Keith Turner

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Keith Turner,
a prisoner at HMP Humber,
on 9 January 2020
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
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© Crown copyright, 2024
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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.
Mr Keith Turner died on 9 January 2020, after cutting his throat and wrist at HMP Humber.
He was 50 years old. I offer my condolences to Mr Turner’s family and friends.
In December 2019, Mr Turner told healthcare staff on four occasions that he was having
suicidal thoughts. I am very concerned that healthcare staff did not start Prison Service
suicide and self-harm monitoring or share this information with prison staff.
The clinical reviewer found that there were many missed opportunities for the mental
health team to support Mr Turner’s mental health.
On the morning of Mr Turner’s death, around an hour before he was found, his wife called
the prison’s switchboard and asked if someone could check on her husband because she
had not heard from him that morning. I am concerned that the switchboard operator did not
refer Mr Turner’s wife to the Safer Custody hotline. This was a missed opportunity for
someone to check on Mr Turner.
I am also concerned that there was a delay in sending an emergency ambulance to treat
Mr Turner, as prison staff initially gave insufficient information to the Ambulance Service
for them to treat the call as an emergency.
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 October 2020
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 5
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 13
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Summary
Events
1. On 6 March 2019, Mr Keith Turner was sentenced to three years and nine months
imprisonment for engaging in controlling or coercive behaviour in an intimate
relationship. On 19 March, Mr Turner was moved to HMP Humber.
2. On 29 November, Mr Turner told a supervising officer and his offender supervisor
that he was concerned about a new police investigation into a historical allegation
from a former partner.
3. On 14 December, a senior nurse saw Mr Turner for a mental health review. She
noted that Mr Turner said he was “terribly down and does not think he can get much
lower”, and that he had suicidal thoughts. The senior nurse did not start Prison
Service suicide and self-harm monitoring (known as ACCT).
4. On 18 December, Mr Turner completed a mental health referral form and said he
had suicidal thoughts daily, but that his wife and daughter stopped him from taking
his life.
5. Two days later, a nurse saw Mr Turner for a mental health review. She noted that
Mr Turner said he woke up every morning with thoughts of suicide but was adamant
that he would not act on them. The nurse noted that she did not have any concerns
about Mr Turner’s risk of self-harm so did not start ACCT monitoring.
6. On 31 December, the senior nurse saw Mr Turner for a mental health review. She
noted that Mr Turner said he had daily suicidal thoughts and “did not want to be
here”.
7. On 5 and 7 January 2020, two nurses saw Mr Turner, who said that he was really
struggling. Both nurses referred Mr Turner to the mental health team, though the
referrals were not reviewed until after his death.
8. At 8.08am on 9 January, an officer unlocked Mr Turner’s cell but did not open the
door or check on his welfare. At 8.28am, an officer looked through the observation
panel into Mr Turner’s cell and then walked to the next cell. He told the investigator
that while he could not remember looking into Mr Turner’s cell, he would have
noticed anything untoward.
9. At 8.53am, Mr Turner’s wife telephoned Humber’s switchboard and asked if
someone could check on her husband as she had not heard from him that morning.
The operator told her that as Mr Turner had contacted her within the last seven
days, they could not ask for an update. They did not refer Mr Turner’s wife to the
prison’s Safer Custody hotline.
10. At approximately 9.55am, a prisoner found Mr Turner on the floor of his cell in a
pool of blood. He shouted to staff. Two officers responded and found that Mr Turner
had cut his throat. An officer called a code red emergency (which indicates that a
prisoner has suffered a severe loss of blood). Healthcare staff quickly responded.
They started cardiopulmonary resuscitation, inserted an airway, gave Mr Turner
oxygen and attached a defibrillator.
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11. The control room called for an ambulance at 9.58am. Paramedics reached Mr
Turner at 10.10am but they were unable to resuscitate him and, at 10.34am, an air
ambulance doctor declared that he had died.
Findings
Assessment of Mr Turner’s risk of suicide and self-harm
12. In December 2019, Mr Turner made four statements to healthcare staff that he was
having suicidal thoughts. We are very concerned that healthcare staff did not start
ACCT monitoring or pass this information to prison staff.
Mental health
13. The clinical reviewer found that the mental health care Mr Turner received was not
equivalent to that which he could have expected to receive in the community. There
were missed opportunities to support Mr Turner as no one monitored his withdrawal
from citalopram (an antidepressant), replaced his allocated nurse when he left, or
checked on him after being tasked to do so by primary care colleagues.
Mr Turner’s wife’s call to Humber’s switchboard
14. We are concerned that the prison’s switchboard did not pass Mr Turner’s wife’s
concerns to the Safer Custody hotline. Therefore, the prison missed an opportunity
to check on him.
Unlock
15. Staff are supposed to check on a prisoner’s welfare when unlocking their cell, either
by getting a response or checking for movement. We are concerned that the officer
who unlocked Mr Turner’s cell did neither. While we acknowledge that it appears Mr
Turner was still alive 20 minutes later, it is important that staff follow the correct
unlock procedures.
