Christine McDonald

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Ms Christine
McDonald, a prisoner at HMP
Styal, on 3 March 2019
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to
any cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Ms Christine McDonald died in hospital on 3 March 2019. She had been found hanging in
her cell at HMP Styal the day before. Ms McDonald was 55 years old. I offer my
condolences to her family and friends.
Ms McDonald was at Styal for just over 24 hours. She had several factors which increased
her risk to herself when she arrived. I am concerned that staff did not sufficiently consider
these risk factors.
Ms McDonald was withdrawing from drugs. This was not appropriately managed. She
was not observed in line with policy, she was not appropriately assessed when she
returned from hospital; and significant interactions with her were not always recorded.
I am also concerned that staff did not use the correct emergency code when they found
Ms McDonald, resulting in a delay in calling the ambulance.
Ms McDonald is the third woman to die in the first night centre at Styal since February
2018. I have repeated our previous concerns that, apart from when nurses visited to give
medication three times a day, there was no healthcare presence in the first night centre
and it was staffed by prison officers who had no specialist training in the management of
prisoners who are withdrawing from drugs. I have escalated these concerns to the Prison
Group Director for women’s prisons.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister, CB
Prisons and Probation Ombudsman March 2020
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 8
Findings ........................................................................................................................... 8
Summary
Events
1. On 1 March 2019, Ms Christine McDonald was sentenced to 12 weeks
imprisonment and taken to HMP Styal. She had witnessed her child falling from a
third-floor window earlier that day and was concerned about her.
2. Ms McDonald told an officer and nurse that she was withdrawing from drugs.
However, as she could not provide a urine sample, they were unable to prescribe
her methadone. She said she had no thoughts of suicide or self-harm. She asked
staff what had happened to her child.
3. The next day, Ms McDonald continued to suffer apparent withdrawal symptoms.
She was still unable to provide a urine sample. Nurses were concerned about her
symptoms and behaviour and continued high pulse rate. They arranged for her to
be taken to hospital for assessment. Officers escorted Ms McDonald to hospital but
she discharged herself and returned to the prison.
4. One of Ms McDonald’s children telephoned the prison that evening and told the
Orderly Officer that Ms McDonald’s other child, who she had seen falling, had
serious injuries but was stable. The Orderly Officer agreed to tell Ms McDonald but
did not do so immediately as he had other duties.
5. At 10.30pm, an officer support grade (OSG) spoke to Ms McDonald in her cell. He
said had no concerns about her. Other prisoners said that they heard Ms
McDonald screaming that night and expressing concern about her child.
6. At 11.07pm, the Orderly Officer and the OSG went to Ms McDonald’s cell to tell her
that her child was stable. They found that Ms McDonald was hanging from her
observation panel. They requested medical assistance and went into the cell.
Nurses arrived within seconds and tried to resuscitate Ms McDonald. She was
taken to hospital but died at 5.06pm the next day.
Findings
Assessment of risk
7. Ms McDonald had several risk factors for suicide and self-harm when she arrived at
Styal. We are concerned that in assessing Ms McDonald’s risk to herself, staff did
not consider all these factors but relied on her assurances that she had no thoughts
of harming herself.
8. We accept that the Orderly Officer had not been told that Ms McDonald was in
distress. Nevertheless, we think he should have appreciated how anxious Ms
McDonald be would naturally about her daughter and should either have prioritised
telling her himself or should have asked someone else to tell her as soon as
possible.
Prisons and Probation Ombudsman 1
Clinical care
9. Ms McDonald’s physical and substance misuse healthcare was not equivalent to
that which she could have expected to receive in the community. Healthcare staff
did not consider information from Ms McDonald’s person escort record (PER).
Nurses did not record all significant interactions they had with Ms McDonald. When
Ms McDonald returned from hospital after discharging herself against medical
advice, healthcare staff did not assess her. We are also concerned that healthcare
staff did not monitor Ms McDonald’s drug withdrawal symptoms appropriately.
10. Ms McDonald is one of three women to die in the first night centre at Styal since
February 2018. We are concerned that, apart from when nurses visited to give
medication three times a day, there was no healthcare presence in the first night
centre and it was staffed by prison officers who had no specialist training in the
management of prisoners who are withdrawing from drugs.
Emergency response
11. Staff did not use the appropriate emergency code when they found Ms McDonald
hanging. While this, by chance, did not lead to a delay in nurses attending, it did
lead to a delay in calling an ambulance. We found that staff were generally unclear
about the emergency codes used at Styal.
Recommendations
• The Governor and Head of Healthcare should ensure that reception staff:
• have a clear understanding of their responsibilities and the need to
share all relevant information about risk;
• do not rely solely on what a prisoner says or how they appear but
consider and record all the known risk factors of a newly arrived
prisoner when determining the risk of suicide and self-harm; and
• open ACCT procedures when indicated.
• The Governor and Head of Healthcare should ensure that nurses conducting
reception health screenings always have access to the PER.
• The Head of Healthcare should ensure that the clinical record is an accurate
reflection of significant interactions between staff and prisoners.
• The Governor and Head of Healthcare should ensure that:
• healthcare staff assess prisoners in reception when they return from
hospital; and
• there is effective written communication of clinical risks and health
needs of prisoners returning from hospital and a formal discharge
summary informs their care.
• The Governor and Head of Healthcare should ensure that all prisoners arriving
with or developing signs of drug or alcohol withdrawal are regularly monitored,
including clinical observations overnight and during the day, until they are stable.
2 Prisons and Probation Ombudsman
• The Prison Group Director for women’s prisons should write to the Ombudsman
setting out what he has done to satisfy himself that there is sufficient healthcare
presence in the first night centre; that prison staff working in the first night centre
have been adequately trained in the management of prisoners withdrawing from
drugs and alcohol; and that steps are being taken to ensure that staff do not
become desensitised to residents’ distress.
• The Governor should ensure that all prison staff are made aware of and
understand their responsibilities during medical emergencies, in particular that
staff efficiently communicate the nature of a medical emergency using the
appropriate code.
• The Head of Healthcare should share this report with healthcare staff named in it
and discuss its findings with them.
• The Governor should ensure that this report is shared with a CM and a OSG and
that a senior manager discusses our findings with them.
Prisons and Probation Ombudsman 3
The Investigation Process
12. The investigator issued notices to staff and prisoners at HMP Styal informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
13. The investigator visited Styal on 5 March. She obtained copies of relevant extracts
from Ms McDonald’s prison and medical records.
14. The investigator interviewed 16 members of staff and 4 prisoners at Styal in March
and April.
15. NHS England commissioned a clinical reviewer to review Ms McDonald’s clinical
care at the prison. The clinical reviewer conducted joint interviews with the
investigator.
16. We informed HM Coroner for Cheshire, Halton and Warrington of the investigation
who gave us the results of the post-mortem examination. We have sent the coroner
a copy of this report.
17. One of the Ombudsman’s family liaison officers contacted Ms McDonald’s next of
kin, to explain the investigation and to ask if she had any matters she wanted the
investigation to consider. She asked:
• Who assessed Ms McDonald when she arrived at Styal?
• Was Ms McDonald prescribed methadone at Styal?
• What happened when Ms McDonald was taken to hospital on 2 March? Was
she told anything that heightened her risk to herself?
• What physical healthcare did Ms McDonald receive when she returned to
prison from hospital?
• What was Mc McDonald’s mood like on 2 March? Did she have contact with
other prisoners?
• Did she press her cell bell before the officer spoke to Ms McDonald at
10.30pm on 2 March? What did they talk about?
• How did Ms McDonald take her own life?
• Why did it take the custodial manager three hours to relay a message to Ms
McDonald about her other child?
18. We have addressed these questions in this report.
19. Ms McDonald’s family received a copy of the draft report. The solicitor representing
Ms McDonald provided evidence of the time Ms McDonald’s next of kin telephoned
the prison. The report has been amended accordingly. They also raised a number
of questions that do not impact on the factual accuracy of this report. We have
provided clarification by way of separate correspondence to the solicitor.
4 Prisons and Probation Ombudsman
20. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is annexed to this
report.
Prisons and Probation Ombudsman 5
Background Information
HMP Styal
21. HMP Styal holds up to 486 women. There are a variety of residential units, with 16
separate houses holding about 20 women, and a mother and baby unit.
22. Spectrum Community Health runs healthcare services at the prison. Greater
Manchester West Mental Health NHS Foundation Trust provides mental health
services. There are nurses on duty at all times with one registered nurse and a
health support worker available at night. GP sessions are held every day except
Sundays, when there is an out of hours service. There is no inpatient facility.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Styal was in May 2018. Inspectors reported
that women were well cared for when they arrived at Styal and induction was
thorough. Prisoners stayed on the first night centre for 48 hours before moving
elsewhere in the prison. They found that the management of prisoners on ACCTs
was good. The availability of illicit substances was high and over 50% of women
said they had a drug problem on arrival. However, inspectors found that the supply
reduction strategy was practical, well informed and focussed on supporting women,
alongside preventative measures.
24. Inspectors found that new arrivals with substance misuse issues were promptly
identified, received appropriate medication and were referred for psychosocial
support. However, they found that during the first five days of drug detoxification,
daytime monitoring was inconsistent and there was no routine night-time monitoring
which created significant risks for those prisoners.
Independent Monitoring Board
25. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to April 2018, the IMB reported that
appropriate care and support was given to new prisoners in reception and the first
night centre. They found that ACCT procedures were generally being used
effectively.
Previous deaths at HMP Styal
26. Ms McDonald’s death is the fifth death to occur at Styal since 2016. Two of these
previous deaths were self-inflicted, one was due to natural causes and in one the
cause of death was unascertained. There has been a further self-inflicted death
since that of Ms McDonald. Three of these deaths have occurred in the first night
centre.
27. Our previous investigations have raised issues about assessing a prisoner’s risk to
themselves, use of emergency codes and the presence of healthcare staff in the
first night centre. It is troubling to be raising these issues once more.
6 Prisons and Probation Ombudsman
Assessment, Care in Custody and Teamwork (ACCT)
28. ACCT is the care planning system the Prison Service uses to support prisoners at
risk of suicide or self-harm. The purpose of the ACCT is to try to determine the
level of risk posed, the steps that staff might take to reduce this and the extent to
which staff need to monitor and supervise the prisoner. Checks should be made at
irregular intervals to prevent the prisoner anticipating when they will occur. Part of
the ACCT process involves assessing immediate needs and drawing up a caremap
to identify the prisoner’s most urgent issues and how they will be met. Staff should
hold regular multidisciplinary reviews and should not close the ACCT plan until all
the actions of the caremap are completed. Guidance on ACCT procedures is set
out in Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of
harm to self, to others and from others (Safer Custody).
Prisons and Probation Ombudsman 7
Key Events
29. Ms Christine McDonald had previously served short sentences in prison, most
recently in 2014. In 2014, Ms McDonald told a prison nurse that she had previously
self-harmed and had taken an overdose four years ago. She also had thoughts of
taking her own life and was subject to Prison Service suicide and self-harm
prevention procedures, known as ACCT, for a short time. She was treated for
depression by her GP in the community. In 2018, Ms McDonald was referred to the
community mental health team but did not attend appointments and was discharged
from the service.
