TA — HMP Chelmsford
Serious Self-Harm
1 July 2013
The report of the independent investigation conducted by Barbara Stow into the incident of life-threatening self-harm involving ‘TA’1at HMP Chelmsford on 1 July 2013 is published here. Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at the prison.
Key Findings
The investigation found that TA, a first-time prisoner with a history of depression and self-harm, was not adequately assessed or supported during his 11 days in custody. Critical information about his past self-harm was not properly followed up, a required second healthcare assessment was missed, and several warning signs from staff observations were not recorded or investigated. Furthermore, the emergency response to his self-harm had deficiencies, and subsequent investigations by the prison and healthcare agencies were fragmented and lacked the necessary rigor.
Learning Points (11)
Learning Point 1
We recommend that HMPPS reviews the current instructions on healthcare assessments for new prisoners to ensure that there is no doubt that a second medical assessment within a prisoner’s first week is a mandatory requirement.
HMPPS Response
HMPPS is committed to enabling healthcare providers to conduct medical assessments in accordance with NHSE specifications and NICE guidance. This includes a second assessment within seven days, and as the report acknowledges, this is happening in practice. This will be reflected as a mandatory action in the early days in custody policy when this is next updated.
Learning Point 1
We draw to the attention of HMPPS the NICE Quality Standard and guidance for the health of people in prison and, in particular, the presumption that prisoners with a history of self-harm should be referred for mental health assessment. It may be appropriate to take account of this in Prison Service Instructions.
HMPPS Response
HMPPS is committed to enabling healthcare providers to conduct medical assessments in accordance with NHSE specifications and NICE guidance. This includes a second assessment within seven days, and as the report acknowledges, this is happening in practice. This will be reflected as a mandatory action in the early days in custody policy when this is next updated.
Learning Point 2
We recommend that HMPPS and NHSE/I consider specific guidance for the process of ligature cut down to ensure optimum management of the unconscious patient. This will include clarification of whether emergency bags should contain a soft cervical collar as a standard item.
HMPPS Response
HMPPS and NHS England have considered the need for guidance regarding the process of ligature cut down and the inclusion of soft cervical collars in emergency bags, and we do not think either is necessary. Prison staff respond in accordance with emergency first aid training and receive specific guidance on ligature cutdown in the form of a filmed simulation. This does not include the assessment of injuries and decisions about the immobilisation of neck and spine, which are for paramedics, not for prison/healthcare staff undertaking emergency first aid. Emergency response in prison centres on preserving life; airway, breathing and circulation, e.g. CPR, stemming bleeding, etc. This would be equivalent to emergency response in a community settings and is reflected in Resus UK standards for emergency bags which does not include the provision of soft collars in emergency bags. There is little evidence internationally on the use of a soft collar for spinal immobilisation.
Learning Point 2
We ask the Governor of Chelmsford and HMPPS what arrangements are in place to ensure that all prison staff who may be first on scene in a medical emergency are adequately trained to provide immediate care.
HMPPS Response
HMPPS and NHS England have considered the need for guidance regarding the process of ligature cut down and the inclusion of soft cervical collars in emergency bags, and we do not think either is necessary. Prison staff respond in accordance with emergency first aid training and receive specific guidance on ligature cutdown in the form of a filmed simulation. This does not include the assessment of injuries and decisions about the immobilisation of neck and spine, which are for paramedics, not for prison/healthcare staff undertaking emergency first aid. Emergency response in prison centres on preserving life; airway, breathing and circulation, e.g. CPR, stemming bleeding, etc. This would be equivalent to emergency response in a community settings and is reflected in Resus UK standards for emergency bags which does not include the provision of soft collars in emergency bags. There is little evidence internationally on the use of a soft collar for spinal immobilisation.
Learning Point 3
We recommend that men in prison for the first time should be distinguished as a category of prisoners requiring extra vigilance and support for the first two to four weeks in custody and that HMPPS and the Governor of Chelmsford consider setting this out in policy guidance.
HMPPS Response
HMPPS policies (PSI 07/2015 ‘Early Days in Custody’ and PSI 64/2011 ‘Safer Custody’) are based on the principle that we treat people according to their individual needs, and we do not believe that distinguishing this category of prisoners for differential treatment would be helpful. These policies, and associated guidance including the early days and transitions toolkit and risk identification toolkit, recognise that those in custody for the first time may be at increased risk and/or require additional support. Where this is the case this should be managed through the appropriate process (e.g. ACCT for those identified as being at risk of self-harm or suicide, or key work / peer support for those requiring lower level support) rather than a separate policy that applies only to this cohort.
Learning Point 4
We recommend that the Governor of Chelmsford ensures that, in accordance with PSI 07-2015, a telephone call is offered consistently in reception or on the first night location to all new prisoners, including those subject to harassment measures, that the outcome is documented, and that local policies include these requirements.
HMPPS Response
The Head of Residence at HMP Chelmsford has reminded the managers of the first night centre and reception of the requirement to offer a telephone call to all new prisoners and for this offer to be documented on NOMIS. Whether a phone call has been made/offered to all new prisoners is checked as part of the first night assurance process.
Learning Point 5
We recommend that the facility of a social visit for newly convicted prisoners should apply equally to newly sentenced prisoners who have previously been at liberty on bail.
HMPPS Response
This is existing policy. Newly sentenced prisoners who have previously been at liberty on bail are classed as newly convicted prisoners on arrival at prison and would therefore be offered a social visit within 72 hours of reception.