Emergency response
16. We are concerned that, during the emergency response, an officer managed the
emergency bag rather than one of the many healthcare staff standing outside the
cell. Also, when staff initially called for an ambulance, they gave insufficient
information for the Ambulance Service to treat the call as an emergency, which
delayed the arrival of the ambulance by four minutes.
Staff support
17. We are concerned that one officer involved in the emergency response was not
given a TRiM assessment and another was not given immediate support from
senior prison managers.
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Incident report forms
18. We are concerned that we only received one Incident Report Form from the prison
staff involved in the emergency response.
Recommendations
• The Governor and the Head of Healthcare should ensure that all staff have a clear
understanding of their responsibilities to manage prisoners at risk of suicide and
self-harm in line with national guidelines and, in particular understand:
• the need to record, share and consider all relevant information about risk,
and start ACCT procedures when indicated; and
• the need to consider risk factors rather than simply relying on what the
prisoner says or how he presents.
• The Head of Healthcare should share a copy of this report with Senior Nurse A and
Nurse B and discuss the Ombudsman’s findings with them.
• The Head of Healthcare should ensure that:
• mental health tasks are checked daily, clearly actioned and allocated to
appropriate members of the team;
• mental health services are prioritised and reallocated when staff leave the
service; and
• all staff are trained in the use of the patient health questionnaire and the
generalised anxiety disorder score and they feel competent to complete
them.
• The Effective Practice and Service Improvement Group should liaise with SSCL to
ensure that any calls raising credible concerns about a prisoner should be
transferred to Humber’s Safer Custody hotline.
• SSCL should provide refresher training to its switchboard staff to ensure that they
know what to do when they receive calls raising concerns about a prisoner’s
wellbeing.
• The Governor should ensure that, when a cell door is unlocked, officers satisfy
themselves of the wellbeing of the prisoner and that there are no immediate issues
that need attention.
• The Governor should share a copy of this report with Officer A and ensure that a
senior manager discusses the Ombudsman’s findings with him.
• The Governor and the Head of Healthcare should ensure that healthcare staff are
responsible for managing emergency bags during medical emergencies, unless
they are not available.
• The Governor should ensure that when staff call a medical emergency code, they
promptly provide information about a prisoner’s condition to the control room so that
they can pass this information to the Ambulance Service.
• The Governor should ensure that staff are offered appropriate support, including
access to TRiM practitioners, following a death in custody or other traumatic event.
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• The Governor should ensure that all managers follow the national instructions for
dealing with a death in custody or serious incident, including that all staff directly
involved in an incident complete Incident Report Forms as soon as possible.
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The Investigation Process
19. The investigator issued notices to staff and prisoners at HMP Humber informing
them of the investigation and asking anyone with relevant information to contact
him. Two prisoners responded.
20. The investigator visited Humber on 16 January 2020. He obtained copies of
relevant extracts from Mr Turner’s prison and medical records.
21. NHS England commissioned an independent clinical reviewer to review Mr Turner’s
clinical care at the prison.
22. The investigator interviewed 15 members of staff and two prisoners at Humber on
16 January and 3, 4 and 5 March, and two members of staff by telephone on 28
February and 18 March. The clinical reviewer accompanied the investigator for the
interviews on 3 and 4 March.
23. We informed HM Coroner for East Riding and Kingston Upon Hull of the
investigation. He has not given us the results of the post-mortem examination, as
they are not yet available. We have sent the coroner a copy of this report.
24. One of the Ombudsman’s family liaison officers wrote to Mr Turner’s wife to explain
the investigation and to ask if she had any matters she wanted the investigation to
consider. She did not have any questions.
25. 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.
26. Mr Turner’s wife received a copy of the initial report. She did not raise any further
issues, or comment on the factual accuracy of the report.
27. The clinical reviewer received a copy of the initial report. She pointed out some
factual inaccuracies and/or omissions. This report has been amended accordingly.
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Background Information
HMP Humber
28. HMP Humber is a medium security prison in Yorkshire that holds approximately
1,000 men. It was created in 2014 by the merger of two previously separate
prisons, HMP Wolds and HMP Everthorpe. City Health Care Partnership provides
healthcare services. There are always healthcare staff on duty.
29. In August 2018, Humber was selected to be part of the ‘10 Prisons Project’, which
seeks to improve safety, security and decency in the prisons involved. The project
was focused on reducing violence, improving living conditions, preventing drugs
from entering the prison and enhancing the leadership and training available to
staff.
HM Inspectorate of Prisons
30. The most recent inspection of HMP Humber was in December 2017. Inspectors
reported a high number of self-harm incidents, though they found that ACCT
management was multidisciplinary and many entries showed good care and
interaction with prisoners.
31. Inspectors found that health services were reasonable, though they were unable to
meet all mental health needs. The small mental health team provided immediate
support for those prisoners with immediate needs but had high caseloads and were
unable to meet longer term needs.
