PPO Reports & Self-Inflicted Deaths – Health Notes w/c 11 Nov 2019

Last week the PPO published 12 reports relating to deaths in custody. The causes are categorised as follows:

  • Natural Causes = 7
  • Self-Inflicted = 3
  • Other Non-Natural = 2

Below is a summary of those self-inlflicted and other non-natural deaths, with specific focus on those aspects of Healthcare services that are integral within prisons:

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

29 Nov 2018 – HMP Pentonville. Self-Inflicted Death.

Key Events

On 5 November 2018, Mr Robert Ginn was sentenced to 12 months imprisonment for sexual offences. He was sent to HMP Pentonville.

The following day, a nurse started Prison Service suicide and self-harm monitoring (known as ACCT), after Mr Ginn told her he was having thoughts of suicide.

On 20 November, a senior mental health practitioner saw Mr Ginn for a mental health assessment. When asked what support he wanted, Mr Ginn said that he wanted some morphine to take his life. Mr Ginn said he had plans to kill himself but would not tell her or she would stop his plans. The practitioner planned for Mr Ginn to continue with his prescribed medication and for the primary care mental health team to review him within 2 weeks.

On 26 November, a psychiatrist saw Mr Ginn for a mental health assessment. Mr Ginn joked about his previous episodes of self-harm and that he would be better off being stabbed by another inmate. Mr Ginn said that his daughters and a female friend were protective factors and that he was scared of dying. The psychiatrist diagnosed Mr Ginn with an adjustment disorder (a stress-related condition). The psychiatrist decided to increase Mr Ginn’s antidepressant prescription, referred him for cognitive behaviour therapy and planned to see him before the Christmas holidays.

At 3.30pm on 28 November, an officer spoke to Mr Ginn, who said he was “in a very bad way”. Mr Ginn said that he had nothing to live for, would be better off dead and that he was upset because a female friend had accused him of lying to her about his crimes.

Just after 1.00am on 29 November, an operational support grade (OSG) began checking on certain prisoners and, when she reached Mr Ginn’s cell, she saw that he had tied a ligature around his neck. She called to another OSG for help. The second OSG called a Code Blue emergency at 1.08am but neither of them entered Mr Ginn’s cell. 4 prison officers and 2 nurses quickly responded. They entered the cell, removed the ligature and started cardiopulmonary resuscitation (CPR).

At 1.10am, an officer called for an ambulance and paramedics reached Mr Ginn at 1.24am. The paramedics were unable to resuscitate Mr Ginn and, at 2.10am, declared that he had died.


Reception Screening

When Mr Ginn arrived at Pentonville from court, he arrived with a Person Escort Record that recorded he was at risk of suicide and self-harm, though it did not give details. An officer and a nurse also interviewed Mr Ginn and his responses demonstrated that he was at risk as shown by the 4 ‘yes’ answers on the Risk of Self-Harm or Suicide Form and his comment about having fleeting suicidal thoughts comment.

Despite having reviewed various documents and interviewed Mr Ginn, neither the officer nor the nurse opened an ACCT. They also did not explicitly record their reasons for not doing so. Although starting ACCT procedures at an earlier time would not have changed the outcome for Mr Ginn, it could be critical in other cases.

Management of Risk of Suicide and Self Harm

Staff underestimated Mr Ginn’s risk of suicide and self-harm by not placing sufficient weight on his regular suicidal comments, his deteriorating mental health and his previous suicide attempts while in the community. Staff were not aware of the significance of the breakdown in Mr Ginn’s relationship with a friend and that this did not result in an immediate ACCT case review.

There were other deficiencies with the ACCT process. Mr Ginn had been on an ACCT for 23 days yet prison staff only held 4 ACCT case reviews during that time. The gaps between ACCT case reviews were deemed too long, mental health staff did not attend 2 of the 4 reviews, and staff regularly failed to observe him as specified – on one occasion, he was not checked for 5 hours and 30 minutes when he should have been checked every 2 hours.

Mr Ginn’s mental health deteriorated while at Pentonville and the Clinical Reviewer considered that, from 26 November, his care should have been transferred to the inreach mental health team.

Psychoactive Substances/Illicit Drugs

The toxicology examination revealed prescribed medication within therapeutic ranges, which had no impact on Mr Ginn’s death. No illicit substances were found in his blood sample.

