PPO Reports & Self-Inflicted Deaths – Health Notes w/c 04 Nov 2019

Last week the PPO published 4 reports relating to deaths in custody. The causes are categorised as follows:

  • Natural Causes = 3
  • Self-Inflicted = 1
  • Other Non-Natural = 0

Below is a summary of those self-inlflicted deaths, with specific focus on 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)

03 April 2018 – HMP Leeds.

Key Events

On 22 February 2018, Mr Daniel Wilcock was sentenced to 20 weeks imprisonment for breaching a restraining order and was sent to HMP Leeds. He had been diagnosed with narcissistic and borderline personality disorder and had a history of depression.

On 12 March, a nurse saw Mr Wilcock for a mental health triage but ended the appointment because he would not answer any questions and was argumentative, abusive and threatening. The following day, a multidisciplinary team meeting discussed Mr Wilcock and noted that he did not have any mental health concerns so they discharged him from the mental health team.

At 10.45am on 29 March, Prison Service suicide and self-harm monitoring (ACCT) procedures began after Mr Wilcock said that he had planned to kill himself with a ligature the previous night. At 9.30am on 31 March, a prison manager held the first ACCT case review. Mr Wilcock said that his thoughts of hurting himself had lessened, though he was struggling to cope with recent family bereavements and was worried about his housing situation on release. The manager decided that Mr Wilcock needed help with his housing and that he should continue working with the substance misuse team. As Mr Wilcock seemed calmer, the manager closed the ACCT.

At 5.20pm on 3 April, an officer reopened Mr Wilcock’s ACCT after he said that he had swallowed four razor blades. The officer asked for healthcare assistance but a nurse did not see Mr Wilcock because she said he would digest the razor blades.

At 7.00pm, a prison manager held the second ACCT case review and Mr Wilcock said that he felt hopeless because he was being released shortly but had nowhere to live. He also said that he had mental health issues and agreed to see the mental health team after initially refusing help. The manager noted that Mr Wilcock engaged fully in the review so decided that he presented a low risk of suicide and self-harm (on a scale of low, raised, high and no change).

At 8.35pm, an operational support grade (OSG) checked on Mr Wilcock and found that he had covered his observation panel with a cabinet. The OSG asked for assistance and an officer responded. After moving the cabinet, they saw Mr Wilcock hanging from a ligature. At 8.42pm, the OSG called a code blue emergency and staff entered the cell. Staff lowered Mr Wilcock to the floor and started cardiopulmonary resuscitation. Two nurses and a prison GP quickly responded to the code blue emergency and they assisted with the resuscitation.

The control room log noted that they called for an ambulance at 8.45pm, though Yorkshire Ambulance Service recorded it was requested at 8.48pm. Paramedics reached Mr Wilcock at 8.53pm but were unable to resuscitate him and at 9.23pm, the prison GP declared that Mr Wilcock had died.


Reception Screening

When he arrived at Leeds, a nurse saw Mr Wilcock for an initial health assessment. Mr Wilcock said he had depression and narcissistic personality disorder, and that he was taking mirtazapine (used to treat depression) though he had recently stopped taking olanzapine (an antipsychotic drug used to support people with personality disorders). The nurse found that Mr Wilcock’s urine tested positive for amphetamine, methadone and cocaine and he admitted to using psychoactive substances (PS). Mr Wilcock was referred to the mental health team, the substance misuse team and a prison GP.

Mr Wilcock had been diagnosed with narcissistic and borderline personality disorder and had a history of depression, though there was nothing in his medical record to show that he had engaged with community mental health services. He also misused alcohol and drugs, including cocaine, opiates and cannabis. Mr Wilcock’s community GP summary but did not identify any current concerns or risks.

The nurse assessed Mr Wilcock’s risk of sharing a cell and decided that he presented an increased risk due to his personality disorder. A prison manager allocated him a single cell.

Management of Risk of Suicide and Self Harm

A senior drug therapist opened the ACCT document at 10.45am on 29 March and recorded that Mr Wilcock had planned to kill himself with a ligature but could not find a place to fix it. To comply with PSI 64/2011, the first ACCT case review should have taken place within 24 hours but actually took place nearly 48 hours later at 9.30am on 31 March.

Staff underestimated Mr Wilcock’s risk of suicide and self-harm by not placing sufficient weight on his recent self-harm, unresolved concerns, and apparent mental health issues. Investigators found no evidence that staff looked for a ligature after Mr Wilcock told a drug therapist that he had one in his cell. Investigators were also concerned that healthcare staff did not assess Mr Wilcock after he told a prison officer that he had swallowed four razor blades.

Investigators found a number of deficiencies with the ACCT process. The first ACCT case review was not held within 24 hours, caremap actions were inappropriately recorded as completed, and staff did not observe him hourly as specified – on one occasion Mr Wilcock was not checked for 95 minutes.

Following the first ACCT case review, the attendees decided to close the ACCT because Mr Wilcock knew that his issues were not being ignored. Investigators were concerned about the speed of this decision because Mr Wilcock had planned to kill himself with a ligature two days earlier, and his issues, particularly his anxieties about his housing on release, had not been resolved. The prison manager added caremap actions for Mr Wilcock, which included contacting the resettlement team about his housing on release and him continuing his substance misuse work with a senior drug therapist. These actions were marked as having been completed on 31 March, although Mr Wilcock’s housing issue had not been resolved and he did not see the senior drug therapist for another substance misuse session before his death.

Despite being diagnosed with a narcissistic and borderline personality disorder, the mental health team did not assess Mr Wilcock for 18 days. The mental health team discharged Mr Wilcock without completing his triage appointment.

Psychoactive Substances/Illicit Drugs

Mr Wilcock had a history of drug and alcohol abuse so healthcare staff promptly referred him to the substance misuse team. Mr Wilcock received regular monitoring of his withdrawal and could easily access substance misuse support.

Investigators were concerned that Mr Wilcock told a senior drug therapist that he was struggling on his methadone dose on 13 March and that it was not increased until 19 March. The Clinical Reviewer determined that a 6-day delay was too long based on his presentation.

The toxicology examination revealed medication within therapeutic ranges, which had no impact on Mr Wilcock’s death. No other illicit substances were found in his blood or urine samples.

Emergency Response

An OSG called a code blue emergency at 8.42pm but the prison’s control room log recorded that they did not call an ambulance for at least 3 minutes. According to the Yorkshire Ambulance Service, the prison’s control room did not call for the ambulance until 8.48pm, a delay of 6 minutes. While the precise length of the delay cannot be determined, Investigators were concerned that the control room ignored the requirement in PSI 03/2013 as they failed to immediately call for an ambulance.

Clinical Care

The Clinical Reviewer determined that Mr Wilcock’s mental health care was not equivalent to that which he could have expected to receive in the community. For the most part, Mr Wilcock received a good standard of substance misuse care that was equivalent to that which he could have expected to receive in the community. However, notable concerns were that Mr Wilcock waited 6 days for his methadone dosage to be increased.


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

  • hold a multidisciplinary case review within 24 hours of an ACCT being opened;
  • consider all risk factors, including suicidal statements, current self-harming behaviour and previous suicide attempts, when assessing a prisoner’s risk;
  • do not record ACCT caremap actions as complete until they have been completed;
  • do not close ACCTs until the caremap actions have been completed; and
  • adhere to the frequency of observations set out in the ACCT document.

Rec 2: The Governor should ensure that when prisoners say they have ligatures, staff search them and their cells as soon as possible and remove any ligature.

Rec 3: The Head of Healthcare should ensure that healthcare staff assess and treat all prisoners who have self-harmed, including those who report self harm.

Rec 4: The Head of Healthcare should ensure that prisoners:

  • are seen within prescribed timescales; and
  • are not discharged from the mental health team without being assessed.

Rec 5: The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, including that control room staff call an ambulance as soon as an emergency code is called.

Rec 6: The Governor should ensure, in line with PSI 64/2011, that where it has not been possible for someone from the prison to inform the family about a death in custody, prison staff should arrange a visit as soon as possible afterwards.

Full Report Here

Thanks to Jon Tyson for making this photo available freely on Unsplash

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