Nicola Birchall

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Ms Nicola Birchall,
a prisoner at HMP/YOI Styal, on
4 February 2018
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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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 Nicola Birchall died from multiple drug use with chronic obstructive pulmonary disease
on 4 February 2018, two days after arriving at HMP Styal. She was 41 years old. I offer
my condolences to Ms Birchall’s family and friends.
Ms Birchall had abused both illicit and prescription drugs for several years. She had very
poor physical and mental health. She was detoxing when she arrived at Styal and was
prescribed medication for her withdrawal symptoms.
The clinical reviewer is satisfied that the healthcare Ms Birchall received at Styal was
equivalent to that which she could have expected to receive in the community.
I am concerned, however, that although prison staff observe all new prisoners hourly
during their first night in custody, there are no formal observations on those women who
are detoxifying after this. I am also concerned that although healthcare staff visit the First
Night Centre three times a day to issue medication, the Centre is staffed by prison officers
who have no specialist training in the management of prisoners who are withdrawing from
drugs.
Ms Birchall vomited a great deal during her time in the Centre, but prison staff considered
that this was normal for prisoners who were withdrawing and did not seek medical advice.
We cannot say whether the outcome might have been different for Ms Birchall if she had
been reviewed by a healthcare professional.
I am also concerned that the officer who unlocked Ms Birchall on the morning of her death
did not obtain a response from her, as she should have done. As a result, it was another
hour before her cellmate realised, she was unresponsive. We cannot say whether the
outcome might have been different for Ms Birchall if she had been found earlier.
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 September 2019
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. On Friday 2 February 2018, Ms Nicola Birchall was remanded to HMP Styal after
being arrested and charged with possession of class A drugs with intent to supply.
Ms Birchall had been at Styal previously and was known to staff.
2. When she arrived at the prison, Ms Birchall was taken to the First Night Centre
(FNC) and she was assessed by a healthcare assistant (HCA). The HCA recorded
a detailed medical history. Following the initial health screen, a further assessment
and more in-depth record of Ms Birchall’s medical history was completed by a
nursing practitioner.
3. Ms Birchall was identified as detoxing from illicit drugs and she was also in receipt
of a regular methadone prescription. Medication to alleviate symptoms of
withdrawal were prescribed and on Saturday 3 February, Ms Birchall was
prescribed 70ml of methadone.
4. Ms Birchall vomited a great deal and spent much of her time sleeping, although she
did leave her room at times to associate with other prisoners.
5. At 9.10am on Sunday 4 February 2018, an officer began to unlock the women on
the FNC to collect their breakfast. At 10.10am, staff were alerted by a commotion
upstairs. They immediately ran upstairs and found Ms Birchall lying unresponsive
on her bed. An officer immediately used her radio to call a medical emergency
code.
6. A nurse arrived and checked for a pulse but found none. More staff arrived and
brought the emergency medical equipment, including a defibrillator. Staff began
cardiopulmonary resuscitation (CPR) until an ambulance arrived at 10.20am.
7. Staff and paramedics continued resuscitation for 60 minutes but Ms Birchall did not
respond to treatment. At 11.15 am, the paramedics confirmed that Ms Birchall had
died.
8. The post-mortem report gave the cause of death as multiple drug use with chronic
obstructive pulmonary disease.
Findings
9. The clinical reviewer is satisfied that the clinical care Ms Birchall received at Styal
was equivalent to that which she could have expected to receive in the community.
She said that Ms Birchall’s physical and mental health concerns were identified and
recorded appropriately and that she was prescribed appropriate medications,
including methadone, for her drug withdrawal.
10. We are concerned that although prison staff observe all new prisoners hourly in the
FNC during their first night in custody, there is no formal monitoring of those women
who are detoxifying from drugs after this.
11. We are also concerned that apart from when nurses visit to give medication three
times a day, there is no healthcare presence in the FNC and it is staffed by prison
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officers who have no specialist training in the management of prisoners who are
withdrawing from drugs.
12. When an officer unlocked Ms Birchall’s room door on 4 February, she did not wait to
get a response from Ms Birchall before moving onto the next room, which is
contrary to Prison Service instructions. As a result, Ms Birchall was not found
unresponsive until an hour later. We cannot say whether earlier intervention might
have changed the outcome for Ms Birchall.
Recommendations
• The Governor and Head of Healthcare should review the presence of
healthcare and substance misuse staff in the First Night Centre.
• The Governor should consider detoxification awareness training for all officers
who work in the First Night Centre, to ensure safe and supportive management
of prisoners withdrawing from drugs.
• The Head of Healthcare should ensure that prison staff in the FNC have written
guidance on what symptoms they should watch for in detoxing prisoners and
when they should seek medical help.
• The Governor should review the procedures for unlocking prisoners and
ensure that, when a cell door is unlocked, staff satisfy themselves of the safety
of the prisoner and that there are no immediate issues that need attention.
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The Investigation Process
13. HMPPS notified us of Ms Birchall’s death on 5 February 2018.
14. The investigator issued notices to staff and prisoners at HMP Styal informing them
of the investigation and asking anyone with relevant information to contact him. No
one responded.
15. The investigator obtained copies of relevant extracts from Ms Birchall’s prison and
medical records.
16. The investigator interviewed four members of staff at HMP Styal on 15 March 2018.
17. NHS England commissioned a review into Ms Birchall’s clinical care at the prison.
The reviewer attended all interviews.
18. We informed HM Coroner for Cheshire of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
19. The Coroner concluded an inquest on 29 July 2024 into Ms Birchall’s death and
concluded that her death was the result of long term and ongoing drug use, which
included a severe respiratory disease.
20. The Ombudsman’s family liaison officer contacted Ms Birchall’s to explain the
investigation and to ask if they had any matters, they wanted us to consider.
• Ms Birchall had a badly infected leg prior to going into custody. Did she
receive the appropriate treatment for this?
• Did Ms Birchall press the cell bell to call for help on the morning of 4
February?
• Was Ms Birchall checked during the night?
• Did Ms Birchall receive appropriate treatment for her withdrawal, and could
her death have been prevented?
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Background Information
HMP Styal
21. HMP Styal is a female prison holding up to 460 women. There is a variety of
residential units with 16 separate houses each holding about 20 women, and a
mother and baby unit.
22. Spectrum Community Health provides healthcare services at the prison. Lifeline
delivers psychosocial intervention to substance users. 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 in-patient facility.
HM Inspectorate of Prisons
23. HMP Styal is a female prison holding up to 460 women. There is a variety of
residential units with 16 separate houses each holding about 20 women, and a
mother and baby unit.
24. Spectrum Community Health provides healthcare services at the prison. Lifeline
delivers psychosocial intervention to substance users. 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 in-patient facility.
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
very appropriate care and support was given to new admissions through Reception
and on to the First Night Centre, and that both units made good use of peer
mentors in supporting the new admissions.
Previous deaths at HMP Styal
26. Ms Birchall’s death was the third death at HMP Styal since August 2016. One of
the previous deaths was self-inflicted and one was from natural causes. There
were no significant similarities with Ms Birchall’s death. There have been three
apparently self-inflicted deaths since.
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Key Events
27. On Friday 2 February 2018, Ms Nicola Birchall was remanded to HMP Styal after
being arrested and charged with possession of class A drugs with intent to supply.
Ms Birchall had been at Styal previously and was known to staff.
28. When she arrived at the prison, Ms Birchall was taken to the First Night Centre
(FNC) where she had a reception screen and was assessed by a healthcare
assistant (HCA). The HCA recorded a detailed medical history, recording that Ms
Birchall had a twenty-year drug history and was an intravenous drug user. Ms
Birchall said that she had been injecting drugs into her groin. The HCA took Ms
Birchall’s clinical observations of heart rate, blood pressure (which was raised at
131/96), and temperature, which was normal, and all indicative of withdrawal
symptoms. She also examined Ms Birchall’s groin area and recorded that there
were no signs of infection.
29. Ms Birchall told the HCA that she did not have any thoughts of suicide or any intent
to self-harm while in custody but said that she had made cuts to her arms prior to
custody, although she did not indicate how long before. The HCA did not consider
there was a need for Ms Birchall to be monitored under suicide and self-harm
prevention procedures (known as ACCT).
30. A further assessment and more in-depth record of Ms Birchall’s medical history was
completed by a Nursing Practitioner. The nursing practitioner noted that Ms Birchall
had a 20-year history of poly-drug use, intravenous heroin use and alcohol abuse.