Emergency Response

When the OSG found Mr Ginn, she panicked and called for help from another OSG rather than calling a Code Blue emergency. Although the second OSG responded quickly and called the Code Blue, there were concerns that failing to use the correct emergency code may result in unnecessary delays in the future.

After calling the Code Blue emergency, neither OSG’s entered Mr Ginn cell. There was a 2-minute delay before the control room called an ambulance.

Iinvestigators acknowledge the distress of seeing a prisoner in such circumstances and that officers must have regard for their own safety when deciding whether to enter a cell or not, however they expressed that they did not understand why both OSG’s concluded that it was not safe to enter Mr Ginn’s cell given what they had seen. By failing to follow PSI 24/2011 and immediately enter Mr Ginn’s cell, there was an unnecessary delay in treating him.

Clinical Care

The Clinical Reviewer considered that, at this point, Mr Ginn’s level of risk had increased and his mental health had deteriorated to an extent that he should have been referred to the mental health inreach team. This would have allowed Mr Ginn to receive continuing oversight from appropriate clinicians. However, there is no record that anyone made or contemplated making a referral to the mental health inreach team. In failing to do so, the Clinical Reviewer considered that Mr Ginn’s mental health care was not equivalent to that which he could have expected to receive in the community.


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

  • consider all risk factors, including suicidal statements, apparent planning and previous suicide attempts, when assessing a prisoner’s risk;
  • schedule case reviews at appropriate intervals, in line with the prisoner’s level of risk;
  • hold multidisciplinary case reviews, attended by all relevant people involved in a prisoner’s care;
  • adhere to the frequency of observations set out in the ACCT document and that observations take place at unpredictable times;
  • record details of protective factors and potential triggers in the ACCT document;
  • involve the prisoner’s family when that would be appropriate.

Rec 2: The Governor and the Head of Healthcare should ensure that reception staff examine all available documentation about a prisoner and consider and record all the known risk factors of newly arrived prisoners when determining their risk of suicide or self-harm. When they decide not to begin ACCT procedures for prisoners with significant risk factors, or who arrive with documents detailing a risk of suicide and self-harm, they should clearly record the reasons.

Rec 3: The Head of Healthcare should ensure that there is effective and clear liaison between the primary care mental health team and the mental health inreach team, which allows a prisoner’s suitability for each mental health team to be promptly reassessed.

Rec 4: The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, including that:

  • staff enter cells as quickly as possible in a life-threatening situation.
  • staff radio an appropriate emergency code.
  • control room staff call an ambulance as soon as an emergency code is called.

Rec 5: The Governor should ensure, in line with PSI 64/2011, that:

  • when a prisoner changes their next of kin, staff update the prisoner’s NOMIS prison record promptly; and
  • a family liaison officer breaks the news of a death to a next of kin in person as soon as possible.

Rec 6: The Governor should ensure that, following a death in custody, staff receive adequate support and that a manager, not involved in the death, leads a hot debrief and records who attends.

Full Report Here

07 Feb 2018 – HMP Nottingham. Self-Inflicted Death.

Key Events

On 5 February 2018, Mr Capewell appeared at Magistrates Court and was remanded into custody charged with indecent exposure and racially threatening behaviour. He was due to appear at Crown Court on 26 February.

A Supervising Officer (SO) saw Mr Capewell when he arrived in reception at 12.45pm. He signed the Prisoer Escort Record (PER) and Suicide & Self Harm Warning (SSHW) forms and immediately opened an ACCT. He assessed Mr Capewell as being at high risk of suicide or self-harm. His level of observations was set at hourly throughout the day and night until the first case review.

On 6 February, at 3.10pm, an officer assessed Mr Capewell as part of ACCT procedures, which was outside of the mandatory 24 hours of an ACCT being opened. Mr Capewell said he had consumed a lot of alcohol and smoked PS before his arrest. He said he had self-harmed and made a ligature while at court out of frustration at being returned to prison. Mr Capewell said that he had attempted to take his own life on several occasions in the past by using a ligature. He said he had no contact with his family nor did he have any plans to contact them. The officer recorded that Mr Capewell was on an alcohol detoxification programme and that he wanted to contact his solicitor and probation officer.