Independent Monitoring Board
32. 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 December 2019, the IMB
reported that they had seen an overall improvement in the welfare and general
safety of prisoners during the reporting year. The Board noted that staff showed
professionalism, thoroughness and compassion when conducting ACCT reviews,
which were of a very high quality.
33. The IMB reported that many prisoners had mental health issues, which placed the
mental health team under considerable pressure. They reported that at times, the
number of ACCTs the mental health team were dealing with interfered with their
other work, particularly preventative treatment.
Previous deaths at HMP Humber
34. Mr Turner was the 10th prisoner to die at Humber since January 2018. Two of the
previous deaths were self-inflicted, three were drug-related, two were from natural
causes, one was due to an accidental fall and one is unascertained. We have
previously made recommendations about properly assessing prisoners’ risk of
suicide and self-harm, checking on the wellbeing of a prisoner when unlocking cells
and delays in providing information to the Ambulance Service.
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Key Events
35. On 6 March 2019, Mr Keith Turner was sentenced to three years and nine months
imprisonment for engaging in controlling or coercive behaviour in an intimate
relationship. He was sent to HMP Hull.
36. When Mr Turner arrived at Hull, a nurse saw him for an initial health assessment.
Mr Turner said that he suffered from anxiety and depression, which was treated
with diazepam and citalopram, and he wanted to be referred to the mental health
team. The nurse had no concerns about Mr Turner’s risk of suicide or self-harm.
37. The following day, a prison GP saw Mr Turner and told him that there was no
clinical justification for taking diazepam over a long period of time. Mr Turner said
that he did not want to reduce his diazepam prescription but the prison GP
decreased the dose from 10mg to 5mg.
38. On 19 March, Mr Turner was moved to HMP Humber. When Mr Turner arrived at
Humber, a nurse saw him for an initial health assessment. Mr Turner told him that
he suffered from depression, though he refused a referral to the mental health
team. The nurse told Mr Turner how he could refer himself to the mental health
team and he noted that he had no concerns about Mr Turner’s mental state.
39. Five days later, a nurse saw Mr Turner, who was anxious that his diazepam
prescription had run out and he thought it had been stopped. He said that he had
taken it for seven years so the nurse referred Mr Turner to the prison GP.
40. On 12 April, a prison GP saw Mr Turner and told him that diazepam should not be
taken long-term and that he would need to start a slow reduction. The prison GP
decreased the dose to 4mg.
41. On 18 April, Mr Turner’s offender supervisor saw him. Mr Turner said that he was
struggling with his emotional wellbeing since his diazepam had been reduced,
though he said that he was not having thoughts of suicide or self-harm. She noted
that Mr Turner was tearful so she reminded him of the Listeners scheme (prisoners
trained by the Samaritans to provide support to other prisoners) and suggested that
he speak to his key worker and the mental health team.
42. The same day, Mr Turner completed a healthcare application and said that he had
been “getting lower and lower” since prison GPs reduced his diazepam dose. Mr
Turner said that he was not coping on a day-to-day basis so he needed help.
43. The next day, a nurse saw Mr Turner, who said that the reduction in his diazepam
had caused him to suffer with anxiety, knots in his stomach and irritable bowel
syndrome. The nurse referred Mr Turner to a prison GP.
44. On 29 April, an officer saw Mr Turner for a key worker session. Mr Turner said that
the last week had been tough for him, which he put down to prison GPs changing
his medication. Mr Turner said that he was over the worst of it and appreciated the
support of staff, other prisoners and his family.
45. On 30 April, Mr Turner did not attend a mental health triage appointment. A nurse
sent Mr Turner a letter reminding him that he had missed the appointment.
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46. On 8 May, a prison GP saw Mr Turner and reiterated that diazepam should not be
taken long-term. The prison GP advised Mr Turner that he needed to see the
mental health team for a review and that the slow reduction of diazepam should
continue.
47. On 20 May, Mr Turner did not attend a mental health triage appointment. A support
worker sent Mr Turner a letter reminding him that he had missed the appointment.
Four days later, Mr Turner declined a further appointment so the mental health
team discharged him.
48. On 3 June, an offender supervisor saw Mr Turner, who said that he was struggling
with post-traumatic stress disorder (PTSD) and suffered some concerning
symptoms. She asked Mr Turner’s key worker to contact the mental health team,
though there is no record that this happened.
49. On 20 August, a pharmacist noted that Mr Turner was not taking his morning
diazepam dose and referred him to a prison GP for a medication review. A week
later, a prison GP saw Mr Turner and decided that Mr Turner could continue to take
his diazepam when needed, as a long-term prescription. Mr Turner said that he did
not want to consider distraction techniques for PTSD, as it was rare for him to suffer
flashbacks.
50. Between 28 August and 21 November, an officer saw Mr Turner for 11 key worker
sessions. On each occasion, she noted that Mr Turner appeared to be in good
spirits and she did not record any concerns.
51. On 2 September, a probation officer completed Mr Turner’s OASys Assessment
and noted that she did not have any concerns about his risk of suicide or self-harm.
52. On 27 November, wing staff contacted a nurse because they were concerned that
Mr Turner was struggling with his reduced medication. She referred Mr Turner to a
prison GP for a medication review.
53. Two days later, a supervising officer (SO) saw Mr Turner, who said that he was
struggling to sleep, eat or visit the gym and was lethargic. Mr Turner said that he
had no thoughts of suicide or self-harm, as he had support from his wife and
daughter, but that a new police investigation was causing him concern. The SO
spoke with the healthcare department, who said that Mr Turner had a GP
appointment on 20 December.
54. The same day, Mr Turner’s probation officer saw Mr Turner. He said that the police
investigation into a historical allegation from a former partner was making him feel
very anxious and worried. He said that he did not have any thoughts of suicide or
self-harm. His probation officer tried to make a referral to the mental health team for
one-to-one support for Mr Turner but they said he had to apply himself.
55. On 4 December, a nurse noted that wing staff were concerned about Mr Turner’s
mental health and asked whether his GP appointment could be brought forward
from 20 December.
56. On 9 December, Senior Nurse A sent Mr Turner a positive mental health pack,
which held information about managing his mental health.
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57. The same day, an officer saw Mr Turner for a key worker session. Mr Turner said
that he was struggling with his mental health and had completed an application to
the mental health team and was waiting to be seen.
58. On 10 December, a prison GP and a healthcare assistant saw Mr Turner, who said
that he was suffering with stress and that his original 10mg dose of diazepam had
helped with this, as well as his anxiety. The prison GP decreased the diazepam
dose to 2mg, due to its addictive nature, though Mr Turner disagreed with this
decision. Mr Turner said that his anxiety was getting worse but he refused any
treatment except an increase in diazepam. The prison GP ended the appointment
early, as Mr Turner allegedly began swearing and being argumentative, though the
healthcare assistant noted that he had not been rude or sworn. The prison GP
planned to review Mr Turner in two months or sooner if he experienced new or
worsening symptoms and referred him to the mental health team.
59. On 14 December, Senior Nurse A saw Mr Turner for a mental health review. She
noted that Mr Turner said he was “terribly down and does not think he can get much
lower”, and that he had suicidal thoughts but tried to get rid of them by reading or
doing crosswords. He said that, since the reduction in his diazepam dose, he was
not eating, felt constantly tearful, was not sleeping and had panic attacks. Senior
Nurse A completed a patient health questionnaire (known as PHQ-9) and a
generalised anxiety disorder (known as GAD7) score with Mr Turner, which showed
that he had severe depression and severe anxiety disorder. Senior Nurse A
planned to discuss Mr Turner’s medication and asked another senior nurse to check
his depression and anxiety scores. There is no record that the other senior nurse
did this. Senior Nurse A did not start Prison Service suicide and self-harm
monitoring (known as ACCT).
60. Two days later, a SO saw Mr Turner, who was upset that his legal visit had been
cancelled and said that he was struggling to sleep. The SO confirmed that the
police had cancelled their visit and she arranged for Mr Turner to move cells to aid
his sleeping.
61. On 18 December, Mr Turner completed a mental health referral form and said that
he had suicidal thoughts daily, but that his wife and daughter stopped him from
taking his life.
62. Two days later, Nurse B saw Mr Turner for a mental health review. She noted that
Mr Turner was increasingly unkempt and officers had noticed a severe change in
his mood. Mr Turner said that he woke up every morning with thoughts of suicide
but he was adamant that he would not act on them. Nurse B noted that she did not
have any concerns about Mr Turner’s risk of self-harm. She asked the mental
health team to check on Mr Turner. She did not start ACCT monitoring.
63. On 21 December, a nurse saw Mr Turner for a welfare check and noted that he
presented as a low risk of suicide. She noted that Mr Turner said he had no
thoughts of or plans for suicide or self-harm and that his wife and daughter were
protective factors. He said that he felt sick and anxious daily but that he was trying
to occupy his time by colouring and talking to officers. She noted that Mr Turner
presented as flat in mood and with tears in his eyes, though he kept good eye
contact and was appropriate and polite throughout. The nurse reassured Mr Turner
and discussed the extra support that the mental health team could provide him.
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64. The same day, Mr Turner wrote a letter to his family and said that he was at his
lowest point. Mr Turner said that he had begged for help but that doctors did not
seem to want to help him, and that he “simply cannot do it anymore”.
65. On 24 December, an officer saw Mr Turner for a key worker session, as his key
worker had been off work. Mr Turner said that he felt at his lowest, as he wanted his
medication sorted.