1 March 2019
30. On 1 March 2019, Ms McDonald was arrested and sentenced to 12 weeks
imprisonment for an offence of shoplifting and taken to HMP Styal. When she was
arrested she was with one of her children who had tried to escape through a third-
floor window and fallen to the ground. Ms McDonald had witnessed this and had
seen her child being treated by ambulance staff before she was taken away by the
police.
31. Ms McDonald arrived at Styal at 6.30pm. An officer interviewed her in reception.
Ms McDonald declined a telephone call as she said she did not have any telephone
numbers with her. She told the officer that she had no current or previous thoughts
of suicide or self-harm. The officer noted that Ms McDonald seemed “quite tired”
and was detoxing from drugs. She recorded that Ms McDonald was concerned
about her child, as she did not know what had happened to her. The officer
telephoned the local hospital, but Ms McDonald’s child had not been admitted there.
32. At 7.35pm, Ms McDonald moved to the first night centre. Her person escort record
noted no risks of suicide or self-harm. At 8.50pm, a nurse assessed Ms McDonald.
She told the nurse that she used heroin and amphetamines in the community. The
nurse noted that Ms McDonald was anxious, irritable and appeared tired. She
scored 13 on the clinical opiate withdrawal scale (COWS) which indicated that she
was suffering from moderate withdrawal symptoms. Ms McDonald’s pulse was
abnormally high, at 130 beats per minute. The nurse was concerned about this and
told the investigator that she asked night staff to check this again. Ms McDonald
told the nurse that she had no history of attempting suicide or self-harm. The nurse
told the investigator that she had no concerns Ms McDonald was a risk to herself.
33. Ms McDonald was unable to provide a urine sample. As a result, the nurse could
not prescribe methadone in line with Ms McDonald’s wishes. (Both national and
local policy require that a prisoner must test positive for opiates before being
prescribed methadone, otherwise there is a risk of opiate overdose.) The nurse
prescribed symptomatic relief: ibuprofen, loperamide (to counteract diarrhoea),
mebeverine (to counteract gut spasms), metoclopramide (to lessen nausea),
paracetamol and quinine sulphate (to lessen muscle cramps).
34. An officer saw Ms McDonald shortly afterwards in her cell. The officer said that Ms
McDonald was not happy that she could not provide a sample and therefore get the
medication that she wanted. The officer told the investigator that she thought Ms
McDonald had symptoms of drug withdrawal. Ms McDonald told the officer that she
8 Prisons and Probation Ombudsman
was worried about her child and staff tried, unsuccessfully, to find out which hospital
she had been taken to.
35. Later that evening, Ms McDonald told an officer that she was concerned about her
child. She said she had no thoughts of suicide or self-harm. During the medication
rounds, the officer went to Ms McDonald’s cell and asked if she had been
prescribed any medication. She said that Ms McDonald was making sounds as if
she was in significant pain, groaning and clutching her stomach. Ms McDonald said
she could not get downstairs to get any pain relief (where the nurse was located.)
The officer therefore asked the nurse to go to Ms McDonald’s cell and assess her
when she had finished giving other prisoners their medication.
36. A nurse went to see Ms McDonald. She told the clinical reviewer that she took Ms
McDonald’s clinical observations, including blood pressure, heart rate, temperature,
assessed her using the COWS tool and asked Ms McDonald about her withdrawal
symptoms. She said Ms McDonald told her that she had stomach ache and was
still unable to provide a urine sample. She did not record this information but the
officer also recalled her assessing Ms McDonald. The only entry from the nurse in
the medical record is at 11.59pm when she gave Ms McDonald her prescribed
medication to assist in alleviating her withdrawal symptoms.
37. An Officer Support Grade (OSG) observed Ms McDonald hourly between 9.00pm
and 7.00am, as was standard with all prisoners on their first night. He said that Ms
McDonald was either awake and talking to her cellmate or asleep. The OSG told
the investigator that he had no concerns about Ms McDonald.
38. Prisoners told the investigator that Ms McDonald was suffering severe withdrawal
symptoms when she arrived at Styal. They said that Ms McDonald could not drink
water because she was too nauseous and was concerned she could not provide a
urine sample. Prisoners said that she had hot and cold sweats, stomach ache,
aching legs and was vomiting. They tried to assist her by taking it in turns to sit with
her, talk to her, reassure her and make her cups of tea. Prisoners said that Ms
McDonald was also very concerned about her child’s welfare. One prisoner told the
investigator that Ms McDonald had told her, “I don’t feel like living.”
39. Ms McDonald’s shared a cell. Her cellmate said that Ms McDonald managed to eat
a little food and drank tea. She also tried to comfort and assist Ms McDonald.
Some prisoners said that after she was locked in her cell, Ms McDonald banged on
her cell door until the early hours of the following morning, shouting that she needed
her medication. Prisoners also said that she pressed her cell bell. (No electronic
records of cell bells are kept at Styal.) They said that staff responded by telling Ms
McDonald that they could not give her methadone and that she should go to sleep.
2 March
40. On 2 March, a member of the chaplaincy team spoke to Ms McDonald in the
morning. She told them that she was concerned about her child. They said they
would contact the local hospital to try and find out details of her child’s condition.
41. Her cellmate said that Ms McDonald did not want to speak other people that
morning because of her withdrawal symptoms. She said they made some toast and
ate breakfast together but that Ms McDonald seemed “really weak”.
Prisons and Probation Ombudsman 9
42. At 11.10am, a nurse assessed Ms McDonald for her secondary healthscreen. The
nurse told the investigator that Ms McDonald came into her office wearing her coat
even though it was not very cold. Her heart rate and blood pressure were both very
high. She noted that Ms McDonald appeared “quite lethargic”. Ms McDonald was
still unable to provide a urine sample. She noted that Ms McDonald appeared to
become increasingly confused and disoriented during their assessment. The nurse
took Ms McDonald up to her cell and helped her into bed, as she was unsteady.