At 5.00pm, a SO held the first ACCT case review with Mr Capewell (and again, outside of the mandatory 24 hours of an ACCT being opened). No one else was present or provided any input into the review. Mr Capewell said he was upset at being back in prison as he had managed to stay out of prison for 2 months. He said he would need help to find accommodation on his release.

The SO told the investigator that he was aware that the ACCT review should have been done much earlier in the day. He said that no one from healthcare was available and mental health nurses only work up to 5.00pm, Monday to Friday.

On 7 February, at 10.24am, a SO took Mr Capewell from his cell to a private area on D Wing and chaired an ACCT case review with a mental health nurse and Mr Capewell present. Mr Capewell said he was embarrassed about his offence and was aware of the support available to him. He said that he wanted to contact his solicitor. The SO and nurse agreed that Mr Capewell’s risk of suicide and self-harm was low. They, and Mr Capewell, agreed to close the ACCT. The SO recorded that he would obtain the number of Mr Capewell’s solicitor. He also recorded that the caremap had been updated, although the action had not been completed. A post-closure review was scheduled for 15 February.


Reception Screening

The reception procedures at Nottingham were not conducted in line with mandatory instructions. The reception nurse had not seen the SSHW form completed at court on 5 February. Investigators were concerned that reception procedures at Nottingham could inhibit appropriate risk assessment.

Management of Risk of Suicide and Self Harm

Since 2010, Mr Capewell had been monitored under ACCT over 40 times during his time in prison.

ACCT procedures at Nottingham were not conducted in line with mandatory national instructions. Some reviews were not completed when required, not all case reviews were multidisciplinary, and there were inappropriate assessments of Mr Capewell’s risk of self-harm.

Staff correctly opened an ACCT on 5 February, immediately on Mr Capewell’s arrival at Nottingham. However, national instructions explicitly state that it is mandatory for both the ACCT assessment and first case review to be completed within 24 hours of an ACCT being opened. Neither of these happened on time.

The ACCT was opened on 5 February but closed on 7 February, despite Mr Capewell making 2 attempts at self-harm by ligature within the previous 48 hours. Mr Capewell was found hanged in his cell less than 7 hours after the ACCT had been closed.

Psychoactive Substances/Illicit Drugs

A post-mortem examination confirmed that the cause of Mr Capewell’s death was hanging. The toxicology results confirmed that Mr Capewell was not under the influence of alcohol or any illicit drugs at the time of his death.

Emergency Response

The control room log shows the Code Blue was called over the radio at 5.00pm and an ambulance was called immediately. East Midlands Ambulance Service records confirm that the 999 call was received at 5.00pm.

The offender health paramedic immediately responded to the Code Blue call. He told the officer to stop the resuscitation and used an automated external defibrillator, which administers electrical shocks to restore a normal rhythm to the heart if any is found. The defibrillator found no shockable rhythm, and at 5.02pm, he pronounced Mr Capewell dead.

Clinical Care

The Clinical Reviewer considered that Mr Capewell received appropriate care from healthcare staff at HMP Nottingham and this was equivalent to the care he would have received in the community.

Mr Capewell was correctly put on a 5-day detoxification programme with medication prescribed to supplement vitamins in his body and medication to relieve anxiety and reduce the likelihood of fits during withdrawal. Mr Capewell was correctly monitored for detoxification during the 48 hours before his death.

The Clinical Reviewer commends the offender health paramedic for his swift and confident response to the emergency response on 7 February 2018, utilising his training, experience and following national guidelines on when it is inappropriate to perform CPR.


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

  • conducting ACCT reviews as specified in the national instructions;
  • assessing the level of risk and recording the reasons for decisions; and
  • setting and recording appropriate levels of observations which are adjusted as the perceived level of risk changes.

Rec 2: The Governor should ensure that, in line with national instructions, reception staff examine and record all relevant information about newly arrived prisoners, that all relevant staff see person escort records and suicide and self-harm warning forms and that there is a clear audit trail to demonstrate that this happens.

Full Report Here

13 Jan 2018 – HMP Hull. Other Non-Natural Death.

Key Events

Mr Daniel Raworth arrived at HMP Hull on 16 November 2017. On 23 November, he was sentenced to three and a half years imprisonment for supplying Class A drugs.

Mr Raworth had a history of substance misuse but on arrival at Hull he denied any recent drug use and declined a referral to the Drug and Alcohol Recovery Team. During his time at Hull, there was no intelligence to suggest he took or was involved in drugs.