66. At 11.30am, a clinical manager saw Mr Turner for a mental health review and noted
that he presented as a low risk of suicide. Mr Turner said that his mood had
declined significantly since his diazepam dose had been decreased and that
citalopram was not working. He decreased the citalopram dose to 20mg and
prescribed a 50mg dose of sertraline (another antidepressant) from 3 January 2020.
Mr Turner was not happy at the reduction but he explained this was needed before
introducing sertraline. The clinical manager tasked Nurse C, an agency nurse, to
monitor Mr Turner’s medication withdrawal.
67. Later that day, another senior nurse reallocated the monitoring task to Senior Nurse
A. There is no record that Senior Nurse A or any other nurse monitored Mr Turner’s
withdrawal.
68. On 31 December, Senior Nurse A saw Mr Turner for a mental health review. Mr
Turner said that he needed a replacement for his diazepam prescription but Senior
Nurse A said this could not happen. Mr Turner said that he had daily suicidal
thoughts and that he did not “want to be here”. Senior Nurse A suggested cognitive
behavioural therapy (CBT – a talking therapy that can help you manage your
problems by changing the way you think and behave) could help with Mr Turner’s
anxiety and he agreed to try it.
69. The same day, a mental health team meeting decided that Nurse C needed to
monitor Mr Turner’s withdrawal from citalopram as Senior Nurse A felt she did not
have the right skills to support him. The meeting decided that once Mr Turner’s
medication stabilised, a nurse could see him for CBT. Later that day, a senior
healthcare manager told Nurse C that his final shift at the prison would be on 7
January 2020, though Nurse C did not return. (A new nurse was not allocated to Mr
Turner until 9 January.)
70. On 5 January 2020, Nurse B saw Mr Turner, who said that he was very low in
mood, struggling and “only just coping”. Nurse B referred Mr Turner to the mental
health team, though the referral was not reviewed until after his death. There is no
record that Nurse B recorded this information in Mr Turner’s electronic medical
record and it was only recorded on the referral to mental health.
71. On 7 January, Nurse D saw Mr Turner, who said he was “really struggling” so
wanted something to help him sleep and to talk to someone in the mental health
team. Nurse D referred Mr Turner to a prison GP and the mental health team,
though the mental health referral was not reviewed until after his death.
72. The same day, Mr Turner wrote in his diary that it was “another feeling really low
day”.
73. On 8 January, Mr Turner met with his solicitor and they discussed the pre-interview
disclosure provided by North Yorkshire Police. The police were investigating two
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serious sexual offences and one false imprisonment offence and planned to
interview Mr Turner on 10 January.
74. The same day, Mr Turner wrote in his diary that he was “absolutely gobsmacked at
the allegations but guilty or not, it will change lives. I have never ever done anything
FACT. Can’t do this anymore. I love my family so so much.”
Events on 9 January 2020
75. At 7.33am, Mr Turner pushed his cell bell. An officer responded and Mr Turner said
he had pushed it by accident, as he had meant to turn on his cell light.
76. At 8.08am, Officer A started unlocking cells on Mr Turner’s landing. Officer A
unlocked Mr Turner’s cell, but did not open the door, and then quickly moved onto
the next cell.
77. At 8.28am, Officer B checked on Mr Turner’s landing to see whether prisoners had
gone to work. Officer B looked into the cell, through the observation panel, and then
quickly moved onto the next cell.
78. At 8.53am, Mr Turner’s wife telephoned Humber’s switchboard and said she had
not heard from him that morning. She said that Mr Turner had been “feeling really
low” and she wanted to know whether the prison could check on him. The call
handler, working for Shared Services Connected Ltd (SSCL) on behalf of HM
Prison and Probation Service, said that she could not ask for an update because Mr
Turner had contacted his wife in the last seven days and due to “data protection,
security and safety reasons”.
79. At approximately 9.55am, a prisoner went to Mr Turner’s cell, as he had not seen
him that morning, and found him on the floor in a pool of blood. He shouted to staff.
Two officers responded and found that Mr Turner had cut his throat three times and
his left wrist once with a razor blade. An officer placed a towel on Mr Turner’s neck
and the other officer called a code red emergency (which indicates that a prisoner
has suffered a severe loss of blood).
80. Two nurses and two healthcare assistants quickly responded to the code red
emergency. Initially, a nurse found that Mr Turner was breathing and had a faint
pulse, though he quickly stopped breathing. They started cardiopulmonary
resuscitation (CPR), inserted an airway (without lubricant, as an officer could not
find it), gave Mr Turner oxygen and attached a defibrillator, which did not detect a
shockable heart rhythm and advised to continue CPR. A nurse asked a healthcare
assistant to apply pressure to Mr Turner’s neck with his foot but he refused as he
had a hamstring injury and did not think it was appropriate. Once he left the cell, the
other healthcare assistant applied pressure to the right side of Mr Turner’s neck
with his foot.
81. At 9.58am, an operational support grade officer (OSG) called for an ambulance,
though he was unable to immediately give the Yorkshire Ambulance Service
sufficient information to determine the urgency of the call. He also named another
prisoner as the patient rather than Mr Turner. Four minutes into the call, the OSG
passed on information from the scene that Mr Turner did not have a pulse. At that
point, the Ambulance Service sent two ambulances and an air ambulance, which
reached Mr Turner at 10.10am, 10.23am and 10.29am respectively. They took over
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the resuscitation attempt and gave Mr Turner adrenaline and sodium chloride. The
paramedics were unable to resuscitate Mr Turner and, at 10.34am, an air
ambulance doctor declared that he had died.
82. Mr Turner left two notes to his family in his cell and wrote an entry in his diary. The
notes said he could not live with the allegations that he was facing and could not
cope with the backlash they would cause. The diary entry said, “I cannot live with
that, please understand I am so so sorry” and “I was intent on doing this”.
Contact with Mr Turner’s family
83. Following Mr Turner’s death, the prison appointed a SO as the prison’s family
liaison officer (FLO). At 12.15pm, the FLO and the Deputy Governor visited the
home address of Mr Turner’s wife and broke the news of his death. They offered
their condolences and support.
84. Later that day, Mr Turner’s wife called the FLO and said that she had called the
prison that morning to raise concerns about him but she was told that no action
would be taken unless she had not heard from him for seven days.
85. On 10 January, Mr Turner’s wife told the FLO that she wanted minimal contact from
the prison and did not want any prison staff to attend Mr Turner’s funeral. The FLO
followed her wishes and had limited contact with Mr Turner’s wife until his funeral,
which was held on 30 January. The prison contributed towards the costs of the
funeral in line with national instructions.
Support for prisoners and staff
86. After Mr Turner’s death, senior prison managers spoke with most of the staff
involved in the emergency response to offer support. The staff care team and TRiM
practitioners (prison staff trained to deliver trauma risk management and ongoing
support) offered support to most staff.
87. The prison posted notices informing other prisoners of Mr Turner’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 Mr Turner’s death and
started ACCT monitoring for a prisoner to ensure that he received adequate
support.
Post-mortem report
88. The coroner has not yet provided us with a copy of the post-mortem or toxicology
reports.
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Findings
Assessment of Mr Turner’s risk of suicide and self-harm
89. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), provides a non-exhaustive list of
a number of risk factors and potential triggers that might increase a prisoner’s risk
of suicide and self-harm. These require staff to take appropriate action, such as
starting ACCT procedures or referring prisoners to the mental health team. Staff
must identify prisoners at risk of self-harm and suicide, and that information should
be shared between prison and healthcare staff.
90. We have considered whether staff at Humber should have recognised that Mr
Turner was at risk of suicide and begun ACCT procedures to support him.
91. Mr Turner had some key risk factors: he was struggling with his mental health; he
had been convicted of a violent offence against a former partner; and he was
concerned that he could be facing further serious charges which could result in a
lengthy prison sentence.
92. Between 14 and 31 December, Mr Turner made four statements that he had had
suicidal thoughts, to Senior Nurse A, to Nurse B and on a mental health referral
form. Despite making these statements, neither nurse started ACCT monitoring.
Senior Nurse A told the investigator that she did not think Mr Turner’s statement
was sufficient to justify putting him on an ACCT, as “a thought is a thought”, while
Nurse B thought it was more chronic rather than him actively wanting to take his
own life. Both nurses felt that the fact that Mr Turner had friends on the wing and
was associating was an added reason not to do so.
93. While Senior Nurse A and Nurse B told the investigator why they decided not to
start ACCT monitoring, they did not record their reasoning on Mr Turner’s electronic
medical record. Additionally, there is no record that Senior Nurse A or Nurse B
made prison staff aware that Mr Turner had made these suicidal statements and
that they had decided not to start ACCT monitoring. The prison staff interviewed by
the investigator had no knowledge that Mr Turner had suicidal thoughts before his
death and most expressed surprise that the nurses had not shared this information.
Conversely, the healthcare staff interviewed by the investigator had no knowledge
that Mr Turner was worried about another police investigation, which may have
added context to his suicidal statements.
94. We are very concerned that Senior Nurse A and Nurse B did not put Mr Turner on
an ACCT and that they placed too much emphasis on his statements that he would
not act on his suicidal thoughts or that he could distract himself. We are also
concerned that prison and healthcare staff did not share information about Mr
Turner so no one recognised that his risk of suicide had markedly increased.
95. In a learning lessons thematic, Risk factors in self-inflicted deaths in prisons,
published by the Prisons and Probation Ombudsman in April 2014, we identified
that too often when risk is assessed, evidence of risk factors is not fully considered
and that too great an emphasis is placed on staff perception of a prisoner’s state of
mind. We make the following recommendations:
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The Governor and the Head of Healthcare should ensure that all staff have a
clear understanding of their responsibilities to manage prisoners at risk of
suicide and self-harm in line with national guidelines and, in particular,
understand:
• the need to record, share and consider all relevant information about
risk, and start ACCT procedures when indicated; and
• the need to consider risk factors rather than simply relying on what the
prisoner says or how he presents.
The Head of Healthcare should share a copy of this report with Senior Nurse
A and Nurse B and discuss the Ombudsman’s findings with them.
Mental health
96. On 14 December, Mr Turner’s PHQ-9 and GAD7 scores showed that he had severe
depression and severe anxiety disorder. While these scores were only relevant on
the day Senior Nurse A completed them, there is no record that they were repeated.
Senior Nurse A also told the investigator that she asked her colleagues for their
views on his scores because she was not used to completing the PHQ-9 or GAD7,
though she never received a reply.
97. From 24 December, after the clinical manager decided that healthcare staff needed
to monitor Mr Turner’s withdrawal from citalopram, the mental health team chose
Senior Nurse A to monitor his medication withdrawal. There are no entries on Mr
Turner’s electronic medical record between 24 and 31 December and it is not clear
why Senior Nurse A or any other member of healthcare staff did not monitor Mr
Turner’s withdrawal or perform a simple welfare check.
98. On 31 December, Nurse C replaced Senior Nurse A as Mr Turner’s mental health
keyworker, though he stopped working at Humber that day. No one was allocated to
Mr Turner until 9 January, which meant that a mental health nurse did not see Mr
Turner before his death.
99. On 5 and 7 January, Nurse A and Nurse D, respectively, tasked the mental health
team to check on Mr Turner, though a mental health nurse did not review these
tasks until 9 January, the day of his death. During interviews with Senior Nurse A,
the clinical manager and Nurse B, they told the investigator that there was an
expectation that tasks were checked daily. It is not, therefore, clear why these tasks
were not checked until 9 January.
100. We are concerned that there were missed opportunities to support Mr Turner, as no
one monitored his medication withdrawal, promptly replaced Nurse C or checked on
Mr Turner after being tasked to do so by their primary care colleagues. We are also
concerned that there was a lack of peer support within the mental health team as
Senior Nurse A’s request for help with Mr Turner’s PHQ-9 and GAD7 scores went
unanswered.
101. The clinical reviewer concluded that the mental health care Mr Turner received was
not equivalent to that which he could have expected to receive in the community.
We make the following recommendation:
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The Head of Healthcare should ensure that:
• mental health tasks are checked daily, clearly actioned and allocated to
appropriate members of the team;
• mental health services are prioritised and reallocated when staff leave
the service; and
• all staff are trained in the use of the patient health questionnaire and
the generalised anxiety disorder score and they feel competent to
complete them.
102. With regard to Mr Turner’s diazepam prescription, the clinical reviewer considered
that the prison GPs acted appropriately in decreasing his dosage. Mr Turner had
been prescribed diazepam in the community for a lengthy period, which goes
against the prescribing guidelines and can cause dependency.
Mr Turner’s wife’s call to Humber’s switchboard
103. SSCL provided the investigator with an Important Reminder – Safer Custody
document that sets out the processes to be followed if the switchboard receives a
telephone call that raises concern that there has been no contact from a prisoner or
that there is the threat of self-harm or suicide. The document says that the
telephone call should be transferred to the prison’s Safer Custody hotline if there is
a credible concern about a prisoner but no immediate threat. The document does
not make any reference to the length of time that the prisoner has been out of
contact.
104. On the morning of Mr Turner’s death, around an hour before he was found, his wife
telephoned Humber’s switchboard and asked if someone could check on her
husband as she had not heard from him that morning. The operator told her,
incorrectly, that as she had heard from him within the past seven days, they could
not request an update. Although Mr Turner’s wife had heard from Mr Turner on 8
January, we are concerned that the operator did not investigate how unusual Mr
Turner’s behaviour was and so failed to understand that he called his wife before
8.00am every weekday, except Bank Holidays.
105. We are also concerned that, although Mr Turner’s wife raised a credible concern
about Mr Turner’s mood, the operator did not transfer her to Humber’s Safer
Custody hotline. Calls to the hotline are answered by Safer Custody staff between
9.00am and 5.00pm, and calls are diverted to the control room outside those times.
We are concerned that the switchboard operator’s failure to refer Mr Turner’s wife to
the Safer Custody hotline resulted in a missed opportunity for someone to check on
Mr Turner.
106. We make the following recommendations:
The Effective Practice and Service Improvement Group should liaise with
SSCL to ensure that any calls raising credible concerns about a prisoner
should be transferred to Humber’s Safer Custody hotline.
SSCL should provide refresher training to its switchboard staff to ensure that
they know what to do when they receive calls raising concerns about a
prisoner’s wellbeing.
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Unlock
107. PSI 75/2011, Residential Services, says that prison staff play a key role in spotting
any signs of distress in prisoners and that systems need to be in place for staff to
assure themselves of the wellbeing of prisoners during or shortly after being
unlocked.
