Diana Grant

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Ms Diana Grant,
a prisoner at HMP Bronzefield,
on 20 November 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Ms Diana Grant died on 20 November 2021 at HMP Bronzefield. The preliminary post-
mortem report found that her death was caused by an upper airway obstruction (a pair of
women’s underwear was removed from her airway during the post-mortem examination).
She was 42 years old. I offer my condolences to Ms Grant’s family and friends.
Ms Grant had been at Bronzefield for only one day when she died. She arrived on 19
November with a suicide and self-harm warning form and a request that staff assess her
for placement in the prison’s healthcare unit. However, reception staff failed to start
suicide and self-harm prevention procedures (known as ACCT) and she was put in a cell
on a standard houseblock. She was also not seen by a prison GP as she should have
been.
I am extremely concerned that despite Ms Grant arriving at Bronzefield with clear warnings
about her high risk of suicide and poor mental state, staff failed to put in place any
measures to try to protect her. The Governor needs to ensure that reception screening
procedures are improved so that prisoners who are at risk of suicide and self-harm are
promptly identified and supported.
It is not within my remit to consider the decision that led to Ms Grant, a very vulnerable
Black woman who was acutely mentally ill, being sent to prison. However, I am troubled by
the tragic circumstances of Ms Grant’s death, given she took her life just a day after
arriving in prison.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman May 2023
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 12
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 19 November 2021, Ms Diana Grant (formerly Chantelle Grant) was remanded
in prison custody, charged with attempted murder and assault, and sent to HMP
Bronzefield. It was her first time in prison.
2. Ms Grant, who had schizophrenia, had tried to stab her mother multiple times. The
court’s Liaison and Diversion (L&D) Team (who assess individuals with mental
health issues, learning difficulties or other vulnerabilities) prepared a report and
emailed it to the mental health in reach team at Bronzefield. They asked staff to
assess her for placement in the prison’s healthcare unit and said that they had
completed a suicide and self-harm warning (SASH) form. The SASH form said that
Ms Grant was acutely psychotic and at high risk of suicide and self-harm. The
operational manager of Bronzefield’s healthcare unit arranged for a room to be
prepared for Ms Grant and notified the relevant staff.
3. When Ms Grant arrived at Bronzefield, the senior prison custody officer in reception
saw the SASH form and he said he passed it to the interviewing officer. She said
she did not see it and nor did the reception nurse. No one started suicide and self-
harm monitoring (known as ACCT).
4. The reception nurse said he saw the L&D report but did not read the email about
locating Ms Grant in the healthcare unit. He assessed that Ms Grant should be
located on a standard houseblock.
5. The reception GP did not assess Ms Grant. Another GP was supposed to assess
her by telephone the next morning, but he did not know her location because it was
not on her medical record. Ms Grant’s location was on her prison record, but the
GP did not access it or ask anyone to access it for him.
6. That night, prisoners heard Ms Grant shouting about the devil. However, she was
quiet later in the night. The next day, she ran out of her cell when staff opened her
door to give her hot water. She initially refused to go back to her cell but then staff
managed to walk her back. She was shouting and pushing at the window but then
seemed to calm down again.
7. At around 9.05pm, an officer saw Ms Grant on the floor of her cell, half underneath
her bed. He banged on the door, but she did not respond. He called a nurse on the
wing to take a look. The nurse asked to go into the cell and the officer sought
permission from the night orderly officer (the senior officer in charge at night) who
granted it. The nurse found that Ms Grant was not breathing and at 9.14pm, called
a medical emergency code blue. Staff attempted resuscitation before paramedics
arrived. They declared Ms Grant dead at 9.50pm.
8. The final post-mortem report concluded that Ms Grant died from an upper airway
obstruction which caused cardiorespiratory collapse. A pair of women’s underwear
was removed from her airway during the post-mortem examination.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
9. Neither the interviewing officer in reception nor the reception nurse saw the SASH
form. It is unclear what happened to it. This was a crucial document and should
have prompted reception staff to start ACCT monitoring. Even without the SASH
form, reception staff should have identified Ms Grant’s risk factors for suicide and
self-harm and started ACCT monitoring. Staff placed too much emphasis on Ms
Grant’s apparently calm presentation rather than considering her risk factors.
