PPO Deaths In Custody Reports – Health Notes w/c 25 Nov 2019

Last week the PPO published 5 reports relating to deaths in custody. The causes are categorised as follows:

  • Natural Causes = 3
  • Self-Inflicted = 2
  • 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:

  • 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)

17 Apr 2018 – HMP Bullingdon. Self-Inflicted Death.

Key Events

On 31 January 2018, Mr Rancijh was convicted at Oxford Crown Court of dangerous driving and bailed to appear at a later date for sentencing. On 12 April, Mr Rancijh appeared at court, was sentenced to ten months in custody and sent to HMP Bullingdon. He had not been in prison before. He came from Sri Lanka but understood English.

On Mr Rancijh’s arrival at Bullingdon, staff assessed that he was not at risk of self-harm, and noted that he had no recorded history of physical or mental illness and was not prescribed any medication while in the community. He was allocated to a shared cell.

During the afternoon and early evening of 16 April, Mr Rancijh’s cellmate complained about his bizarre behaviour. Staff observed Mr Rancijh with his jumper over his head, expressing paranoid ideas. At about 5.00pm, a prison paramedic saw him and assessed that he was having an anxiety attack, secondary to paranoid thoughts. At about 8.30pm, Mr Rancijh told an officer that people were trying to get into the cell. She made a request for an urgent mental health referral the next day.

At about 11.00pm, Mr Rancijh’s cellmate pressed the cell bell and told an operational support officer (OSG) that he could not cope with Mr Rancijh’s behaviour any more. He said Mr Rancijh had urinated in the cell, slapped him round the face and put a noose round his own neck.

The night orderly officer was called and moved Mr Rancijh to the healthcare unit because he thought he might have mental health issues. An OSG in the unit checked Mr Rancijh twice around midnight.

At 6.46am on 17 April, a member of staff found Mr Rancijh hanging in his cell. He had clearly been dead some time. An ambulance was called and staff began cardiopulmonary resuscitation. Paramedics arrived, but at 7.20am, they stopped resuscitation and pronounced Mr Rancijh dead.


Reception Screening

When Mr Rancijh arrived at Bullingdon, he had some risk factors for suicide and self-harm in that he had just been sentenced and this was his first time in prison. However, he appeared calm, engaged well, there was no warning form from court or escort staff, and he had no recorded physical or mental health issues and no recorded history of self-harm.

Management of Risk of Suicide and Self Harm

Investigators considered that staff should have monitored Mr Rancijh under suicide and self-harm prevention measures (ACCT) on the night of 16 April when he behaved bizarrely and they suspected he had mental health problems.

The evidence suggests that the OSG who was told that Mr Rancijh had tied a noose did not pass this key information on to the orderly officer.

The orderly officer did not communicate the concerns about Mr Rancijh’s mental health when Mr Rancijh was relocated in the healthcare unit and did not specify how often he wanted Mr Rancijh observed.

Psychoactive Substances/Illicit Drugs

A post-mortem examination found that the cause of Mr Rancijh’s death was suspension (hanging). Toxicology results showed that Mr Rancijh was not under the influence of alcohol or any illicit drugs at the time of his death.

Emergency Response

Two nurses started CPR when they entered Mr Rancijh’s cell even though a nurse said that rigor mortis was clearly evident, indicating that Mr Rancijh had been dead for some time. This is undignified for the deceased and unnecessarily distressing for staff.

Clinical Care

The clinical reviewer concluded that the healthcare provided to Mr Rancijh was not equivalent to that he could have expected to receive in the community.

The Clinical Reviewer held a concern that the paramedic who saw Mr Rancijh did not make a detailed record of Mr Rancijh’s behaviour to inform subsequent decision-making, and that Mr Rancijh was not assessed when he was admitted to the healthcare unit.

Investigators were also very concerned that a nurse made a false entry in Mr Rancijh’s medical records to say she had observed him sleeping through the night.


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

  • open an ACCT whenever a prisoner has recently self-harmed or expressed suicidal intent;
  • identify risk factors and assess a prisoner’s risk based on their risk factors; and
  • share information to ensure effective communication between healthcare and prison staff when there are potential concerns about a prisoner’s mental health.

Rec 2: The Governor should share this report with the staff involved and arrange for a custodial manager (CM) and an occupational support grade (OSG) to receive refresher training in ACCT as a matter of urgency and let the Ombudsman know when this has been done.

