Sebastião Lucas

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Independent investigation into
the death of Mr Sebastião
Lucas, AKA Mr Sebastião Joao,
a prisoner at HMP Wandsworth,
on 12 May 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
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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 Sebastião Lucas died on 12 May 2021 having been found hanging in his cell at HMP
Wandsworth. Mr Lucas was also known as Mr Sebastião Joao. He was 34 years old. I
offer my condolences to Mr Lucas’ family and friends.
Mr Lucas had been at Wandsworth for around 48 hours when he hanged himself. Before
he came to prison, he had been in the process of being sectioned under the Mental Health
Act because he was considered to be at risk of suicide. Mr Lucas had been desperate to
return to hospital after he was arrested and taken to prison.
It is therefore very concerning that the prison failed to assess his risk adequately or keep
him safe. Key information was not sufficiently communicated or considered. In addition,
the clinical reviewer concluded that Mr Lucas’ mental healthcare in relation to his risk of
suicide was not adequate or equivalent to that he could have expected to receive in the
community.
Mr Lucas had been treated as a high risk to himself in hospital, police custody and court
custody and was being dealt with urgently. I am dismayed that once he arrived at
Wandsworth the need for the same level of urgency and for acute care was not
recognised. We cannot say whether better risk assessment and a greater sense of
urgency would have saved his life, but it may have done.
When Mr Lucas arrived at Wandsworth, he had a substantial quantity of suspected drugs
taken from him. This information was not adequately communicated or considered in light
of Mr Lucas’ risk to himself or from other prisoners.
When Mr Lucas was discovered unresponsive in his cell, control room staff told the 999
operator that he was breathing. This was inaccurate. Although I do not consider that this
affected the outcome for Mr Lucas, it could make a critical difference in other medical
emergency situations since the priority given to the ambulance may depend on the
information provided.
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 June 2022
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 15
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Summary
Events
1. On 10 May 2021, Mr Sebastião Lucas appeared in court charged with grievous
bodily harm and was remanded to custody. He had allegedly assaulted a hospital
nurse while he was being sectioned under the Mental Health Act due to his suicidal
thoughts. He was taken to HMP Wandsworth. Mr Lucas arrived with documents
which noted that he had said he would kill himself and had been subject to constant
supervision in police and court custody.
2. Mr Lucas told a prison nurse that he was going to kill himself. She started Prison
Service suicide and self-harm monitoring procedures (known as ACCT) and
referred Mr Lucas to the mental health team. A body scan in reception showed that
Mr Lucas had a large quantity of suspected drugs secreted in his rectum. He
eventually gave these up and was moved to the first night centre.
3. A manager completed the ACCT immediate action plan around midnight that
evening, and a member of staff observed him hourly overnight. The next day, staff
completed Mr Lucas’ ACCT assessment and first ACCT case review and continued
his hourly observations. After the ACCT review, the nurse reviewed Mr Lucas’
clinical record and added him to the mental health team’s caseload. Later that
afternoon, the liaison and diversion services emailed the mental health team with
further details of Mr Lucas’ recent psychiatric history and suicidal thoughts.
4. The next morning, several staff spoke to Mr Lucas. None had any concerns about
him. An officer gave him his lunch at 11.42am and noted that he had no issues. No
one checked him after that until 2.26pm, when an officer discovered Mr Lucas
hanging in his cell. They raised the alarm, staff responded and attempted to
resuscitate him.
5. The prison’s control room called an ambulance, but told the emergency services
that Mr Lucas was breathing, which was not the case. Paramedics arrived at
3.36pm and at 3.42pm, they pronounced Mr Lucas had died.
Findings
Assessment and management of risk
6. Mr Lucas had several significant risk factors for suicide and self-harm including the
fact that he was in the process of being sectioned under the Mental Health Act at
the time of his arrest, and his stated intention to kill himself now he was in prison.
Staff appropriately opened an ACCT shortly after his arrival.
7. However, we are concerned that Mr Lucas’ risk to himself was underestimated and
crucial information relevant to this risk was not adequately communicated or
considered. Staff only included one action on his caremap which was wholly
inadequate and did not reflect his level of distress or need.
8. ACCT observations did not always take place as frequently as specified, most
notably in the two hours before Mr Lucas was found unresponsive. Overnight
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observations also took place at very predictable intervals which is not in line with
Prison Service policy.
Mental healthcare
9. The clinical reviewer concluded that the mental healthcare Mr Lucas received was
not of the required standard and was not equivalent to that which he could have
expected to receive in the community. She noted that risk assessments were not
informed by evidence and a care plan was not put in place to support Mr Lucas.
10. In addition, the mental health team did not act on further information received from
the liaison and diversion service about Mr Lucas, they did not assess Mr Lucas
within 48 hours of him arriving at Wandsworth, and his multiple NHS records were
not merged until after he had died.
Drugs
11. Mr Lucas had a large quantity of suspected drugs taken from him in reception. This
information was not adequately communicated, nor were the implications for Mr
Lucas’ risk to himself or from others assessed in light of this find. Wandsworth’s
Secreted and Swallowed Items Policy does not give any instructions for actions to
take when a prisoner has given up any secreted items, only if staff suspect that they
remain inside the prisoner.
Emergency response
12. The emergency response was swift and appropriate. However, staff in the control
room told the 999 operator that Mr Lucas was breathing. This was not the case.
This did not affect the outcome for Mr Lucas but might do so in another emergency.