10. The reception nurse ignored the information about locating Ms Grant in the prison’s
healthcare unit. Again, he focused on Ms Grant’s presentation at that time, rather
than the L&D assessment.
11. Neither of the GPs made adequate attempts to assess Ms Grant and the reception
GP failed to make any record of why she had not seen Ms Grant.
12. There was a delay in going into Ms Grant’s cell while the officer sought permission
from the night orderly officer. This was unnecessary in the circumstances.
Recommendations
• The Director and the Head of Healthcare should ensure that reception staff:
• are aware of the risk factors that might increase a prisoner’s risk of suicide and
self-harm;
• consider all relevant documentation that arrives with a prisoner, in particular the
PER (and SASH form, if completed);
• base their assessment on a prisoner’s known risk factors and not on their
presentation;
• record the risk factors they have identified and their reasoning for not starting
ACCT procedures; and
• retain the completed paperwork and store it securely.
• The Director should share this report with SPCO A, PCO A and PCO B and arrange
for a senior manager to discuss the Ombudsman’s findings with them.
• The Head of Healthcare should share this report with Nurse A and discuss the
Ombudsman’s findings with him.
• The Head of Healthcare should ensure that when senior staff indicate that a new
prisoner should be located in the healthcare unit, the reception nurse is made aware
and consults with senior staff if they propose to locate the prisoner on a standard
houseblock.
• The Head of Healthcare should ensure that:
• newly arrived prisoners are seen by a GP if they are referred for a GP
assessment; and
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
• if a prisoner is not seen, the GP records the reason in the prisoner’s medical
record and arranges for them to be seen as soon as possible.
• The Director should ensure that staff understand that they can enter cells at night in
medical emergencies without the permission of the night orderly officer in line with
PSI 24/2011.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Bronzefield informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
14. The investigator obtained copies of relevant extracts from Ms Grant’s prison and
medical records.
15. The investigator interviewed 16 members of staff during February and March 2022.
NHS England commissioned a clinical reviewer to review Ms Grant’s clinical care at
the prison. The investigator and clinical reviewer jointly interviewed healthcare staff
and some custodial staff.
16. We informed HM Coroner for Surrey of the investigation. The coroner gave us the
preliminary post-mortem report. We have sent him a copy of this report.
17. The Ombudsman’s family liaison officer contacted the solicitor acting on behalf of
Ms Grant’s next of kin to explain the investigation and ask if there were any issues
they wanted us to consider. The solicitor sent us questions about Ms Grant’s time
at Bronzefield which are covered in this report.
18. Ms Grant’s family received a copy of the initial report. The solicitor representing
them wrote to us seeking clarification on certain matters before he forwarded them
the report, and we answered by way of separate correspondence. We did not
receive any further correspondence about any factual inaccuracies.
19. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Bronzefield
20. HMP Bronzefield holds adult and young offender women prisoners. It has four
houseblocks, plus a healthcare unit providing 24-hour care for up to 17 prisoners.
21. The prison is operated by Sodexo Justice Services (SJS) who provide primary
healthcare including mental health and integrated substance misuse services.
Secondary mental health care is provided through the mental health inreach team
by Central Northwest London NHS Foundation Trust (CNWL). General
practitioners are employed through a contract with Med-Co Secure Healthcare
Services Ltd.
HM Inspectorate of Prisons
22. HM Inspectorate of Prisons (HMIP) carried out an unannounced inspection of
Bronzefield in January and February 2022. Inspectors found a prison working hard
to care for many women with serious mental health difficulties. They noted that
many of these women did not belong in prison and had been placed there as a
place of safety because of inadequate service provision (86 women in the
preceding two years). They also found that women arriving at the prison received
good individual support and interviews were appropriately focused on safety.
23. Recorded rates of self-harm were 72% higher than at the previous inspection, but a
small number of women accounted for almost two thirds of all incidents.
Independent Monitoring Board
24. 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. Their latest annual report for the year to 31 July 2021 noted that the
number of self-harm incidents had escalated during the reporting year to an
average of 220 per month (from 175). They also noted an improvement in the
transfer of severely mentally unwell prisoners to secure inpatient mental health
hospitals. There was an increase in missed GP and nurse appointments with both
rates doubling.
Previous deaths at HMP Bronzefield
25. There were no deaths at Bronzefield in the two years before Ms Grant’s death.
Assessment, Care in Custody and Teamwork
26. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
27. As part of the process, a caremap (a plan of care, support and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the caremap
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011,
Management of prisons at risk of harm to self, to others and from others (Safer
Custody).
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
28. On 19 November 2021, Ms Diana Grant (formerly Chantelle Grant) was remanded
in prison custody, charged with attempted murder and assault, and sent to HMP
Bronzefield. It was her first time in prison.
29. Two days before, Ms Grant, who had schizophrenia, had tried to stab her mother
multiple times. Afterwards, witnesses saw Ms Grant crawling naked down the road.
When she was arrested, she told police she had been hearing voices for two or
three days, even though she was on medication.
30. At 12.30pm on 19 November, a member of the Willesden Magistrates’ Court Liaison
and Diversion (L&D) Team emailed the mental health inreach team at Bronzefield
about Ms Grant. (L&D services, run by the NHS, identify and assess individuals in
the criminal justice system who have mental health issues, learning disabilities or
other vulnerabilities.) She attached an L&D report on Ms Grant and said that a
suicide and self-harm warning (SASH) form had been completed and placed in Ms
Grant’s Person Escort Record (PER, a form that accompanies all prisoners when
they move between police custody, court and prisons, which sets out the risks they
pose). She also asked for staff to assess Ms Grant for placement in the prison’s
healthcare unit.
31. The Inreach consultant forensic psychiatrist received the email and at 1.15pm,
forwarded it to the operational Head of the prison’s healthcare unit. The
psychiatrist’s covering message said that Ms Grant ‘might need to come into
healthcare’.
32. At 1.41pm, the operational Head forwarded the email to several people. Her
covering email message said that they were looking to make space in the
healthcare unit for Ms Grant. She also spoke to a Senior Prison Custody Officer
(SPCO) and the duty manager and told them that room 12 was being prepared for
Ms Grant.
33. A nurse saw the email at approximately 3.00pm in the afternoon. She phoned
Nurse A, the reception nurse, and told him about the email, including the plan to
locate Ms Grant in the healthcare unit. She did this because she knew from
experience that clinical information did not always reach the nurse completing the
reception health screen.
HMP Bronzefield
34. Ms Grant arrived at Bronzefield shortly before 6.00pm. SPCO A spoke to her when
she arrived and described her as quiet and timid. He reviewed the Person Escort
Record and found a loose SASH form. It said that Ms Grant was presenting as
acutely psychotic, had a history of suicidal thoughts and was assessed as at high
risk of suicide and self-harm. It recommended an ACCT assessment and an
assessment for placement in the prison’s healthcare unit. It also said that an urgent
referral had been made to the prison’s mental health inreach team. The SPCO said
he passed the PER and SASH form to Prison Custody Officer (PCO) A, the
interviewing officer in reception.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
35. PCO A noted in Ms Grant’s electronic prison record (NOMIS), ‘First time in prison.
Pleasant and polite during interview’. She told the investigator that she did not see
the SASH form. Neither she nor the SPCO started ACCT procedures.
36. PCO B, a member of the safer custody team, also saw Ms Grant in reception. She
noted it was her first time in prison, but she appeared calm and had no thoughts or
history of self-harm. She told the investigator that she did not see any paperwork.
She did not start ACCT procedures.
37. Nurse A carried out Ms Grant’s reception health screen. He saw the PER but not
the SASH form. He was aware from the telephone call from his colleague that an
L&D assessment had been done in court, that he would need to assess Ms Grant
and decide on the best place to locate her and refer her to the mental health team.
He read the L&D report but not the covering email about the SASH form and the
plans to locate Ms Grant in the healthcare unit. He noted that Ms Grant was
schizophrenic and that she had been charged with the attempted murder of her
mother.
38. Nurse A described Ms Grant as distant, guarded, pensive and preoccupied.
However, she said she had no current thoughts of suicide or self-harm. He did not
start ACCT procedures.
39. Nurse A recorded that Ms Grant needed an urgent assessment by a psychiatrist
and a nurse. He emailed the mental health team later that evening and made a
referral for her to see a psychiatrist. He also referred her to the GP, who was still in
reception. He expected the GP to see her that evening. He recorded that Ms Grant
should be located in Houseblock 2. When interviewed, he said he could see no
clinical reason why Ms Grant needed to go to the healthcare unit as she had no
physical health needs, no substance misuse issues and no psychotic symptoms at
that time.
40. A prison GP in Reception that evening told the investigator that she recalled
speaking to Nurse A and that he told her Ms Grant needed a mental health review.
She said she was unaware of the L&D report and the psychiatrist’s email. She said
that she had called Ms Grant in to see her, but she had already been taken down to
the houseblock and she thought she was going to be brought back to see her. She
said she added Ms Grant’s name to the GP ledger so a doctor could see her the
following morning. She did not make a record of her discussion with Nurse A or
record why she had not seen her.
41. Once the reception process was completed, a PCO took Ms Grant to Houseblock 1.
It is unclear who decided she should be taken to Houseblock 1 instead of
Houseblock 2 (Houseblock 1 had a nurse presence which Houseblock 2 did not).
42. Staff checked on Ms Grant six times during the night (in line with first night checks).
Although an officer noted Ms Grant was shouting and woke people up at around
10.10pm, by the time a PCO came on shift an hour or so later, Ms Grant was quiet.
She remained quiet for the rest of the night.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
20 November
43. At 10.41am, a PCO noted on Ms Grant’s electronic prison record (NOMIS) that Ms
Grant had asked other prisoners if they had heard the devil screaming in the night
and that she would refer her to the mental health team.
44. At 10.50am, PCO C noted on NOMIS that Ms Grant was behaving oddly. She
would freeze with an empty look for a few moments before talking normally again
but without maintaining eye contact. Other prisoners had reported that Ms Grant
was shouting during the night and talking in a distorted voice about the devil. The
PCO recorded that she had asked Ms Grant if she had any intentions of self-harm,
but she said she did not. She noted that the spur SPCO was going to make a
mental health referral.
45. PCO C recorded that Ms Grant’s room was in good order, but her phone was
missing, and she said she was not given a PIN at reception. The SPCO provided a
new phone and, later on, the PCO looked into the PIN issue.
46. That afternoon, at approximately 2.30pm, staff opened Ms Grant’s cell door to give
her some hot water and she ran out of her cell. She ran downstairs and refused to
go back into her cell when staff ordered her to do so. Eventually, PCO C and the
SPCO were able to walk Ms Grant back to her cell. The PCO recorded that Ms
Grant was ‘screaming her lungs out’. She went back a bit later and gave Ms Grant
her PIN. Ms Grant was shouting and pushing at her window. The PCO asked her
to come to the hatch to speak to her, and she seemed to calm down. She said she
did not know where her daughter was, so the PCO suggested she should call
someone to find out. Ms Grant tried to make a call, but it would not go through.
47. Ms Grant was locked in her cell for the night at around 5.20pm. At 5.30pm, the
SPCO checked Ms Grant when he was completing the roll check. She was sitting
on her bed, talking to herself but did not seem distressed. Approximately an hour
later, a PCO referred Ms Grant to the mental health team because of her behaviour
earlier in the day.
Emergency response
48. Shortly after 9.00pm, two PCOs started checking all the cell doors and completing a
roll check as part of the handover between day and night shifts.
49. At approximately 9.05pm, PCO D looked through Ms Grant’s cell door observation
panel and saw she was lying on the floor and mostly underneath the bed. He told
the investigator that it was not unusual for newly arrived prisoners to sleep under
their beds and as Ms Grant had been behaving erratically, he was not initially
concerned. However, within a few seconds, he decided to go back and check on
Ms Grant. He banged on the door, but she did not respond.
50. PCO D called to a nurse who was on the landing and asked him to come and take a
look. The PCO said he felt hesitant about going straight into the cell because of Ms
Grant’s earlier behaviour. The nurse looked in and the PCO radioed the night
orderly officer for permission to enter the cell. The night orderly officer did not hear
him at first, so the PCO tried again, and was then given permission to go into the
cell.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
51. Ms Grant’s mattress was lying on the floor, pushed up against the door, but the staff
gained entry eventually and pulled Ms Grant out from under the bed. Ms Grant did
not respond to her name being shouted or physical attempts to rouse her.
52. At 9.14pm, once he realised that Ms Grant was not breathing, the nurse called a
medical emergency code blue (used when a prisoner is unconscious or has
breathing difficulties) and control room staff called for an ambulance.
53. The nurse asked PCO E to get his emergency bag while he and PCO D started
chest compressions. When PCO E returned, the nurse asked him to get some
oxygen while he applied the defibrillator which advised no shock. When the PCO
came back with it, a nurse accompanied him.
54. Ms Grant’s jaw was locked, she was cold to the touch, with some blood around her
mouth and her trousers were wet. The nurse tried to insert an airway but was not
successful. Staff delivered chest compressions and oxygen through a cylinder.
55. Paramedics arrived at Ms Grant’s cell at 9.34pm. They inserted a nasal airway and
continued chest compressions, but they could not resuscitate her. She was
declared dead at 9.50pm.
Contact with Ms Grant’s family
56. On 20 November, the prison appointed a family liaison officer. She visited the next
of kin to break the news in person in the early hours of that morning.
57. Ms Grant’s funeral was held on 12 January 2022. Bronzefield contributed to the
costs of Ms Grant’s funeral in line with national policy.
Support for prisoners and staff
58. After Ms Grant’s death, the Director 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.
59. The prison posted notices informing other prisoners of Ms Grant’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 Grant’s death.
Post-mortem report
60. The preliminary post-mortem report concluded that Ms Grant died of
cardiorespiratory collapse caused by the obstruction of the upper airway by a
foreign body. The routine post-mortem examination was stopped when a pair of
women’s underwear was found in Ms Grant’s upper airway. The operating
pathologist indicated that she could not have placed the underwear there herself.
The operating pathologist requested that a special post-mortem should be
conducted by a Home Officer forensic pathologist. The forensic pathologist noted
no signs of third-party assault or restraint and considered that it was consistent with
a self-inflicted act.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Inquest
61. An inquest was concluded on 2 April 2025. A jury gave a narrative conclusion.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment of Ms Grant’s risk of suicide and self-harm
62. Prison Service Instruction (PSI) 64/2011 on safer custody provides guidance to staff
on identifying prisoners who might be at risk of suicide and self-harm. It lists the
risk factors and triggers that might increase a prisoner’s risk and sets out the
procedures (known as ACCT) that staff should follow when they identify a prisoner
at risk of suicide and self-harm. Ms Grant had several risk factors for suicide and
self-harm: it was her first time in prison; she had been charged with a violent
offence against a family member; and she had a mental illness diagnosis
(schizophrenia).
63. Ms Grant arrived at Bronzefield with a SASH form that said she was acutely
psychotic and at high risk of suicide and self-harm. SPCO A saw the SASH form
and passed it, along with the PER, to the interviewing officer, PCO A. He said he
placed it on her desk with the other forms. When asked if he had read the SASH
form, he said he would have done. He also said that he would have flagged it to the
interviewing officer and asked them to consider opening an ACCT, though it would
have been their decision once they had completed the interview.
64. PCO A told the investigator she did not see the SASH form. She said that she did
not always see the PER either as sometimes the nurse kept it as they saw it first.
She was aware of Ms Grant’s offence but nothing else. She said that Ms Grant
appeared calm at interview, and she had no concerns about her.
65. PCO B from the safer custody team also saw Ms Grant in reception. She told the
investigator she did not see any paperwork. She thought Ms Grant seemed calm
and had no concerns.
66. Nurse A, the Reception nurse, carried out Ms Grant’s reception health screen. He
told the investigator that he saw the PER but not the SASH form. He also saw the
L&D report. However, he was satisfied that Ms Grant was not showing any signs of
psychosis when he saw her and assessed that she did not need to be supported
using ACCT procedures. He told the investigator that if he had seen the SASH
form, he would have started ACCT monitoring.
67. Our first concern is that apart from SPCO A, none of the staff who saw Ms Grant in
reception saw the SASH form that arrived with her. This was a crucial document
that said Ms Grant was at high risk of suicide and self-harm. If either the
interviewing officer or the reception nurse had seen it, it should have triggered the
immediate opening of an ACCT. It is unclear what happened to it after the SPCO
saw it. It would also appear that the SPCO did not flag it to the interviewing officer,
so she was unaware of it when she did her reception screening interview.
68. We are also concerned that regardless of the SASH form, neither PCO A nor Nurse
A gave sufficient consideration to Ms Grant’s risk factors for suicide and self-harm.
