PPO Deaths In Custody Reports – Health Notes 06 Jan 2020

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

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

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)

13 Feb 2017 – HMP Lewes. Self-Inflicted Death.

Key Events

Mr Barrell was released on licence from HMP High Down on 26 January 2017 after serving 3 months of a 6-month sentence for theft and possession of a knife. He failed to report to his offender supervisor and was recalled to custody. He was arrested on 6 February and was remanded to HMP Lewes on 7 February.

Mr Barrell said he had been drinking alcohol daily since his release from High Down. He had been prescribed anti-depressants in the past and had a history of taking heroin and crack cocaine but had not recently self-harmed and had no thoughts of taking his life.

Mr Barrell was admitted to the drug stabilisation unit and started an alcohol detoxification treatment programme. His referral to the mental health team due to a history of psychosis was put on hold until his detoxification was completed. He was told he would be released on 27 April.

Mr Barrell wrote several letters to his mother, which she received the day after his death. He said he felt unwell, was hearing voices, had sold his food for tobacco, felt alone and had thoughts of ending his life. He did not tell nursing staff, officers or his cellmate how he was feeling.

On 13 February at about 10.00am, a psychologist from the mental health team saw Mr Barrell. He told her that he wanted medication for anxiety but did not elaborate. He said he was not feeling suicidal. Mr Barrell’s cellmate was moved to another wing at about 11.00am as he had finished his detoxification treatment. Mr Barrell collected his lunch and was last seen by an officer at 12.05pm locked in his cell, sitting, eating his meal.

A psychosocial caseworker went to Mr Barrell’s cell between 12.30pm and 1.30pm to ask him to complete some paperwork but when he looked in the cell and could not see Mr Barrell, he assumed he was in the toilet and told the officer on duty he would return later.

At about 2.00pm, an offender manager told the officer on duty that she needed Mr Barrell to sign his licence recall documentation (for his revised release date of 17 February) but when she had looked through the door observation panel of his cell, she could not see him. The officer remarked that she was the second member of staff to make the same comment. He opened the cell door and found Mr Barrell hanged in the toilet.

The officer was not carrying a ligature-cutting tool. He radioed for assistance. Staff responded quickly and began cardiopulmonary resuscitation. Paramedics arrived, examined Mr Barrell and at 2.59pm recorded that he had died.


Reception Screening

Mr Barrell’s clinical record recorded that he had tried to take his life in the community on at least 3 occasions since 2005, the most recent attempt in October 2016. His Person Escort Record (PER) flagged up issues of depression and anxiety and on arrival, he said that he had been prescribed medication. However, there was no obvious indication that he was likely to take his life and at an initial health check, he denied suicidal intent.

With the benefit of hindsight, he could have had a more in-depth assessment of his risk given that he was undergoing detoxification and he had been recalled to custody, factors that heightened his risk of self-harm, but there was little to suggest that staff should have begun ACCT procedures.

Management of Risk of Suicide and Self Harm

Mr Barrell arrived with some risk factors: his PER noted he had depression and anxiety. When he arrived at Lewes, he acknowledged he had harmed himself in the past and told 2 nurses and an officer that he had no thoughts of suicide or self-harm. He gave similar answers 3 days before his death to his psychosocial caseworker and only hours before he was found, to a psychologist who probed why he wanted medication for anxiety.

Only his letters to his family, to which staff were not privy, revealed the inner distress he was feeling. Outwardly, he appeared normal in mood to staff and his cellmate. Investigators were satisfied that staff considered his risk and it was reasonable for them to conclude that Mr Barrell did not need to be monitored under ACCT procedures and he could be safely left in a cell by himself.

PSI 64/2011 sets out the roles and responsibilities of Governors and other staff in risk management and the preservation of life. Following the officer’s disclosure that he was not carrying an anti-ligature cut-down tool when he found Mr Barrell, the investigator communicated to the Governor the concern that such a situation could arise. The Governor asked a senior manager to carry out an audit of anti-ligature cut-down tools.

The senior manager told the investigator that the database of ligature-cutting tools had been poorly maintained. The officer had been a workshop instructor when the anti-ligature cutting-tools had first been introduced and it had been decided at that time that workshop instructors did not need to be issued with such tools but that this decision would be reviewed.

The investigator returned to Lewes in July to re-interview the officer. He said that he had not received ACCT training and still was not carrying a cut-down tool. It is unacceptable that an officer was dependent on the arrival of a colleague to remove the fabric from the prisoner’s neck, or that he would remain on duty without a cut-down tool for next 5 months.

Psychoactive Substances/Illicit Drugs

Mr Barrell was appropriately identified as suitable for alcohol detoxification. He was placed in a residential unit dedicated for drug and alcohol stabilisation and received appropriate care equivalent to that which he could have expected to receive in the community.

The post-mortem report gave the cause of death as hanging. Toxicology tests showed that Mr Barrell had benzodiazepines (chlordiazepoxide from the alcohol detox and diazepam) in his bloodstream and urine at the time he died in small quantities.

Emergency Response

The prison communications room incident log records the officer radioed for staff assistance at 2.09pm. Lewes called an ambulance at 2.10pm. An ambulance arrived at 2.20pm and another ambulance at 2.26 pm. Ambulance staff tried to resuscitate Mr Barrell but he was pronounced dead at 2.59pm.

The officer who found Mr Barrell hanging was not carrying a ligature-cutting tool. He gave the investigator unsatisfactory, inconsistent, incomplete and misleading accounts of his actions that day but has since retired.

Clinical Care

After Mr Barrell was released from High Down, he had been consuming large amounts of alcohol every day and was homeless. When he arrived at Lewes, he was feeling physically unwell.

The Clinical Reviewer concluded that the healthcare he received was equivalent to that which he could have expected to receive in the community. He was promptly assessed for substance misuse issues and given a bed immediately in a specialist unit. He saw a GP promptly and was prescribed appropriate medication for his throat infection. His responses to the detoxification programme were regularly monitored. He was referred to the mental health team and a counselling psychologist from the team also visited him.

There were no obvious omissions in the care he received and, unfortunately, he chose not to disclose his thoughts or feelings about ending his life.


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

  • All uniformed staff in contact with prisoners are issued with a personal ligature-cutting tool and that it is worn at all times while on duty.
  • All staff in contact with prisoners are trained in suicide and self-harm prevention procedures with appropriate refresher training.
  • Staff ensure they receive a response from prisoners if they are not visible or otherwise enter the cell.

Full Report 13 Feb 2017 – HMP Lewes. Self-Inflicted Death.

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.

15 Sep 2018 – Full Sutton. Natural Causes.


No recommendations.

Full Report 15 Sep 2018 – Full Sutton. Natural Causes.

02 Dec 0218 – Heathrow IRC. Natural Causes.


Rec 1: The Director and the Head of Healthcare at Heathrow IRC should ensure that all staff are made aware of, and understand, their responsibilities during medical emergencies. Staff should use an emergency code immediately when there are serious concerns about the health of a detainee to ensure that the emergency response is not delayed.

Rec 2: The Home Office should ensure that the family of deceased detainees are informed according to the provisions of DSO 08/2014.

Full Report 02 Dec 0218 – Heathrow IRC. Natural Causes.

07 Aug 2019 – HMP Holme House. Natural Causes.


Rec 1: The Governor at HMP Kirklevington Grange should ensure, in line with PSI 64/2011, that staff engage with the next of kin of seriously ill prisoners and keep them informed of any changes in their condition.

Full Report 07 Aug 2019 – HMP Holme House. Natural Causes.

Thanks to Leon Overweel for making this photo available freely on Unsplash