Rec 3: The Governor and Head of Healthcare should have a protocol in place which enables collaborative working and information sharing between discipline and healthcare staff.

Rec 4: The Head of Healthcare should ensure that all clinical staff maintain accurate and comprehensive records in accordance with professional guidance.

Rec 5: The Head of Healthcare should refer a nurse to the Nursing and Midwifery Council to consider undertaking a professional standards investigation to ensure competence to continue clinical practice.

Rec 6: The Head of Healthcare should give clear guidance to staff about the circumstances in which resuscitation is inappropriate.

Rec 7: The Prison Group Director for the South Central Group should provide the Ombudsman with an account of what he has done to ensure that meaningful action is taken at Bullingdon to address our recommendations.

Full Report Here

26 Mar 2018 – HMP Frankland. Self-Inflicted Death.

Key Events

Mr Stephen Harper was sentenced to life imprisonment in 2003 for rape. In 2008 he was treated in Broadmoor Secure Mental Hospital but returned to the prison system at his own request. He was diagnosed as having anti-social and borderline personality disorders with paranoid traits. Between 2011 and 2014 he was treated on the Fens Personality Disorder Treatment Unit at HMP Whitemoor. He was deselected after disengaging from treatment. On 24 March 2015, he transferred to HMP Frankland in order to undertake the Sex Offender Treatment Programme (SOTP).

Mr Harper did not comply with the conditions necessary to begin SOTP at Frankland and also refused to work with the mental health team to explore his non-compliance. He had a history of depression, suicidal thoughts and self-harm by cutting. His complex mental health needs required and received considerable input from staff and he was often managed using Prison Service suicide and self-harm monitoring procedures (ACCT).

On the morning of 26 March, a custodial manager received information that Mr Harper intended to hang himself using a piece of wood (his tapestry easel) in his cell. No one assessed Mr Harper’s risk of suicide and self-harm and whether ACCT monitoring was appropriate. At 10.18am on 26 March, the Dedicated Search Team (DST) searched Mr Harper’s cell and removed his tapestry easel.

At 11.49am, two officers discovered Mr Harper hanging when they unlocked his cell for lunch. The officers raised the alarm and a nurse who was already on the wing started cardio-pulmonary resuscitation. Paramedics checked Mr Harper but he was pronounced dead at 12.37pm.


Reception Screening

On 24 March 2015, Mr Harper moved to HMP Frankland to be assessed for SOTP. He declined to engage with assessment and then with one to one work with the mental health team to address his motivation. Mr Harper maintained his innocence and said he did not want to engage with offending behaviour programmes.

Management of Risk of Suicide and Self Harm

Mr Harper had complex personality disorder issues and limited coping mechanisms. He had a number of factors that indicated he was at risk of suicide and self-harm and his mental health issues meant that this risk fluctuated according to context but was never absent. Overall, Mr Harper was well supported by staff, although a number of weaknesses were identified in the ACCT process from which the prison can learn. It was understand and accepted that Mr Harper was a challenging man to manage and many of the issues identified are procedural ones which would not necessarily have impacted significantly on his care:

  • There was no one from healthcare at Mr Harper’s first case review as there should have been.
  • Case reviews were not sufficiently multi-disciplinary and were sometimes held by one member of staff and Mr Harper.
  • Of the three caremap actions identified at the first review, two were marked as complete the same day and the third the following day. No new actions were added at the next seven reviews.

The ACCT was closed on 31 October even though the reviewers noted that Mr Harper was still waiting for a decision on whether he was going to the Westgate Unit and this was known to be an issue for him.

The ACCT was re-opened on 1 November, but a caremap action was only added on 3 January 2018. During this period the ACCT was reviewed 14 times without any apparent consideration of what was needed to reduce Mr Harper’s risk. A lot of work was done at this time to find Mr Harper employment but none of this is reflected on the caremap or elsewhere on Mr Harper’s prison record. Subsequent concerns were that Mr Harper appeared to have been under the impression that his referral to the Westgate Unit was ongoing for some 2 months after the referral panel wrote to him rejecting his application.

The ACCT remained open for another 3.5 months and only one further action was added. This was not marked as completed when a Supervising Officer (SO) closed Mr Harper’s ACCT on 16 March. The ACCT was closed in Mr Harper’s absence. Mr Harper frequently refused to attend reviews when a SO was present and he was also known to self-harm in response to decisions he did not like. For both reasons, someone should have spoken to him to explain the decision to stop monitoring.

Psychoactive Substances/Illicit Drugs

The pathologist concluded that Mr Harper died from pressure on the neck due to hanging. Toxicology showed the presence of 3 medications prescribed to Mr Harper at therapeutic doses, none of which contributed to his death.

Emergency Response

At about 11.45am two officers began unlocking the cells on Mr Harper’s landing for lunch. CCTV showed that an officer got to Mr Harper’s door at 11.49am. The officer said he noticed a note on the floor outside that said, “Do not unlock for lunch”. He looked through Mr Harper’s observation panel and saw him hanging from his window bars. He told the other officer, who opened the cell immediately, grabbed Mr Harper by the waist and tried to lift him to relieve pressure on his neck. He heard Mr Harper exhale as he lifted him and so thought he was still breathing.

An officer said he was aware of the emergency code system but acknowledged he did not use it when he discovered Mr Harper hanging at 11.49am – he was in shock. Other staff were quickly on scene but they did not radio an emergency code either. An emergency code would have alerted staff throughout the prison, including the emergency response nurse, and signalled the control room to call an ambulance immediately.

A nurse arrived at 11.52am and realised immediately that Mr Harper was not breathing. The control room did not call an ambulance until 11.59am, some 10 minutes after Mr Harper was discovered and 7 minutes after the nurse had asked for a Code Blue to be called. Frankland were unable to provide investigators with the emergency radio traffic so it is not known exactly who called the Code Blue and when. The 999 call recording indicated the control room were aware that it was a Code Blue and called an ambulance at 11.59am in response.

Although Mr Harper received reasonably prompt emergency aid from a nurse, any delay can be crucial to the outcome in cases of hanging and paramedics offer a higher level of airway management and advanced life support. Since Mr Harper’s death, the prison has issued a new emergency protocol, including wallet size cards with the different codes. In light of this, no recommendation was made.

Call logs and telephone recordings of the 999 calls showed that the prison first called for an ambulance at 11.59am. At 12.02pm, after triage, the ambulance service allocated a response time of 18 minutes or sooner. The prison called back at 12.04pm to confirm Mr Harper was not breathing and the response was upgraded. The first ambulance reached the prison at 12.19pm.

Clinical Care

Mr Harper had a history of depression, suicidal thoughts and self-harm by cutting. His complex mental health needs required and received considerable input from staff and he was often managed using Prison Service suicide and self-harm monitoring procedures (ACCT). Despite some deficiencies in the way staff operated ACCT procedures from which the prison can learn, investigators considered that, overall, Mr Harper received very good care at Frankland.


Rec 1: The Governor and Head of Healthcare should ensure that all staff are aware of their responsibilities to keep prisoners safe and begin ACCT procedures when they receive information or observe behaviour that may indicate a risk of suicide or self-harm.

Rec 2: The Governor should ensure that there are sufficient first aid trained staff on duty at all times and that staff administer basic life support as needed until healthcare staff arrive.

Rec 3: The Governor should ensure that staff manage prisoners identified as at risk of suicide or self-harm in line with national guidelines, including:

  • Holding multi-disciplinary case reviews attended by all relevant people involved in a prisoner’s care. A member of healthcare staff should attend all first case reviews.
  • Setting effective ACCT caremap objectives which are specific and meaningful, aimed at reducing a prisoner’s risk and which identify who is responsible for them. Progress should be considered at each review and the caremaps updated if additional needs are identified.
  • Ensuring that all caremap actions have been completed before ACCT monitoring is stopped.

Full Report Here

Other Recommendations From Deaths Attributed To Natural Causes.

From the 3 remaining reports published last week, these were the recommendations for those deaths in custody attributed to natural causes.

10 Jan 2018 – HMP Manchester.

Rec 1: The Governor should ensure, in line with Prison Rule 22 and PSI 64/2011, that prison staff inform the next of kin of seriously ill prisoners immediately when they are admitted to hospital.

Full Report Here

15 Jul 2018 – HMP Woodhill.

Rec 1: The Head of Healthcare should ensure that all clinical staff are aware of the risk factors for pulmonary embolism and complete a Wells score and, where appropriate, a D-dimer blood test on all patients with relevant symptoms.

Full Report Here

24 Mar 2019 – Fleming House Approved Premises (On Licence From HMP Wharton).

No recommendations.

Full Report Here

Thanks to Veri Ivanova for making this photo available freely on Unsplash

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