WA — HMP Ranby
Serious Self-Harm
18 February 2012
The independent investigation conducted by Barbara Stow into the life-threatening self-harm of WA at HMP Ranby on 18 February 2012 is published. 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 a series of systemic failures in WA's healthcare and management across HMP Lincoln and HMP Ranby, leading to a loss of opportunity for specialist mental health assessment and a failure to identify his vulnerabilities. Key issues included inadequate information transfer during his prison transfer, insufficient healthcare screening and follow-up at Ranby, and a lack of adherence to risk assessment policies. While the self-harm incident itself was not immediately foreseeable by staff, these cumulative failings in continuity of care and engagement likely contributed to the tragic outcome.
Learning Points (8)
Learning Point 1
I recommend that, those responsible for healthcare governance at HMP Lincoln and HMP Ranby: identify the requirements of good practice in the specific areas identified below, in the light of the problems that occurred in this case and taking account of NHS and NOMS policies; review their current arrangements and amend them if necessary to meet the requirements of good practice; check that effective processes are in place to ensure common expectations and compliance by all staff who undertake these procedures, including any temporary staff. At Lincoln, the areas for review are: (a) making and monitoring referrals for assessment for NHS mental health units (b) considering the circumstances in which to flag a patient for ‘clinical hold’ (c) the scope of the assessment of fitness for transfer and the process to be followed (d) handing over significant information to healthcare staff at the receiving prison when a patient is transferred, with particular but not exclusive reference to patients of the primary and secondary mental health teams. At Ranby, the areas for review are: (a) ensuring that healthcare screening in reception is always undertaken by clinically qualified staff (b) defining requirements for the scope of the reception screening (c) ensuring that all prisoners receive a full healthcare assessment by a qualified physician, including review of previous history, within 72 hours of admission as recommended by HMCIP (d) defining requirements for the assessment and review of prisoners in segregation
Learning Point 2
I recommend that NHS England and NOMS: take note of the findings in Chapter 11, and consider jointly in the light of this investigation whether the lessons of this investigation have a wider application; in particular, that they consider whether they are satisfied that adequate arrangements are now in place to ensure that consistent standards of delivery are achieved by diverse healthcare providers throughout the prison estate in the following areas: (a) continuity of care when prisoners are transferred between establishments, including the transfer of records, guidance on ‘clinical hold’, and the circumstances in which summary written or oral handover is required; (b) induction of healthcare staff, including temporary staff, so that they are familiar with the protocols and standards that govern procedures in prison that do not apply in community settings: particular areas are reception, segregation, administration of medication, and the identification of, and support for, prisoners at risk of self-harm.
Learning Point 3
I recommend that the Governor of HMP Ranby establishes: that the prison’s current practice complies with the requirement to check the OASys risk assessment of newly admitted prisoners and to inform their location of any identified risk of harm to self or others; and that residential staff at Ranby are made aware of what is expected of them when sentence management staff notify them that low, medium or high risks of self-harm have been recorded in an OASys assessment.
Learning Point 4
I recommend that NOMS look into whether the requirement for early checking of OASys assessments for new prisoners is consistently observed in other prisons and consider whether further measures are necessary to ensure that the system is used and understood.
Learning Point 5
I recommend that the Governor of HMP Ranby is asked: to note the absence of case notes or other evidence of constructive engagement with WA; to consider what practical arrangements are now in place at Ranby to cultivate positive interaction between staff and prisoners and whether more can be done; and to report to NOMS accordingly.
Learning Point 6
I recommend that NOMS checks whether provision and deployment of first aid staff and equipment at Ranby are now at an acceptable level.
Learning Point 7
I recommend that NOMS reviews the guidance to establishments about action following life-threatening incidents of self-harm to ensure that it makes clear that evidence must be preserved.
Learning Point 8
I recommend to NOMS that: An inquiry into an incident of life-threatening self-harm should always include an examination of healthcare as well as the actions of the discipline staff. Findings and conclusions should take account of both aspects considered jointly.