She also noted that Ms Birchall’s physical health problems were extensive and
included kidney, chest, circulatory and breathing problems associated with asthma
and chronic obstructive pulmonary disease (a collection of lung diseases), epilepsy,
cellulitis (an infection of the skin), abscesses and leg ulcers (from intravenous drug
injection sites) and deep vein thrombosis. Ms Birchall’s medical history recorded
that she frequently refused to engage with mental health, physical health and
substance misuse services, both in the community and during previous periods in
prison.
31. Ms Birchall also had a history of poor mental health. She had been diagnosed with
paranoid schizophrenia in 2011/2012, had a history of depression, and had been
detained under the Mental Health Act in 2011.
32. The nursing practitioner prescribed methadone (for drug detoxification), mirtazapine
(used to treat depression) and quetiapine (an antipsychotic drug used to treat
paranoid schizophrenia).
33. Ms Birchall said that she regularly took 300mg of pregabalin, twice a day, in the
community. (The clinical reviewer could find no record that Ms Birchall had been
prescribed pregabalin.) Pregabalin is used for the treatment of epilepsy and anxiety
and for pain relief. It is frequently abused because of its euphoric effects. The
nursing practitioner told Ms Birchall that she would not be prescribed pregabalin as
tradable and abused medications such as pregabalin are not prescribed under the
prison’s drug policy.
34. The nursing practitioner recorded that Ms Birchall had last used heroin and crack
cocaine on 31 January. She identified that Ms Birchall was showing signs of
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moderate levels of opiate withdrawal. Ms Birchall refused to comment when asked
about her alcohol consumption. Her scores for alcohol withdrawal were zero. The
nursing practitioner prescribed medication to alleviate the symptoms of opiate
withdrawal and made a routine referral to the mental health team.
35. Ms Birchall was located in a shared room in the FNC. She was observed hourly
during her first night. (All new prisoners are observed hourly on their first night, not
just those detoxing.)
36. On the morning of 3 February, an HCA completed Ms Birchall’s secondary health
screen. The HCA repeated the assessment to gauge the level of opiate withdrawal
and the results showed it had reduced.
37. A member of staff from the Chaplaincy noted that he had seen Ms Birchall that
morning but that she “was too ill and out of things to talk to”.
38. Later that day, a mental health nurse went to see Ms Birchall to complete a routine
mental health assessment. Ms Birchall declined to engage with her because she
said she was feeling unwell due to detoxing but said she would engage with the
service when she was feeling better. The mental health nurse placed Ms Birchall
on the list for discussion by the mental health team on 6 February.
39. That afternoon, the nursing practitioner prescribed 70ml of methadone after
confirming Ms Birchall’s prescription with the community pharmacy.
40. Ms Birchall’s cellmate told the investigator that although Ms Birchall was clearly
detoxing and unwell, she had left their room on Friday evening and Saturday
morning to associate with the other women in the unit. The prisoner said that she
did not see Ms Birchall use any illicit drugs at Styal.
41. An officer told the investigator that Ms Birchall appeared to be detoxing. She said
she had vomited in the association room on Friday evening and Saturday morning
and had spent much of the time sleeping since arriving in the FNC. The officer said
that Ms Birchall was known to be detoxing and although she was unwell, this was
not unusual when women were detoxing, and she had no other reason to alert
healthcare staff about Ms Birchall’s condition.
Events of 4 February 2018
42. The cellmate told the investigator that Ms Birchall had been in and out of sleep
during the night and they were both awake at around 6.00am in the morning, then
Ms Birchall went back to sleep. Ms Birchall did not ring her cell bell during the night
or morning of 4 February.
43. At 9.10am, an officer began to unlock the women in the FNC for breakfast. The
officer was not available for interview, but provided the investigator with a statement
which said that when she unlocked Ms Birchall’s room door, she looked in and Ms
Birchall appeared to be asleep. The officer did not call out to Ms Birchall and wait
for a response. She then unlocked the remainder of the rooms, before returning
downstairs to the ground floor.
44. The officer said that based on her observation of Ms Birchall over the weekend, she
did not think it was unusual for Ms Birchall to still be sleeping. Although, Ms Birchall
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did not collect her breakfast on the Sunday morning, the officer said that she was
satisfied she had seen Ms Birchall at unlock. There are no organised activities in
the FNC Centre on a Sunday, so she did not feel it necessary to ensure that Ms
Birchall was up and about, but decided to let her rest, as she had obviously not
been very well over the weekend.
