PPO Deaths In Custody Reports – Health Notes w/c 02 Dec 2019

PPO Deaths In Custody Reports – Health Notes w/c 02 Dec 2019
Last week the PPO published 5 reports relating to deaths in custody. The causes are categorised as follows:

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

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)

03 Apr 2018 – HMP Downview. Self-Inflicted.

Key Events

In 2016, Ms Bosteyo Ahmed-Ali was sentenced to eight years imprisonment. She said that she had no mental health or drug issues, but wanted to address her alcohol use. She also wanted to improve her literacy during her time in prison. She had no history of self-harm.

Ms Ahmed-Ali arrived at HMP Downview in May 2017. Records show occasional verbal outbursts against staff and prisoners. She undertook education courses and showed signs of settling but still had problems, both with her behaviour and her poor attendance at classes. She took offender behaviour courses to help her manage her emotions and to help her address her drug and alcohol issues.

In February 2018, Ms Ahmed-Ali told her personal officer that she was concerned about her health and mood, and later asked to see the mental health team. A member of the team assessed her and arranged for her to see a community psychiatric nurse, who planned further support and referred her to a psychiatrist. The nurse noted that she had no thoughts of harming herself.

In March, Ms Ahmed-Ali told a member of the mental health team that she was stressed, paranoid, and not sleeping well. She saw the prison doctor, who prescribed anti-depressants. He recorded that she was not suicidal. On 27 March, Ms Ahmed-Ali saw a psychiatrist, who added to her prescribed medication.

On 23 March, Ms Ahmed-Ali and some friends were involved in a fight with 2 other prisoners in the exercise yard. Several prisoners, including Ms Ahmed-Ali, were put on disciplinary charges.

On 28 March, staff moved Ms Ahmed-Ali’s friend to another wing because she and Ms Ahmed-Ali had been antagonising another prisoner.

On 31 March, Ms Ahmed-Ali told a prison officer that the 2 other prisoners involved in the fight had been taunting her. The officer was unable to secure a move for her but submitted a report form, told staff to be aware of the situation, and made arrangements for a move when possible. Ms Ahmed-Ali appeared satisfied with this.

On 3 April, Ms Ahmed-Ali was due to attend her disciplinary hearing but it was postponed. Ms Ahmed-Ali then tried to leave the wing, telling staff that she was expected in the education department. They confirmed that this was not the case. A prison officer spoke to Ms Ahmed-Ali while she walked her back to her cell. The officer said that she had no concerns about her at that point.

Another prisoner later saw Ms Ahmed-Ali sitting in her cell, listening to loud music. The prisoner assumed that she did not hear her knock because of the music or that she did not want to be disturbed, so she left. She had no concerns about Ms Ahmed-Ali.

At 4.57pm, two prisoners went to Ms Ahmed-Ali’s cell and saw that she had a ligature around her neck. They alerted staff, who began resuscitation. Nurses arrived and continued to provide medical assistance until paramedics arrived and took over. At 6.15pm, it was agreed that Ms Ahmed-Ali had died.

Findings

Reception Screening

On 12 May 2016, Ms Ahmed-Ali was convicted of causing grievous bodily harm with intent. She was sentenced to eight years imprisonment. At her reception interview she said that she struggled with her literacy and wanted to address this. She said that she had used cannabis but particularly wanted to address issues she had with alcohol. She had never had any contact with mental health services and had no history of self-harm.

Ms Ahmed-Ali arrived at HMP Downview in May 2017. Records show occasional verbal outbursts against staff and prisoners. She undertook education courses and showed signs of settling but still had problems, both with her behaviour and her poor attendance at classes. She took offender behaviour courses to help manage her emotions.

Management of Risk of Suicide and Self Harm

In February 2018, Ms Ahmed-Ali told her personal officer that she was concerned about her health and mood, and later asked to see the mental health team. A member of the team assessed her and arranged for her to see a community psychiatric nurse, who planned further support and referred her to a psychiatrist. The nurse noted that she had no thoughts of harming herself.

In March, Ms Ahmed-Ali told a member of the mental health team that she was stressed, paranoid, and not sleeping well. She saw the prison doctor, who prescribed anti-depressants. He recorded that she was not suicidal. On 27 March, Ms Ahmed-Ali saw a psychiatrist, who added to her prescribed medication.

Although Ms Ahmed-Ali had no history of self-harm, she did have some particular issues in the month or so before her death: she was struggling with her mental health; she was on the basic regime and awaiting a disciplinary hearing; she had complained that she did not feel supported by her personal officer; she was in conflict with some other prisoners on her wing; and she had recently been separated from her friend, Prisoner A. Her friends told the investigator that she had been unsettled in the days leading up to her death and that she felt paranoid and under pressure from prisoners and staff, particularly in relation to the incident in the exercise yard on 23 March.