Mr Raworth’s cellmate told the investigator that Mr Raworth went to sleep at about 10.30pm on 12 January, and he went to sleep at about 11.00pm.

On the morning of 13 January 2018, Mr Raworth’s cellmate realised something was wrong when he could not wake Mr Raworth. He fetched officers who came to the cell. They could not get a response from Mr Raworth and then noticed vomit on his bed. They called a medical emergency code. A nurse arrived who assessed that Mr Raworth had signs of rigor mortis, so he did not attempt to resuscitate him. Paramedics confirmed Mr Raworth’s death at 9.53am.


Reception Screening

A nurse conducted Mr Raworth’s reception health screen. She recorded that he appeared fit and well and was not on any medication. Although Mr Raworth had a history of substance misuse, he denied using drugs in the last month and refused a referral to the Drug and Alcohol Recovery Team.

Management of Risk of Suicide and Self Harm


Psychoactive Substances/Illicit Drugs

The post-mortem examination found no evidence of natural disease that could have caused or contributed significantly to Mr Raworth’s death.

Toxicology tests showed that Mr Raworth had a number of prescription-only drugs in his blood, namely buprenorphine, pregabalin, and quetiapine. None had been prescribed to Mr Raworth.

None of the drugs found in Mr Raworth’s system were at levels associated with toxicity. However, the pathologist concluded that the combination of buprenorphine, pregabalin and quetiapine was likely to have caused fatal respiratory depression, and that Mr Raworth died from the effects of these 3 drugs.

Emergency Response

A nurse heard the Code Blue and responded immediately. He found that Mr Raworth was cold to touch and his limbs were rigid. He concluded that Mr Raworth was showing signs of rigor mortis and therefore did not attempt to resuscitate him.

Investigators expressed no concerns about the emergency response and were content that the nurse’s decision not to attempt resuscitation was correct.

Clinical Care

The Clinical Reviewer was satisfied that the care Mr Raworth received at HMP Hull was equivalent to that he could have expected to receive in the community. During his reception screen he was offered a referral to the Drug and Alcohol Recovery Team which he declined.

The Clinical Reviewer agreed with the nurse’s assessment on 13 January that Mr Raworth showed signs of rigor mortis and that attempting cardiopulmonary resuscitation would not, therefore, have been appropriate.


Rec 1: The Governor should ensure that the key drug issues at Hull continue to be identified and that the prison’s local drugs strategy is revised to ensure that these key issues are being addressed.

Full Report Here

22 Nov 2017 – HMP Exeter. Self-Inflicted Death.

Key Events

Mr Dwayne Stoneman was convicted of assaulting his former partner. On 30 May 2017, he was sentenced to 13 months imprisonment and was sent to HMP Exeter. Mr Stoneman had a comprehensive mental health assessment and was diagnosed with moderately severe depression and anxiety. He denied having thoughts of self-harm and prison service suicide and self-harm prevention measures (ACCT) were not started. A care plan was put in place and after regular support from the mental health and substance misuse teams, he improved.

Mr Stoneman was moved to a lower security prison, HMP Channings Wood, in July 2017 and was released on licence on 13 October.

On 22 October, Mr Stoneman was arrested for breaching the conditions of his licence. He had deliberately scalded his hand with hot water before being taken into custody. At the police station, he was interviewed by a nurse from the Devon Liaison and Diversion Team (DLDT) as he was banging his head against his cell wall. He said he had constant thoughts of dying since his release from prison and had started to plan how he might take his life. The nurse assessed that he would be at a higher risk of suicide if remanded to custody and emailed her concerns to Exeter’s mental health team administrator. It was not acted on as the administrator was on leave.

Mr Stoneman arrived at Exeter with an exceptional risk form completed by court escort staff, highlighting his suicide risk. Staff began ACCT procedures. A nurse saw him for an initial health check but she was unaware of the liaison and diversion team assessment of his risk. Mr Stoneman saw a mental health nurse the next day who noted his low mood but found him willing to discuss his future. She discharged him from the mental health team caseload. His frequency of observations on ACCT were reduced until the ACCT was closed on 31 October.

On 30 October, the Liaison and Diversion assessment was added to Mr Stoneman’s clinical records by the administrator when she returned to work. A psychiatrist reviewed Mr Stoneman’s case at a healthcare meeting on 6 November. She considered that he was adjusting to his circumstances but that he could be referred to the mental health team again if necessary. While at Exeter, Mr Stoneman did not harm himself or express thoughts of self-harm to staff or other prisoners.

At about 4.15am on 22 November, Mr Stoneman’s cellmate woke up and found Mr Stoneman hanging from the window by a bed sheet. He pressed his emergency cell bell, cut the ligature and shouted for assistance.

Mr Stoneman’s cellmate said he pressed the emergency cell bell, banged on his cell door and shouted. He thought about 10 minutes passed before 2 officers and a nurse arrived. Cell bell records indicate that the cell bell was pressed at 4.17am and answered at 4.19 am.

Staff and paramedics tried to resuscitate Mr Stoneman but they were unable to do so. At 4.51am Mr Stoneman was pronounced dead.


Reception Screening

On 23 October, Mr Stoneman was remanded in to custody and was sent to HMP Exeter. He arrived with a Person Escort Record (PER) and an exceptional risk form, completed by the court escort staff, which said he was still suicidal. The PER noted that Mr Stoneman had been charged under the Protection from Harassment Act, was at exceptional risk of self-harm, violent and on licence from a previous sentence. It described his current medical and mental risks as depression, self-inflicted burn to the hand and that he had banged his head on the wall in custody. The DLDT assessment was not available to reception staff.

An officer started prison service suicide and self-harm support procedures known as ACCT. A Supervising Officer (SO) drew up an immediate action plan that Mr Stoneman would be observed hourly and placed in a shared cell. They completed a first night immediate risk and needs assessment. Mr Stoneman said there were restrictions on his contact with his family and that he did not have a telephone PIN access. The restrictions applied only to contact with his former partner.

A nurse saw Mr Stoneman for an initial health check. She wrote in his clinical record that he had a history of deliberate self-harm and he had hit his head on the walls in police custody. She referred him for a mental health assessment and noted that he was depressed, was taking fluoxetine, an antidepressant, and had arrived with a suicide and self-harm warning form completed by court escort staff. A prison GP prescribed fluoxetine and planned that Mr Stoneman should see a GP in 2 weeks’ time to review his depression. She did not see him in person.

A mental health nurse saw Mr Stoneman because he was a newly received prisoner. She noted that he had a history of mental health problems, was on an open ACCT document, feeling low, and he had headbutted the cell wall in the police station, but he assured her he had no intention of taking his life and had no thoughts of suicide or self-harm. The nurse noted that Mr Stoneman was waiting for an appointment with a GP to discuss his antidepressant medication, which he had been taking for 7 months but found ineffective and gave him heartburn. They discussed his restraining order and that he missed his son. The nurse found him willing to talk about his future and establishing contact with his son through social services when released. He said that his mother provided him with support. The nurse decided that he did not need further mental health team contact.

Management of Risk of Suicide and Self Harm

Staff correctly began ACCT suicide and self-harm prevention procedures as soon as Mr Stoneman arrived at Exeter but he was monitored under ACCT procedures for only the first week of his time there. Investigators expressed concerns about the management of his risk, specifically when even in the absence of the court liaison and diversion team information, it is hard to see why the initial assessment of risk at the first ACCT case review was low, given that many of the known risk factors of suicide were clearly present in the information the prison had about Mr Stoneman.

Despite making a note of the issues, the SO who carried out the first ACCT review did not identify the risks or draw up a caremap at the review or in the following days. The SO who chaired the second case review did not draw up a caremap either and, thinking that Mr Stoneman was at low risk, chose to close the ACCT. This meant that there was no structured means of checking whether the relevant issues had been highlighted and satisfactorily resolved and that Mr Stoneman had good sources of support.

While the post-closure interview took place on a later date than scheduled, the delay gave staff an added opportunity to explore the significant outstanding matters of Mr Stoneman’s court appearance, its outcome, the length of his recall to custody and how he was coping, given that change in custodial status is a known trigger of self-harm. These topics were not addressed.

Psychoactive Substances/Illicit Drugs


Emergency Response

The officer radioed a Code Blue. Staff in the control room called an ambulance at 4.20am. A Custodial Manager (CM) and 2 officers responded. The nurse checked Mr Stoneman and found no pulse. He was pale and cold to the touch. The CM removed the ligature and brought an emergency bag. The nurse started cardiopulmonary resuscitation by doing chest compressions and administered oxygen through an ambu bag. Paramedics arrived at 4.27am and continued emergency treatment until they declared Mr Stoneman dead at 4.51am.

Clinical Care

The Clinical Reviewer concluded that the care Mr Stoneman received was equivalent to that which he could have expected to receive in the community. He found that all but one of the assessments made by clinical and mental health staff were comprehensive but noted that Mr Stoneman should have had a clinical assessment when he returned from court on 13 November, after charges had been dropped against him but he remained in custody. The Clinical Reviewer did not feel that the delay in receiving mental health risk information impacted adversely on Mr Stoneman’s care.

The assessment from the DLDT set out to a very significant degree the level of risk Mr Stoneman posed to himself. He was candid during the assessment about his intentions and the risk factor that caused him the most distress, a court order preventing contact with his son, was ever present. It was most unfortunate that the assessment was not communicated quickly to the mental health team at Exeter and its absence was a missed opportunity. If it had been, the triage mental health team nurse who saw Mr Stoneman the day after his arrival at Exeter could have pin-pointed and challenged his claims that he did not have thoughts or plans of suicide and self-harm in prison. In addition, the first ACCT case review would have had more robust information to base its assessment of risk on, and staff would have had the opportunity to rely less on Mr Stoneman’s external presentation, affable manner and insistence that he had no thoughts of self-harm, and more on his known risk factors.

PSO 3050 on continuity of healthcare describes court appearances as one of the significant events that can have a major impact on the health and risk of a prisoner. It recognises that the prison reception is a key area where the vulnerable can be reached. Mr Stoneman told a nurse on his return from court on 13 November that the charges against him had been discontinued. The nurse did not probe him further and Mr Stoneman noticeably did not mention the court order made against him. This was a missed opportunity to gauge the impact on him of remaining in custody.

As a result of Mr Stoneman’s death, a number of changes have been made to the operation of the mental health team at Exeter. A generic email inbox has been established so that information from the courts can be accessed daily by a number of duty workers rather than one specific member of staff. Mental health referrals are categorised as urgent (must be seen within 48 hours) or routine priority (within five working days). The mental health team only sees newly received prisoners who have been referred or self-referred rather than all new receptions. This allows it to focus on prisoners who are the most vulnerable. In light of these changes, the PPO made no recommendation.


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 they:

  • Ensure ACCT reviews are multidisciplinary and that mental health staff attend or contribute.
  • Assess the level of risk based on all available information and known risk factors and not on a prisoner’s presentation, and record the reasons for the decision.
  • Ensure that a caremap is drawn up and that the ACCT is not closed until the caremap actions have been completed.
  • Assess prisoners on their return from court if there has been a change in custodial status.

Full Report Here

03 Oct 2017 – Morton Hall IRC. Other Non-Natural Death.

Key Events

Mr Carlington Spencer arrived at Morton Hall Immigration Removal Centre on 31 May 2017, pending deportation to Jamaica. He had been transferred to Morton Hall on completion of his prison sentence.

Mr Spencer was an insulin dependent diabetic. He also took medication for high blood pressure and high cholesterol. He was overweight and a smoker. He was known to have used psychoactive substances (PS) in prison.

On 9 August, Mr Spencer collapsed in his room. Officers suspected he had taken PS. He was checked by a nurse and observed regularly until he recovered. The nurse made a referral to the Substance Misuse Service, who created a substance misuse recovery care plan.

At 3.30pm on 28 September, officers suspected Mr Spencer had taken PS again. A nurse assessed him and officers observed him regularly. At 11.37pm, a nurse and a healthcare assistant went to Mr Spencer’s room and found him sitting on the floor. He could not stand up without the assistance of staff but denied having taken illicit substances. An officer observed him every hour during the night.

At approximately 9.30am on 29 September, a detainee told an officer that Mr Spencer was unwell. Mr Spencer told a nurse he had taken PS. Officers observed him every 30 minutes and made a referral to the Substance Misuse Service. He agreed to discuss his use of PS with a substance misuse practitioner later that day.

At approximately 12.45pm, a detainee alerted a nurse that Mr Spencer was unwell. The nurse assessed Mr Spencer and noted that he had the symptoms of a stroke. She went to the healthcare unit where at 1.09pm, she telephoned for an emergency ambulance. Paramedics arrived at Mr Spencer’s room at 2.25pm and took Mr Spencer to hospital.

On 30 September, Mr Spencer was moved to a specialist stroke unit. After a brain stem test on 3 October showed no brain activity, hospital doctors decided to withdraw Mr Spencer’s clinical care. He was pronounced dead at 3.32pm on 3 October.

The post-mortem report shows that Mr Spencer died from a stroke. The pathologist found no vascular abnormality that might have explained the development of a stroke. She noted that PS use can cause strokes and it was possible this had caused Mr Spencer’s stroke, although she could not be certain.


Reception Screening

On arrival at Morton Hall on 31 May, a nurse completed Mr Spencer’s initial health assessment. She noted he had type 1 diabetes, high blood pressure, high cholesterol, anxiety and was prescribed sertraline (an antidepressant). He was a smoker and declined help to stop. She also noted Mr Spencer’s history of using psychoactive substances (PS) in prison and made a referral to the substance misuse service. She recorded Mr Spencer’s blood pressure as slightly high and his body mass index as 27 (overweight). Nurses created a care plan to manage Mr Spencer’s diabetes. IRC GPs prescribed medication for high blood pressure and high cholesterol.

Management of Risk of Suicide and Self Harm


Psychoactive Substances/Illicit Drugs

Mr Spencer had a history of using PS in prison and at the IRC and this may have caused his stroke. The standard of substance misuse support Mr Spencer received at Morton Hall was good. Since Mr Spencer’s death, Morton Hall has taken steps to reduce the availability of PS in the IRC.

When Mr Spencer was found sitting on the floor of his room on the evening of 28 September, healthcare staff considered that his condition was due to the use of PS. Whilst this is possible, it is equally possible that had suffered a ‘mini stroke’, in which case it should have been treated as a medical emergency.

The post-mortem report found that Mr Spencer died from a right middle cerebral artery infarction (stroke). Toxicology tests did not identify the presence of PS but the toxicologist noted that these drugs would have been excreted over the 4 days between Mr Spencer taking them and him dying in hospital. The pathologist did not identify any vascular abnormality that might explain the development of a stroke. She noted that PS use had been linked to the development of stroke and considered that PS use was a possible cause of stroke in Mr Spencer’s case.

Emergency Response

When the nurse saw Mr Spencer at 12.45pm on 29 September after residents raised the alarm about his health, she recognised that Mr Spencer was showing the signs of a stroke. Expectations would have been that she should have used her radio to call an emergency code, but instead she returned to the healthcare unit and telephoned for an ambulance. She did not make this telephone call until 1.09pm, 24 minutes after she first attended to Mr Spencer. In a medical emergency it is imperative that the correct procedures are followed and that an ambulance is called immediately.

The ambulance did not arrive at Morton Hall for over one hour after it was requested. The Clinical Reviewer noted that this was outside the standards expected for emergency ambulance response times.

There had been some confusion among IRC staff about the correct medical emergency code to use when the system was Code One and Code Two. On 9 August and 28 September, the wrong code was used when Mr Spencer was found unresponsive. Subsequently, the code system has since changed to Code Blue and Code Red, and on this basis the PPO made no recommendation.

Investigators were concerned that the nurse did not radio an emergency code when she suspected that Mr Spencer had suffered a stroke on 29 September. Instead, she returned to the healthcare unit and called for an ambulance 24 minutes after she first saw Mr Spencer. This caused an unnecessary delay.

Clinical Care

The Clinical Reviewer concluded that the standard of Mr Spencer’s clinical care at Morton Hall was not equivalent to that which he could have expected to receive in the community.

The Clinical Reviewer considered that Mr Spencer received a good standard of substance misuse care at Morton Hall.


Rec 1: The Head of Healthcare should ensure that detainees with risk factors for cardiovascular disease are offered routine monitoring.

Rec 2: The Head of Healthcare should ensure that healthcare staff record a patient’s blood pressure in routine clinical observations.

Rec 3: The Centre Manager and Head of Healthcare should ensure that all staff are reminded of the procedures they must follow in a medical emergency, as set out in DSO 09/2014.

Full Report Here

Thanks to Jason Rosewell for making this photo available freely on Unsplash

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