Learning Point 6
We recommend that HMPPS and the Governor of HMP Chelmsford review current policy and practice to ensure that it is clear that compliance with national and local policies following an incident of serious self-harm does not replace the general duty under PSO 1300 to commission a formal investigation of a serious incident.
HMPPS Response
In July 2019 HMPPS circulated a Senior Leaders Bulletin (SLB) to remind senior managers to consider the circumstances of the incident and the purpose of the investigation before deciding which type of investigation to commission. This was reissued in December 2019. The annex to the SLB, which sets out the four HMPPS policies (including PSO 1300) that provide guidance to prisons about conducting investigations following serious incidents of self-harm or assault, is now available to all staff on the HMPPS intranet. In April 2023 HMPPS circulated a SLB to remind senior managers to consider whether a formal investigation is required in line with PSO 1300 ‘Investigations’ following incidents of serious self-harm and assaults. It set out that where it becomes clear (either immediately, or on completion of the fact-finding template) that an incident has major consequences such as disorder, damage, injury etc or there was serious harm to a person, a formal investigation should be commissioned to allow a broader scrutiny into the facts to gather wider learning, which will result in a more detailed report along the lines set out in annex D of PSO 1300. Additionally, HMPPS has amended the fact-finding report template annexed to PSI 15/2014 ‘Investigating incidents of serious self-harm or assault’ requiring the Governor or the Deputy Governor to sign off the report and to consider whether a formal investigation is required. A new health and injuries section of the template will assist Governors/Directors to consider whether a formal investigation is required in line with PSO 1300 ‘Investigations’. HMP Chelmsford undertakes reviews when an incident of serious self-harm takes place and will consider if a formal investigation is required in accordance with PSO 1300.
Learning Point 6
We draw to the attention of the Governor of HMP Chelmsford deficiencies in the collection, recording and preservation of evidence that we have found in this case.
HMPPS Response
In July 2019 HMPPS circulated a Senior Leaders Bulletin (SLB) to remind senior managers to consider the circumstances of the incident and the purpose of the investigation before deciding which type of investigation to commission. This was reissued in December 2019. The annex to the SLB, which sets out the four HMPPS policies (including PSO 1300) that provide guidance to prisons about conducting investigations following serious incidents of self-harm or assault, is now available to all staff on the HMPPS intranet. In April 2023 HMPPS circulated a SLB to remind senior managers to consider whether a formal investigation is required in line with PSO 1300 ‘Investigations’ following incidents of serious self-harm and assaults. It set out that where it becomes clear (either immediately, or on completion of the fact-finding template) that an incident has major consequences such as disorder, damage, injury etc or there was serious harm to a person, a formal investigation should be commissioned to allow a broader scrutiny into the facts to gather wider learning, which will result in a more detailed report along the lines set out in annex D of PSO 1300. Additionally, HMPPS has amended the fact-finding report template annexed to PSI 15/2014 ‘Investigating incidents of serious self-harm or assault’ requiring the Governor or the Deputy Governor to sign off the report and to consider whether a formal investigation is required. A new health and injuries section of the template will assist Governors/Directors to consider whether a formal investigation is required in line with PSO 1300 ‘Investigations’. HMP Chelmsford undertakes reviews when an incident of serious self-harm takes place and will consider if a formal investigation is required in accordance with PSO 1300.
Learning Point 7
We recommend that an inquiry into an incident of life-threatening self-harm by a prisoner should include an examination of healthcare as well as the actions of the discipline staff and that findings and conclusions should take account of both aspects.
HMPPS Response
In April 2023 HMPPS circulated a SLB to remind senior managers that every effort must be made to ensure that investigations by prisons and healthcare providers to identify learning from serious incidents of self-harm and assault are joined up by sharing relevant information, and that wherever possible, conclusions and recommendations are consistent and jointly owned. HMPPS has updated the fact-finding report template annexed to PSI 15/2014 ‘Investigating incidents of serious self-harm or assault’ to include a section on whether the healthcare provider has conducted an investigation. Where a healthcare investigation has taken place, the fact-finding report should include whether it has highlighted any issues or recommendations that are relevant to the prison/operational workings. At HMP Chelmsford, where investigations are conducted into incidents of serious self-harm, the healthcare provider will be invited to contribute to the process (subject to confidentiality restrictions).
Learning Point 7
We understand that the healthcare agencies have their own structures and systems for reviewing adverse incidents quickly, but we hope that healthcare providers can be encouraged to enable staff to contribute to the investigation by prisons of incidents of serious self-harm, and that there should be arrangements at establishment level for joint consideration by HMPPS and healthcare staff of the findings, lessons and recommendations of reports on serious incidents of self-harm.
HMPPS Response
In April 2023 HMPPS circulated a SLB to remind senior managers that every effort must be made to ensure that investigations by prisons and healthcare providers to identify learning from serious incidents of self-harm and assault are joined up by sharing relevant information, and that wherever possible, conclusions and recommendations are consistent and jointly owned. HMPPS has updated the fact-finding report template annexed to PSI 15/2014 ‘Investigating incidents of serious self-harm or assault’ to include a section on whether the healthcare provider has conducted an investigation. Where a healthcare investigation has taken place, the fact-finding report should include whether it has highlighted any issues or recommendations that are relevant to the prison/operational workings. At HMP Chelmsford, where investigations are conducted into incidents of serious self-harm, the healthcare provider will be invited to contribute to the process (subject to confidentiality restrictions).