45. At 10.10am, the officer heard “a lot of commotion” upstairs, and somebody shouting
and screaming. The officer and another officer immediately ran upstairs and found
the cellmate in a hysterical state and shouting, ‘She’s dead.’
46. The officer saw Ms Birchall lying on her bed and radioed a code blue emergency
(indicating that a prisoner is unconscious or having breathing difficulties). An
ambulance was called immediately by staff in the control room.
47. A nurse responded. She saw Ms Birchall lying on the bed, facing away from her.
When she turned Ms Birchall over she noted that her mouth and hands were blue
and she had a pale complexion. There was also a bucket of vomit next to her bed.
The nurse checked for a pulse but found none.
48. A custodial manager arrived, followed by an HCA who brought the emergency
medical equipment, including a defibrillator. They started cardiopulmonary
resuscitation (CPR). Another nurse also arrived. She assisted with CPR and
helped to move Ms Birchall out of the room and onto the landing.
49. At interview staff said that Ms Birchall did not show signs of rigor mortis. She was
warm to touch, although mottled and pale. She had cyanosed lips (low levels of
oxygen) and blue hands.
50. Healthcare and custodial staff continued with CPR until paramedics arrived at
10.20am. Staff and paramedics continued resuscitation for 60 minutes. Ms Birchall
did not respond to treatment and at 11.15am, the paramedics confirmed that Ms
Birchall had died.
Contact with Ms Birchall’s family.
51. Following Ms Birchall’s death, the Governor visited Ms Birchall’s family to inform
them of her death. The family were told that an investigation would follow and they
were offered continued support.
52. The prison contributed towards the cost of Ms Birchall’s funeral in line with national
policy.
Support for prisoners and staff
53. After Ms Birchall’s death, the duty governor debriefed the staff involved in the
emergency response, alongside the Governor to ensure they had the opportunity to
discuss any issues arising, and to offer support.
54. The prison posted notices informing other prisoners of Ms Birchall’s death and
offering support. The residents were briefed in person regarding Ms Birchall’s
death, including a member of the Chaplaincy team to offer further support. Staff
reviewed all prisoners assessed as being at risk of suicide or self-harm in case they
had been adversely affected by Ms Birchall’s death.
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Post-mortem report
55. The toxicology tests found that several substances were present in Ms Birchall’s
system, including methadone, cocaine, free morphine, dihydrocodeine, quetiapine
and quinine.
56. The pathologist found that the individual levels of drugs were an indication of heavy
use prior to Ms Birchall being arrested on 2 February, and that drug interactions
were complex and unpredictable.
57. The pathologist concluded that on the balance of probabilities, the effects of Ms
Birchall’s long-term drug use had a bearing on her death, due to her congested
lungs. The pathologist gave the cause of death as multiple drug use with chronic
obstructive pulmonary disease.
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Findings
Clinical care
58. Ms Birchall had a very long history of poly-drug misuse, and often failed to engage
with mental, physical and substance misuse services in the community, despite
services attempting to engage with her. Thorough first and second reception
screenings were completed by healthcare staff at Styal. Mental health services
attempted to engage with Ms Birchall, but she declined.
59. The clinical reviewer is satisfied that the clinical care Ms Birchall received at Styal
was of a good standard and equivalent to that which she could have expected to
receive in the community.
60. The clinical reviewer considered that Ms Birchall’s leg ulcers were due to her
intravenous drug injecting. Her community medical records noted that she had
frequently failed to attend appointments to have the ulcers treated and dressed.
61. It is unclear what condition the leg ulcers were in when she arrived at the prison as
there is no evidence that Ms Birchall told staff that they were a problem or needed
attention. The clinical reviewer said that Ms Birchall’s clinical observations were all
within acceptable limits for her age and indicated no signs of infection from the
ulcers at that time. The pathologist recorded that Ms Birchall had " chronic
ulceration to the lower left shin” and noted that, although “there was a small amount
of surface pus staining, there did not appear to be a significant infection in the
surrounding tissues".
Detoxification monitoring arrangements.
62. Ms Birchall was located in the FNC at Styal. All women entering the prison are
expected to remain in the FNC for at least 48-72 hours, during which time they will
be seen and interviewed by support services including the Drug and Alcohol
Recovery Service (DARS) and the Chaplaincy. Nursing staff attend the FNC every
morning, afternoon and evening to issue medications, but there is no healthcare or
DARS presence on the unit outside of these times.
63. All prisoners in the FNC are observed by prison staff hourly during the first night in
custody. This is routine and regardless of any concerns relating to underlying risk,
such as detoxification. After the first night, there are no further requirements for
staff to monitor prisoners, including those who are detoxing (unless they are subject
to ACCT procedures).
64. The clinical reviewer found that the management of Ms Birchall’s detoxification was
reasonable. Healthcare staff appropriately identified that Ms Birchall was showing
signs of drug withdrawal during her reception screen and prescribed the most
appropriate medication in line with withdrawal guidelines. Opiate withdrawal drugs
were prescribed in the appropriate timescales, and signs of alcohol and drug
withdrawal were noted in her medical records, using the appropriate withdrawal
scoring systems.
65. However, we are concerned that there is insufficient healthcare and DARS
presence in the FNC to support and monitor women who are detoxing from drugs.
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Although prison officers have no official substance misuse training, they are
expected to contact healthcare staff or use the out of hours service if they have any
concerns. We have not seen any guidance that tells them what concerning
symptoms they should look for or when they should seek medical attention for a
prisoner.
66. Ms Birchall had symptoms of opiate withdrawal on her arrival at the prison and she
was prescribed methadone. It is clear that she was unwell and had been vomiting
over the weekend. The officer said that she was aware that Ms Birchall was unwell
due to withdrawal symptoms but that this was not unusual and that there was,
therefore, no reason to alert healthcare staff to Ms Birchall’s condition.
67. We are concerned that Ms Birchall was not formally monitored by healthcare staff
while she was detoxing. There is no evidence that healthcare staff advised prison
staff what to do if Ms Birchall continued to vomit for a prolonged period or if she
showed any other symptoms.
68. We are also concerned that there is a lack of support for the prison officers in the
FNC who are not medically trained or trained in the management of opiate
substitute treatment but are expected to support those prisoners going through the
detoxification process. Prison staff told the investigator that there is a team of staff
who predominantly work in the FNC, but that any member of prison staff could be
asked to work there. The FNC would benefit from having nursing staff more
frequently available.
69. We cannot say whether the outcome might have been different for Ms Birchall if she
had been reviewed by a healthcare professional.
70. We make the following recommendations:
• The Governor and Head of Healthcare should review the presence of
healthcare and substance misuse staff in the First Night Centre.
• The Governor should consider detoxification awareness training for all
officers who work in the FNC, to ensure safe and supportive
management of prisoners withdrawing from drugs.
• The Head of Healthcare should ensure that prison staff in the FNC have
written guidance on what symptoms they should watch for in detoxing
prisoners and when they should seek medical help.
Unlocking procedures
71. The cellmate said that Ms Birchall was alive at around 6.00am on 4 February. Staff
said that rigor mortis was not present when Ms Birchall was found unresponsive in
her room at 10.10am. This suggests that she may have been alive or very recently
dead when the officer unlocked her room at 9.10am.
72. On unlock procedures, Prison Service Instruction (PSI) 75/2011, Residential
Services, says:
- ‘Reports from the Prisons and Probation Ombudsman on deaths in custody
have identified cases in which a prisoner has died overnight … but staff
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unlocking them have not noticed that the prisoner had died. This is not
acceptable ...
- ‘[Differing] arrangements will depend on the local regime, but there need to be
clearly understood systems in place for staff to assure themselves of the
wellbeing of prisoners during or shortly after unlock ... Where prisoners are not
necessarily expected to leave their cell, staff will need to check on their well-
being, for example by obtaining a response during the unlock process.’
73. The officer did not check the welfare of Ms Birchall when she unlocked her room,
which is not in line with Prison Service instructions. As a result, Ms Birchall’s
condition went unnoticed until her cellmate was unable to rouse her an hour later.
We cannot say whether earlier intervention might have changed the outcome for Ms
Birchall.
74. We make the following recommendation:
• The Governor of HMP Styal should review the procedures for unlocking
prisoners and ensure that, when a cell door is unlocked, staff satisfy
themselves of the safety of the prisoner and that there are no
immediate issues that need attention.
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