Recommendations
• The Governor and Head of Healthcare should ensure that staff manage prisoners at
risk of suicide or self-harm in line with national guidelines, including in particular
that:
• reception staff all have access to, and consider, information relevant to risk
from PERs and suicide and self-harm warning forms;
• ACCT assessment interviews and the first ACCT case review are conducted
separately, in line with PSI 64/2011;
• all known risk factors are considered when determining the level of risk of
suicide and self-harm;
• ACCT reviews determine the required frequency of conversations with the
prisoner, as well as the required frequency of observations;
• ACCT observations take place as specified, are unpredictable and are
recorded accurately;
• all staff receive appropriate ACCT training;
• ACCT reviews are held whenever an event occurs that could mean a prisoner
is at increased risk;
• all relevant information about risk is documented in the ACCT document; and
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• staff ensure caremaps contain meaningful actions to address an individual’s
risks and make use of protective factors.
• The Governor and Head of Healthcare should share this report with SO A, Nurse A,
CM A, Officer C and CM B and discuss the Ombudsman’s findings with them.
• The Head of Healthcare should ensure that any new information received by the
mental health team from the liaison and diversion services after a prisoner has
arrived at Wandsworth must inform a review of the level of risk and plan of care.
• The Head of Healthcare should ensure that all prisoners with multiple NHS numbers
have their records merged within 24 hours of arriving at Wandsworth.
• The Governor and Head of Healthcare should review the Swallowed and Secreted
Items Policy to include prisoners who have had illicit items taken from them and
ensure any information about secreted illicit items is communicated and considered
appropriately.
• The Governor and Head of Healthcare should ensure that accurate information is
given from the scene of an emergency incident to staff in the control room about the
condition of a prisoner.
•
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The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Wandsworth
informing them of the investigation and asking anyone with relevant information to
contact her.
14. Due to the COVID-19 pandemic, the investigator was unable to visit the prison. She
obtained copies of relevant extracts from Mr Lucas’ prison and medical records via
post and email.
15. The investigator interviewed 15 members of staff. NHS England commissioned a
clinical reviewer to review Mr Lucas’ clinical care at the prison. The investigator and
clinical reviewer jointly interviewed healthcare staff. Nurse B did not make himself
available for interview.
16. We informed HM Coroner for Inner West London of the investigation. She gave us
the results of the post-mortem examination. We have sent the coroner a copy of
this report.
17. One of the Ombudsman’s family liaison officers contacted Mr Lucas’ parents to
explain the investigation and to ask if they had any matters they wanted the
investigation to consider. Mr Lucas’ father asked:
• What information did the hospital give to the prison about Mr Lucas’ mental
state?
• Was Mr Lucas’ mental healthcare appropriate?
• Was Mr Lucas under the care of the mental health team? If not, should a
referral have been made?
• What was the cause of the wounds on Mr Lucas’ forehead? Was he assaulted
before his death?
• Was the way Mr Lucas’ parents were informed of his death appropriate? Why
did the family liaison officer give incorrect information initially about how Mr
Lucas was found?
These questions are answered as far as possible in this report.
18. Mr Lucas’ next of kin received a copy of the initial report. The solicitor representing
them indicated that they had not identified any factual inaccuracies.
19. The initial report was also shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Wandsworth
20. HMP Wandsworth is a local Category B prison in London. It holds around 1,600
men in eight residential wings. Oxleas Foundation Trust provides physical
healthcare services at the prison. Mental health services are provided by South
London and Maudsley NHS Foundation Trust. There is an inpatient unit for up to
six prisoners.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Wandsworth was in September 2021. The
report of this inspection was not available at the time of writing.
22. Before this, the most recent inspection of HMP Wandsworth was in March 2018.
Inspectors found a third of prisoners were receiving psychosocial help for substance
misuse problems and prisoners reported that it was easy to obtain illicit drugs.
They found that around 450 prisoners were referred to the mental health team each
month. They reported that healthcare was reasonably good.
23. HMIP found that Prison Service suicide and self-harm procedures (known as
ACCT) had not improved since the previous inspection and that the management of
safer custody lacked drive and focus. Prisoners who had been subject to ACCT
monitoring told the inspectors that they did not feel supported by staff. The prison
had not implemented the learning from the PPO’s previous fatal incident
investigations.
24. HMIP also carried out a Short Scrutiny Visit at Wandsworth in April 2020 to look at
how the prison was responding to the COVID-19 pandemic. While time out of cell
had been necessarily limited, HMIP considered that good attention had been paid to
the provision of in-cell activity, and in-cell telephones were described as a great
help for staff to speak to prisoners and prisoners to their families. All isolating
prisoners told HMIP that they felt well supported by staff.
25. HMIP reported that primary mental health applications had increased due to
prisoners’ anxieties about their health and regime restrictions, but these were
managed creatively through in-cell assessment forms, work packs and health
information leaflets.
Independent Monitoring Board
26. 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 31 May 2020, the IMB were
impressed by the prison’s speedy response to the COVID-19 pandemic but were
concerned that the aging and cramped accommodation could no longer meet
prisoners’ needs. The IMB reported that the prison’s key worker scheme had been
suspended due to the pandemic, but that it had been replaced by welfare checks.
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The IMB reflected that the primary mental health team received multiple referrals
every day, but that the majority were seen within 48 hours.
27. The IMB found that the Prison Service system used to support prisoners at risk of
suicide or self-harm (known as ACCT) was often compromised by operational
constraints. They found that, although prisoners appreciated the support and
guidance the ACCT process provided, it was less successful in resolving the
underlying issues involved. The IMB was concerned that consistent case mangers
did not always chair reviews.