108. On 29 January 2019, Humber issued a Staff Information Notice that reminded staff
that, when unlocking prisoners, they should get a verbal response or see physical
movement before moving onto the next cell.
109. CCTV footage shows that on the morning of Mr Turner’s death, Officer A unlocked
Mr Turner’s cell but did not open the door. He spent a matter of seconds outside Mr
Turner’s cell and could not have obtained a verbal response or seen any
movement.
110. Twenty minutes later, at 8.28am, Officer B looked through Mr Turner’s cell’s
observation panel. He told the investigator that he could not recall looking through
the observation panel though he would have noticed if Mr Turner had been on the
floor in a pool of blood.
111. While we recognise that Mr Turner appears to have been alive when Officer A
unlocked his cell, we are concerned that he did not check on his wellbeing and that
such an error could be vital in the future. We make the following recommendation:
The Governor should ensure that, when a cell door is unlocked, officers
satisfy themselves of the wellbeing of the prisoner and that there are no
immediate issues that need attention.
The Governor should share a copy of this report with Officer A and ensure
that a senior manager discusses the Ombudsman’s findings with him.
Emergency response
Resuscitation attempt
112. After an officer called the code red emergency, many healthcare staff quickly
responded. Although two nurses and two healthcare assistants entered Mr Turner’s
cell and tried to resuscitate him, we are concerned that no other healthcare staff
took over management of the emergency bag from the officer. From reviewing
body-worn camera footage, the officer could not easily find the correct equipment
that the nurses wanted so there was a slight delay in locating the bag mask valve
and a nurse had to insert the airway without lubrication. While this is unlikely to
have affected the outcome for Mr Turner, it could be vital in the future. We make the
following recommendation:
The Governor and the Head of Healthcare should ensure that healthcare staff
are responsible for managing emergency bags during medical emergencies,
unless they are not available.
113. The body-worn camera footage and a witness statement from a healthcare
assistant revealed that he felt uncomfortable being asked to use his foot to stem the
bleeding from Mr Turner’s throat. While we appreciate that placing a foot on a
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wound is not standard procedure, we agree with the clinical reviewer that the
nurses were working to save Mr Turner’s life and that any criticism would be unfair.
Ambulance call
114. PSI 03/2013, Medical Emergency Response Codes, contains mandatory
instructions that staff must use emergency codes to clearly convey the natural of
the medical situation and that on hearing a code red or blue, control room staff must
call an ambulance immediately.
115. Humber’s Emergency Medical Response Codes protocol says the member of staff
calling an emergency code must provide information on whether the prisoner is
breathing, whether they are conscious and a brief summary of what is wrong with
them, as this will allow the control room operator to relay the information to the
Ambulance Service.
116. An officer called the code red at 9.58am and an OSG immediately called for an
ambulance. However, due to delays in passing information about Mr Turner’s
condition from the scene to the control room, it took four minutes for the Yorkshire
Ambulance Service to appreciate the severity of the incident and to send
emergency ambulances. The officer told the investigator that he could only use his
radio to call an emergency code and was not allowed to send additional information
about what had happened.
117. While the officer met the requirements of PSI 03/2013, we are concerned that he
did not follow Humber’s local protocol by providing information about Mr Turner’s
condition. This caused a four-minute delay in sending emergency ambulances.
While we cannot say whether providing this information would have changed the
outcome for Mr Turner, it could be critical in other cases. We make the following
recommendation:
The Governor should ensure that when staff call a medical emergency code,
they promptly provide information about a prisoner’s condition to the control
room so that they can pass this information to the Ambulance Service.
Staff support
118. Following Mr Turner’s death, senior prison managers and TRiM practitioners offered
support to most of the staff involved in the emergency response. However, we are
concerned that the officer, who found Mr Turner, told the investigator that he had
not received a TRiM assessment and an officer, who was the third officer to enter
Mr Turner’s cell, told the investigator that he had not received immediate support
from senior prison managers. While we appreciate that Humber did not intend to
exclude both officers, we are concerned that both officers did not receive full
support for such a traumatic incident. We make the following recommendation:
The Governor should ensure that staff are offered appropriate support,
including access to TRiM practitioners, following a death in custody or other
traumatic event.
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Incident report forms
119. PSI 64/2011 sets out the actions that should be taken following a death in custody.
This includes that all staff directly involved in an incident, particularly those first on
scene, must complete Incident Report Forms as soon as possible.
120. As part of the investigation, Humber provided six statements from the healthcare
staff involved in the emergency response and an officer gave one directly to the
investigator. However, none of the other prison staff involved in the emergency
response completed Incident Report Forms, despite being asked to do so by an
officer on 15 January. We make the following recommendation:
The Governor should ensure that all managers follow the national
instructions for dealing with a death in custody or serious incident, including
that all staff directly involved in an incident complete Incident Report Forms
as soon as possible.
Inquest
121. At the inquest, held from 16 to 23 September 2024, the jury concluded that Mr
Turner died by suicide.
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