Her skin indicated that she was dehydrated. The nurse encouraged Ms McDonald
to drink two glasses of water.
43. The nurse told the investigator that Ms McDonald returned to the office about 30
minutes later, presenting very differently, more alert, less unsteady and said she
wanted to provide a urine sample. She was then unable to do so and again
became unsteady. She told the investigator that Ms McDonald did not complain of
any withdrawal symptoms from drugs.
44. The nurse said that she was concerned that there was “something not right” and
spoke to another nurse for a second opinion. Both nurses went to see Ms
McDonald. A nurse told the investigator that Ms McDonald’s presentation
fluctuated between lethargic and unsteady with slurred speech, to more alert. The
nurse did not think that the symptoms were typical of a prisoner withdrawing from
drugs or who had used illicit drugs.
45. Since Ms McDonald’s pulse remained high, the nurses decided to do an ECG
(electrocardiogram – to check the heart’s electrical activity). The service which
interprets prisoners’ ECGs was unable to do so due to Ms McDonald’s high heart
rate and advised that Ms McDonald needed to go to hospital for assessment (since
there was no doctor in the prison as it was the weekend). They confirmed that she
could go by taxi rather than ambulance.
46. All new prisoners at Styal have a mental health assessment within 24 hours of
arriving. At 12.30pm, a nurse wrote up her notes from assessing Ms McDonald that
morning. The nurse had seen Ms McDonald in her cell since she had told her that
she was withdrawing from drugs and wanted to stay in bed. The nurse said that
she did not witness any physical withdrawal symptoms herself. Ms McDonald said
that she suffered from low mood but had not sought assistance with this in the past.
She said she did not like using drugs or the associated lifestyle and she thought
drugs would kill her. She said she had no current or past thoughts of suicide. She
said she was worried about her child who she thought would be going to prison in
the next few days. She said she wanted to engage with the mental health team.
The nurse noted that she would refer her to a Psychology Wellbeing Practitioner to
speak about her low mood.
47. Two officers escorted Ms McDonald to hospital. A nurse gave an officer a letter
outlining her concerns about Ms McDonald to give to hospital staff. She also
outlined her concerns to the officers. An officer told police that Ms McDonald was
unsteady and said she was struggling to breathe. Ms McDonald was handcuffed by
a single handcuff to an officer and, at 1.00pm, they left the prison in a taxi.
48. An officer told police that Ms McDonald was “agitated” and appeared as though she
was withdrawing from drugs. He said that she was jerking her legs and “hunching
over as though she had stomach pain”. An officer told police that she seemed to be
10 Prisons and Probation Ombudsman
“in serious distress”, was shaking, in pain and could not stay still. While waiting to
be assessed at the hospital, Ms McDonald told the officers that she had been in
hospital a few weeks before due to heart problems.
49. At 2.15pm, escorting staff noted that hospital staff said Ms McDonald’s blood
pressure was normal but her pulse was high. She needed to have a blood test but
she became fidgety while waiting for this to happen and repeatedly asked staff to
take her back to Styal. The officers tried to persuade her that it was in her best
interests to stay at the hospital to be properly assessed. At 3.00pm, escorting staff
noted that hospital staff said Ms McDonald’s ECG was high. The officers had also
disclosed Ms McDonald’s recent hospital stay to medical staff. At 3.15pm, Ms
McDonald discharged herself from hospital against medical advice. As she left the
hospital, an officer said that she told the nurses that she could get methadone at
prison. On the way back to the prison, an officer told the police that she continued
to be in distress.
50. At 4.35pm, Ms McDonald’s cellmate was taken to hospital. Ms McDonald returned
to the prison at 5.30pm. A nurse received a document with her abnormal ECG but
did not see Ms McDonald herself. The nurse recorded this in her medical record
along with a note that staff should obtain her heart rate later. The nurse did not
receive Ms McDonald’s hospital discharge summary. Despite requests, the
investigator has also not been able to obtain a copy. An officer said that the nurse
asked him to take Ms McDonald to her office, which he did and handed her over to
nursing staff there. No nurses the investigator spoke to said they had seen Ms
McDonald on her reception to the prison.
51. An officer unlocked Ms McDonald for her medication at 7.45pm. She had a urine
sample in a cup. A nurse was issuing medication that evening and explained she
could not accept the urine sample as Ms McDonald had to provide the sample in a
nurse’s presence to prove it was her own. Ms McDonald was unhappy about this
and left the medication hatch without taking any of her other medication. The nurse
told the investigator that Ms McDonald seemed “fine” and she had told her that if
she felt unwell to let staff know. The nurse sent an electronic message to
healthcare administration for them to make an appointment for Ms McDonald with a
GP or Advanced Nurse Practitioner (ANP).
52. Ms McDonald returned to her cell - which she was in on her own as her cellmate
had not returned – and an officer locked her in. Ms McDonald started banging her
observation flap around five minutes later, so the officer returned upstairs and Ms
McDonald told her she was annoyed that healthcare staff had not accepted her
sample. The officer reiterated the reasons why, spoke to her for a few minutes and
then left the cell. She said had no concerns that Ms McDonald was a risk to herself
and she did not observe that Ms McDonald was suffering from any physical
withdrawal symptoms.
53. The nurse told the investigator that before she finished her shift at 9.00pm, she
gave a handover to the night healthcare staff that Ms McDonald had been to
hospital, had a high heart rate and had self-discharged. She asked the nurses to
monitor Ms McDonald and expected they would go and see her. A Healthcare
Assistant told the investigator that she was aware that Ms McDonald had been out
to hospital but said that no concerns were passed to her.
Prisons and Probation Ombudsman 11
54. An Officer Support Grade (OSG) started working in the first night centre at 8.15pm
that evening. He visited all prisoners on the unit. When he got to Ms McDonald’s
cell, he said that the observation panel was shut and locked, as it should have
been. He said Ms McDonald was sitting in bed, with the light on in the cell. He told
the investigator that he asked how she was and she replied, “Fine, thank you boss.”
The OSG said that he had no concerns about her and she seemed “friendly” and
“content”.
55. A Custodial Manager (CM) was the Orderly Officer in charge of the prison that
night. During his handover, another CM told him that Ms McDonald had been to
hospital and had an irregular heartbeat but had discharged herself from hospital.
He said he passed this information on to the OSG. When asked by the investigator,
the OSG did not recall this handover.
56. One of Ms McDonald’s children telephoned the prison at 8.26pm and spoke to a
CM. (The CM thought it was later than this but the investigator has since received
Ms McDonald’s next of kin telephone records confirming the time of the call.) She
said that Ms McDonald’s other child who had fallen from the window was stable but
had injuries to her back, shoulder and pelvis. The CM told Ms McDonald’s next of
kin that he could not confirm whether Ms McDonald was at the prison but that if she
was, he would pass on the news and would ask Ms McDonald to call her back
tomorrow.
57. At 8.40pm, an officer heard banging coming from the cells upstairs (where Ms
McDonald was located). She went upstairs and spoke to Ms McDonald whose
observation panel was open. CCTV shows the panel had been opened a few
seconds earlier. (The police have since found that the panel was faulty and,
although appearing locked, could still be opened from the inside.) The officer told
the investigator that Ms McDonald said she was “fine” when she asked how she
was, and that she had no concerns about her.
58. A CM went to the first night centre at 9.50pm where he spoke with the OSG. He
intended to pass on the message he had received for Ms McDonald but said he
was then called away to check the key safe which took around 20 minutes and was
an urgent task.
59. The OSG returned to Ms McDonald’s corridor around 10.30pm, as it was a stormy
night and he heard things rattling. He saw that Ms McDonald’s light was on and
spoke to her through the viewing window. He told the investigator that she was
sitting up in bed and he asked her, “Are you okay? Aren’t you tired?” and that she
replied, “Alright boss, thank you”. The observation panel remained closed. The
OSG said he suggested that Ms McDonald have a cup of tea and watch some
television. CCTV shows that he spoke to Ms McDonald for around one minute.
60. A prisoner in a neighbouring cell, said that Ms McDonald was suffering severe
withdrawal symptoms that evening. She said she kept screaming and she assumed
Ms McDonald was pressing her cell bell as an officer kept coming to talk to her.
She said she heard the officer who responded tell her to “have a cup of tea and get
her head down”. She said that the officer was dismissive of her symptoms. She
said shortly after the officer had gone, Ms McDonald shouted that she was going to
kill herself. She said shortly after this Ms McDonald stopped banging on her cell
door and shouting.
12 Prisons and Probation Ombudsman
61. A prisoner also thought that the OSG was a bit abrupt but said that in general staff
were trying to support Ms McDonald. She said she heard Ms McDonald shout that
she was going to kill herself as she could not cope anymore, did not know where
her child was, felt helpless and would be better off dead. She shouted to her to try
to reassure her.
62. A CM returned to the first night centre at around 10.35pm. The OSG told him that
he had just spoken to Ms McDonald and had no concerns about her. At 10.38pm,
CCTV shows Ms McDonald’s observation panel opening and her arm can be seen
coming out through the panel. The panel remained open from this point.
63. The CM asked the OSG when he would next be checking prisoners, as he did not
want to disturb them further. He said he would be doing so at 11.00pm and The
CM said he would accompany him as he had some news for Ms McDonald. He told
the investigator that he would have gone to see Ms McDonald straight away if he
had thought that she was distressed. The CM and the OSG went to Ms McDonald’s
cell at 11.07pm (according to CCTV). The OSG noticed that the observation panel
was open which he thought was strange as he had not opened the hatch when he
last spoke to Ms McDonald.
64. The CM looked into Ms McDonald’s cell through the observation panel. He thought
Ms McDonald was sitting behind the door. He told her about her daughter’s
condition but she did not reply and he said to the OSG, “Something’s not right.” He
then looked into the cell more carefully and noticed there was a ligature (a pair of
leggings) tied around Ms McDonald’s neck and secured to the observation panel.
He had not noticed this initially as the leggings were the same colour as the
observation panel.
65. The CM cut the ligature using his anti-ligature knife. He told the OSG to get prison
and healthcare staff. The OSG radioed for healthcare staff to attend the first night
centre. The CM unlocked the door and, after some difficulty getting into the room,
as Ms McDonald was slumped against the door, both staff went in. CCTV shows
this was around two and a half minutes after they first got to the cell. The CM laid
Ms McDonald flat on the floor and checked for signs of life.
66. A nurse and a healthcare assistant were together on their way to another part of the
prison when they received the OSG’s message to go to the first night centre. They
went there first, by chance, as it was closer than where they had been heading.
When they got to the cell (20 seconds after the officers had gone in) and realised
the nature of the emergency, the nurse told the healthcare assistant to get the
emergency equipment from the office. The nurse checked for signs of life and they
moved Ms McDonald to the corridor where there was more room. The nurse asked
staff to request an ambulance and get a defibrillator. She started chest
compressions. The OSG radioed for an ambulance to be requested. Staff in the
communications room immediately telephoned an ambulance. The healthcare
assistant went to get the defibrillator. Other staff arrived to assist.
67. The healthcare assistant returned to the cell with the emergency equipment.
Nurses inserted an airway and administered oxygen while officers continued chest
compressions. They attached the defibrillator and followed its instructions.
Paramedics got to Ms McDonald’s cell at 11.27pm and took over her care. They
obtained a pulse and blood pressure.
Prisons and Probation Ombudsman 13
3 March
68. On 3 March, at 12.10am, paramedics took Ms McDonald to hospital in an
ambulance. She was admitted in a critical condition. At 2.00am, an officer, one of
the escorting staff, noted that hospital staff had asked that Ms McDonald’s next of
kin be informed of her condition. She informed the CM.
69. At 2.10am, the CM telephoned Ms McDonald’s child whom he had spoken to earlier
but there was no reply. At 7.00am, staff contacted the police trying to find out which
hospital Ms McDonald’s other child was in. At 8.40am, staff obtained a number for
another of Ms McDonald’s children and telephoned her but there was no reply. At
10.15am, staff spoke to Ms McDonald’s next of kin but the telephone line was
unclear and she said she would call back. The Duty Governor, and a CM went to
her home address, broke the news of her mother’s condition and took her to the
hospital. At 1.40pm, Ms McDonald’s other children and sister arrived at the
hospital. Ms McDonald died at 5.06pm, with her family present.
Support for prisoners and staff
70. After Ms McDonald’s death, the Duty Governor, debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
71. During the debrief, the OSG said that Ms McDonald had asked to see a nurse that
night and he had said he would contact the nurse and ask her to come over when
she was free. When asked about this, the OSG told the investigator that he could
not remember Ms McDonald asking to see a nurse but that he did not contact one
as he would have waited to speak to them when they came to the first night centre
to administer medication between 10.30pm and 11.00pm.
72. Most staff felt well supported following Ms McDonald’s death, except for a CM who
would have liked more support from the senior management team.
73. Staff personally told prisoners in the first night centre that Ms McDonald had died.
Prisoners said they had felt well supported. The prison also posted notices
informing other prisoners of Ms McDonald’s death, and offering support. Staff
reviewed all prisoners assessed as being at risk of suicide or self-harm in case they
had been adversely affected by Ms McDonald’s death.
Post-mortem report
74. The post-mortem examination concluded that Ms McDonald died due to hypoxic
ischaemic brain injury (caused by a lack of oxygen to the brain), which was caused
by a cardiac arrest as a result of Ms McDonald hanging herself.
75. Toxicology results showed evidence of amphetamine and heroin use. The
pathologist said that, while this may have influenced her mental state, it did not
directly contribute to Ms McDonald’s death.
14 Prisons and Probation Ombudsman
Findings
Assessment of risk
76. Prison Service Instruction (PSI) 64/2011, Safer Custody, which governs ACCT
suicide and self-harm prevention procedures, requires all staff who have contact
with prisoners to be aware of the risk factors and triggers that might increase the
risk of suicide and self-harm and take appropriate action. Any prisoner identified as
being at risk of suicide or self-harm must be managed under ACCT procedures.
We have considered whether staff at Styal should have recognised Ms McDonald
as being at risk and begun ACCT procedures to support her.
77. Ms McDonald had some risk factors for suicide and self-harm when she arrived at
Styal. She had a history of mental health issues, said she suffered from low mood,
had a history of drug misuse and was currently withdrawing from drugs. In 2014,
she had taken an overdose and considered suicide and self-harm.
78. We recognise that many women arrive at Styal with similar risk factors and that it is
not necessary or desirable to manage them all under the ACCT process. However,
Ms McDonald had an additional significant risk factor: she was very concerned
about the welfare of her child who she had seen fall out of a third-floor window. This
was, not surprisingly a significant issue for Ms McDonald. She asked staff about her
child in reception and again when she arrived in the first night centre, and she
raised her concerns again the following morning with a chaplain and with a nurse.
She also shared her concerns about her child with other prisoners. We are
concerned that staff paid insufficient attention to this.
79. Staff judgement is fundamental to suicide and self-harm prevention, and relies on
their using their experience and skills, as well as local and national assessment
tools, to determine risk. We are concerned that in assessing Ms McDonald’s risk to
herself, staff did not consider all the risk factors involved but relied on Ms
McDonald’s assurances that she had no thoughts of this nature. Although we
cannot say that staff should definitely have begun ACCT procedures, this was a
finely balanced decision that should have taken account of all the risk factors,
including her concerns about her child. We have not seen any evidence that this
occurred. We make the following recommendation:
The Governor and Head of Healthcare should ensure that reception staff:
• have a clear understanding of their responsibilities and the need to
share all relevant information about risk;
• do not rely solely on what a prisoner says or how they appear but
consider and record all the known risk factors of a newly arrived
prisoner when determining the risk of suicide and self-harm; and
• open ACCT procedures when indicated.
Prisons and Probation Ombudsman 15
Clinical care
80. The clinical reviewer concluded that the decision not to prescribe methadone was in
line with both national substance misuse guidance and local policy with one
exception: that if a specialist substance misuse doctor had been available when Ms
McDonald had arrived they may have prescribed a low dose of methadone based
on their clinical judgement. In the circumstances, the decision not to prescribe
methadone was the safest decision.
81. However, the clinical reviewer found that other aspects of Ms McDonald’s physical
and substance misuse healthcare were not equivalent to what she could have
expected to receive in the community.
82. Nurses told the investigator that when they assess a prisoner arriving at Styal they
do not have access to their PER. This contains vital information about a prisoner’s
risk to themselves and others, along with healthcare and substance misuse issues.
The Head of Healthcare said that she would expect staff to have access to this
information. We make the following recommendation:
The Governor and Head of Healthcare should ensure that nurses conducting
reception health screenings always have access to the PER.
83. We are concerned that some significant interactions between healthcare staff and
Ms McDonald were not appropriately recorded. When a nurse assessed Ms
McDonald on the evening of 1 March following staff concerns, she did not document
the observations that she took, only that she had given Ms McDonald her
prescribed medication. When the nurse was unable to accept Ms McDonald’s urine
sample on 2 March, Ms McDonald left without taking her prescribed medication.
This incident was not adequately documented. We make the following
recommendation:
The Head of Healthcare should ensure that the clinical record is an accurate
reflection of significant interactions between staff and prisoners.
84. A nurse told the investigator that when a prisoner returns from hospital, healthcare
staff should assess them. The nurse said that rarely happened as nurses were
often unaware they had returned. However, the officers who escorted Ms
McDonald back from hospital said that they spoke to the nurse on their return.
Despite this, no one assessed Ms McDonald when she returned to the prison. This
was a missed opportunity to assess Ms McDonald’s overall health, withdrawal
symptoms and mood, particularly as she had discharged herself from hospital with
a raised heart rate against medical advice. We make the following
recommendation:
The Governor and Head of Healthcare should ensure that:
• healthcare staff assess prisoners in reception when they return from
hospital; and
• there is effective written communication of clinical risks and health
needs of prisoners returning from hospital and a formal discharge
summary informs their care.
16 Prisons and Probation Ombudsman
85. We are also concerned that Ms McDonald was not adequately monitored for her
withdrawal from drugs. Apart from her initial and secondary healthcare screening on
1 March and 2 March, there were no healthcare observations or assessments noted
in her clinical record. The nurse did assess her on the evening of 1 March when an
officer expressed concerns about her, but she did not record this assessment.
Several staff either recorded that Ms McDonald’s heart rate should be taken (as it
was abnormally high) or told the investigator that they asked or expected other staff
to do this. This did not happen.
86. The healthcare provider’s substance misuse policy refers to the need for regular
observations overnight for women arriving in possible drug or alcohol withdrawal.
This was not understood by some nurses and did not happen for Ms McDonald.
The substance misuse manager said that two sets of observations should have
been done overnight at 11.00pm and 3.00am. The clinical reviewer concluded that
Ms McDonald’s observations and general physical presentation should have been
monitored overnight on 1 March with a view to considering whether she should be
transferred to hospital.
87. HMIP identified concerns about inconsistent daytime and night-time monitoring for
prisoners withdrawing from drugs in June 2018. It is therefore troubling that no
progress seems to have been made in a year to reduce the risk created by this gap
in service provision. We make the following recommendation:
The Governor and Head of Healthcare should ensure that all prisoners
arriving with or developing signs of drug or alcohol withdrawal are regularly
monitored, including clinical observations overnight and during the day, until
they are stable.
88. During the staff debrief after Ms McDonald had been taken to hospital, the OSG
said that Ms McDonald had asked to see a nurse that evening and that he had told
her he would contact the nurse and ask her to come over. When asked about this
by the investigator, he said that he could not remember Ms McDonald asking to see
a nurse but said that if it was urgent he would have asked for a nurse to assess her
immediately. Otherwise he said he would have waited until a nurse came to the
wing to dispense medication later that evening.
89. We think it is most likely that Ms McDonald did ask for a nurse that evening since
the OSG mentioned it at the debrief held shortly after her death. We would have
expected the OSG to have made a record of Ms McDonald’s request and we would
also have expected him to contact healthcare and tell them about the request. It
would then have been for nurse, and not the OSG, to say whether Ms McDonald
needed to be seen immediately or whether the request could wait. We are
concerned that the OSG took no action.
90. We also note that there is a significant difference between the OSG’s account that
Ms McDonald was “content” and told him that she was fine, and the accounts of
other prisoners that she was screaming and banging her cell door and expressing
concern about her child.
91. Following the death of a prisoner who was detoxing in the first night centre in
February 2018, we recommended that the Governor and Head of Healthcare should
review the presence of healthcare staff and substance misuse staff in the first night
Prisons and Probation Ombudsman 17
centre. We also recommended that prison officers working in the centre receive
detoxification awareness training and guidance on symptoms to be alert to in
detoxing prisoners and when they should seek medical help.
92. The prison accepted these recommendations. We were told that the Head of
Healthcare was reviewing and actioning healthcare staffing levels in the first night
centre with a target date for completion of December 2019. We were also told that
staff training would be arranged and that there would be a core group of staff in the
first night centre who would take a consistent approach to detoxification issues, and
that healthcare would produce an information sheet and guidance for prison staff
that would be displayed in the first night centre.
93. Since then, there have been two further deaths in the first night centre (including Ms
McDonald’s) while prisoners were detoxing.
94. We remain concerned that, at the time of Ms McDonald’s death, apart from when
nurses visited to give medication three times a day, there was no healthcare
presence in the FNC and it was staffed by prison officers.
95. We are also concerned that prison staff working in the first night centre may
become desensitised to prisoners shouting and screaming as a result of drug
detoxification and may come to regard this as normal behaviour and, in the absence
of advice from healthcare staff, this may lead them to miss other possible causes of
distress (such as Ms McDonald’s concern about her child).
96. For these reasons, consider that, at the time of Ms McDonald’s death, the first night
centre was a potentially unsafe environment for prisoners who are detoxing. We
recommend:
The Prison Group Director for women’s prisons should write to the
Ombudsman setting out what he has done to satisfy himself that there is
sufficient healthcare presence in the first night centre; that prison staff
working in the first night centre have been adequately trained in the
management of prisoners withdrawing from drugs and alcohol; and that steps
are being taken to ensure that staff do not become desensitised to residents’
distress.
Telephone call from Ms McDonald’s Next of Kin
97. Ms McDonald’s next of kin rang the prison at 8.26pm and told a CM about her other
child’s condition. Since issuing our initial report, the timing of this call has been
verified by Ms McDonald’s child’s telephone records. The CM had thought that he
received the telephone call at approximately 9.25pm although he acknowledged it
may have been “a little bit earlier” than this. Ms McDonald’s next of kin told the
PPO’s family liaison officer that she told the CM that her mother would be “freaking
out” not knowing what had happened to her sibling.
98. CCTV shows Ms McDonald’s arm coming out through her observation panel at
10.38pm and it seems likely that this is the point at which she tied the ligature. The
CM went to her cell to tell her that her child was stable at 11.07pm, by which time
Ms McDonald had hanged herself. We do not know what led Ms McDonald to
decide to take her life but it seems likely that worry about her child would have
18 Prisons and Probation Ombudsman
played a part. We, have, therefore, considered whether the CM should have passed
on the message about her child’s condition sooner.
99. The CM told the investigator that he prioritised relaying the message from Ms
McDonald’s child to her. He wanted to see Ms McDonald personally as soon as
possible. He initially went to the first night centre to relay the message to Ms
McDonald at 9.50pm (which was nearly an hour and a half after the telephone call
had taken place) but then got called away to another area of the prison. He
returned around 10.35pm to relay the message but waited until 11.07pm to tell Ms
McDonald (which was two hours and forty minutes after the telephone call).
100. We cannot say whether the news that her child was in a serious but stable condition
would have prevented Ms McDonald using a ligature. However, if the CM had gone
to give Ms McDonald the news sooner when he visited the first night centre for the
second time, she would have been found sooner and her chances of being
resuscitated successfully would have been higher (although by no means certain).
101. We recognise that as Orderly Officer, in charge of the prison overnight, the CM
would have had many duties and responsibilities. Although he acknowledged that
Ms McDonald’s next of kin was anxious about her when he spoke to her, he had not
been told of any issues with Ms McDonald and could not have been expected to
know the extent of her distress that evening. When he returned to the first night
centre for the second time, the OSG told him that he had just seen Ms McDonald
and that he had no concerns about her.
102. We accept that the CM would have gone to speak to Ms McDonald more quickly if
he had been told she was in distress. However, it should have been obvious that
Ms McDonald would be very anxious about her child and we consider that he
should have given greater priority to telling her or should have asked the OSG or
another member of staff to pass the news to her when he realised he would not be
able to do so quickly himself.
Emergency response
103. Prison Service Instruction (PSI) 03/2013, Medical emergency response codes, says
that the Governor must have a medical emergency response code protocol that
ensures that an ambulance is called automatically in a life-threatening medical
emergency. The protocol gives guidance on efficiently communicating the nature of
a medical emergency, ensuring that staff take the correct equipment to the incident
and that there are no delays in calling an ambulance. It explicitly states that all
prison staff must be made aware of, and understand, the protocol and their
responsibilities during medical emergencies.
104. Governors are required to have a two-code medical emergency response system
based on the instruction. Styal uses code blue to indicate an emergency when a
prisoner is unconscious or having breathing difficulties, and code red for when a
prisoner is bleeding. The control room should call an ambulance immediately when
an emergency code is used.
105. The OSG did not use an emergency code. Instead, he radioed for healthcare staff
to attend the first night centre. This did not convey that healthcare needed to attend
a life-threatening incident immediately, as an emergency code would have done.
Prisons and Probation Ombudsman 19
By chance two members of healthcare staff were close to the first night centre and
diverted from their intended route to go there first. As a result, the failure to call an
emergency code did not delay the healthcare response, as it might easily have
done. However, the healthcare staff were not prepared for the situation they were
to encounter and did not bring the emergency equipment with them as they would
have done when responding to an emergency code. The failure to call an
emergency code also meant that control room staff did not call an ambulance
immediately and this led at least a three-minute delay before an ambulance was
called.
106. The OSG said that he was aware of the emergency codes used at Styal but in the
pressure of the situation, forgot to use one. While we appreciate he found himself
in an unexpectedly shocking situation, in the absence of using a code, he needed to
at least, convey the severity if the situation.
107. We are also concerned that the CM did not tell the OSG to call an emergency code
but instead told him to ask healthcare and prison staff to attend. As Orderly Officer,
we would have expected him to have understood the importance of calling a
medical emergency code.
108. On 15 March 2019, following Ms McDonald’s death, a notice to staff was issued
reiterating the need to use the correct codes in a medical emergency. However, the
OSG told the investigator that he was not aware of any guidance issued to staff
since Ms McDonald’s death, and some of the other staff the investigator interviewed
remained unclear about when to use an emergency code.
109. It is evident that the Governor needs to do more to ensure that staff understand and
follow emergency procedures. We make the following recommendation:
The Governor should ensure that all prison staff are made aware of and
understand their responsibilities during medical emergencies, in particular
that staff efficiently communicate the nature of a medical emergency using
the appropriate code.
Future learning
110. We consider it important that frontline staff are able to learn from our investigations.
We, therefore, make the following recommendations:
The Head of Healthcare should share this report with healthcare staff named
in it and discuss its findings with them.
The Governor should ensure that this report is shared with the CM and the
OSG and that a senior manager discusses our findings with them.
20 Prisons and Probation Ombudsman
Inquest
111. The inquest into Ms McDonald’s death concluded on 10 May 2024. It concluded
that Ms McDonald died of suicide which was contributed to by failures of prison and
healthcare staff.
Prisons and Probation Ombudsman 21
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk