PPO Reports & Self-Inflicted Deaths – Health Notes w/c 28 Oct 2019

Last week, the Prisons & Probation Ombudsman published 5 reports relating to deaths in custody. The causes being categorised as follows:

  • Natural Causes = 2
  • Self-Inflicted = 1
  • Other Non-Natural = 2

Below is a summary of the self-inlflicted and non-natural deaths, with those aspects of Healthcare services that 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)

21 Mar 2014 – HMP Wymott

Key Events

On 23 January 2014, the man (his name withheld throughout this report) transferred to Wymott. It was noted on his escort record that he had previously self-harmed, had drug and alcohol issues in prison, but did not have any known physical or mental health problems. He signed prison compacts in reception and staff noted no concerns.

A nurse examined the man and noted that he had no physical or mental health problems and interacted well. He was not prescribed any medication, but had a history of cannabis and benzodiazepine misuse. He told a nurse that he used to drink ten units of alcohol a day in the community. He said he had no current thoughts of suicide or self-harm. He then went to the therapeutic community, and staff gave him information about the regime as part of his induction.

The man’s personal officer, saw him most days. The officer told the investigator that the man settled well, was happy to be nearer to his family and was always polite. He appeared to get on well with other prisoners. On 5 February, the officer recorded that he was keen to complete the therapeutic community programme and was currently working on the welcome desk (greeting and assisting visitors to the therapeutic community), as a cleaner and in the servery. The officer told him that he could talk to him about any problems. He last saw him on 17 March and had no concerns about him at the time.

On the day of the incident, the man gave a presentation about support networks to other prisoners as part of the therapeutic community programme.

  • Prisoner A, who was at the presentation, told the investigator that the presentation had been well received.
  • The course facilitator told the investigator that the man appeared highly motivated to complete the programme and had agreed to do the presentation to help improve his confidence. He had been nervous that morning, but she said that this was to be expected. She said that he had delivered the presentation very well.
  • A therapeutic community facilitator saw the man on the wing after the presentation. He told the facilitator that the presentation had gone well and he was pleased about the response. The facilitator told the investigator that the man seemed to be in a good mood.

The man went to Prisoner A’s cell and had a cup of coffee with him. The prisoner said he had no concerns about him. The man went to the servery to help serve lunch at about 11.45am and invited Prisoner A and Prisoner B to have a cup of tea with him. Prisoner B said that they went to see him at about 12.00pm and stayed for ten minutes. Both prisoners said that they had no concerns about him at the time.

At about 12.45pm, Prisoner A said he saw the man on the landing and he thanked him for helping him to write a Mothers’ Day card. He had hugged the prisoner and said he loved him. They then went back to their cells for the afternoon roll check. The prisoner told the investigator that when he got to his cell, he had been slightly worried about him as he had never displayed such emotion before and he thought that this was strange. However, he soon dismissed this thought and believed that he had appeared to be okay.

At 12.45, an officer conducted the 12.45pm roll check and locked the cells. He said that the man was on his bed watching television when he got to his cell and said hello to him. He raised no concerns. Prisoners remained locked in their cells until about 1.30pm when two officers began unlocking them to collect their weekly prison shop orders, known as canteen. Officer A said she had unlocked his cell about 2.00pm, but did not talk to him or open the door wide enough to see him. Once all prisoners were unlocked, the officers began issuing the canteen orders.

Prisoner B said that he had joined the queue to collect his canteen when his cell was unlocked. He noticed that the man was not in the queue and thought he might be sleeping. He went to his cell and found the door shut but unlocked. He went in and found him hanging by a strip of bed sheet attached to the top of the shower area doorway. He immediately went to alert staff.


Management of Risk of Suicide and Self Harm

At the time that the man transferred to Wymott on 23 January 2014, he had not been identified as a risk of suicide and self-harm. Prison staff at Wymott would have seen his escort record which noted his previous self-harm and they did not have any concerns about him. The PPO investigators were unable to interview the nurse who conducted the reception health screen and mistakenly recorded that he had not previously harmed himself. This suggests that she had not seen his escort record or read his medical record, which contained references to his previous self-harm at Forest Bank in 2012 and his threat to self-harm at Featherstone in 2013. Investigators were satisfied that there was no reason to open an ACCT when he arrived at Wymott. His previous self-harm had been very minor and some time in the past. However, important information, which could be crucial in another case, was overlooked.

Psychoactive Substances/Illicit Drugs

The investigator was not able to find any evidence to confirm the information, received after the man’s death that he was in debt to other prisoners after obtaining illicit drugs and medication from them. His prison record indicates that he had a history of getting into debt with other prisoners, usually for tobacco, but access to tobacco does not appear to have been a problem at the time of his death. He had ordered tobacco from the prison shop and had sufficient money in his prison account to pay for it. Investigators know that he must have taken some illicitly obtained medication as the toxicology test, conducted as part of the post-mortem examination, found tramadol and codeine present in his blood. He had not been prescribed either medication.

Codeine and tramadol are often diverted and misused in prisons for their euphoric potential and can be quite valuable as commodities for trading. Investigators understand that, since the man’s death, tramdadol is no longer prescribed ‘in possession’ and all such medication is given under supervision to help reduce opportunities for diversion and misuse. The Independent Monitoring Board for Wymott indicated in their latest published annual report that the misuse of drugs and medication was a problem on the therapeutic community. There is no clear evidence that abuse of medication was a factor in his death, but such use, particularly if it leads to associated debt, can be a factor which increases the risk of suicide and self-harm. Mental health nurses at the prison told us that issues arising from debt between prisoners are a significant problem at the prison.

Emergency Response

The three officers responded immediately when they were informed that the man was found hanging. One officer pressed the general alarm on the way to the cell, but she did not know the nature of incident. When the officers arrived at the cell and found that he was hanging, none of them radioed a code blue emergency as national instructions and Wymott’s local policy requires. This meant that other staff who responded did not know the nature of the incident and that the control room did not call an ambulance immediately as should have happened. One officer contacted the control room and asked for healthcare staff to attend but did not ask for an ambulance to be called or give details about the emergency. An ambulance was not requested until 2.11pm, at least five or six minutes after the man had first been found hanging.

HMP Wymott has local procedures, which are in accordance with PSI 03/2013, but they were not followed. Even a short delay in such circumstances can have a significant impact on a person’s chance of survival and it is important that prison managers make sure that all relevant prison staff understand the emergency procedures.

At least five members of staff arrived at the man’s cell before the nurse, yet none of them examined him for any signs of life or attempted resuscitation. The first three officers at the cell had not received first aid training for at least four years and, in one case, not at all. One of the officers said that they had gone into shock.

The clinical reviewer notes that there is no evidence to suggest that, had resuscitation been attempted immediately, there would have been a different outcome. However, it is vital that if a person is unconscious, cardiopulmonary resuscitation is started as soon as possible to improve the chances of survival. Unless there are clear signs of death, staff should attempt resuscitation and continue until expert help arrives.

Clinical Care

The clinical reviewer considered that the standard of healthcare the man received at Wymott was equivalent to that he could have expected to receive in the community.


Rec 1: The Governor and Head of Healthcare should ensure that all healthcare staff in reception see information about risk from escort records and review previous medical records when assessing risk of suicide and self-harm.

Rec 2: The Governor should ensure that, when a cell door is unlocked, staff satisfy themselves of the safety of the prisoner and that there are no immediate issues that need attention.

Rec 3: The Governor should ensure that all relevant staff are familiar with and act on the PSI 03/2013 and Wymott’s local protocol for calling an emergency ambulance (40/2013) and are aware of their responsibilities during medical emergencies which should include:

  • Efficiently communicating the nature of a medical emergency;
  • Ensures staff initiate basic life support as needed until health care staff arrive;
  • Ensuring staff called to the scene attend as quickly as possible and bring the relevant equipment; and
  • Ensures there are no delays in calling, directing or discharging ambulances.

Rec 4: The Governor should ensure that there are sufficient first aid trained staff on duty at all times and that when a prisoner is not breathing all officers understand how to begin basic life support and do so until trained staff arrive, unless there is clear evidence that it would be futile in the circumstances.

Rec 5: The Governor should ensure that Wymott has effective strategies to reduce the availability of illicit drugs and trading of prescribed medication and to tackle issues arising from prisoners in debt to each other.

Full Report Here

15 Feb 2016 – HMP Forest Bank.

Key Events

On 7 November 2015, Mr James Hunter was remanded to custody at HMP Forest Bank charged with sexual offences against children. He had a history of depression and alcohol misuse and, in 2014, he had reported suicidal thoughts.

In December 2015, he was seen by a mental health nurse, having told staff he felt depressed and anxious. In January 2016, Mr Hunter submitted a number of complaints which alleged he was being victimised by another prisoner.

In the early hours of 15 February 2016, Mr Hunter told staff he had overdosed on prescribed medication. His clinical observations were not identified as abnormal and, he was left in his cell, with his elderly cell mate. Prison Service suicide and self-harm prevention measures (ACCT) were started.

At 7.10am, a prison officer found Mr Hunter unresponsive sitting on the toilet. Resuscitation was not attempted as there were clear signs he had died. Paramedics arrived and confirmed Mr Hunter’s death at 7.41am. It was his 36th birthday.


Management of Risk of Suicide and Self Harm

PPO Investigators were satisfied that there was no indication that Mr Hunter was at increased risk of suicide and self-harm prior to his disclosure about his overdose. The investigator did not identify any reason why Mr Hunter’s birthday would have been a trigger for suicide or self-harm.

The night patrol operational support officer began ACCT procedures at 2.00am on 15 February. The night manager should have completed an immediate action plan within an hour, but did not do so. He told the investigator that he (or his assistant night manager) would typically have completed the plan but accepted that the failure to complete an action plan was an oversight on his part. Investigators were concerned that this important part of the ACCT process was not carried out.

An officer recorded in Mr Hunter’s ACCT that he had observed him sitting on the toilet at 7.00am, but CCTV footage shows he did not go to Mr Hunter’s cell. Further, the officer altered an entry on the ACCT ongoing record, having altered ‘sat on chair no toilet’ to ‘sat on chair no issues’.

A senior manager at Forest Bank conducted an internal investigation into events between 5.00am and 7.10am on 15 February. The officer told the senior manager that he thought he heard another officer shout to him that Mr Hunter was on the toilet, as an explanation for this entry, but accepted he did not conduct the check himself. The officer denied altering the ACCT, but said that he did not fully remember events.

Psychoactive Substances/Illicit Drugs

A pathologist concluded that Mr Hunter died from citalopram toxicity (overdose). Mr Hunter’s blood concentration level was 19.6mg (fatal cases of citalopram toxicity have been reported in cases of above 1.5mg). Although the contents of Mr Hunter’s stomach suggested citalopram had recently been consumed, the pathologist was unable to establish exactly when before he died. No other illegal drugs or alcohol were detected.

Emergency Response

Forest Bank’s local emergency response codes protocol reflects the national guidance contained within PSI 03/2013.

An officer correctly radioed an emergency medical code at 7.10am, but an ambulance was not requested by the control room until 7.30am (control room records note the call was made at 7.25am). The two operational support officers in the control room were inexperienced and had never dealt with an emergency situation. They told the investigator they were not sufficiently trained and were unaware what to do when a medical emergency code was radioed.

Prison training records were provided, signed by both men, which showed this had been addressed during their induction training. A senior manager said that that following an internal investigation, both officers were given an improvement notice (a first formal warning) and further training.

While the delay in calling an ambulance would not have altered the outcome for Mr Hunter, as it is apparent that he had been dead for some time, in other emergencies any delay could be critical.

Forest Bank issued a Director’s Instruction (No9) – Emergency Response Codes on 26 April 2016, reiterating the need for control room staff to request an ambulance immediately a medical emergency code is radioed, in line with national guidance. Given the prison has already taken steps to address this issue, no further recommendation was made.

Clinical Care

The clinical reviewers found that the care received by Mr Hunter was not equivalent to the care he could have expected to receive in the community. They found that in the community, Mr Hunter would have been referred to A&E for assessment and treatment following his disclosure that he had taken an overdose, and therefore the failure of prison staff to do so meant that Mr Hunter did not receive equivalent care.

When a nurse took Mr Hunter’s clinical observations following his disclosure that he had taken an overdose, he recorded that they were satisfactory in spite of his pulse rate being elevated and his respiratory rate being at the lower end of normal. On the basis that he had no concerns about Mr Hunter’s welfare, he was kept in his cell rather than being moved to the observation ward. The nurse also failed to contact Toxbase, a 24-hour national poisons information service, or the local accident and emergency department for advice.

Sodexo Justice Services suspended the nurse on 17 March 2016, and he was later dismissed on 14 December 2016.


Rec 1: The Director should commission an investigation under the terms of PSI 06/2010 & AI 05/2010, Conduct and Discipline, into the decision by an operational manager not to move Mr Hunter to healthcare, not to complete a thorough cell search and the failure to complete an immediate ACCT action plan.

Rec 2: The Director and Head of Healthcare should ensure that staff manage prisoners at risk of suicide and self-harm in line with national guidelines, in particular:

  • All staff should have adequate ACCT training and refresher training.
  • All staff should take the possible side effects of medication and other substances into account when assessing risk of suicide and self-harm.
  • Staff should set actions on the immediate action plan and caremap that are specific, meaningful and tailored to the individual to reduce their risk.

Rec 3: The Director should review the effectiveness of HMP Forest Bank’s violence reduction policy and its delivery, specifically ensuring:

  • The effective identification and management of victims and alleged perpetrators.
  • Effective support and protection for apparent victims with meaningful objectives and long-term solutions, which address their individual situations.
  • The risk of suicide or self-harm to victims of bullying and intimidation is considered.

Rec 4: The Head of Healthcare should review the recording system for prescriptions to ensure there are no discrepancies between electronic and paper records, and ensure healthcare staff accurately update medical records.

Rec 5; The Head of Healthcare should ensure mental health assessments take into account all relevant information, use standard mental health assessment tools, and assessment and treatment are in line with NICE guidelines.

Full Report Here

16 Jun 2018 – HMP Lewes.

Key Events

On 23 March 2018, Mr Neville McNair was remanded to HMP Lewes.

Mr McNair had a leg ulcer, and a history of psychiatric issues and of using illicit substances. He was thought to be under the influence of an unknown substance on arrival at Lewes.

When he arrived at Lewes, a nurse referred Mr McNair to the mental health in-reach team and he had regular input from them. However, despite apparently using drugs, no one referred him to substance misuse services.

In April, he was suspected of diverting (for selling or sharing?) his prescribed medication (which included morphine for pain relief). His morphine prescription was stopped as a result. He self-harmed in a superficial way when his morphine was stopped. Staff started suicide and self-harm prevention measures, known as ACCT, for two days but closed the ACCT when Mr McNair’s risk was considered to have reduced.

At the same time, Mr McNair approached the substance misuse service and asked to be referred. The substance misuse team tried to see him on three occasions that month, but Mr McNair did not make himself available. He was finally seen on 1 May when he said things had changed for him and he no longer needed the service’s help.

Also in April, Mr McNair told a mental health nurse that he was feeling suicidal and that he was struggling on the wing and was being bullied for his medication. He was moved to a different wing the next day and staff subsequently reported that he had settled well and that his mood was brighter.

On the evening of 16 June, a nurse gave Mr McNair his prescribed medication at 6.40pm, before an officer locked him in his cell for the night. Mr McNair was chatty and bright and did not appear to be under the influence of drugs.

An hour later, an officer conducting a roll check saw Mr McNair on his knees in his cell. The officer called Mr McNair’s name and banged on the door but he did not get a response. The officer’s radio reception was not clear so he ran 30 metres down the wing to summon help from staff. He and another officer then entered the cell and the other officer called an emergency code blue. Prison healthcare staff attended quickly and tried to resuscitate Mr McNair.

The control room log states that the code blue was called at 7.39pm, but it does not say when an ambulance was called. The ambulance service’s log says they did not receive a call until 7.45pm, and that paramedics arrived at the prison at 7.55pm but were not allowed into the prison until 8.03pm. Staff and paramedics were unable to resuscitate Mr McNair and at 9.02pm, it was confirmed that Mr McNair had died.

The post-mortem investigation concluded that heroin toxicity was the probable cause of death. Mr Neville McNair would have been 52 years old the following day.


Management of Risk of Suicide and Self Harm

PPO Investigators identified some deficiencies in the operation of ACCT procedures in this case. Mr McNair was only briefly subject to ACCT monitoring between 10 and 12 April after a superficial self-harm incident. There appears to be no evidence to suggest that Mr McNair deliberately took a drugs overdose with the intention of ending his life, and investigators do not consider that the deficiencies in ACCT procedures impacted on his death. Nevertheless, investigators consider that it is important to highlight them as learning for the prison.

The ACCT assessment, which was good, identified that Mr McNair’s risk factors were that he was worried about his upcoming court appearance; being taken off medication; and mobility issues with his current location. The ACCT was closed the next day at the first review without any reference to these risk factors and a caremap was not completed. Investigators considered that there was too much reliance on what Mr McNair said rather than an objective evaluation of his risks. The ACCT should not have been closed until Mr McNair’s issues had been addressed.

A post-closure review was scheduled for 19 April, but there is no record that it took place.

Psychoactive Substances/Illicit Drugs

Mr McNair was suspected of diverting medication from the medication hatch on a number of occasions. The first instance occurred on 3 April and an intelligence report was submitted. There were three further instances of suspected non- compliance on 4 April, 6 April and 9 April. Although there is no evidence of any further intelligence reports being completed, the pharmacy worker did ask a GP to review the situation and Mr McNair’s morphine prescription was stopped as a result.

The investigator asked the Head of Healthcare whether healthcare staff have access to the necessary system to file intelligence reports and, if not, what mechanisms exist to share information about a prisoner’s suspected substance misuse with discipline staff. He said that most healthcare staff did have access to the system and he would have expected them to file intelligence reports when they suspected a prisoner is under the influence of drugs or secreting medication. He said that any staff who do not have access can ask prison staff to log onto the security system for them and take them through the report template. Healthcare staff also attend monthly security meetings to ensure that substance misuse information is shared between all staff in the prison.

On 11 April, Mr McNair told a GP that staff were mistaken about him diverting medication, but on 17 April, he told a member of staff that he had been pressured into selling his medication and wanted to move wings. He was moved to a different wing on 21 April, and entries on his record suggest that he reported being much happier.

Investigators were satisfied that in this instance, the prison took action to protect Mr McNair’s well-being.

Emergency Response

Investigators were concerned that when an officer could not get a response from Mr McNair (on 16 June), he did not call an emergency code over his radio or enter Mr McNair’s cell, instead he went to get help from the wing office which was approximately 30 metres away.

The investigator asked the officer to describe his decision making at the point he decided to fetch assistance rather than radio for it or go into the cell alone. The officer said that, at the time, he had only recently been trained and this had been his first set of night shifts. He was able to demonstrate he understood the emergency code system. He said that he had a radio with which to summon assistance but issues with the airwaves meant it was much quicker for him to go and fetch a colleague.

The officer said that during training he had been told categorically he could never go into an unlocked cell alone because of safety and security issues. The officer said that his training was clear that whatever the circumstance he should not enter a locked cell alone. This is not correct (in accordance with PSI 24/2011).

Clinical Care

Mr McNair had issues with chest pain and a leg ulcer which were appropriately investigated, monitored and managed. The clinical reviewer is satisfied that the care Mr McNair received at Lewes was equivalent to that which he could have expected to receive in the community.


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

  • ACCT caremaps should have specific, meaningful actions aimed at reducing prisoners’ risk to themselves and progress should be considered and documented at each review.
  • All caremap actions have been completed before ACCT monitoring is stopped.
  • Post-closure reviews are completed within seven days of closure and the outcome documented in the ACCT.

Rec 2: The Governor should ensure that staff are reminded of the national and local policies on entering cells during medical emergencies.

Rec 3: The Executive Director of Performance in HMPPS should ensure that POELT training accurately reflects national policies on entering cells during medical emergencies.

Rec 4: The Governor should ensure that:

  • control room staff call an ambulance immediately when a medical emergency is called; and
  • arrangements are in place to escort ambulance personnel to medical emergencies as quickly as possible.

Rec 5: The Head of Healthcare should ensure healthcare staff file intelligence reports where they suspect a prisoner is engaging in behaviour relating to substance misuse and/or the diversion of medication.

Rec 6: The Chief Executive of HMPPS should provide the Ombudsman with a revised date for issuing detailed national guidance on measures to reduce the supply and demand of drugs in prisons, and an assurance that this new date will be met.

Full Report Here

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