PPO Reports & Self-Inflicted Deaths – Health Notes w/c 21 Oct 2019

Last week the PPO published 11 reports relating to deaths in custody. The causes are categorised as follows:

  • Natural Causes = 6
  • Self-Inflicted = 4
  • Other Non-Natural = 1

Below is a summary of those self-inlflicted death’s, in particular, the factors where Healthcare services are integral within prisons:

  • The Management of Risk of Suicide and Self-Harm (Mental Health Teams),
  • Psychoactive Substances/Illicit Drugs (Substance Misuse Services),
  • Emergency Response (Primary Care/Physical Heath teams)

HMP Northumberland on 1 July 2016 – Mr. Robert Chapman

Key Events

On 14 October 2015, Mr Robert Chapman was remanded into custody at HMP Holme House. Mr Chapman had been in prison before and had served several custodial sentences, the last of which had ended in January 2015. Mr Chapman had a history of mental illness and drug abuse and of attempted suicide and self- harm.

On 15 October, Mr Chapman attempted suicide by hanging. He was resuscitated and taken to hospital and staff began ACCT procedures to support him. Mr Chapman was discharged from hospital on 21 October, and the ACCT plan was closed on 29 October. On 31 October 2015, Mr Chapman was transferred to HMP Durham.

On 21 March 2016, Mr Chapman appeared in court and, following trial, was convicted and sentenced to 78 months in custody. After he apparently took a deliberate overdose of illicit drugs, a suicide and self-harm warning form was completed at court. But on his return to Durham, no one considered that he was at risk of self-harm or suicide. On 23 March, Mr Chapman self-harmed again and staff then began ACCT procedures.

On 7 April, Mr Chapman was transferred to HMP Northumberland with the ACCT plan still open. On 11 April, the ACCT plan was closed.

On 1 July, an officer informed Mr Chapman that his step-father had died. At 8.58pm, another officer found Mr Chapman hanging in his cell and called for emergency medical assistance. Staff responded and started cardiopulmonary resuscitation (CPR). An ambulance was called at 9.02pm. Paramedics arrived at 9.20pm and, at 10.27pm, pronounced Mr Chapman dead.

Findings

Management of Risk of Suicide and Self Harm

The investigation found that Mr Chapman should have been managed under ACCT procedures when he returned to Durham from court on 21 March.

There were deficiencies in the operation of suicide and self-harm prevention procedures at Northumberland. Case reviews were not multidisciplinary and the assessment of Mr Chapman’s risk failed to include consideration of all his risk factors. Plans were closed without any evidence that his risk of suicide and self-harm had reduced. ACCT procedures should have been put in place to support Mr Chapman when he received the news that his step-father had died.

New Psychoactive Substances/Illicit Drugs

The PPO are concerned at the evident availability of illicit drugs at both Durham and Northumberland, particularly New Psychoactive Substances (NPS). The post-mortem and toxicology results show that Mr Chapman used illicitly-obtained prescription drugs at the time of his death, and he also may have used NPS.

Emergency Response

The PPO are concerned about the emergency response. After officers called an emergency it took four minutes before support staff called an ambulance. While a quicker response may not have affected the outcome for Mr Chapman, it could be crucial in other circumstances.

Clinical Care

The clinical reviewer judged that, overall, the care that Mr Chapman received from healthcare staff at Northumberland was equivalent to that he could have expected to receive in the community.

The clinical reviewer commented that Mr Chapman appeared to have had limited insight into the effect that illicit substances had on his mental health. Mr Chapman admitted that he turned to drugs when his mood was low or in reaction to stressful circumstances. Toxicology results confirm that Mr Chapman had taken illicitly obtained prescription drugs prior to his death and may have used NPS.

Recommendations

Rec 1: The Governor of Durham should ensure, in line with PSI 64/2010, that measures are in place for identifying prisoners at risk of suicide and self-harm and for managing and supporting them. In particular, this should ensure that reception staff:

  • Have a clear understanding of their responsibilities and the need to share all relevant information about risk;
  • Consider and record all the known risk factors of a prisoner when determining their risk of suicide or self-harm, including information from PERs and other sources;
  • Open an ACCT whenever a prisoner has recently self-harmed or expressed suicidal intent.

Rec 2: The Director of Northumberland should ensure that prison staff manage prisoners at risk of suicide or self-harm in line with national guidelines, including:

  • Understanding their responsibilities and the need to share all relevant information about risk;
  • Considering and recording all the known risk factors of a prisoner when determining their risk of suicide or self-harm;
  • Assessing the level of risk and recording the reasons for decisions;
  • Conducting ACCT reviews as specified in the national instructions.

Rec 3: The Governor of Durham and the Director of Northumberland should ensure there is an effective supply and demand reduction strategy to help eradicate the availability of New Psychoactive Substances and other drugs, and that staff are vigilant to signs of their use and know how to respond when a prisoner appears to be under the influence of such substances.

Rec 4: The Director of Northumberland should ensure that all prison staff are made aware of and understand PSI 03/2013, Medical Emergency Response Codes and their responsibilities during medical emergencies which:

  • Ensures staff immediately call for an emergency ambulance when a medical emergency code is used;
  • Ensures that an emergency response protocol is in place with the ambulance service;

Rec 5: The Director at Northumberland should ensure that when a prisoner dies, the next of kin is informed without undue delay in accordance with national instructions.

Full Report Here


HMP Preston on 18 July 2016 – Mr. Ashley Gerrard.

Key Events

On 23 December 2015, Mr Ashley Gerrard was remanded to Preston charged with burglary and using a firearm to resist arrest. Mr Gerrard had a history of suicide attempts, self-harm and mental health problems. He arrived with a suicide and self-harm warning form because he had told police officers that he would kill himself if he was remanded to prison. Prison staff began Prison Service suicide and self-harm prevention procedures (known as ACCT) when he arrived, assessed him as at a high risk of suicide and constantly supervised him for three days. On 29 December, staff concluded that Mr Gerrard’s risk of suicide and self-harm was low and ended ACCT monitoring.

When Mr Gerrard first arrived at Preston, a doctor prescribed him antidepressant medication. On 16 June, Mr Gerrard stopped taking the medication because he thought it was causing a rash on his face. He did not resume taking the medication until 11 July.

Staff submitted a number of security intelligence reports indicating that Mr Gerrard was involved in the supply of drugs in the prison, in particular New Psychoactive Substances (NPS) as a result of which he was subject to a range of sanctions. On 7 April 2016, a targeted search found that Mr Gerrard had a mobile phone. As a result, Mr Gerrard was made subject to closed visits. Due to ongoing security intelligence concerns, Mr Gerrard was still subject to closed visits when he died. On 4 July, Mr Gerrard was again linked with the supply of drugs in the prison and he was dismissed from his job in the prison gardens.

On 16 July, Mr Gerrard climbed onto a wall. He was distressed and frustrated and discussed a number of concerns with staff, including that he had been subject to closed visits for too long and was having relationship problems. Mr Gerrard told an officer that he had considered hanging himself, but had chosen to climb the wall instead. About three hours later, staff persuaded him to climb down and he was moved to the segregation unit where he was treated as an escape risk and subject to frequent checks.

A manager talked to Mr Gerrard to explore whether he was at risk of suicide and self-harm. Mr Gerrard said he had no thoughts of either and staff concluded that he did not need to be supported by ACCT procedures. They did not record that they had considered all of his risk factors for suicide and self- harm. Segregation unit staff recorded no concerns about him that evening and a nurse assessed him as able to cope with a period of segregation.

At around 3.15pm on 17 July, Mr Gerrard phoned his girlfriend several times. They argued and accused each other of being in relationships with other people. A supervising officer realised that Mr Gerrard was upset but Mr Gerrard reassured him that he was all right. The officer did not tell other staff about Mr Gerrard’s phone call.

At about 4.30pm, another supervising officer unlocked Mr Gerrard’s cell to give him his evening meal. He found Mr Gerrard hanging from a ligature made of sheets, which he had tied to the ceiling light fitting. The supervising officer radioed a medical emergency, and officers and nurses attended and attempted resuscitation. Paramedics arrived promptly and, after continued resuscitation, detected a pulse. At 5.29pm, paramedics transferred Mr Gerrard to hospital. Sadly, he did not regain consciousness and died, with his family beside him, the following afternoon.

Findings

Management of Risk of Suicide and Self Harm

When staff assessed Mr Gerrard’s risk of suicide and self-harm after he climbed the wall on 16 July, he said that he had contemplated suicide and it should have been apparent that he was at an increased risk of suicide and self- harm. Staff were reassured by his demeanour and did not begin ACCT procedures. These risks were heightened further following a distressing telephone conversation he had with his girlfriend in the segregation unit. The PPO considered staff did not take sufficient account of his heightened and recorded risk factors in deciding not to begin suicide and self-harm procedures.

Psychoactive Substances/Illicit Drugs

A substantial and growing body of intelligence indicated that Mr Gerrard was involved in the supply and use of drugs in the prison. We are concerned that the prison’s approach to this was exclusively restrictive and failed to take account of the impact on Mr Gerrard’s welfare. None of the information was passed to the police for investigation. The PPO are concerned that the prison missed opportunities to manage his behaviour using a multidisciplinary approach, rather than focusing exclusively on his security risk.

Emergency Response

None.

Clinical Care

Although the clinical reviewer concluded that Mr Gerrard received generally appropriate healthcare at Preston, the PPO conclude that healthcare staff should have taken more action when Mr Gerrard stopped taking his medication.

The clinical reviewer concluded that Mr Gerrard received good quality healthcare at Preston, equivalent to what he might have expected to receive in the community. However, PSI 64/2011 provides guidelines about managing prisoners with complex behaviour, mental health issues and depression. It suggests that prison healthcare departments devise a system whereby prisoners who do not collect their antidepressants or antipsychotic medication are followed up to find out why. Preston does not have a written policy about missed medication, however a nurse told the investigator that if patients fail to take their mental health medication for three days, nurses are expected to add the patients to a non compliance log, review them and find out why they are not taking them.

When Mr Gerrard arrived at Preston, a prison GP prescribed an antidepressant, sertraline, which Mr Gerrard took every day until 16 June. The clinical reviewer established that Mr Gerrard did not take his medication between 16 June and 11 July. On 21 June, Mr Gerrard told a nurse that he had stopped taking his medication because it had caused a rash on his face. She referred him to the GP but did not add his name to the non-compliance log and no one from the healthcare department took any further action to discuss his decision with him. On 7 July, a nurse noted that Mr Gerrard was not collecting his medication and added him in the non-compliance log. On 11 July, after an appointment with the prison GP, Mr Gerrard began taking sertraline again. We conclude that healthcare staff should have taken more proactive steps to monitor and challenge Mr Gerrard’s decision not to take his antidepressants.

Recommendations

Rec 1: The Governor and Head of Healthcare should ensure that staff manage prisoners at risk of suicide and self-harm in line with national guidelines, including that:

  • All known risk factors and triggers are considered when determining the level of risk of suicide and self-harm.
  • Initial Segregation Health Screenings assess a prisoner’s wellbeing, including his risk factors for suicide and self-harm.

Rec 2: The Governor should ensure that restrictive measures taken to address security threats are considered and proportionate and that their potential impact on the welfare of prisoners is taken into account.

Rec 3: The Head of Healthcare should ensure that there are effective procedures to monitor prisoners’ compliance with their medication and that nurses responsible for coordinating mental health care follow up missed medication as part of an active care plan approach.

Full Report Here


HMP Liverpool on 17 September 2017 – Mr. Terence Storey

Key Events

In August 1996, Mr Storey was sent to HMP Liverpool after being charged with murder. In October 1997, he was sentenced to life imprisonment with a minimum term of 17 years. During his sentence, Mr Storey was located in a number of prisons including HMP Grendon, HMP Bullingdon, HMP Coldingley and HMP Wandsworth.

Mr Storey had been diagnosed with personality disorders and depression, had a history of self-harm, and had made numerous suicide attempts in prison. At various times during his sentence, staff managed Mr Storey under suicide and self-harm prevention procedures (known as ACCT) and the mental health team provided ongoing support.

In August 2016, the Parole Board did not support Mr Storey’s request to transfer to open conditions. From October to December 2016, Mr Storey made three suicide attempts using a ligature and by trying to set fire to himself. On 28 December 2016, he was transferred to a medium secure mental hospital under the Mental Health Act.

On 19 May 2017, Mr Storey was discharged from the hospital and transferred to HMP Liverpool. Staff noted Mr Storey’s history of suicide attempts and self-harm and that he been diagnosed with severe depression and two personality disorders. They started ACCT procedures in reception and Mr Storey was placed under constant observation in the prison’s inpatient unit.

On 8 June, staff reduced the frequency of Mr Storey’s observations from constant to six an hour during the day with constant observation at night. On 12 June and 23 June, Mr Storey attempted suicide using ligatures. Following each incident, staff provided emergency medical treatment and held an ACCT case review where they assessed Mr Storey’s risk as high and continued to monitor him under constant observation. From July until September, staff assessed Mr Storey’s level of risk as high or raised and gradually reduced the frequency of his observations.

On 21 August, Mr Storey punched an officer through the hatch of his cell. Staff held an ACCT case review, assessed his risk as high, and increased the frequency of his observations. Staff disciplined Mr Storey and referred the assault to the police.

On 17 September, Mr Storey gave a nurse a blade. The nurse did not hold an ACCT case review and there are no further notes about this in Mr Storey’s records.

At 4.20pm, a nurse spoke to Mr Storey through the hatch of his cell. Mr Storey gave the nurse some ligatures he had made from torn bed sheets but told her he did not intend to harm himself. The nurse did not hold an ACCT case review, or change his assessed level of risk or frequency of observations. At 5.00pm, a healthcare assistant noted that Mr Storey was standing at his hatch and that he said he was fine.

At 5.50pm, the nurse went back to Mr Storey’s cell to give him his medication. She looked through the hatch and saw Mr Storey hanging. She asked another nurse to press the general alarm and told an officer to call an emergency code. The officer asked for assistance over the radio but did not call an emergency code. Nursing staff waited for an officer to arrive before going into Mr Storey’s cell to give emergency medical treatment. After listening to staff over the radio, an officer in the control room decided to call an ambulance at 5.56pm. Shortly afterwards, a governor called a code blue emergency (indicating that a prisoner is unconscious or having difficulty breathing). Staff continued trying to resuscitate Mr Storey until paramedics arrived at 6.30pm. At 6.44pm, paramedics took Mr Storey to hospital but recorded that he died at 6.56pm.

Findings

Management of Risk of Suicide and Self Harm

The investigation found that Mr Storey had a number of very clear risk factors for suicide and self-harm but that staff relied on his presentation in assessing his level of risk and setting the frequency of observations. Staff did not schedule a case review to reassess his level of risk when he gave staff items that he could use to harm himself. ACCT observations were often recorded at predictable intervals.

Psychoactive Substances/Illicit Drugs

None. The toxicology report found Mr Storey had a number of medications in his system at therapeutic levels only.

Emergency Response

The PPO consider that healthcare staff should have gone into Mr Storey’s cell to administer basic first aid as soon as they discovered that he had hanged himself. Nursing staff waited outside Mr Storey’s cell for an officer to arrive and said they would not go into a cell without an officer present under any circumstances.

Staff did not call an emergency code as soon as they found Mr Storey in his cell. This resulted in a delay of five minutes until the officer in the control room decided to call an ambulance after listening to what was happening over the radio. A governor called an emergency code just after the officer called an ambulance.

Recommendations

Rec 1: The Governor and Head of Healthcare should ensure that staff manage prisoners at risk of suicide and self-harm in line with national guidelines, including in particular that:

  • staff consider all known risk factors when determining the level of risk of self-harm;
  • staff hold a case review when significant new information about risk becomes known; and
  • ACCT observations are at irregular and unpredictable intervals.

Rec 2: The Head of Healthcare should ensure that all staff understand the importance of entering a cell without delay in an emergency in order to help preserve the life of a prisoner.

Rec 3: The Governor and Head of Healthcare should ensure that all prison and healthcare staff are made aware of and understand PSI 03/2013 and their responsibilities during medical emergencies as outlined in the local Medical Emergency Response Code Protocol so that staff efficiently communicate the nature of a medical emergency, and there is no delay in calling, directing or discharging ambulances.

Rec 4: The Prison Group Director, North West, should assure himself that realistic action is now taken to address these and previous recommendations.

Full Report Here


HMP Winchester on 22 October 2018 – Mr. Trevor Oakley

Key Events

On 14 February 2018, Mr Trevor Oakley was remanded in prison custody, charged with sexual offences, and sent to HMP Winchester. This was his first time in prison.

Mr Oakley was supported using Prison Service suicide and self-harm prevention procedures (known as ACCT) on three occasions, on 16 February, from 9 to 19 March and from 8 to 9 August. On each occasion, his risk of suicide and self- harm increased when he either protested his innocence, was anxious about court proceedings or was due to appear in court.

Mr Oakley’s trial was due to start on 22 October. That morning, when an officer arrived at Mr Oakley’s cell during the early morning roll check, he could not see him. The officer tried to get a response by tapping the door and switching the light on and off but without success. He went to the wing office to check whether there was a prisoner in that cell and then returned with another officer. They entered the cell and found Mr Oakley hanging from the window. Staff radioed a code blue medical emergency at 6.27am and attempted resuscitation. However, paramedics pronounced Mr Oakley dead at 6.50am.

Findings

Management of Risk of Suicide and Self Harm

Staff failed to start ACCT procedures for Mr Oakley when he arrived at Winchester, despite having several risk factors for suicide and self-harm. We also found some deficiencies in the way the subsequent ACCT procedures were managed.

The PPO are concerned that staff failed to identify that Mr Oakley’s risk of suicide and self-harm might increase when he was due to appear in court at the start of his trial, despite prison and healthcare staff being aware that he had either become ill or had been supported by ACCT procedures on previous occasions.

Psychoactive Substances/Illicit Drugs

None. A toxicology report shows there were no substances in Mr Oakley’s blood at the time of his death, other than those prescribed.

Emergency Response

There was a delay in staff entering Mr Oakley’s cell. Although it made no difference in Mr Oakley’s case, this could be critical in future cases.

Clinical Care

Mr Oakley was assessed by a nurse when he arrived at Winchester, but due to restricted access to reception, did not have a full healthscreen. The nurse flagged the need for him to be examined by the night nurse, but was called away to attend to other significant incidents during his night shift.

The clinical reviewer noted that Mr Oakley’s medical records were detailed and of a good standard. During his time at Winchester there were no major concerns about Mr Oakley’s physical or mental health, any new symptoms that he developed were always promptly addressed and treated by the appropriate healthcare professionals, and his case was discussed at multidisciplinary meetings. The clinical reviewer concluded the care Mr Oakley received was of a good standard and equivalent to that which he could have expected to receive in the community.

Recommendations

Rec 1: The Governor and Head of Healthcare should ensure that reception staff start ACCT procedures whenever a prisoner has significant risk factors, regardless of the prisoner’s stated intentions.

Rec 2: The Governor and Head of Healthcare should ensure that staff manage ACCT procedures in line with the guidance in PSI 64/2011, including that:

  • healthcare staff always attend the first case review; and
  • staff hold post-closure reviews within seven days of the ACCT being closed, and complete the post-closure review paperwork fully and accurately.

Rec 3: The Governor and Head of Healthcare should develop a system to identify and record dates that might be triggers for suicide and self-harm, such as court dates, and ensure wing and healthcare staff are made aware.

Rec 4: The Governor and Head of Healthcare should ensure that prisoners passing through reception on return to the prison after a court appearance, or any other event that might increase their risk, are screened to assess their risk of suicide and self-harm and for potential health problems.

Rec 5: The Governor should ensure that where a member of staff cannot see a prisoner in their cell, and they consider it unsafe to enter the cell alone to check on the prisoner, they request assistance immediately.

Rec 6: The Governor should ensure all staff, irrespective of status, position or experience, are offered formal support from the prison, following a death in custody.

Full Report Here


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