Last week the PPO published 9 reports relating to deaths in custody. The causes are categorised as follows:
- Natural Causes = 6
- Self-Inflicted = 2
- 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)
8 Jul 2017 – HMP Coldingley. Self-Inflected Death.
On 3 January 2006, Mr Dunnings was convicted of robbery and received an indeterminate sentence of Imprisonment for Public Protection (IPP), with a minimum tariff to serve of 2 years and 9 months before he could be considered for parole. He was released in 2011, but his licence was revoked in July 2014 and he was returned to prison. He was transferred to Coldingley on 8 September 2016. He had a history of self-harm, which manifested during times of emotional distress and anxiety.
On 14 June 2017, Mr Dunnings was moved to the segregation unit after he was involved in an incident on his wing. Staff began ACCT procedures after he made cuts to his wrist.
Mr Dunnings was a Category C prisoner. On 21 June, he was re-categorised to Category B on the basis of his disruptive behaviour, but was never formally notified of this decision and only learned about it the day before he took his life.
While segregated, Mr Dunnings was assessed by the mental health team, GPs and a psychiatrist. He was offered medication for symptoms of anxiety and depression but often refused to take his medication as he said that it did not help.
On 29 June, Mr Dunnings told staff that he would end his life after his next visit from his family. After his biological mother visited him on 7 July, an ACCT review considered that his risk had increased, but no additional safeguards were identified or proposed and he continued to be checked once an hour.
At around 1.05am on 8 July, an officer found Mr Dunnings hanged in his cell. Staff and paramedics tried unsuccessfully to resuscitate him. At 2.12am, paramedics confirmed that Mr Dunnings had died.
On 8 September 2016, Mr Dunnings was moved to HMP Coldingley. At a reception health screen, he told a nurse that he had no thoughts of suicide or self-harm, but she referred him to the mental health team because of his anxiety. On 18 September, Mr Dunnings did not attend his mental health appointment, and said that he was not interested in mental health support.
Management of Risk of Suicide and Self Harm
Prison Service Instruction (PSI) 64/2011 on safer custody says that prisoners subject to ACCT monitoring should only be segregated in exceptional circumstances as it heightens their vulnerability, and the reasons and options considered must be clearly documented in the ACCT plan. The initial decision to segregate Mr Dunnings, while he was subject to ACCT procedures, was not unreasonable as he had been involved in two serious incidents on 14 June.
No senior manager formally considered whether there were exceptional reasons for holding Mr Dunnings in the segregation unit and no one considered alternative locations.
Many of Mr Dunnings’ ACCT reviews were procedural and lacked meaningful discussion of issues that might affect his level of risk such as his re-categorisation, IPP status, deferred parole hearing, ongoing investigations by police and elevated levels of anxiety. As a result, many of the case reviews failed to address his concerns and assess his level of risk effectively. Reviews also failed to address the impact of Mr Dunnings’ limited access to activities during his time in the segregation unit and on 25 June, his observations were reduced without an ACCT review.
Although some of the caremap objectives for Mr Dunnings such as his continuing contact with the prison psychiatrist, budgeting for tobacco, and keeping contact with family were useful, they were not aimed at reducing his risk or addressing recurrent concerns about being transferred, re-categorisation and his medical issues. Staff failed to recognise how important it was for Mr Dunnings to be near his family, that he did not understand why he remained in segregation and that he did not know whether he was being re-categorised and how it would affect him as an IPP prisoner.
Many of the checks on Mr Dunnings were carried out at regular intervals, contrary to PSI 64/2011 which requires ACCT observations are conducted at unpredictable intervals. This would have allowed Mr Dunnings to predict when the next check would be. The frequency of checks did not consistently reflect the number of checks required.
Staff judgement is fundamental in operating ACCT procedures. The system relies on staff using their experience and skills, as well as local and national assessment tools to determine risk. While a prisoner’s presentation is important and reveals something of their level of risk, it is only a reflection of their state of mind at the time and should be considered as a single piece of evidence when judging risk. Staff should consider all risk factors to ensure that a prisoner’s level of risk is judged holistically. Investigators took the view that staff did not interact effectively to identify Mr Dunnings’ issues, needs and risk which would have provided him with relevant support in the weeks leading to his death.
Psychoactive Substances/Illicit Drugs
A post mortem examination concluded that the cause of Mr Dunnings’ death was hanging. A toxicology examination found pregabalin and a low concentration of sertraline in Mr Dunnings’ bloodstream when he died, both of which were consistent with a therapeutic dosage.
At midnight, Officer A saw Mr Dunnings standing in his cell. He carried out a further check at 1.04am on 8 July. He said that he could not see Mr Dunnings through the observation panel. He then checked on the 3 remaining prisoners in the segregation unit before returning to Mr Dunnings cell at 1.05am, where he shone his torch through the observation panel. The officer said that he could not see Mr Dunnings, but then saw his feet and what appeared to be his body leaning against the cell door.
At 1.06am, the night custodial manager and Officer A arrived at Mr Dunning’s cell. The manager shone his torch through the door for about 20 seconds and saw that Mr Dunnings appeared to be sitting by the door. He turned the cell light on and saw that Mr Dunnings had hanged himself. He unlocked the cell door and went in, followed by 2 officers, who had responded to the earlier call for assistance. The manager held Mr Dunnings while both officers cut the ligature. The ligature, made of bedding, was tied around the hinge of the cell door and Mr Dunnings had also tied it around his ankles. The officers found no signs of life. Officer B said Mr Dunnings was cold but that rigor mortis had not set in.
The officers started cardiopulmonary resuscitation. Officer A started chest compressions while Officer B gave breaths. At about 1.11am, the night custodial manager called a medical emergency code blue, indicating that a prisoner is unconscious or having difficulties breathing, and asked for an ambulance. The 2 operational support grades immediately called an ambulance. The manager left the cell to provide information to the ambulance service. As he was speaking to the emergency services, other officers arrived at the segregation unit and the defibrillator was taken to the cell.
Returning to the cell a little later, the night custodial manager asked an officer to take over chest compressions from Officer A and later asked another officer to help. Officer B continued giving breaths throughout the resuscitation efforts. An officer attached the defibrillator but it found no shockable heart rhythm.
At about 1.30am, paramedics arrived and continued unsuccessfully to resuscitate Mr Dunnings. At 2.12am, paramedics noted that Mr Dunnings had died.
The Clinical Reviewer highlighted numerous failings in Mr Dunnings’ clinical management at Coldingley, including the management of Mr Dunnings’ diagnosis, prescription of medications, mental healthcare and the organisation and communication between healthcare disciplines. The conclusion was that the care Mr Dunnings received was not equivalent to that which he could have expected to receive in the community. The Head of Healthcare will need to address the Clinical Reviewer’s numerous recommendations.
The Clinical Reviewer noted that all the medications prescribed to Mr Dunnings were appropriate to manage his anxiety and depression. However, given the number of medications that Mr Dunnings was prescribed, concerns were that this was not always brought to the attention of his supervising clinicians and when it was, medical reviews did not always follow. The Clinical Reviewer concluded that it might have been better for staff to have focused on psychological interventions.
The Clinical Reviewer noted that although Mr Dunnings’ mental health was reviewed in December 2016, he was not diagnosed with anxiety and personality disorder until May 2017 when plans were made to address his needs. He reported that when a plan was eventually made for Mr Dunnings, few of the recommendations were subsequently taken forward. The Clinical Reviewer concluded that the many months it took to diagnose and develop a care plan could have been shortened, allowing Mr Dunnings to access appropriate care sooner.
The Clinical Reviewer noted that Mr Dunnings needed tailored mental health support which he never received. He reported that healthcare staff relied on conversations between different healthcare teams, and there is no evidence to indicate that mental health referrals were made or followed up and that care management plans were monitored.
Although he noted a good working relationship between GPs, healthcare and mental healthcare services. The arrangements were informal and there were few structured multidisciplinary team meetings. He noted that prison GPs never met to review care and learn lessons. He concluded that informal conversations should be supplemented with clinical notes which would clarify what progress had been made against management plans.
Rec 1: The Governor should ensure that staff manage prisoners at risk of suicide or self-harm in line with national guidelines. In particular, that:
- Prisoners assessed as at risk of suicide or self-harm are not held in the segregation unit unless all other options have been considered and excluded. A senior manager of governor grade should record the exceptional circumstances for segregation.
- Case reviews are multidisciplinary and include all relevant people involved in a prisoner’s care, including mental health staff, where appropriate, and healthcare staff attend all first case reviews.
- Staff read the ACCT document and familiarise themselves with all relevant issues and known risk factors before holding reviews, and ACCT case reviews should assess and record the level of risk, considering all risk factors.
- Caremap actions, are specific, meaningful and time-bound, aimed at reducing prisoners’ risks and review them at each case review.
- The frequency of observations should reflect the prisoner’s risk and be adjusted when that risk changes. Staff should check on prisoners, who are subject to ACCT procedures, at unpredictable intervals and record their observations.
- The Governor should ensure that ACCT case managers consider involving the prisoner’s family in the ACCT process and understand the procedures to do so.
- The Governor should ensure that there are procedures in place to check the quality of ACCT procedures, identify bad practice, learn lessons, and where appropriate, provide staff refresher training on ACCT procedures.
Rec 2: The Governor should ensure that staff understand and follow the procedures for the re-categorisation of prisoners, inform them of decisions and reasons for re-categorisation and provide them with information about the appeal process.
Rec 3: The Governor and Head of Healthcare should ensure that staff manage prisoners held in segregation in line with national guidelines, including that:
- A mental health assessment is carried out within 24 hours whenever ACCT procedures are started for a prisoner in the segregation unit.
- Segregation algorithms are completed when prisoners in segregation become subject to ACCT procedures.
- Segregation review boards include the ACCT case manager when a prisoner is identified as at risk of suicide and self-harm. The review chair should consider and record whether there are exceptional reasons to authorise continuing segregation.
- All attendees at segregation reviews understand the purpose of the review and be confident about challenging continued segregation when they have concerns about a prisoner’s vulnerability.
- Healthcare representatives at segregation reviews are fully briefed about relevant aspects of the prisoner’s health needs and where possible, should be the person responsible for the individual’s care.
- Segregation review boards are held more frequently than the minimum requirement for prisoners subject to ACCT procedures.
- Authorisation for segregation is completed promptly and accurately, and set out in full the reasons for the decision.
Rec 4: The Head of Healthcare and the Mental Health Team should ensure that all patients with mental health problems are assessed promptly in line with National Institute for Health and Care Excellence (NICE) guidance and a written care management plan is developed and actioned.
Rec 5: The Head of Healthcare should ensure that:
- GPs review prisoners’ prescriptions when appropriate to ensure that their medication needs are addressed; and
- Healthcare staff regularly meet to review patient care, including holding multidisciplinary meetings, where appropriate.
Full PPO Report 8 Jul 2017 – HMP Coldingley. Self-Inflected Death.
10 Nov 2018 – HMP Lincoln. Self-Inflected Death.
On 6 December 2016, Mr Ean Smith was remanded in custody, charged with sexual offences, and sent to HMP Lincoln. He was later sentenced to 4 years and 3 months in prison and was due to be released in January 2019.
Throughout his time at Lincoln, Mr Smith told staff that he worried about whether his relationship with his wife would survive and that if she ever left him, he would end his life. On 3 occasions, staff monitored Mr Smith under ACCT procedures. The last period of ACCT monitoring ended on 31 August 2017.
Mr Smith had depression and met with a prison therapist frequently. She noted that his mood was very closely linked to the amount of contact he had received from his wife and how anxious he was about the state of their relationship. Mr Smith met his therapist on 7 November, and then she saw him again on the wing on 9 November. Both times, she assessed that he was not at risk of harming himself.
On the morning of 10 November, Mr Smith received an email from his wife saying she was no longer in love with him. He made 2 telephone calls to her that afternoon saying he was sorry for everything and that he would be dead soon.
At around 3.00pm, Mr Smith’s wife telephoned the prison and said she felt that her husband had just made a ‘goodbye’ call. A supervising officer on Mr Smith’s wing went to Mr Smith’s cell to try to find him but it was empty. When he shouted Mr Smith’s name, someone said he had gone to the gym.
At around 4.00pm, an officer went to find Mr Smith as he was due to start his job as a healthcare orderly. Mr Smith’s cellmate told him he had last seen Mr Smith around 2.45pm, walking towards the showers. When the officer and Mr Smith’s cellmate got there, they found Mr Smith hanging. Healthcare staff attended and carried out CPR until ambulance paramedics arrived. They pronounced Mr Smith’s death at 4.46pm.
A nurse conducted his reception health screen. He told her he had fractured his shoulder 2 days earlier, when he fell from a tree trying to hang himself. He said he had a history of depression and had been a heavy drinker. The nurse started ACCT procedures and referred Mr Smith to the mental health team and to the fracture clinic. Mr Smith declined a referral to the prison’s substance misuse service.
Management of Risk of Suicide and Self Harm
Mr Smith was managed under ACCT procedures on 3 occasions at Lincoln: from when he first arrived on 6 December 2016 until 10 February 2017; from 20 to 26 June 2017; and from 22 to 31 August 2017. On each occasion, staff correctly identified that Mr Smith was at risk of suicide and self- harm and managed him appropriately under ACCT.
Throughout his time in prison, Mr Smith said that he thought about suicide. He also said repeatedly that he would end his life if his wife left him. He met frequently with a therapist and would often discuss his worries about his relationship with his wife. She noted that Mr Smith’s anxiety centred around his relationship with his wife, as well as his release.
On 10 November, Mr Smith received an email from his wife saying that she would always love him but was no longer ‘in love’ with him and could not understand how he could have committed his offences. Mr Smith made 2 telephone calls to his wife later that day saying he could not go on without her, that he was sorry and that he would be dead soon. Mr Smith’s realisation that his wife no longer wanted to be in a relationship with him seems to have been the trigger for him to take his own life.
Psychoactive Substances/Illicit Drugs
The toxicology examination found no evidence of illicit drug use.
An officer told the investigator he knew he should have radioed a medical emergency Code Blue but ‘froze’ when he found Mr Smith. A CM called a Code Blue a few minutes later at 4.18pm, and control room staff called an ambulance at 4.21pm.
Control room staff said this delay was because they were obtaining more information about Mr Smith before calling the ambulance, which is not in line with policy, which says an ambulance should be called immediately in response to a medical emergency code. It made no difference in this case because it appears Mr Smith was dead when found, but it is important that the correct medical emergency procedures are followed so that prisoners can receive life-saving treatment as quickly as possible.
The Clinical Reviewer noted that Mr Smith had regular support from the prison’s mental health team and was prescribed appropriate medication for his depression. Mr Smith engaged in fortnightly IPT meetings with a mental health nurse and then monthly CBT with the therapist.
The Clinical Reviewer concluded that the support given to Mr Smith was in accordance with NICE guidance on treating depression and that, overall, his clinical care was equivalent to the care he could have expected to receive in the community.
Rec 1: The Governor should ensure that when staff are alerted to serious concerns about a prisoner’s welfare, they ensure the prisoner is located and spoken to as soon as possible.
Rec 2: The Governor should ensure that all prison staff are made aware of and understand the need to use appropriate codes to communicate a medical emergency, in line with national and local instructions, and that control room staff call an ambulance immediately when a medical emergency code is called.
Full PPO Report 10 Nov 2018 – HMP Lincoln. Self-Inflected Death.
28 Feb 2018 – HMP Humber. Other Non-Natural Death.
In June 2014, Mr Alan Tyers was sentenced to 8 years in prison. He was transferred to HMP Humber in August 2017. During his time at Humber, Mr Tyers received very positive reports from prison staff and worked in a role reserved for trusted prisoners.
Mr Tyers’ cellmate told investigators that he frequently used psychoactive substances (PS). At around 7.15pm on 27 February 2018, Mr Tyers collapsed after smoking PS. His cellmate raised the alarm and a nurse assessed Mr Tyers. The nurse asked prison staff to “keep an eye” on him, but did not specify how frequently or for how long they should observe him. The night patrol officer stopped observing Mr Tyers a little over an hour later, thinking he was now fine and had settled for the night. No one from the healthcare team returned to assess him further.
At 8.05am on 28 February, an officer unlocked Mr Tyers’ cell and found that he had died.
Mr Alan Tyers served several prison sentences from the 1980s onwards. His final period in custody began when he was remanded to HMP Nottingham on 10 March 2014. During his time in prison, he was prescribed tramadol (a strong opiate-based painkiller) for long-term back pain, and mirtazapine (an antidepressant). In June 2014, Mr Tyers was sentenced to 8 years in prison for robbery. He was transferred to HMP Stocken shortly afterwards.
At Stocken, Mr Tyers worked with the substance misuse team and completed several courses to address his drug misuse in the community. In April 2016, prison staff recorded that they suspected Mr Tyers used PS, and that other prisoners might have given him PS to test his reaction to it.
Mr Tyers was transferred to Humber on 31 August 2017. He continued to be prescribed tramadol and mirtazapine throughout his time at Humber.
Management of Risk of Suicide and Self Harm
No issues or concerns noted.
Psychoactive Substances/Illicit Drugs
Toxicology examinations showed that Mr Tyers had used PS sometime before he died. The post-mortem report found that his death was consistent with synthetic cannabinoid (PS) intoxication.
At 8.05am, an officer began to unlock cells for the morning. He found Mr Tyers lying on his bed, and noted that it was unusual as Mr Tyers was normally ready for work. He shouted to Mr Tyers but had no response. He opened the cell and found Mr Tyers not breathing, pale and hard to touch. He radioed a medical emergency Code Blue. The control room operator telephoned for an ambulance immediately.
The officer said that he did not consider trying to resuscitate Mr Tyers as rigor mortis appeared to have set in. A nurse reached the same conclusion when she responded to the emergency message. Paramedics later confirmed that Mr Tyers had died.
The Clinical Reviewer, found that the lack of additional clinical assessment meant that Mr Tyers’ care was not equivalent to that which he could have expected to receive in the community.
There was a clear failure in communication on the night Mr Tyers died. It was not clear to wing staff how frequently they should observe Mr Tyers or when they should stop doing so. There was also a lack of clinical follow-up.
Since Mr Tyers’ death, Humber have introduced an ‘enhanced supervision log’ for prisoners found under the influence of PS drugs. This requires healthcare staff to set a specific frequency of observations for wing staff to complete and record on a log. After 2 hours, healthcare staff will assess the patient, including taking clinical observations, and determine whether to continue or close the enhanced supervision log.
It was encouraging that Humber have identified lessons to learn from Mr Tyers’ death and introduced procedures to try to prevent a recurrence. On this basis, the PPO made no recommendation.
Full PPO Report 28 Feb 2018 – HMP Humber. Other Non-Natural Death.
Other Recommendations From Deaths Attributed To Natural Causes.
From the 6 remaining reports published last week, these were the recommendations for those deaths in custody attributed to natural causes.
28 Aug 2018 – HMP Wymott. Natural Causes Death.
Rec 1: The Governor should ensure that all staff undertaking risk assessments for prisoners in 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 28 Aug 2018 – HMP Wymott. Natural Causes Death.
16 Jan 2019 – HMP Isle of Wight. Natural Causes Death.
Rec 1: The Head of Healthcare should ensure that all patients with long-term health conditions have clear personalised care plans, with stated aims, planned interventions and monitoring.
Rec 2: The Governor should ensure that applications for compassionate release are submitted to the Public Protection Casework Section without delay.
Rec 3: 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 PPO Report 16 Jan 2019 – HMP Isle of Wight. Natural Causes Death.
25 Jan 2019 – HMP Cardiff. Natural Causes Death.
Rec 1: The Head of Healthcare should ensure that all staff understand their professional requirement to maintain clear, accurate, contemporaneous healthcare records.
Rec 2: The Head of Healthcare should ensure that staff put in place appropriate chronic disease management plans.
Rec 3: The Head of Healthcare should ensure that staff complete the medical section of the escort risk assessment fully and accurately, so that custodial staff have the information they need to make an informed decision on the appropriateness of restraints.
Rec 4: The Governor and Head of Healthcare should ensure that information requested by the PPO after a death in custody is provided promptly.
Full Report 25 Jan 2019 – HMP Cardiff. Natural Causes Death.
12 Mar 2019 – HMP Wakefield. Natural Causes Death.
Rec 1: The Governor and Head of Healthcare should ensure that all staff understand the procedures for responding to a medical emergency code so that there is no delay in calling an ambulance.
Rec 2: 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.
13 Jul 2019 – HMP Whatton. Natural Causes Death.
Full Report 13 Jul 2019 – HMP Whatton. Natural Causes Death.
23 Jul 2019 – HMP Wakefield. Natural Causes Death.
Rec 1: The Head of Healthcare should ensure that staff are aware of the need to appropriately escalate any clinical concerns.
Rec 2: The Head of Healthcare should ensure that staff consider transferring patients to the inpatient facility if they assess that there is a clinical need.
Rec 3: The Governor and the Head of Healthcare should ensure that applications for compassionate release are progressed in a timely manner and submitted as promptly as possible.