28. The IMB also found that, on several occasions, new prisoners arriving at
Wandsworth were placed in cells without basic amenities.
Previous deaths at HMP Wandsworth
29. Mr Lucas was the tenth prisoner to die at Wandsworth since May 2019. Of the
previous deaths, three were from natural causes, one was drug-related and five
were self-inflicted. We have not yet completed our investigation into one of the self-
inflicted deaths. Following deaths in February and March 2021, we recommended
that risk assessment and ACCT management should be improved at the prison and
that healthcare staff should ensure they share information that may be relevant to a
prisoner’s risk of suicide or self-harm with prison staff. We have made similar
recommendations in this case.
30. It is also of note that there were seven self-inflicted deaths at Wandsworth within
just over six months. Mr Lucas’ death was the fourth of these deaths. The
subsequent three self-inflicted deaths are currently being investigated by the
Ombudsman.
Assessment, Care in Custody and Teamwork (ACCT)
31. 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
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
32. As part of the process, a caremap (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, Safer
Custody.
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Key Events
6 May – 9 May 2021
33. On 6 May 2021, Mr Sebastião Lucas (who was also known as Mr Sebastião Joao)
told police he was having suicidal thoughts. He was taken by ambulance to St
Thomas’s Hospital where he was admitted. On 7 May, he was assessed and when
a nurse told him he would be admitted to the Maudsley Hospital in London rather
than a hospital in Essex (which was his preference), he allegedly assaulted them.
Mr Lucas was arrested and taken into police custody. On 8 May, he was charged
with grievous bodily harm and kept in police custody. He was constantly observed
due to his risk to himself.
10 May
34. On 10 May, Mr Lucas was taken from police custody to Westminster Magistrates’
Court. Court staff recorded on Mr Lucas’ Person Escort Record (PER) that he had
been kept under constant supervision and was a risk to himself. It noted that, while
in police custody, Mr Lucas had said that he would self-harm or kill himself. Staff
had also noted on the PER that Mr Lucas “self-harms but would now say how or
when”. (It is unclear whether this was a typing error and should have read “would
not say how or when”.)
35. At 8.46am, Mr Lucas arrived at court. He told court custody officers that he still felt
low and suicidal. They said that they had a mental health team who could speak to
him and they put him in a CCTV cell so that he could be constantly observed. At
11.05am, Mr Lucas appeared in court and was remanded to custody until his next
appearance at court on 7 June. Court staff filled in a suicide and self-harm warning
form noting that Mr Lucas had told police he would attempt suicide or self-harm.
36. Mr Lucas arrived at HMP Wandsworth at 2.37pm. Supervising Officer (SO) A was
managing reception that afternoon. Although the SO did not recall meeting Mr
Lucas specifically, she said she met all new arrivals individually at the reception
desk. She told the investigator that she would have checked Mr Lucas’ PER, asked
him how he was and if he had any issues. She said that she did not remember
seeing Mr Lucas’ suicide and self-harm warning form and that Mr Lucas must have
told her he was ‘okay’. She finished work around 5.00pm.
37. At 4.52pm, Nurse A assessed Mr Lucas. She said she did not see Mr Lucas’ PER
or suicide and self-harm warning form. The nurse said that Mr Lucas was very
quiet, but she also felt “overwhelming anger” from him, and he told her that he was
going to kill himself. Mr Lucas said he had not made any plans as to how he would
kill himself but would “use whatever it took”. She noted that Mr Lucas said that he
had recently discharged himself from a psychiatric hospital where he was taking
medication but could not remember what this was.
38. Mr Lucas told Nurse A that he would not share a cell and would assault any
cellmate if he was made to share. She completed Mr Lucas’ cell sharing risk
assessment (CSRA) and assessed him as a standard risk, suitable to share a cell.
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39. Mr Lucas told Nurse A that he thought police and NHS staff were going to kill him.
He said that he did not misuse alcohol or drugs. He asked to be referred to the
mental health team. She completed a referral to the team, asking them to see him
as soon as possible, although she did not mark it as urgent. She also noted that an
ACCT was “to be opened”.
40. All new arrivals at Wandsworth are scanned for illicit items secreted inside them,
such as drugs, weapons or mobile phones. At around 5.45pm, Mr Lucas’ scan
indicated that he had a substantial quantity of suspected drugs secreted in his
rectum. Officer A told Mr Lucas that the scan had picked something up and he
would need to be rescanned in 15 minutes. He put Mr Lucas in a holding cell. He
told the investigator that Mr Lucas said he did not have anything inside him, and the
machine must be broken. He scanned Mr Lucas again which again confirmed that
he did have something secreted inside him. The officer explained to Mr Lucas that,
in reception, prisoners are offered amnesty so that if they get rid of any illicit items
at that point, there are no further consequences for them as a result. Mr Lucas
maintained he did not have anything secreted inside him.
41. Officer A became concerned that Mr Lucas was not going to give him the illicit item,
so he telephoned his managers. He said that they contacted the duty governor,
who told him to submit an intelligence report about what had happened and then to
send Mr Lucas to the first night centre since there were no cells in the segregation
unit to move Mr Lucas to (which would have been the usual procedure).
42. Mr Lucas then told Officer A that he was ready to be scanned again. However, the
scanner had overheated, so the officer took Mr Lucas back to his holding cell. He
then X-rayed Mr Lucas’ property bag (that he had been given when he came into
prison) and found a fist sized amount of what looked like cannabis. The officer
showed Mr Lucas what he had found. He then put Mr Lucas into a cell with other
prisoners. He said that usually he would have scanned Mr Lucas again to ensure
that there was nothing still secreted in him, but the machine had overheated, so this
was not possible.
43. Officer A submitted an intelligence report. He told the investigator that Mr Lucas
seemed calm although he was visibly upset about the suspected drugs that he had
had confiscated from him. He said he did not know that Mr Lucas was on an ACCT
and that he had no concerns that Mr Lucas was a risk to himself. In interview, he
said that he told his managers about the suspected drugs he had found. Neither
managers could recall being told about this. The officer said that he would usually
also have noted the information on Mr Lucas’ record, but he could not recall
whether he had done this. (He had not.)
44. At 6.15pm, Nurse A started Prison Service suicide and self-harm support measures
(known as ACCT). She filled in a concern and keep safe form, noting that Mr Lucas
had said that now he was in prison he was going to kill himself. She noted that Mr
Lucas said that he had recently discharged himself from a psychiatric hospital,
would not share a cell and would attack his cellmate if he was made to share. She
told us that after completing the concern and keep safe form, she handed it to an
officer in reception. She could not recall who this officer was.
45. At 8.00pm, Officer B noted in Mr Lucas’ ACCT observations that he was in the First
Night Centre and chatting to other prisoners. This was the first entry in his ACCT
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ongoing record. She said she did not know that he had had drugs confiscated from
him in reception. She met Mr Lucas around 8.30pm. She told the investigator that
he was calm and engaged with her. Mr Lucas told her that he had problems in the
prison, which she understood to mean that he felt at risk from other prisoners.
46. Officer B completed the other part of Mr Lucas’ cell sharing risk assessment
(CSRA). She recorded that Mr Lucas said that he was high risk to share a cell but
there was no evidence to support this. She assessed him as standard risk and
suitable to share a cell. She told the investigator that Mr Lucas was very focussed
on being located on his own in a cell. However, she did not think this was
appropriate for his own safety as an ACCT had been opened. Mr Lucas was later
located in a cell on his own, but she was not involved in this decision and we have
not been able to understand why this was the case.
47. Officer B said that Nurse A had already completed section two of the CSRA, so she
saw the statement that Mr Lucas had said he was going to kill himself. She said
she would have spoken to him about the statement but that she could not
remember what he said. She said she assessed that Mr Lucas was more
concerned about being at risk from others than he was a risk to himself.
48. An Operational Support Grade (OSG) was responsible for doing Mr Lucas’ ACCT
observations overnight. At 11.00pm, Mr Lucas rang his cell bell. She responded
and Mr Lucas asked her for a television and a kettle. She asked managers whether
this was possible, and they said it might not be possible that evening, but Mr Lucas
would get the items in the morning. When she explained this to Mr Lucas, he
appeared to understand.
49. CM A was in charge of the prison that evening. When he came in, he read the
briefing sheet which included details of the suspected drugs that had been
confiscated from Mr Lucas. Just before midnight, he completed an ACCT
immediate action plan with Mr Lucas. He told the investigator that he could not
specifically remember meeting Mr Lucas, but he would have seen the concern and
keep safe form and would have asked him how he was feeling. He said he also
would have considered the issue of the drugs which had been taken from him,
whether another prisoner had been expecting to receive them and whether Mr
Lucas felt under threat as a result.
50. CM A told the investigator that he assessed that staff needed to check Mr Lucas at
least once per hour “to be on the safe side”. He described the level of observations
as a “cautious approach” until the ACCT assessment when staff could obtain more
information. He said he had not seen the PER or suicide and self-harm warning
form. He noted that Mr Lucas should be referred to the mental health team. He
told the investigator that he could not do this at night but would have expected it to
be added to the caremap and picked up by the staff doing the ACCT assessment
the next day and during the initial case review.
51. The OSG continued doing hourly checks overnight and recorded that Mr Lucas
stayed awake. She said that she asked Mr Lucas if he was okay each time, and he
replied that he was. She said that he did not seem happy, but that was
understandable given he was in prison, and she had no concerns about him.
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11 May
52. At 7.30am, an officer gave Mr Lucas a kettle. At 8.30am, an officer noted on Mr
Lucas’ ACCT observations that he had asked for a television and phone. They said
that they would try to get Mr Lucas one.
53. At 9.44am, a nurse completed Mr Lucas’ secondary health screen. She noted that
he had no thoughts of suicide or self-harm. The nurse described Mr Lucas as
cheerful and sociable and said she did not have any concerns about him. She did
not write in Mr Lucas’ ACCT, nor is there any evidence that she had read his
previous medical notes or was aware that he was subject to ACCT monitoring.
54. At 10.30am, Officer C, CM B and a nurse from the mental health team completed
Mr Lucas’ ACCT assessment and initial case review with him. Normally the
assessment and review are completed separately but staff decided to conduct them
together. None of the staff present were aware that Mr Lucas had had suspected
drugs taken from him in reception. Mr Lucas said he had not self-harmed before
but had thoughts of suicide and felt paranoid. He said that he had recently been
sectioned and had attempted to jump from a building. Mr Lucas told staff that he
used cannabis occasionally and thought people were trying to kill him. He said he
had not had a chance to hurt himself. Mr Lucas said he felt hopeless, had lost
everything, was not sleeping properly and had nightmares. He said he had nothing
left to live for but had not planned how to take his own life. The officer noted in the
assessment that Mr Lucas had no telephone or television. The officer told the
investigator that Mr Lucas did not seem emotional or stressed.
55. CM B noted on the case review that Mr Lucas did not make much sense at times.
He said that it did not matter whether he killed himself because if he did not do it
then someone else would kill him. Mr Lucas was not able to substantiate or provide
any evidence for these comments.
56. Mr Lucas said that he had recently tried to jump off a building, but the police had
stopped him. Mr Lucas said that he thought he should be in hospital, not prison, but
that the alleged assault on a nurse had prevented him from going there and he had
been brought to prison instead. CM B told the investigator that she asked him
about saying that he would kill himself now he was in prison and Mr Lucas was
“quite dismissive” and said he did not feel that way now.
57. The nurse noted that Mr Lucas did not appear psychotic during the review but
appeared to be exaggerating some paranoid beliefs to try to be diverted back to
hospital. Mr Lucas repeatedly said that he knew the nurse and CM B, despite this
not being the case.
58. CM B and the nurse assessed Mr Lucas’ risk to himself as raised. The CM told the
investigator she assessed him as a raised risk as Mr Lucas had seemed confused
and she was unsure how he was feeling at present. They kept Mr Lucas on hourly
observations and set the next ACCT review for 18 May. The nurse said she could
not determine whether Mr Lucas was genuinely at risk from others or if Mr Lucas
was being paranoid. The nurse told the investigator that Mr Lucas did not seem low
in mood or suicidal. Mr Lucas’ caremap had one action on it which was for him to
get a television.
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59. After the ACCT review, the nurse reviewed Mr Lucas’ medical record. She noted
that he had previously been admitted to a medium secure psychiatric unit for
treatment relating to psychosis. (Since Mr Lucas had multiple aliases, prison
numbers and NHS numbers, all his records were not merged and available to staff
until after his death.) On the basis of this, the nurse discussed Mr Lucas with the
mental health team, including two psychiatrists, and agreed he would be added to
the mental health team’s caseload and he would be reviewed by a psychiatrist to
determine how best to support him in prison.
60. At 11.45am, a Supervising Officer (SO) noted on Mr Lucas’ record that he was
making a late entry that Mr Lucas had been body scanned when he arrived, and
staff found a substantial amount of suspected drugs secreted inside him.
61. At 1.27pm, a mental health practitioner from South London and Maudsley Criminal
Justice Mental Health (SLAM CJMHS) Liaison and Diversion Service, emailed HMP
Wandsworth’s mental health team. She noted that she wished to refer Mr Lucas to
the mental health team and that he had several different NHS numbers and aliases.
She wrote that before Mr Lucas’ arrest he had been assessed by psychiatric liaison
services who were arranging an admission to a SLAM inpatient bed after Essex
NHS Mental Health Trust declined to admit him. She noted that he was a suicide
risk and he had been taken to St Thomas’s Hospital by ambulance.
62. The mental health practitioner also wrote that Mr Lucas was known to mental health
services in Essex and had had several admissions in April under the Mental Health
Act. She recorded that she had met Mr Lucas twice while he was in police custody
and that he had told her he would kill himself if he was not admitted to hospital. Mr
Lucas had also told her that he was being followed in the community by police and
others who wanted to harm or kill him.
63. The mental health practitioner also wrote that in recent weeks, Mr Lucas had been
coming to the attention of police and emergency services in crisis, stating that he
would harm himself. He had climbed onto the top of a police station and said he
would jump. During hospital admissions, he had expressed paranoia that his food
was being poisoned and he was aggressive and hostile at times. She also
recorded that when she had met Mr Lucas, he did not seem depressed or suicidal,
but he was increasingly paranoid about all staff, including police and prison officers.
64. The mental health practitioner asked Wandsworth’s mental health team to have Mr
Lucas assessed by a psychiatrist to determine whether his paranoia was genuine.
Her email was uploaded to Mr Lucas’ medical record the following day at 9.58am by
healthcare administrative staff.
65. At 4.33pm, an officer completed Mr Lucas’ welfare check and noted that Mr Lucas
raised no issues.
66. A prisoner, who was employed as a decency representative on the first night centre,
spoke to Mr Lucas that afternoon through his cell door. Mr Lucas told him he had
no television or phone. The prisoner provided Mr Lucas with these items. Mr Lucas
told him that his cousin lived downstairs on the wing and he wanted to contact him.
The prisoner shouted down to Mr Lucas’ cousin to tell him he was there as he could
see him on the landing below.
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67. At 5.02pm, psychiatrist replied to the mental health practitioner’s email, indicating
that he would try to assess Mr Lucas over the next few days.
68. At 7.50pm, a member of staff noted that Mr Lucas had covered his observation
panel. He uncovered it and explained to Mr Lucas that he needed to be able to see
him.
69. The OSG was again responsible for Mr Lucas’ ACCT checks overnight. Again, Mr
Lucas stayed awake. At one point, he covered his observation panel with a tissue.
She said she explained that he would have to move it each time she checked him.
He said this was fine as he was not sleeping, and he removed it every time she
checked him.
12 May
70. On 12 May, between 7.00am and 10.00am, only one ACCT observation was noted.
At 10.36am, Officer D met Mr Lucas for the first time when he did an ACCT
observation. The officer told the investigator that Mr Lucas was calm and polite.
He asked Mr Lucas if he was okay, and he replied that he was.
71. Around 11.00am, a prisoner was walking past Mr Lucas’ cell, when he called out to
him and asked him if his cousin was out of his cell. The prisoner told him that he
was not. CCTV shows that the prisoner stood and spoke to Mr Lucas for around
eight minutes. The prisoner could not recall what they spoke about but told the
investigator that he had no concerns that Mr Lucas was a risk to himself, nor did he
seem fearful of other prisoners. Mr Lucas did not say he was worried about
anything. CCTV shows that the prisoner appeared to slip something under Mr
Lucas’ door. He could not remember what this was.
72. At 11.20am, a senior resettlement caseworker went to see Mr Lucas in his cell.
She sees all prisoners within five days of them arriving at Wandsworth to assess
their resettlement needs. She opened Mr Lucas’ observation panel and noted that
it was quite dark in his cell. Mr Lucas told her that he did not need help with
resettlement and had no further issues. She said she would return to see Mr Lucas
in a few days. she told the investigator she had no concerns that Mr Lucas was a
risk to himself.
73. Officer D told the investigator that he looked through Mr Lucas’ observation panel
on several occasions that morning and had no concerns about him. CCTV footage
shows that between 10.04am and 11.51am, staff interacted with him seven times.
74. Around 11.30am, Officer D tried to speak to Mr Lucas about his name and the
languages he spoke, since he thought that they might share a similar ethnic
background, but Mr Lucas was quiet and did not want to engage in conversation.
The officer asked Mr Lucas how he was feeling, and he said he was okay. He also
asked if he had any concerns, but Mr Lucas said he did not. He had no concerns
about Mr Lucas. At 11.42am, he noted on Mr Lucas’ ACCT observations that he
gave him food, he appeared fine and noted “no issues”.
75. Around 12.15pm, a SO asked the three officers covering the wing over lunchtime to
also cover the first night centre - where Mr Lucas was located on the top floor of the
wing.
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76. At 2.25pm, after they had returned from their lunchbreak, Officer D and Officer E
began unlocking prisoners’ cells on the wing. When Officer E got to Mr Lucas’ cell
at 2.26pm, he looked through the observation panel and saw him hanging from the
shower curtain rail by a ligature made from bedding. Officer E shouted to Officer D
on the other side of the landing and they both went into the cell straight away, along
with Officer B. Officer E cut Mr Lucas down using his anti-ligature knife. Officer B
radioed a code blue (a medical emergency code indicating a life-threatening
situation) and asked for medical assistance.
77. Staff in the control room immediately asked for an ambulance. The investigator
listened to the 999 call during which staff told them that Mr Lucas was unconscious
but breathing. This was not the case. The member of staff said that they could not
give the 999 operator any further information as they were not “on the scene”.
78. Officer F, who also works as an ambulance technician, saw the officers go into Mr
Lucas’ cell and went into the cell with them. Officer E could not find a pulse, so
Officer F asked him to give Mr Lucas two breaths while another officer started chest
compressions. Three minutes after they had discovered Mr Lucas unresponsive,
Nurse B got to the cell and asked an officer to get a defibrillator. A SO immediately
got this and an officer attached it. They continued trying to resuscitate Mr Lucas
until the paramedics arrived at 3.36pm and took over Mr Lucas’ treatment.
Paramedics pronounced that Mr Lucas had died at 3.42pm.
Contact with Mr Lucas’ family
79. Mr Lucas had not nominated a next of kin. When he got to Wandsworth, he had
asked for two telephone numbers to be put on his prison telephone account, one
was his solicitor’s number and the other was his cousin’s. He had not rung either
number.
80. After Mr Lucas’ death, a SO telephoned his cousin’s number at 6.20pm. After the
SO introduced himself, Mr Lucas’ cousin immediately became upset and said she
would pay his debts. The SO broke the news of Mr Lucas’ death to his cousin and
offered his condolences. Mr Lucas’ cousin said that she would try and find his
mother. The SO stayed in contact with Mr Lucas’ cousin and offered her a
contribution to Mr Lucas’ funeral in line with Prison Service policy.
81. On 18 May, police contacted the prison to say that the person the SO had been
speaking to was not Mr Lucas’ cousin and should not be updated with any further
details about his death.
82. The police gave the SO Mr Lucas’ parents’ details. On 22 May, the SO contacted
Mr Lucas’ parents, gave his condolences and offered them a contribution to Mr
Lucas’ funeral expenses. The SO had initially been given incorrect information
about how Mr Lucas had been found and therefore contacted his family the next
day to clarify the circumstances of his death. On 24 May, he visited them at their
home address and took them Mr Lucas’ property.
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Support for prisoners and staff
83. After Mr Lucas’ death, the Head of Security 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.
84. The prison posted notices informing other prisoners of Mr Lucas’ 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 Lucas’ death.
Post-mortem report
85. The pathologist concluded that the cause of Mr Lucas’ death was hanging. No
alcohol or drugs were detected in his blood although a hair sample showed Mr
Lucas had used heroin, cocaine and cannabis in the seven months before he had
died.
Information after Mr Lucas’ death
86. After Mr Lucas’ death, his records were merged to include all his alias names and
alternative NHS numbers and showed a significant mental health history. He had
last been released from prison in July 2020 when he had been held in the
segregation unit for eight months. The mental health team had been trying to get
him assessed for a hospital admission under the Mental Health Act when he was
released without charge. He was distrustful of prison and healthcare staff when in
custody and concerned that his food was being poisoned.
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Findings
Assessment and management of risk
87. Mr Lucas hanged himself just over two days after he had arrived at Wandsworth
and we have, therefore, considered whether his risk of suicide or self-harm was
appropriately assessed and managed.
88. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm. It says all staff should be alert to the
increased risk of self-harm or suicide posed by prisoners with these risk factors and
should act appropriately to address any concerns. The PSI also states that any
information that becomes available which may affect a prisoner’s risk of harm to self
must be recorded and shared, to inform proper decision making.
89. Staff at Wandsworth appropriately identified that Mr Lucas was at risk shortly after
he arrived at the prison, and there was some good practice. A mental health nurse
attended the first case review and staff clearly tried to engage with Mr Lucas.
However, we are concerned that overall staff did not adequately assess or manage
his risk.
Assessment of risk
90. Mr Lucas had been in the process of being sectioned under the Mental Health Act
due to his risk to himself when he was arrested. He had been subject to constant
supervision in both court and police custody before arriving at Wandsworth. Mr
Lucas also arrived with a warning form indicating that he had said he would attempt
suicide or self-harm. Despite this, when he arrived at Wandsworth around 3.00pm,
SO A did not open an ACCT when she spoke to him at the reception desk. She
could not recall whether she had seen the warning form but said she would have
seen the PER which also detailed Mr Lucas’ risk to himself.
91. SO A said that if a prisoner told her that they did not have any issues she would not
open an ACCT, even if they had come in with warnings on their PER. We have
said repeatedly over many years that staff too often assess a prisoner’s risk based
on how he appears and what he says, and do not give enough weight to a
prisoner’s risk factors. She should have considered the information available to her
and opened an ACCT. We are shocked that a SO working in reception was not
aware of this.
92. Nurse A then assessed Mr Lucas. She said she did not see Mr Lucas’ PER or
suicide and self-harm warning form. We find it shocking that a nurse based in
reception does not routinely review these documents before assessing a prisoner.
She said that if she had known about the circumstances of Mr Lucas’ arrest, she
probably would have told managers in charge of the prison at the time. She would
also have used this information to inform her assessment of his risk to himself.
93. Mr Lucas told Nurse A that he was going to kill himself. She opened an ACCT at
6.15pm, despite her assessment with Mr Lucas taking place before 5.00pm. This
meant that when an officer found a large quantity of suspected drugs secreted in Mr
Lucas around 5.45pm, he did not know that Mr Lucas was at risk of suicide and had
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no opportunity to consider whether the confiscation of the suspected drugs might
increase Mr Lucas’ risk or to contribute to Mr Lucas’ ACCT.
94. PSI 64/2011 instructs that within an hour of the ACCT being opened, a manager
must speak to the prisoner and complete the immediate action plan. CM A did not
complete this until nearly midnight, some six hours after the ACCT had been
opened and nine hours after Mr Lucas had arrived at Wandsworth with a suicide
and self-harm warning form. It is not clear why this action plan was not completed
earlier, either by day staff or the CM.
95. CM A knew that Mr Lucas had had suspected drugs confiscated from him and said
he considered the risk implications of this. However, there is no evidence that he
asked Mr Lucas about this directly, nor did he record this information on the ACCT.
He told the investigator that he could not remember meeting Mr Lucas that evening.
He said he had not seen the PER or suicide and self-harm warning form.
96. Although Mr Lucas was assessed as suitable to share a cell, he was very reluctant
to do so, and he was located in a single cell. The reason for this is not clear, nor is
it evident whether staff considered allocating Mr Lucas a shared cell for his own
safety.
97. The next day, three members of staff completed Mr Lucas’ ACCT assessment and
case review together. Officer C told the investigator that she preferred doing ACCT
assessments on her own with prisoners as she felt she could build a better rapport.
The assessment documented limited information in relation to Mr Lucas’ risk. Mr
Lucas told staff the circumstances of his arrest but because none of them had seen
the PER or the suicide and self-harm warning form, they could not corroborate this
information and Mr Lucas seemed confused. They considered that he may have
been exaggerating paranoid beliefs to go back to hospital. They were also unaware
that Mr Lucas had had drugs confiscated from him in reception.
98. It is not clear why the ACCT assessment and first ACCT case review were done
together in Mr Lucas’ case. PSI 64/2011 makes it clear that the ACCT assessment
interview and the first ACCT case review are separate procedures. We consider
that the assessment and the first ACCT review serve different purposes and that it
is important that staff follow the PSI and conduct them separately.
99. The assessment is an opportunity to have a one-to-one discussion with the prisoner
to explore his concerns and his risks, triggers and protective factors. Prisoners may
feel more comfortable discussing their concerns on a one-to-one basis rather than
in a bigger group. Assessors should capture all the necessary information on the
assessment form which must highlight any areas of risk discussed as part of the
assessment, and any protective or mitigating factors that would be helpful to
mitigate the risk.
100. While the role of the assessment interview is to identify and record the prisoner’s
risks, the role of the first case review is to use that information to assess the
seriousness of the prisoner’s risk to himself, to put support actions in place to
mitigate and lower risk, and to set appropriate levels of observations. If the two are
combined there may be a tendency to move too quickly to trying to identify
‘solutions’ rather than really paying attention to the prisoner’s risk factors.
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101. We are very concerned that a nurse had not reviewed Mr Lucas’ medical record,
which contained crucial information about his mental health, before the case review.
After the review, she accessed this record and, based on this, discussed him with
the mental health team and he was added to their caseload.
102. CM B said that healthcare staff can access a record of all prisoners newly subject to
ACCT monitoring before they attend a review. Or, if the ACCT has been opened by
healthcare staff, as it had been in Mr Lucas’ case, this information is often
communicated between nurses directly.
103. The clinical reviewer concluded that,
“clinical, demographic and contextual risk factors which placed Mr Lucas at
increased risk of attempting suicide were not clearly accounted for by the
nurse in the ACCT review.”
104. We are not satisfied that prison and healthcare staff had adequately considered or
communicated Mr Lucas’ risk factors: that he had been on constant observation in
police and court custody, that he had had a large amount of suspected drugs taken
from him in reception, that he had been in the process of being sectioned due to his
suicidal thoughts when arrested and he had made a clear statement of intention to
kill himself now he was in prison.
105. The investigator asked CM A whether, on reflection, he thought that Mr Lucas
needed to be on more regular observations than hourly. He did not believe that this
was warranted. CM B and a nurse said that, in their assessment, the continuation
of hourly observations was appropriate. They acknowledged that they should have
also specified that staff should have conversations with Mr Lucas, but they said they
had assumed these would take place at least twice a day.
106. PSI 64/2011 says that while observations are important, prisoners can find them
intrusive and that conversations are generally more supportive and helpful. Having
meaningful conversations also enables staff to judge whether a prisoner’s risk to
himself may be increasing or decreasing.
107. We are concerned that, given Mr Lucas had been deemed to be a high risk of
suicide in both police and court custody and monitored continuously, more
consideration should have been given to Mr Lucas’s risk factors and he should have
been observed more frequently than hourly, at least during his first few days in
prison. The ACCT document itself notes that a prisoner’s risk to themselves may
be assessed as high if they have frequent suicidal ideas which are not easily
dismissed and evidence of mental illness. If assessed as high, the guidance notes
that prisoners should be subject to increased support and therapeutic interventions,
urgently referred to the mental health team and their location in the prison should be
carefully considered.
108. We do not consider that anyone in the prison made a sufficiently informed or
accurate assessment of Mr Lucas’ level of risk.
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Caremap
109. PSI 64/2011 instructs that the caremap must reflect the prisoner’s needs, level of
risk and the triggers of their distress. It must include actions aimed at reducing the
prisoner’s risk to themself. Only one action was included on Mr Lucas’ caremap.
This was for Mr Lucas to have a television. CM B said that because Mr Lucas was
evasive, it had been difficult to identify actions for the caremap as he said his issues
were outside prison. We are not satisfied that the caremap adequately reflected Mr
Lucas’ level of need or actions to reduce his distress.
ACCT observations
110. On the morning of 11 May, no observations were recorded at 7.00am and 9.00am.
The OSG told the investigator that she mistakenly annotated her last check 8.00am,
but it actually took place at 7.00am as she would have left the prison after this. This
meant that there was a gap in observations between 7.00am and 10.30am.
111. Staff also failed to complete ACCT observations that afternoon between 11.42pm
and 2.25pm, when Mr Lucas was discovered hanging. A SO said that staff covering
lunchtime patrol should have known to complete the ACCT observations on the first
night centre without being told. He also said that good practice would have been for
the officers leaving for lunch to have handed over the ACCTs themselves to
covering staff.
112. These morning and lunchtime ACCT observations were missed as staff did not take
responsibility for completing them following a staff change. The Head of Safety told
the investigator that after Mr Lucas’ death the prison introduced an ACCT handover
sheet which meant that whenever there was a change of staff on the wing, staff had
to sign the ACCT over to another member of staff. He said that these handover
sheets are now regularly checked by managers. Concerningly, at the time of
interview in July (two months after Mr Lucas’ death), one of the officers we spoke to
had not heard of these handover sheets. More needs to be done to ensure all staff
are aware of the expectation to complete them and their responsibility to complete
ACCT observations in line with the frequency specified.
113. PSI 64/2011 instructs that ACCT observations must take place at unpredictable
times to ensure prisoners cannot anticipate when they will be checked. Contrary to
this, on the two nights Mr Lucas was at Wandsworth, his ACCT observations took
place on the hour, every hour. We are not critical of the OSG who completed these
observations since she told us it was her first set of nights and no one had informed
her that the ACCT observations should be irregular. OSG training had been put on
hold during COVID-19 and the OSG had learned her role by shadowing another
OSG. After Mr Lucas died, managers informed her that the checks needed to be at
less regular times.
114. Mr Lucas was awake all night on both nights. The OSG noted this on his
observations and informed day staff, but she told us she did not have any concerns
about Mr Lucas. CM A said it was not unusual for prisoners to have difficulty
sleeping on their first nights in prison. While it seems clear that a lack of sleep for
over 48 hours must have affected Mr Lucas’ mental health, we are satisfied that
staff acted appropriately in this matter.
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Training
115. CM B had not received ACCT case manager training at the time Mr Lucas was at
Wandsworth because training had been suspended due to the COVID-19
pandemic. She said that there was a national policy which included a competency
agreement which meant that a member of staff’s line manager could sign them off
as competent to complete reviews. Her line manager and the Head of Safety had
agreed that she was competent, and she told us she felt confident to complete
reviews. After Mr Lucas’ death, she received ACCT case manager training. She
said she had repeatedly asked for it before Mr Lucas died.
116. SO A said the only ACCT training she had was when she started as a prison officer
in 2016. A nurse said she had had no ACCT training and had learned by
shadowing colleagues. The Head of Safety told the investigator that since the
introduction of the newer version of ACCT (version six) in June, they have
prioritised ACCT training for healthcare staff and officers. He had also introduced a
new post of Deputy Head of Safety to help drive improvement in risk assessment
and management.
Protective factors
117. