Last week the PPO published 7 reports relating to deaths in custody. The causes are categorised as follows:
- Natural Causes = 5
- Self-Inflicted = 1
- Other Non-Natural = 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)
02 Feb 2017 – HMP Manchester. Self-Inflicted.
On 26 September 2016, Mr Tomasz Nowosad was remanded to HMP Manchester, charged with a violent offence. Mr Nowosad was Polish and spoke limited English. His younger brother was remanded to Manchester on the same day.
On 9 January 2017, a nurse saw Mr Nowosad for a mental health assessment. He said he had paranoid thoughts and auditory hallucinations about other people wanting to hurt him, so the nurse started Prison Service suicide and self-harm monitoring (ACCT). That day, staff moved Mr Nowosad to a safer cell in the healthcare centre.
Between 9 January and 30 January, staff held 5 ACCT reviews and judged that Mr Nowosad’s risk of suicide and self-harm had decreased to low. For 3 of the ACCT reviews, there was no evidence that staff used or considered using a telephone interpretation service or a member of staff as an interpreter.
On 30 January, a consultant forensic psychiatrist reviewed Mr Nowosad, who said he felt safe on the healthcare centre and was frightened that if he went back to a normal location he might hurt himself or someone else. The psychiatrist considered that Mr Nowosad had improved and that he should not stay on the healthcare centre.
At around 3.45pm on 1 February, staff held a 6th ACCT review prior to discharging Mr Nowosad from the healthcare centre. Using a Polish healthcare assistant as an interpreter, a senior officer explained to Mr Nowosad that he would have a 72 hour assessment to determine whether he could be considered a vulnerable prisoner. Mr Nowosad said that he was happy with this and that he had no current thoughts of suicide or self-harm. Less than an hour later, Mr Nowosad moved from the healthcare centre to a cell on the induction wing. No one from the induction wing was present at the ACCT review.
During 2 February, two members of staff spoke to Mr Nowosad, who said that he was okay. Mr Nowosad reiterated to one of the officers that he wanted to move to the Vulnerable Prisoners’ Unit and the officer said he would talk to the wing manager about this.
At around 7.20pm on 2 February, officers went to Mr Nowosad’s cell to collect a spare mattress from his cell. Upon entering, an officer saw Mr Nowosad hanging from a ligature attached to the cell window. Officers cut the ligature and called a medical emergency priority one (Code Blue). A control room operator immediately called an ambulance. Other officers and nurses attended Mr Nowosad’s cell and started CPR. Paramedics arrived at 7.44pm but they were unable to resuscitate Mr Nowosad and a prison GP confirmed his death at 8.14pm.
Shortly after arriving at Manchester, a healthcare assistant completed Mr Nowosad’s initial health screen. Mr Nowosad said he had been diagnosed with paranoid schizophrenia and had been supported by community mental health services. He denied having any thoughts of suicide or self-harm. She referred him to the mental health in-reach team.
A consultant psychiatrist prescribed olanzapine (an antipsychotic) and a nurse created a schizophrenia care plan to monitor his mental state and his compliance with his medication. The care plan stated that all examinations required an interpreter.
On the day following initial reception, a nurse tried to conduct a mental health assessment of Mr Nowosad but was unable to as he did not speak English. She arranged an appointment for Mr Nowosad with a consultant psychiatrist and herself for the following day so that they could use Language Line (a telephone interpretation service).
Management of Risk of Suicide and Self Harm
Mr Nowosad was a Polish national, who spoke limited English. Although some staff used interpretation services or Polish members of staff as interpreters for some healthcare assessments and ACCT reviews, several ACCT reviews were conducted with Mr Nowosad without the assistance of interpretation services. On 9 January, a nurse noted that Mr Nowosad’s use of English had completely deteriorated, but for his initial ACCT assessment and his first, second and fourth ACCT reviews (on 9, 13 and 22 January), there was no record that staff considered using a telephone interpretation service or an interpreter. The Head of Operations confirmed that an absence of suitable phones was not the cause of this problem because conference phones were available in key areas of the prison, including in the healthcare consultation rooms. Given that staff failed to always use interpretation services, Mr Nowosad was not able to express himself fully during his ACCT reviews and that staff could not properly understand his issues to assess his risk. A prison GP recorded that she did not know how to set up a telephone interpretation service. This may be having an impact on other foreign national prisoners if she and other members of staff cannot access this service.
When a nurse started ACCT procedures for Mr Nowosad, he said that he used to believe that his brother wanted to hang him and that other family members wanted him to hang himself. Investigators noted that while Mr Nowosad continued to experience delusional thoughts, he tended to refer to threats from other prisoners rather than his brother. There is no record that staff considered including Mr Nowosad’s brother, who was still located at Manchester, in the ACCT reviews or that anyone facilitated any other form of contact between them.
When a SO started the caremap for Mr Nowosad, two of the three actions had already been completed. While staff had yet to see the impact of these actions, a caremap should set out new actions to address the prisoner’s risk of suicide or self-harm. Neither the SO nor Mr Nowosad signed the caremap.
For the sixth ACCT review, prior to Mr Nowosad being discharged from the healthcare centre, all the attendees worked in the healthcare centre, including a SO. There was no record that the residential manager or another appropriate member of staff from the induction wing was invited to or attended this ACCT review. This meant that staff on the induction wing did not fully appreciate the risks that Mr Nowosad presented and were only partly equipped to understand his difficulties.
On the day of Mr Nowosad’s death, an officer made two entries, at 8.15am and 11.40am, and Officer A made one entry, at 1.22pm, in Mr Nowosad’s ACCT observation record. In his statement, Officer A stated that later in the day he had observed Mr Nowosad on the exercise yard, noting his isolation, and had spoken to him on the wing to discuss ways of addressing it, yet neither of these material events appeared in the observation record. Had this happened it is unlikely to have changed the outcome for Mr Nowosad, but effective and thorough recording of observations is a key element of the ACCT process and could be vital in the future to highlight a prisoner’s ongoing risk.
Psychoactive Substances/Illicit Drugs
The post-mortem examination concluded that Mr Nowosad died as a result of hanging, and a toxicological assessment found no other substance in his blood, other than a therapeutic level of olanzapine.
At around 7.20pm, Officer A and Officer B went to Mr Nowosad’s cell to collect a spare mattress from the cell. Officer A entered the cell and saw Mr Nowosad hanging from a ligature, made from a bed sheet, attached to the window at the back of the cell. He considered that Mr Nowosad had died because his eyes were fixed open and his skin was bluish-purple.
Officer A tried to use his radio to send an urgent message but was unable to get through, left Mr Nowosad’s cell to activate a general alarm and shouted for help from other officers. He returned to Mr Nowosad’s cell, accompanied by Officer B. Officer B cut Mr Nowosad’s ligature and he fell onto the floor. Officer A then was able to use his radio to call a medical emergency priority one (Code Blue).
Various officers responded to the general alarm and started CPR. As both Officers A and B were quite distressed they were removed from the cell. An officer collected and fitted a defibrillator but it did not detect a shockable heart rhythm and advised to continue CPR. Two nurses responded to the priority one and assisted with the CPR. One nurse told the investigator that when she arrived at the cell, Mr Nowosad’s face was red and his skin was warm but his lips had started to turn blue.
The control room received the emergency priority one at 7.23pm and immediately telephoned for an ambulance (Ambulance Service records confirm this). Paramedics arrived at 7.32pm and they took over Mr Nowosad’s care. However, they were unable to resuscitate him and a prison GP confirmed that Mr Nowosad had died at 8.14pm.
The Clinical Reviewer concluded that the majority of care that Mr Nowosad received was largely equivalent to and, in respect of his mental health care, better than he would have received in the community.
However, as with the management of the ACCT process, the Clinical Reviewer was concerned that not all healthcare staff used interpretation services during their reviews with Mr Nowosad. The variability in use meant that there was a lack of consistency and continuity in assessing Mr Nowosad’s health needs and his risks.
With regard to the decision to transfer Mr Nowosad from the healthcare centre to a standard wing, the investigator noted that he had said on several occasions that he felt safe in the healthcare centre and he had expressed concern that his suicidal thoughts would return if he was moved. Additionally, a consultant forensic psychiatrist felt that Mr Nowosad had improved sufficiently to move from the healthcare centre and staff had tried to make his move as safe as possible by assessing his suitability as a vulnerable prisoner, to which he had agreed. However, the Clinical Reviewer determined that it would have been better to have identified the source of his specific fears and reviewed whether his mental state was as stable as it appeared before healthcare staff discharged him.
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:
- Staff use interpretation services when managing foreign national prisoners with limited English.
- The residential manager is invited to and attends an ACCT review when a prisoner moves from the healthcare centre to a residential wing.
- Staff involve the prisoner’s family when appropriate.
- Staff adhere to the frequency of observations set out in the ACCT document and record details of the observations in the ongoing record.
- Staff set new, specific and meaningful ACCT caremap actions that are aimed at reducing prisoners’ risks to themselves.
Rec 2: The Governor and the Head of Healthcare should ensure that when a prisoner expresses concern about moving wings, the reason for the concern is identified and addressed before the transfer is completed.
Rec 3: The Governor should ensure that next of kin details are recorded on reception, reviewed regularly and kept up to date, so that the next of kin can be informed of a prisoner’s death as soon as possible.
Rec 4: The Governor should ensure that a family liaison officer or appropriate member of staff is appointed as soon as a prisoner dies and they should inform the prisoner’s family promptly, in line with national guidance.
Full Report 02 Feb 2017 – HMP Manchester. Self-Inflicted.
09 Apr 2018 – HMP Guys Marsh. Other Non-Natural Death.
On 9 February 2018, Mr Samuel Groves was sentenced to eight months imprisonment. He was moved to HMP Guys Marsh on 20 February.
Mr Groves had a history of using illicit substances, both in the community and during previous prison sentences. He was also known to try to hide and trade prescription medication in prison. Within 2 days of arriving at Guys Marsh, he was found under the influence of psychoactive substances (PS). This pattern of behaviour persisted and there are frequent entries in his prison record of him being under the influence and engaging in drug-seeking and trading behaviour.
The Integrated Substance Misuse Service (ISMS) team at Guys Marsh sought to engage with Mr Groves and a drugs support worker saw him weekly on a one to one basis, but he continued to use PS, saying that drugs were ‘quite good fun’. Staff filed intelligence reports about Mr Groves’ drug use and took measures including cell checks, random drug testing, putting Mr Groves on a basic regime and an intervention plan to manage his behaviour.
At around 8.45pm on 9 April, an officer saw Mr Groves unresponsive on his cell floor during the evening roll check. He fetched another officer and they both went into the cell. One of them radioed the control room who called an ambulance. Staff attempted to resuscitate Mr Groves and paramedics took over when they arrived. Their attempts were unsuccessful and the paramedics confirmed Mr Groves’ death at 9.46pm.
The post-mortem examination found that Mr Groves had undiagnosed heart disease. PS was found in his body. The pathologist concluded that he died from the effects of PS, in combination with his heart disease.
On 20 February, Mr Groves was moved to HMP Guys Marsh. A paramedic did his first night screen. Mr Groves said he had no drug problems and no issues with bullying or trading medication. He said he had not used drugs in the preceding month. Mr Groves said he was prescribed diazepam, pregabalin and mirtazapine. He said that he smoked and he saw a smoking cessation advisor the next day who gave him some nicotine patches.
Management of Risk of Suicide and Self Harm
None to note.
Psychoactive Substances/Illicit Drugs
The post-mortem report says that Mr Groves died as a result of synthetic cannabinoid (PS) intoxication against a backdrop of chronic myocardial hypertrophy (enlarged heart) and ischaemia (weakened blood supply to the heart). The post-mortem examination found that Mr Groves had significant undiagnosed heart disease and that any sudden rise in blood pressure would have been likely to trigger a defect in the heart’s rhythm or pumping efficiency, with potentially fatal consequences. PS are known to increase blood pressure and therefore, it was likely that the taking of PS was the trigger for Mr Groves’ death.
Mr Groves had a long history of persistent substance misuse both in the community and in prison. During his final prison sentence, Mr Groves was caught smoking illicit substances on his second day in custody and he continued to misuse PS throughout his time at Guys Marsh. However, the Clinical Reviewer concluded that the care Mr Groves received for his substance misuse problems was arguably better that that which he could have expected to receive in the community.
Additionally, PS users seem to be particularly poorly motivated to explore change. Mr Groves had told her that he found illicit substances ‘quite good fun’.
The Clinical Reviewer considered that the continuity of care between Albany, Winchester and Guys Marsh was good and that at Guys Marsh his care – weekly input in his cell from an ISMS worker – was relatively intensive.
The emergency response was not in line with national instructions and a previous recommendation made to Guys Marsh was repeated.
Between 8.40pm and 8.45 pm, an OSG (operational support grade) started his shift on the wing and was briefed by an officer who told him there was ‘Spice’ in the prison. Afterwards, the OSG started the roll count. When he reached Mr Groves’ cell he opened the observation hatch and saw him lying on his front on the floor. Mr Groves was not moving and the OSG thought some fluid had come out of his mouth. The OSG’s statement said he was not particularly concerned initially and thought Mr Groves looked asleep. He turned the light on from outside, banged on the door and shouted Mr Groves’ name, but when Mr Groves did not respond he pressed the personal alarm on his radio to summon assistance. His call was not answered and he told the investigator he thought by this point that Mr Groves was dead as he had not moved at all. The OSG then went to Gwent Wing, which was the closest, and asked an officer to accompany him to Mr Groves’ cell.
When they reached the cell, the officer went in and said he turned the light on. He described Mr Groves as lying face down in vomit, fully clothed. The officer could not find a pulse and said Mr Groves was cold. He asked the OSG to call for assistance as Mr Groves was not breathing. The OSG said in his statement that he ‘did the three shouts over the radio and specified the cell’. He told the investigator that by this he meant he said ‘Assistance required. Assistance required. Assistance required’ over the radio, and that he gave the cell number, wing and the fact a prisoner was unresponsive. The control room log confirms that this happened at 8.55pm and that an ambulance was also called by control room staff at this point.
The officer turned Mr Groves onto his back and started CPR. The OSG went to the main gate to direct the paramedics when they arrived. Another officer arrived and opened Mr Groves’ airway and a third officer arrived and applied a defibrillator. The third officer had arrived for duty as the radio call for assistance was broadcast which is why he took a defibrillator with him. Several other officers had also arrived by the time the officer got there.
The defibrillator did not advise that the officers deliver a shock so they continued with rounds of CPR until the paramedics arrived at approximately 9.20pm. Paramedics were unable to resuscitate Mr Groves and confirmed his death at 9.46pm.
The Clinical Reviewer found that the care Mr Groves received at HMP Guys Marsh was equivalent to that which he could have expected to receive in the community. There were no missed opportunities to diagnose Mr Groves’ heart disease, and the support he received to address his substance misuse was good.
Mr Groves died due to PS use against a background of significant heart disease. Mr Groves’ heart condition was unusual for a man of his age (29) and had not been diagnosed. The Clinical Reviewer examined all Mr Groves’ custodial healthcare records back to January 2007 for any missed opportunities to do so but concluded there were none.
Rec 1: The Governor should ensure that all prison staff are made aware of, and understand, their responsibilities during medical emergencies including entering cells and using emergency codes.
Other Recommendations From Deaths Attributed To Natural Causes.
From the 5 remaining reports published last week, these were the recommendations for those deaths in custody attributed to natural causes.
01 Apr 2018 – HMP Hewell. Natural Causes.
Rec 1: The Head of Healthcare should provide the PPO with evidence that the recommendations in the RCA report into the prescription error have been implemented.
Rec 2: The Head of Healthcare should review the system for the management of complex long-term conditions, and implement a Case Finding and Risk Stratification system in line with NHS England guidance.
Rec 3: The Head of Healthcare should ensure that prisoners with terminal diagnoses are placed on a palliative care register to receive appropriate care.
Rec 4: The Head of Healthcare should review the process for the management of external correspondence from other healthcare providers to ensure that appropriate actions are taken to provide continuity of care.
Full Report 01 Apr 2018 – HMP Hewell. Natural Causes.
27 Sep 2018 – HMP Birmingham. Natural Causes.
Rec 1: The Governor should ensure that staff understand that when there is potentially a risk to life and subject to a personal risk assessment, they should enter a cell at night and radio an appropriate emergency code.
Rec 2: The Prison Group Director for the West Midlands should satisfy herself that effective measures have been taken to address Birmingham’s continuing failure to enter a cell and radio an appropriate emergency code when there is a potential risk to life.
Rec 3: The Governor should ensure that operational support grades receive appropriate training to understand their roles and responsibilities during night state and that they fully understand why they are issued with a night pouch and the circumstances when it should be used.
Rec 4: The Governor and Head of Healthcare should ensure that any staff named in this report are given the opportunity to read the report at the draft stage in line with paragraph 1.11 of PSI 58/2010.
Full Report 27 Sep 2018 – HMP Birmingham. Natural Causes.
03 Mar 2019 – HMP Northumberland. Natural Causes.
Rec 1: The Head of Healthcare should ensure that in line with the national vaccination schedule for prisoners over 65 years old, staff are aware of and offer the pneumococcal vaccination.
27 Apr 2019 – HMP Littlehey. Natural Causes.
Full Report 27 Apr 2019 – HMP Littlehey. Natural Causes.
11 Jul 2019 – HMP Leeds. Natural Causes.
Rec 1: The Governor should ensure that decisions to remove or reduce the level of restraints are communicated immediately to bedwatch staff.
Full Report 11 Jul 2019 – HMP Leeds. Natural Causes.