PCO A was aware of Ms Grant’s offence, yet this is not mentioned as a risk factor in
her NOMIS entry. He appears to have based her assessment that Ms Grant was
not at risk of suicide or self-harm solely on her presentation, which she described as
polite and calm. The nurse also seemed to base his assessment on Ms Grant’s
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
presentation and lack of psychotic symptoms rather than her risk factors for suicide
and self-harm.
69. In addition to staff’s poor assessment of risk, we are concerned that reception
procedures were poorly organised. As well as the SASH form apparently being
temporarily mislaid, the Cell Sharing Risk Assessment (CSRA) form went missing
entirely. Also, three separate first night forms were started for Ms Grant without
explanation. We make the following recommendations:
The Director and the Head of Healthcare should ensure that reception staff:
• are aware of the risk factors that might increase a prisoner’s risk of
suicide and self-harm;
• consider all relevant documentation that arrives with the prisoner, in
particular the PER (and SASH form, if completed);
• base their assessment on a prisoner’s known risk factors and not on their
presentation;
• record the risk factors they have identified and their reasoning for not
starting ACCT procedures; and
• retain the completed paperwork and store it securely.
The Director should share this report with SPCO A, PCO A and PCO B and
arrange for a senior manager to discuss the Ombudsman’s findings with
them.
The Head of Healthcare should share this report with Nurse A and discuss the
Ombudsman’s findings with him.
Location
70. After being alerted to the L&D assessment of Ms Grant and to L&D’s email, the
operational Head put arrangements in place for Ms Grant to be located in the
prison’s healthcare unit. However, Ms Grant was not placed there. Nurse A
understood that it was up to him to decide where to place Ms Grant after carrying
out the reception health screen. He said that he had read the L&D report but not
the covering email that said the intention was to locate Ms Grant in the healthcare
unit. He assessed that Ms Grant did not need to go to the healthcare unit and
recommended she should be placed on a standard houseblock.
71. The clinical reviewer was concerned that Nurse A acted outside his role of reception
nurse by overriding the decision to admit Ms Grant to the healthcare unit. When he
carried out the screening of Ms Grant, he placed emphasis on how she seemed at
the time and did not take account of the wider information available.
72. Healthcare’s own Root Cause Analysis exercise highlighted that had Ms Grant been
in the healthcare unit, it is more likely that an ACCT would have been opened, that
she would have seen a GP and that she would have received oral antipsychotic
medication. We recommend:
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Head of Healthcare should ensure that when senior staff indicate that a
new prisoner should be located in the healthcare unit, the reception nurse is
made aware and consults with senior staff if they propose to locate the
prisoner on a standard houseblock.
Clinical care
73. The reception GP failed to assess Ms Grant or record why she had not done so.
The next day, a prison GP was due to have a telephone appointment with Ms
Grant, but he could not call her because her location was not showing on
SystmOne, the electronic medical record. He would have had to access NOMIS,
the case management system or ask a healthcare colleague or an officer to check
for him.
74. The prison GP told the investigator he could not afford the time to investigate where
Ms Grant was and, if nurses had any concerns, they should have brought her to
him. We consider that neither doctor properly fulfilled their duty to ensure Ms Grant,
a newly arrived prisoner with known mental health difficulties, was seen. We
recommend:
The Head of Healthcare should ensure that:
• newly arrived prisoners are seen by a GP if they are referred for a GP
assessment; and
• if a prisoner is not seen, the GP records the reason in the prisoner’s
medical record and arranges for them to be seen as soon as possible.
Emergency response
75. PSI 24/2011, Management and Security of Nights, says that under normal
circumstances, the night orderly officer must authorise the unlocking of a cell at
night and at least the minimum number of staff (as set out in local risk guidelines)
should be present when it is opened. However, the PSI goes on to say that the
preservation of life must take precedence and where there is or appears to be a
threat to life, cells may be unlocked without the authority of the night orderly officer
and a single member of staff can enter the cell alone, if they feel safe to do so.
76. We accept that Officer D may not have felt safe to enter Ms Grant’s cell alone.
However, we are concerned that once the nurse arrived, he radioed the night
orderly officer for permission to enter. When interviewed, he maintained that
permission from the night orderly officer was always required to go into a cell at
night. We recommend:
The Director should ensure that staff understand that they can enter cells at
night in medical emergencies without the permission of the night orderly
officer in line with PSI 24/2011.
14 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE