JL — HMYOI Feltham
Serious Self-Harm
19 August 2002
The National Offender Management Service (NOMS) response to the independent investigation conducted by Selena Lynch into the life-threatening self-harm of JL at HMYOI Feltham on 19 August 2002 is published. JL was remanded into custody at HMYOI Feltham on 19 July 2002. On 19 August at 14.30 hours he was discovered hanging. After being resuscitated he was taken to hospital. He temporarily returned to custody but was subsequently transferred to a brain injury unit in hospital. He remains significantly injured in a Community Rehabilitation Centre.
Key Findings
The investigation found that while JL received significant support and his care was largely well-intentioned, the critical failure was the non-multi-disciplinary closure of his F2052SH (at-risk) form. This deviation from policy excluded key staff like the Chaplaincy, who would have opposed the closure given JL's impulsive behaviour. Other contributing factors included shortcomings in record-keeping, a lack of specialist services for underlying social problems, and challenges in translating detailed policies into accessible instructions for frontline staff.
Learning Points (6)
Learning Point 1
It is noted that the Internal Investigation, 2002, recommended attendance by the Chaplaincy at F2052SH (now ACCT – Assessment, Care in Custody and Teamwork) reviews both locally and nationally, and this recommendation is supported. In cases where drug abuse is involved a CARATS representative should also attend, and Education staff should be invited to attend or make a contribution to the review, where prisoners are attending education classes.
HMPPS Response
The National Offender Management Service (NOMS) recognises the importance of information sharing and how it is recorded and shared. On 1 March 2011 NOMS issued Prison Service Instruction (PSI) 10/2011 Residential Services. The PSI identifies that residential staff will often be the first to pick up information regarding the needs, risks or behaviours of individual prisoners. Paragraph 2.2 sets out where different types of information should be recorded by residential staff. In particular it is stated that “any other important information is recorded in the wing occurrence book or equivalent and passed to any other departments in the prison who need to know.” The handover arrangements in prisons are determined locally by the prison governor, however, residential units in prisons usually hold handovers with staff when there is a shift change. It is expected that important information contained within the occurrence book, sometimes known as the observation book, would be shared with staff coming on duty during the course of the handover. Staff would normally familiarise themselves with recent entries in the occurrence book. Additionally, NOMS is revising its safer custody polices. PSI 64/2011 Safer Custody: Management of Prisoners at Risk of Harm to Self, to Others and from Others includes a chapter on information sharing and a section on the effective ways to share learning. This PSI is currently being finalised and will replace Prison Service Orders (PSO) 2700 Suicide prevention and self-harm management, 2750 Violence reduction (although PSI 9/2011 Cell Sharing Risk Assessment will remain extant) and 2710 Follow up to deaths in custody. In view of the recent reviews of the above mentioned policies, and the changes that have been made to improve information sharing, NOMS does not propose to conduct a further review of the guidance it provides on handovers but will keep this matter under consideration as and when policies are amended in the future.
Learning Point 2
The CARATS teams should record information about their interviews with prisoners in unit history sheets, and share assessments with staff who are managing prisoners, particularly when an ACCT (formerly F2052SH) process has been opened. These records should be available when required for any future investigations.
