weekend
made the following entry in the man’s wing history sheet:
“[The man] can be a drain on staff. He is consistently asking for something
and if he can’t get what he wants he will wait and ask another officer … it
appears he is very agitated about being in prison … he is in need of a solicitor
and I will try to sort this out tomorrow. Although he says he doesn’t
understand he still displays some strange behaviour.”
40. The man’s cellmate left Preston on the 29 January. He said that he spent all
night on 28 January awake with the man. The man was particularly worried
about his cellmate leaving. The cellmate said that he looked after the man.
Other prisoners could be intimidated by the man’s “larger than life” appearance,
but when the cellmate was with him, they did not feel threatened. The cellmate
said that they both cried when he left Preston.
41. Every Monday, the mental health team hold their weekly referral meeting,
attended by all of the inreach team, the primary care mental health worker, and
the team secretary. The aim of the meeting is to discuss every referral and
decide the most appropriate course of action for the prisoner. On 29 January,
they considered two referrals relating to the man, one made by the nurse and
one by the male officer. The team reviewed the man’s clinical record and
decided that his problems were, as described by a mental health inreach nurse,
“mainly anxiety related and may therefore be best met at this stage by a Primary
Care Mental Health Nurse”. The primary care mental health worker was on
leave on 29 January, so the inreach nurse emailed her at around 3:30pm after
Anonymous Report March 2008 15
the meeting had finished. During interview, the primary care mental health nurse
said that it takes an average of two weeks between her receiving a referral and
her meeting the prisoner to assess their needs. In January 2007, she was the
only primary care mental health worker at Preston.
42. Just before lunch at 12.00 noon, the man was moved from the first night centre
to the induction unit. (In fact, the first night centre is located on the same wing
as the induction wing and he just moved down one floor of the same wing.) He
was put in with another prisoner just before the lunch period. Within ten
minutes, the new cellmate had rung the cell bell requesting to be moved out of
the cell. He told staff that the man was threatening him and acting bizarrely.
The officer covering the lunch period attended and spoke to the cellmate. She
persuaded him to give the man a chance to settle down. The cellmate
reluctantly agreed to stay in the cell until after the lunch period to see how it
went.
43. At lunchtime, the prisoners collect their meals and return to their cells to eat
them. The cell doors are then locked to enable officers to go for their lunch.
This means that the prison is in what is known as a ‘patrol state’. Only one
officer is required to stay on the wing to patrol, respond to cell bells and check
at-risk prisoners. The officer can only enter the cell in an emergency and no
prisoners are allowed out of their cells. The officer on duty over the lunchtime
period on 29 January made the following entry in the staff observation block for
the induction wing:
“These two prisoners constantly on the cell bell over dinner patrol. [The man]
appears to have mental issues. Hotel 2 informed and will come and see him
after dinner.” [Hotel 2 is the member of healthcare staff who responds to
requests from officers on the wing and emergencies.]
The cellmate had rung the cell bell many times over the lunchtime period. He
used the in-cell furniture to trap the man at the far end of the cell in order to keep
him away because he felt threatened. The officer on duty over the lunchtime
period was so concerned by the situation that she contacted the orderly officer,
who was in charge of the operations throughout the prison over the lunchtime
period. The officer asked whether cellmate could move cells despite the patrol
state because of the apparently deteriorating situation. The orderly officer
agreed and the officer recorded that the cellmate was moved “because he was
frightened of what [the man] was going to do to him”.
44. In line with national procedures, officers revisited the man’s cell sharing risk
assessment and raised his level to high. As a consequence, he was left in the
cell on his own. The revised risk assessment noted that he “has displayed an
inconsiderate and threatening attitude towards cell mates. Bizarre behaviour
leaves cell mates feeling vulnerable.” At this time, the orderly officer also
checked the progress of the mental health referral and discovered that the man
was to be seen by the primary care mental health worker.
45. At around 1.00pm, three induction wing officers resumed their duties on the
wing, receiving a verbal briefing from the officer covering the lunchtime period
Anonymous Report March 2008 16
about what had happened over lunch. The afternoon proceeded as normal and
no officer recalled the man causing them any concern.
46. At 3.45pm, all prisoners were taken out to the exercise yard for their daily hour of
exercise. Prisoners reported to staff that they overheard heard the man talking
about “killing the infidels”. Prisoners told staff that they found his behaviour
threatening. Even though staff knew about the mental health referrals, one of
the induction officers said that it was agreed by staff in the wing office
“collectively” to contact the mental health team for someone to see the man
urgently in light of his “strange” comments on the exercise yard. The officer
contacted the medical response nurse for the main shift on 29 January. A male
agency nurse was the medical response nurse that day. He was dispensing
treatments with his female colleague, who answered the officer’s first call. She
took the details of the man’s presentation and said that she would contact the
inreach team. When the female nurse called the inreach team, she was told that
the man’s case had been reviewed at the earlier referral meeting and had been
allocated to the primary care mental health worker. The female nurse relayed
that news to the induction officer. The induction officer said that the man needed
to be seen there and then and he was advised to call the mental health team
directly. The officer tried to speak to the inreach team and was referred back to
the emergency response nurse. Eventually, the nurse agreed to see the man
after he had finished dispensing his treatments, but he made it clear to the
officer that he was not trained in mental health. He would be seeing him in the
capacity of a general nurse. In the man’s medical record, the emergency
response nurse wrote:
“I re-stated to staff that [the man] had been referred to the Inreach team and
that they were aware of the situation. The member of staff I spoke to re-
stated that he would like a member of healthcare to see [the man]. I said that
a psychiatric nurse would be required to make a psychiatric assessment but
that I would come and see [the man] after issuing C/D wing treatments.”
47. Earlier in the day, the man’s new cellmate had borrowed a newspaper from a
prisoner who worked as a cleaner on the wing. When the cleaner had asked the
man’s cellmate for his newspaper during the exercise period, the cellmate said
that he had left it in his cell. Prisoners were returned to their cells from the
exercise yard and locked up at 4.30pm.
48. Around 4.35pm, the cleaner went to collect his newspaper from cell D3-13 where
he expected to find the cellmate who he thought was still located with the man.
He opened the observation panel. He thought he saw the man sitting by his
bed, cleaning his teeth. He described the man as being in a seated position with
what appeared to be foam down his left side. The cleaner said that he could not
see very clearly because it was late on a winter afternoon and the cell was quite
dark. He said that the cellmate was always in bed so he turned the night light on
from outside the cell to see more clearly. It was at this point that he saw the
man hanging from the end of his bed.
49. The wing office was located just near the cell. The induction officer had just
finished speaking with the emergency response nurse and was making his way
Anonymous Report March 2008 17
out of the office. The cleaner ran towards the induction officer in a state of
distress. He told the officer that he thought that the man was hanging. The
officer, followed by a second induction officer, who was in the wing office, ran to
the man’s cell. On his way, the first induction officer shouted “Code One” (this is
the radio code used for medical emergencies at Preston). The principal officer
radioed the communications department to tell them that there was a code one
emergency and that healthcare was needed. Two minutes later when the
principal officer had reached the cell, she requested an emergency ambulance.
50. When he reached the cell, the first induction officer unlocked the cell door. Due
to the position of the man’s legs across the entrance, staff could not open the
cell door to get to him. By this time, he had been joined by two more induction
officers. The first induction officer used his shoulder to try and force the door
open and managed to open it a small way. There was only room for a small
individual to get into the cell and all of the officers were too big. The cleaner
volunteered to enter the cell and move the man’s legs so that officers could gain
entry and start resuscitation efforts. This was agreed and the cleaner went into
the cell. The first induction officer estimated that it took around three minutes
before the cleaner entered the cell.
51. The cleaner moved the man’s legs so that staff could enter. He immediately
tried to undo the ligature but he was struggling because his hands were shaking.
The first induction officer undid the ligature and two officers worked with the
cleaner to lower the man gently to the floor and put him in the recovery position,
on his side. During interview, the first induction officer said that he thought about
using a ligature knife but the knot was loose and he thought it would be quicker
to undo it. The other officer thought that he could feel a pulse. He said the
following during interview:
“Now I felt, I thought I could feel a very faint pulse, that’s what – like I said I’ve
not had first aid training since 1988, that was just I’d got a reaction at the
time.”
52. The emergency response nurse was in the treatment room on C-wing, still
dispensing medication to prisoners, when he heard “Code One” being called
over the radio. The nurse told my investigator that a “Code One” radio call
meant that there had been a hanging or an attempted hanging. He took the
emergency response bag from the treatment room and made his way
immediately to the man’s cell. He thought it took no more than thirty seconds to
reach the cell. While he was on the way, another nurse caught up with him.
Although the defibrillator was also located in the treatment room, neither nurse
brought it with them. When they arrived at the cell, they saw the man lying on
his left side on the floor with the ligature removed and officers surrounding him.
Both nurses checked for a pulse but could not find one. The second nurse
inserted an airway to administer oxygen and the emergency response nurse
started chest compressions.
53. At around 4.50pm, the prison doctor was walking to the ground floor ward of the
healthcare centre to do a final round before she left the prison for the day. A
nurse told her that another nurse was looking for her and that she thought that
Anonymous Report March 2008 18
there had been a “Code One” on the induction wing. The doctor does not carry
a radio and, if she is not with the designated medical response nurse, she is not
aware of emergencies until a member of staff tells her. She said that she went
to the induction wing but did not know what she was attending. She does not
take equipment with her because it is expected that the nurse attending the
emergency will bring all of the necessary kit.
54. When the doctor got to the cell she saw that nurses were attending the man.
The doctor said that she was advised by the emergency response nurse that
there had been no sign of life on the nurses’ arrival, five to ten minutes before
the doctor had got to the cell. The doctor examined the man herself and also
found no signs of life. Before the doctor had completed her examination, the
paramedics arrived. The paramedics placed ECG leads onto the man’s chest
and told her that the machine showed complete asystole. (‘Asystole’ is the
absolute standstill of the heart muscle.) The doctor and the paramedics agreed
that the man was clinically dead and at 4.55pm life was pronounced extinct.
Anonymous Report March 2008 19
ISSUES
Family Contact
55. Preston’s Deputy Head of Reducing Reoffending made efforts to contact the
man’s family to notify them of his death. The prison contacted the Nigerian
Embassy who managed to contact his family in Nigeria. Unfortunately, the
prison did not establish direct contact with his family until the week after his
death. My investigator was given details of the efforts made to contact his family
and it is clear that the prison’s efforts were frustrated, despite many attempts on
their part. However, I was concerned that there were no trained Family Liaison
Officers at the prison at the time that the man died. I am pleased to note that a
senior member of staff has been trained in family since his death.
56. My office was contacted two days after the man died by an MP from Nigeria,
acting on behalf of the family. The following day, the man’s older brother called
our office and told my senior family liaison officer, that he wanted to be the main
point of contact for the family. He said he would liaise with the MP from Nigeria
to keep his family there informed. My senior family liaison officer has spoken to
the man’s brother by telephone directly and through his solicitor, throughout the
investigation process. In March, my investigator and my senior family liaison
officer visited the man’s younger brother in Lancaster Farms YOI to explain the
investigation process and to give him the opportunity to raise his concerns.
57. The family has suspected that there was third party involvement in the man’s
death. However, the police visited the cell within hours and have ruled this out.
While this is ultimately a matter for the inquest to determine, given that the man
was located in a locked cell on his own at the time that he died, I too have
concluded that his death was self-inflicted.
58. Another significant issue raised by the family was the time it took for the body to
be released by the Coroner in order for them to proceed with the burial
according to Islamic tradition. While any delay is regrettable, this matter is
unfortunately outside of the remit of my investigation.
59. The man’s brother was concerned that he might not have had access to an
imam. In fact, as I have shown, the man spent some considerable time with the
prison imam and attended weekly Muslim prayers. He was given the Holy
Quran which was found in the cell after he had died.
Staff Support
60. The man was at Preston for less than five days. Staff had not had the
opportunity to get to know him well. However, my investigator was struck by the
number of staff who were affected by his loss and had become acquainted with
him in the short period he was at the prison. All staff felt well supported following
the man’s death. At all levels, they reported good relationships with the
management team at the prison and felt that the Governor was appreciative of
the challenges of their roles. A debrief was held after the man died, which staff
who attended found useful.
Anonymous Report March 2008 20
Clinical Review
61. Central Lancashire PCT commissioned the Healthcare Manager for Lancaster
Prisons to review the clinical care that the man received while he was in custody.
The clinical reviewer had access to the man’s prison files and the transcripts and
notes of the interviews carried out by my investigator.
62. The clinical reviewer concludes there was evidence of acceptable record-
keeping standards. However, he judges that there was some delay in the
mental health referral process which indicated a service gap in the local primary
care mental health service. He also considers that, if the man had been put on
an open ACCT document, he would have been subject to a more in-depth initial
assessment and the outstanding mental health issue might have been dealt with
more quickly.
Mental Health
63. In reception, the man underwent the first reception healthscreen. The nurse at
reception recorded that he was feeling anxious but that “he had no plans to harm
himself at present”. He told her that he had no history of mental health problems
but that was concerned about the charges he was facing. She arranged for an
officer to talk him through his court documentation. The nurse did not make a
referral for a mental health assessment following the healthscreen. In interview,
the nurse said that a lot of prisoners who go through the reception process seem
a bit “panicky”. She thought that once the man had been settled on the first
night centre, and had spoken with his solicitor, he would calm down. She also
knew that he would have a medical check-up the next day, and therefore would
be seen by a healthcare professional who would assess his condition if the
anxiety persisted. She made a clear note on the cell sharing risk assessment
which accompanied the man to the first night centre as follows:
“States he feels anxious about possible sentence and being in prison for first
time but states he doesn’t have any intentions to harm himself at current
time.”
64. The clinical reviewer expresses no concerns with the nurse’s judgement
throughout the screening process. However, he is concerned that she
completed an unfinished form that accompanied the man from his night in court
cells before he arrived at Preston. I agree that a new healthscreen form should
be started for each prisoner on arrival at the prison.
A new first reception healthscreen should be completed for each prisoner
arriving at Preston.
65. The duty first night centre officer said that he had no concerns about the man’s
mental state during the follow-up induction assessment the next morning. He
said that the man was not settled during the interview but was mainly concerned
about contacting his friends or family. The officer filled out an application for an
international telephone call on the man’s behalf, and tried to locate the man’s
Anonymous Report March 2008 21
mobile telephone by contacting the police and the immigration service.
Unfortunately, the mobile telephone had gone missing. The application for an
international telephone call was found in the wrong pigeon hole after the man
had died.
The Governor should consider streamlining the system for prisoners to
apply for international telephone calls, including a fast track system to be
used in an emergency situation.
66. When the man arrived on the first night centre, an officer completed an
immediate needs assessment. The man told the officer that he had no history or
thoughts of self-harm, no history of depression or any health problems that
needed medical attention. The officer remembered that the man was confused
and angry during the assessment. As an officer with a lot of experience on the
first night centre, he said that a lot of prisoners who have just arrived in custody
can present like this and he had no concerns about the man’s mental state. He
thought that his language difficulties might have been a defence mechanism, as
his understanding improved during the course of assessment. The officer did
not think that the man was at risk of self-harm.
67. The following morning, the same nurse that had seen the man on reception
attended his cell to find him panicking on the floor of his cell under his bed. She
said that he was not hyperventilating and that he was not having a panic attack.
However, she was concerned about his mental state. He seemed confused why
he was in prison despite their conversation the previous day. She also
wondered if he was claustrophobic because he seemed most upset about being
locked in his cell. She asked officers to arrange for the imam to visit him and
explained to them that he did not like to be locked in his cell. Officers left the
man’s door open for most of the morning, security permitting. The imam visited
the man as soon as he arrived at the prison. He spoke to him at length about
what was bothering him and encouraged him to attend afternoon prayers. The
nurse also spoke to the doctor about prescribing the man something to calm him
down over the weekend.
68. However, the man was found in a similar state during the lunch hour that same
day. Again, the same nurse attended the cell and again she found the man
under the bed. She tried to calm him down and explained that the door had to
be locked during the lunchtime period. Following this visit, she spoke again with
the doctor and they agreed that the nurse should make a mental health referral.
During interview, the nurse said that she was concerned that she knew the man
would not be seen by the mental health team over the weekend. She thought
that this time might give him to opportunity to settle down so he could be
effectively assessed. However, she said, “there’s no true way of getting
somebody seen straight away if you’re really worried here.” The nurse
expressed frustration that there was no mental health service available over the
weekend.
There should be a review of the referral pathways to mental health services
particularly around responsiveness to perceived crisis and the methods of
communicating actions/decisions.
Anonymous Report March 2008 22
69. The man’s cellmate in the first night centre raised concerns about him with the
officers on duty at the weekend. He complained of “bizarre behaviour”. The
male officer took the man to a quiet office on Sunday afternoon and asked him
what was bothering him. Following a long conversation about his legal
representation, the officer was sufficiently concerned that he wrote a mental
health referral, detailing the following:
“He has displayed odd behaviour, lying under the bed awake! Sometimes he
appears very agitated and ready to ‘blow’.”
70. During interview, the officer told my investigator that he took the mental health
referral form down to the healthcare centre himself but not until Monday
morning. He said that he was a little more concerned about him than other
prisoners. He told healthcare staff that he thought the man needed a “quite a
quick” referral.
71. After the man’s cellmate on the induction wing had moved cells during the
lunchtime period, the man’s cell sharing risk was reviewed. He was assessed as
a high risk to others because of his “inconsiderate and threatening behaviour” to
the cellmate and his “bizarre behaviour”. The principal officer contacted the
mental healthcare team to check that a mental health referral had been made.
She was told that he had been referred onward to the primary care mental health
team.
72. Once prisoners had returned from afternoon exercise, concerns were raised with
staff that the man had been making strange comments in the exercise yard
about how he had been sent from God to kill people. The first induction officer
said that the matter was discussed in the staff office among officers and it was
decided that the mental health team needed to see the man urgently. That
officer told my investigator that when he tried to arrange this he felt he was
“being passed around”. The emergency response nurse on duty at the time
eventually agreed to see the man. During interview, the nurse expressed
frustration that he was not clear about the systems in place at Preston to deal
with mental health emergencies. He said he was told after the man’s death that
the inreach team was able to respond to mental health emergencies when
required. He made the following comment:
“… my understanding was the mental health in-reach team was for the mental
health care of people in the main part of the prison and if that is not the case
then I think it needs to be made clearer.”
73. In fact, when the first induction officer called the inreach team, they referred him
back to the emergency response nurse. So it appears that many staff, including
members of the inreach team themselves, are unclear of the process and
support available. If this had been clear, perhaps the man would have been
assessed more urgently.
Anonymous Report March 2008 23
The Governor and the Head of Healthcare should ensure that staff are clear
about who to access in the event of a prisoner requiring urgent access to
the mental health team.
74. At the weekly mental health meeting at 3.00pm on Monday 29 January, the
referrals made by the officer and the reception nurse were discussed. The
inreach nurse explained to my investigator that it was decided that the man’s
problems were anxiety related. As he seemed to be suffering from anxiety,
which is a primary care mental health problem, he was referred to the primary
care mental health care worker. Unfortunately, the primary care mental health
worker was not at the meeting as she was on annual leave. The inreach nurse
emailed the referral for action on her return from leave. During interview with my
investigator, the primary care mental health worker said that from April 2006 to
April 2007 the average length of time between a routine referral being made and
her seeing the prisoner was 11 days. She said that this compares very
favourably with the service in the community.
75. The clinical reviewer judges that the referral meeting was insufficiently recorded,
and it was not clear what the decision making process has been. I agree that it
would be helpful to keep a clear record of the discussions held at this meeting.
It is recommended that the referral meetings are more comprehensively
recorded so that healthcare staff subsequently attending to the patient
have a clear indication in the clinical record of considerations made and
decisions taken at a referral meeting.
76. The service manager of prison healthcare at Central Lancashire PCT wrote to
my investigator with details of the methods used to respond to mental health
crises at Preston. She explained that:
“… whilst there is currently no dedicated crisis intervention service at HMP
Preston as you would expect to find in a community NHS model, we still as a
Healthcare Team respond to mental health crisis in a number of ways. This
could be either via Hotel 2, attending Special Sick [a system whereby a
prisoner can request an emergency appointment with a doctor for the same
day], requests to the Inpatient Team on Healthcare, a member of Primary
Care assessing or the Primary Care Mental Health Worker.”
77. There is currently only one primary care mental health worker in employment at
Preston. She did not meet the man because she was not working on the few
days that he was in the prison. The service manager of prison healthcare
explained to my investigator that the primary care mental health team at Preston
is currently under development. As part of the expansion, there are plans to
introduce a crisis intervention tool so that prisoners with low level mental health
needs will have access to appropriate support urgently, if required. A paper was
presented to the prison’s senior management team with the following priority
outlined:
“Additional staff working in primary care mental health would enable a crisis
response to be developed in order to respond to actual or perceived mental
Anonymous Report March 2008 24
health crisis amongst prisoners in the prison. This would also seek to improve
joint working with healthcare and prison staff especially in relation to ACCT
and other areas of need. This area of development has been discussed with
the commissioners at the PCT and is seen as priority dependent upon
available funding.”
78. I have commented in past investigations on the level of primary care mental
health provision at Preston. (I acknowledge that this a problem that affects
virtually all prisons.) I am pleased that some progress has been made since
then with the appointment of the primary care mental health worker. The work
outlined above was underway prior to the man’s death. Unfortunately, at the
time of his death, there was not a co-ordinated approach to crisis intervention
and this is echoed in the nurse’s frustration that the man could not been seen by
a mental health professional over the weekend.
79. However, staff took steps to address the problems the man was anxious about -
for example, his claustrophobia, his family contact and his legal representation.
Given the resources available to them at the prison, I judge that staff tried their
very best to help him.
Suicide Awareness
80. The clinical reviewer makes the following comment in the conclusion of his
review:
“It is noted that an ACCT was not opened for [the man] – this would have
provided a greater level of initial assessment by an ACCT assessor and may
have sped up or forced the issue of Mental Health Assessment.”
81. The man told staff that he did not feel suicidal at the first reception healthscreen,
the immediate needs assessment, the follow up assessment and when the imam
spoke at length with him about how he was feeling. Staff assessed his risk of
suicide on all of these occasions. At no time did staff identify him as a risk to
himself. All staff my investigator spoke to were ACCT trained. The nurse, who
assessed the man on reception and visited him in his cell on two occasions, felt
that she had not received full ACCT training, but according to her training
records she had received the training albeit at the basic level. Despite their
repeated concerns about his mental state, all staff were surprised that the man
apparently took his own life. I do not agree that this was due to the lack of
assessment. Furthermore, the weekly meeting remains the single pathway,
through which all mental health referrals are processed. Therefore, I do not
agree that the man’s mental health referral would have been “sped up” as the
clinical reviewer suggests in his review. There was no fast-track procedure at
Preston for mental health referrals. I have commented on how a crisis
intervention process would have helped in this instance.
82. When the man’s cellmate from the first night centre contacted my investigator,
he said that he had told staff he was concerned that the man was a risk to
himself. He said that he had taken a razor blade from him and handed it to staff
on duty at the weekend. My investigator spoke to the two members of staff who
Anonymous Report March 2008 25
were on duty on the weekend of 27 and 28 January. They recalled the cellmate
raising concerns about the man’s behaviour, but neither officer remembered
being handed a razor. There is no surveillance footage to establish if a razor
was handed to officers that weekend. Following the cellmate drawing his
concerns to staff’s attention, the male officer on duty spoke at length with the
man. He was sufficiently concerned about his mental state to make a mental
health referral but did not think that the man posed a risk to himself.
83. The short period in custody was the man’s first time in prison and he was a
foreign national prisoner. He suffered from anxiety and was found on three
occasions in a panicked state in his cell. Irrational behaviour and feelings of
anger or being disconnected are risk factors listed in The ACCT Approach, a
guide for prison officers about caring for prisoners at risk. The guide encourages
staff to consider both what the prisoner says and his behaviour when deciding
whether to open an ACCT document.
84. The man was described as “bizarre” by several staff during interviews. He would
repeatedly ask staff why he was in prison, despite their attempts to explain his
charges. He was frustrated and confused about being in custody. His main
concerns were related to tangible issues, for example legal representation and
international telephone calls. Attempts were made to resolve these issues for
him, and to try and calm him down. The imam spent time with the man, who
assured him he was not thinking of self-harm. He seemed “angry” to officers
who spoke to him about his behaviour. He said that he had not considered
suicide or self-harm in the past. In the final hours of his life, the man was
threatening to a new cellmate and made menacing comments to other prisoners
during the exercise yard.
85. It is easy to say with hindsight that the man’s “bizarre” behaviour was connected
to a risk of self harm. However, at the time staff interpreted his behaviour as
symptomatic of a mental health issue not associated with feelings of suicide.
Staff all assured my investigator that they considered whether the man was at
risk of self harm or suicide, but decided that he was not. In the hours before he
died, staff on the wing collectively talked about the man and decided that he
needed to be seen urgently by the mental health team because of his
threatening behaviour and the risk that he presented to others. They did not
open an ACCT document. I am satisfied that staff took the man’s behaviour
seriously and that action was taken to support him. While others might have
taken the view that an ACCT document should have been opened, I do not think
it was unreasonable for Preston’s staff not to have done so.
86. I have no criticism to make of the care and support that staff offered to the man.
Indeed, had he been on an ACCT document, I do not think that the care plan
that would have been developed would have differed significantly from the care
and support he actually received. An ACCT might have ensured that he was
more regularly observed. However, the man was found by the cleaner within
five minutes of returning from exercise. Even if he had have been on an ACCT
document, it was unlikely that he would have been checked between his return
from the exercise yard, when he was locked in his cell, and when the cleaner
Anonymous Report March 2008 26
found him. Sadly, I do not think that the opening of an ACCT document would
necessarily have changed the outcome.
Emergency Response
87. The man was not subject to ACCT and staff were not, therefore, carrying out
regular checks on him. He was discovered by another prisoner. It would have
been best practice for that prisoner to have been guided away from the cell at
the time staff responded to the emergency call. Indeed, it is surprising that the
prisoner had to be involved for officers to gain entry to the cell because of his
smaller physical size. However, preservation of life took precedence over
procedure and I do not think that officers had any viable alternative. The
prisoner told my investigator that he had been well-supported since the man’s
death. He said the Governor had recognised his efforts and that staff had gone
out of their way to check his welfare. In particular, he commented on the support
that he received from the officer who broke the news of the man’s death to him
in a timely and sensitive manner.
88. I have been pleased to learn that the Governor recognised the prisoner’s efforts.
However, in light of this investigation, I wonder if more formal recognition is
required. For that reason, I make the following recommendation:
The Area Manager should formally commend the prisoner for his actions in
assisting staff when the man was found.
89. When the first induction officer gained entry to the cell, he untied the ligature
from around the man’s neck. In Prison Service Order 2700 (the national
instruction that governs the management of suicide and self harm prevention
across the Prison Service), staff are encouraged to “preserve the knot if
possible”. If the knot is preserved, it can provide useful evidence if there is any
doubt whether the ligature was made by the prisoner’s own hand. However, the
officer described the knot as “loose” and decided that it would be the quickest
way to remove the ligature and bring the man to the floor to commence
emergency first aid. I think the officer’s judgement rightly put the preservation of
life over the preservation of evidence.
90. I agree with the clinical reviewer that a defibrillator is a vital piece of resuscitation
equipment. In fact, I made this recommendation to the Head of Healthcare at
Preston in an earlier investigation. The radio sign “Code One” meant “hanging
or attempted hanging” to all staff asked by my investigator. The two nurses who
attended said that they understood that they were coming to an attempted
hanging. I am therefore concerned that a defibrillator was not taken as a matter
of course. Early application of a defibrillator can be crucial. The emergency
response nurse and the doctor both thought that in this case a defibrillator would
have made no difference because the man showed no signs of life upon
examination by healthcare staff. I am satisfied that, in this case, a defibrillator
would not have changed the outcome. However, I endorse the clinical
reviewer’s recommendation regarding resuscitation and draw it to the attention
of the Governor and the Head of Healthcare.
Anonymous Report March 2008 27
There should be a review of how nurses respond to emergencies and what
equipment they take – a defibrillator should be seen as an integral part of
the resuscitation equipment.
All healthcare staff must be adequately trained and regularly updated in
Basic Life Support and trained to use whatever resuscitation equipment
exists within the prison which includes advisory defibrillators.
91. I am pleased to report that, since my investigator drew this point to the service
manager for prison healthcare and the Governor attention, all healthcare staff
have undergone refresher training in resuscitation and reminded of the
importance of taking a defibrillator to any life-threatening situation.
Anonymous Report March 2008 28
RECOMMENDATIONS
The clinical reviewer identifies five areas of learning and service development for
Preston. One of these has already been acted upon and I hope that the remaining
four will be given swift and due consideration:
A new first reception healthscreen should be completed for each prisoner
entering HMP Preston on every occasion.
There should be a review of the referral pathways to mental health services
particularly around responsiveness to perceived crisis and the methods of
communicating actions/decisions.
It is recommended that the referral meetings are more comprehensively
recorded so that healthcare staff subsequently attending to the patient have a
clear indication in the clinical record of considerations made and decisions
taken at a referral meeting.
There should be a review of how nurses respond to emergencies and what
equipment they take – a defibrillator should be seen as an integral part of the
resuscitation equipment.
All healthcare staff must be adequately trained and regularly updated in Basic
Life Support and trained to use whatever resuscitation equipment exists within
the prison which includes advisory defibrillators.
I have made a further three recommendations:
The Governor should consider streamlining the system for prisoners to apply
for international telephone calls, including a fast track system to be used in an
emergency situation.
The Governor and the Head of Healthcare should ensure that staff are clear
about who to access in the event of a prisoner requiring urgent access to the
mental health team.
The Area Manager should formally commend the prisoner for his actions in
assisting staff when the man was found.
During the consultation process, following the issue of the draft report, the prison
responded with the actions that have been taken in light of these recommendations.
Their response was as follows:
 In terms of mental health provision, the primary care mental health team is
currently under development and additional staff are being recruited to form a
crisis intervention response team. This team will be available 7 days a week,
should staff have concerns about particular prisoners.
 With regards to the recommendation that healthcare staff be adequately and
regularly updated on the basic life support, all healthcare staff have since
Anonymous Report March 2008 29
undergone refresher training in resuscitation and reminded of the importance of
taking a defibrillator to any life threatening situation.
 Processes have also been put into place with regards to International Calls, in
that all Foreign National prisoners are automatically given five pounds worth of
pin phone credit on. On reception subsequent months, Foreign Nationals will be
allowed a free five minute telephone call.
Anonymous Report March 2008 30
ANNEX 1
Documents considered during the investigation
Death in custody documentation
Prisoner Core Record
Custodial Documents File
Immigration documentation
Wing history
Staff observation book from first night centre
Staff observation book from induction wing
Citizenship Programme
Application form regarding international telephone call
Paramedic Record
First reception healthscreen
Prescription chart
Continuous Clinical Record
Mental Health In-reach file
Interview notes/transcripts
Anonymous Report March 2008 31