Psychoactive Substances/Illicit Drugs

The post-mortem report showed that Ms Ahmed-Ali died as a result of hanging. Toxicology reports did not detect any illicit drugs in her system.

Emergency Response

At 4.57pm, Prisoner B and another prisoner went to Ms Ahmed-Ali’s cell door. Prisoner B looked through the observation panel, but the cell was in darkness. She turned on the night light using the switch outside the cell and saw Ms Ahmed-Ali apparently sitting on the floor by the radiator. She called to her but got no response, so she walked away. Almost immediately she stopped and returned, and said that at this point she noticed that Ms Ahmed-Ali had a ligature around her neck.

Prisoner B walked away and the other prisoner ran along the corridor and spoke to Officer B. The prisoner said that she told the officer that Ms Ahmed-Ali had hanged herself. The officer said that the prisoner did not say this, but told her that she should unlock prisoners on the basic regime. Because she was supervising the dinner queue, she told her to ask someone else.

While this was happening, Prisoner B spoke to Officer C. The officer said in her statement that the prisoner had said, “I think you need to check on Bosteyo, she doesn’t look right”. She also said that she might have something around her neck. The officer ran to Ms Ahmed-Ali’s cell, followed by Officer D and, when she saw her colleagues running, Officer B. Officer C looked through the observation panel into Ms Ahmed-Ali’s door, then opened the door and went in. CCTV footage shows this happened at 4.58pm.

Ms Ahmed-Ali was at the back of her cell, hanging by a ligature made from her dressing gown cord. Officer C used her anti-ligature knife to cut the cord and lowered her to the floor. As she did so, Ms Ahmed-Ali vomited. Other staff had arrived, and Officer D used her radio to call a Code Blue emergency. This prompted the control room to request an emergency ambulance. Officers put Ms Ahmed-Ali into the recovery position so Officer C could check for a pulse and for breathing. She was unable to find either, so moved Ms Ahmed-Ali onto her back to begin CPR.

At this point nursing staff arrived and began to assess Ms Ahmed-Ali. CCTV footage shows that this was at 4.59pm. Officer C asked permission to begin CPR but a nurse said that although there were no signs of breathing, she could detect a faint pulse. She left the cell to collect the defibrillator. Another nurse checked Ms Ahmed-Ali but, unable to gain a response, told the prison officers to begin CPR as she continued to assess her. As other prison and medical staff arrived they took it in turns to continue with resuscitation. The defibrillator could not detect a heartbeat and advised them to continue with CPR, which they did until paramedics arrived and took over. Staff continued to try to revive her but, at 6.15pm, they agreed that Ms Ahmed-Ali had died.

Clinical Care

The Clinical Reviewer was satisfied that Ms Ahmed-Ali was thoroughly assessed for her mental health and wellbeing in Downview. She had good relationships with her drug and alcohol worker and her assistant psychologist. She was referred promptly to mental health services when she said she wanted help, and there were no delays in prescribing her medication. The Clinical Reviewer concluded that Ms Ahmed-Ali’s healthcare was equivalent to that she could have expected to receive in the community.

Recommendations

Rec 1: The Governor should issue guidance to ensure that staff are clear on the restrictions that apply to prisoners on the basic regime.

Rec 2: The Governor should ensure that staff are clear on when to deploy body-worn video cameras, and that they do so.

Full Report Here


31 Mar 2018 – HMP Berwyn. Other Non-Natural Death.

Key Events

Mr Luke Jones was sent to prison in February 2016 and was serving a four-year sentence for robbery. He was moved to HMP Berwyn on 12 April 2017.

Mr Jones had a history of mental health issues and substance misuse. He was a frequent user of psychoactive substances (PS) in prison, which he said he used as a coping mechanism. He was supported by the mental health team and Substance Misuse Services (SMS). Mr Jones self-harmed on a number of occasions and was managed under suicide and self-harm prevention procedures (ACCT) on 7 occasions at Berwyn. He was being monitored under ACCT on the day he died.

Mr Jones was found with a noose round his neck on 26 March 2018 and, as a result, he was monitored under constant supervision between 26 and 30 March. On 30 March, observations were reduced to 4 per hour, and on the afternoon of 31 March, observations were set at 2 per hour.

On 31 March, Mr Jones was locked in his room at 5.00pm. An officer checked him at 5.33pm and recorded he was watching television and appeared to be in good spirits. At 6.07pm, the same officer returned to his room to check on him and saw him lying on the floor, unresponsive. The officer immediately used his radio to inform the control room that there was an emergency Code Blue.

Staff responded quickly and started CPR. Paramedics arrived at 6.27pm and transferred Mr Jones by emergency ambulance to Wrexham Maelor Hospital. However, he did not respond to treatment and was pronounced dead at 7.20pm.

The post-mortem examination found that Mr Jones died of an acute cardiac episode, which was caused by PS use. PS was detected in his blood when he died.

Findings

Reception Screening

On arrival at Berwyn, Mr Jones had an initial health screen completed by a nurse. He told her that he sometimes felt depressed and sometimes had panic attacks and asked to be referred to the primary care mental health team.

On 19 April, Mr Jones was seen by a Staff Nurse, who was a member of the primary care team. Mr Jones said that he felt that his mood was very changeable, and that he felt okay at times but very low in mood at other times and this change could happen very quickly. Mr Jones told the staff nurse that he had thoughts of self-harm and suicide, but was unaware of anything that had triggered this, although he said that it had been worse since arriving at Berwyn. Mr Jones described feeling irritated by others and how he had recently thrown objects at his cellmate as a result, and had now moved to a single cell. A Staff Nurse started suicide and self-harm monitoring procedures (ACCT).

Over the next few days, Mr Jones was seen on 5 occasions by staff from healthcare and the mental health team. It was recorded that he was awaiting a full assessment by the mental health team, but stated that he had no imminent thoughts of self-harm and was feeling better. On 21 April, a Nursing Sister, chaired an ACCT case review with Mr Jones. The review was attended by a Healthcare Assistant (HCA), Custodial Manager (CM), and 2 officers.

Management of Risk of Suicide and Self Harm

The ACCT was closed on 31 May 2017, when Mr Jones appeared to be making satisfactory progress. Mr Jones was monitored under ACCT procedures on 6 further occasions between 2 June 2017 and 31 March 2018. ACCT observations were changed dependent on the risk with which he presented, which fluctuated. All reviews were attended by mental health and healthcare staff in addition to prison staff and psychology staff who were working with Mr Jones, and plans to support him were regularly updated.

At 11.00am, on 26 March, Mr Jones was found with a ligature made from torn bedding wrapped around his neck. This was observed by staff completing routine ACCT observations and they intervened. Because of his actions and concerns about his heightened risk, Mr Jones was placed on constant supervision and moved to the constant supervision cell, on Alwen residential unit.

At 4.00pm on 30 March, an ACCT review was held, chaired by the Head of Safety, and attended by 2 Custody Managers, and an officer. It was recorded that Mr Jones engaged well and spoke about being unhappy that he was on constant supervision due to the lack of privacy. He told the review that he had been worried about his mother, but having spoken with his family and obtained more information, he felt reassured. The review recorded that, although Mr Jones’ risk had not changed significantly, he was much happier. It was agreed that observations would be changed to 4 per hour, but Mr Jones would remain in the constant supervision room, to enable the transition while still managing the risk.

For the most part staff managed the ACCT procedures very well and that the decision to stop constant supervision on 30 March was a reasonable one, although on the afternoon of 31 March, Mr Jones should have been observed twice an hour. Checks were made at 4.30pm, 5.00pm, 5.33pm and 6.07pm. Within any one-hour period, there should have been 2 checks, so they did not quite meet the frequency required. However, it is accept they were only slightly out and it was considered unlikely that this made a difference to the outcome for Mr Jones.

Psychoactive Substances/Illicit Drugs

When Mr Jones was found to be using PS, staff challenged his behaviour and supported him in line with the prison’s drug strategy. Nevertheless, Mr Jones continued to use PS despite being made aware of the dangers and despite losing privileges.

Mr Jones said that he had been drinking alcohol heavily from the age of 12 and smoked cannabis from the age of 10. He said that he had also tried cocaine, ecstasy and amphetamines. He said that he had last used cannabis the night before he was sentenced. The Staff Nurse offered to refer Mr Jones to Substance Misuse Services (SMS), however he declined this, saying that he had done this before and knew how to self-refer to the service

Mr Jones said that he had taken an overdose at the age of 16, but had not self-harmed since then. He denied any thoughts or intentions to self-harm at that time, although this had fluctuated over the past week. The Staff Nurse recorded that a follow up appointment to look at mindfulness and other coping techniques would be made for Mr Jones.

The post-mortem found no evidence of bruising or injury to Mr Jones’ neck from the self-harm incident on 26 March, and no evidence of any natural underlying disease that could have caused Mr Jones’ death.

Toxicology tests showed that Mr Jones had PS in his system when he died. The post-mortem report concluded that Mr Jones died from ventricular cardiac arrhythmia (rapid, erratic heartbeat leading to a cardiac arrest) caused by PS use.

Emergency Response

At 6.07pm, the officer returned to Mr Jones’ room to complete a further ACCT observation. When he looked into the room through the observation panel, He said that he could not immediately see Mr Jones, but he then noticed him lying on the floor, unresponsive. He immediately used his radio to inform the control room that there was an emergency Code Blue.

Two other officers were both working on Alwen and responded to the emergency radio call. One of the officers attempted to get a response by calling his name and checked for breathing. The officer said that at this point Mr Jones was breathing, although it was very shallow, and the officers placed Mr Jones into the recovery position.

Two nurses were both on duty and heard the emergency call at 6.08pm and responded immediately, taking with them the emergency medical bag. As they made their way to Alwen, they were updated over the radio that Mr Jones was unconscious, but had shallow breathing. On entering Alwen unit, one of the nurses collected the emergency resuscitation bag from the wing medical treatment room, and the other nurse went straight to Mr Jones’ room, arriving at 6.13pm.

Due to Mr Jones’ size and the limited space within the room, the nurses asked the officers to move him onto the landing, so that treatment could be provided more efficiently. Once on the landing the nurses assessed Mr Jones and identified that his airway was blocked with vomit and that turning his head had little effect. The nursing staff then attempted to insert an airway, but said that this was also ineffective as it filled with vomit. The nursing staff continued to attempt to create an airway, and while they were doing so Mr Jones, stopped breathing, and cardiopulmonary resuscitation was started at 6.18pm. Oxygen was provided to Mr Jones via a mask, but this was also affected by large amounts of vomit. A defibrillator was attached to Mr Jones and this delivered 3 shocks, before the arrival of paramedics.

The first responder paramedic arrived at Mr Jones’ room at 6.27pm. She exchanged the prison defibrillator for her own, and this indicated no shockable rhythm, and CPR continued. She inserted a cannula into Mr Jones’ arm to enable drugs to aid resuscitation to be administered. Two further ambulances arrived and paramedics continued to treat Mr Jones. He was then placed on a stretcher and transferred by emergency ambulance to hospital, accident and emergency (A&E) department, arriving at 7.14pm.

Treatment was handed over to the doctor in charge of A&E, and efforts to resuscitate Mr Jones continued. Mr Jones was pronounced dead at 7.20pm.

After Mr Jones’ death, PS residue was found on pieces of paper and a milk carton in his room.

Clinical Care

The Clinical Reviewer concluded that overall Mr Jones received good care by the prison healthcare service which was equitable and, in many ways, more rapid than the care he would have expected to receive in the community. He received a wide range of inputs from healthcare and there was good multi-disciplinary involvement in his care, including input from mental health and forensic psychiatry. There were no avoidable delays in the emergency response on the day of his death.

The Clinical Reviewer was satisfied that the decisions to stop Mr Jones’ prescribed medication when he was using PS were made after consideration of the balance of risks posed by the interaction of the medication and PS, and not on the basis of a blanket policy.

Recommendations

Rec 1: The Governor should ensure that ACCT checks are carried out at the agreed frequency and that they are at unpredictable times.

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 and homicide.

23 Jan 2018 – HMP Hewell. Homicide

Rec 1: The Governor and Head of Healthcare should ensure that healthcare and substance misuse services are informed every time a prisoner is found under the influence of an illicit substance and this is recorded on his medical record.

Rec 2: The Governor should ensure that the key drug issues at Hewell are identified and that the prison’s local drugs strategy is revised by September 2019 to ensure that these key issues are being addressed.

Full Report Here

22 Oct 2018 – HMP Wakefield. Natural Causes

Rec 1: The Head of Healthcare should ensure that, where a prisoner is considering signing a DNACPR order, their mental capacity is considered and assessed, in accordance with NICE Guidelines, NG108.

Rec 2: The Governor and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that assessments fully take into account the health of a prisoner and are based on the actual risk the prisoner presents at the time.

Full Report Here

10 Jun 2019 – HMP Bullingdon. Natural Causes

Rec 1: The Head of Healthcare should consider including parameters within a patient’s care plan which triggers a microbiological assessment for specimens of urine or sputum for those patients who are a known risk of infection.

Rec 2: The Head of Healthcare should ensure that GPs review the new CUK end of life policy and review the process for discussing advanced directives. This should include timeliness for discussing and recording DNAR decisions.

Rec 3: The Head of Healthcare should review the process for obtaining and storing mental capacity assessment documentation in line with best practice.

Full Report Here


Thanks to Pawel Czerwinski for making this photo available freely on Unsplash