HMPPS Response
You have identified that PSO 4400 (4), Prisoner Communications, Chapter 4, Prisoners’ Use of Telephones, sets out that foreign national prisoners who do not receive domestic visits during the preceding month may be provided with a £3 or £5 phone card. NOMS no longer operates a cardphone based system. This has been replaced by individual electronic prisoner telephone accounts which prisoners access by using a unique PIN number and these accounts operate on a pre-paid basis. It has been longstanding NOMS policy that foreign national prisoners and indeed anyone with close family abroad must be permitted a free five minute call once a month where the prisoner has had no social visits during the preceding month. Until recently this requirement featured as one of the key audit baselines within NOMS Prisoner Communications Performance Standard and as such would have been subject to local audit to ensure that it was delivered. This same requirement has now been incorporated as an output with the Prisoner Communications Services specification under the Specifications, Benchmarking and Costings Programme. More general information about the Programme can be found at http://www.justice.gov.uk/about/noms/noms-specification-benchmarking-and-costing-programme/index.htm. This Specification is enacted and supported by Prison Service Instruction 49/2011, Prisoner Communication Services. The Specification and the supporting Instruction currently also contains an auditable provision whereby if there are compassionate circumstances, such as a domestic crisis, Operational Managers have the discretion to allow calls to be made from either an official telephone or to issue the prisoner with additional telephone credits. This will be at public expense. Given the suggestion that prisoners have the opportunity to earn money which they can spend on telephone calls and the circumstances of this particular incident, it is relevant to record that over the last few years the cost to prisoners of making international calls has reduced considerably. For example since 1998, and through various negotiations with the supplier, the cost of calling Jamaica has been reduced by over two thirds against the original rate.
Learning Point 3
A specialist service should be available to address the underlying social problems associated with risk of self-harm, where needed, for prisoners identified under ACCT (formerly F2052SH).
HMPPS Response
You have stated in your report that the HMYOI Feltham policy on cell sharing appears to be focussed on the risks of prisoners cell sharing rather than the benefits, i.e. that cell sharing can be a supportive measure. You have suggested a review of the current policies on this issue may be helpful. Firstly, I thought it may be useful to set out briefly the considerations given in advance of prisoners sharing cells. As you will know NOMS has a duty to keep prisoners safe and in doing so it must identify prisoners who pose a risk to, or from others with regards to cell sharing. NOMS therefore requires prisons to complete a cell sharing risk assessment (CSRA) for every prisoner held in closed conditions. The CSRA is an essential tool in the identification of prisoners who may pose a risk of assaulting or killing a cell mate in a locked cell. I do not propose to go into detail about the CSRA in this letter as the focus of your recommendation is on the support that a prisoner may receive when sharing a cell. NOMS recognises the potential benefits of prisoners identified at-risk of suicide and or self-harm sharing a cell. Staff would take this into consideration when deciding how best to support the prisoner and reduce the risk of harm to them as part of the CAREMAP. However, decisions to locate an at-risk prisoner in shared accommodation must be made taking into account the needs of the at-risk prisoner, as well as the possible impact on the cellmate. You will be aware that staff will open an ACCT (Assessment, Care in Custody and Teamwork - the care-planning system for prisoners at-risk of suicide and/or self-harm) Plan if they discover a prisoner has self-harmed or are concerned that a prisoner is at-risk of self-harm. The CAREMAP records actions that are tailored to meet the individual needs of the prisoner and are aimed at reducing the risk of harm to them. It reflects the prisoner’s needs, level of risk and the triggers of their distress. PSI 64/2011 Safer Custody: Management of Prisoners at Risk of Harm to Self, to Others and from Others sets out that the completion of the CAREMAP must aim to address the issues identified in the ACCT assessment interview and give consideration to a number of issues, including peer support. PSI 64/2011, which will replace PSO 2700 Suicide prevention and self-harm management, sets out what should happen at each stage of the ACCT process. In particular, the first case review will agree how the prisoner will be supported and, if a view is taken that an at-risk prisoner will benefit from sharing a cell then that will be recorded in the CAREMAP, which is completed at this stage in the process. Once the cell mate has been identified both prisoners will be subject to the CSRA process before sharing commences. NOMS has recently reviewed its self-harm management strategy and work is also underway to produce a new self-harm guidance document for frontline operational staff working with prisoners who self-harm. This will provide further information and advice on the benefits of peer support (in the form of cell-sharing where appropriate, or through other measures.)
Learning Point 4
Where prisoners can be shown through review to have become dependent on the added support the ACCT process provides, consideration should be given to withdrawing the process more gradually as part of the closure plan.
Learning Point 5
Methods of translating Formal Policy Documents into accessible and simplified instructions for Prison Officers using skills-based training methods should be developed.
Learning Point 6
Archived records in accordance with PSO 9020 should be more clearly indexed to facilitate future investigations.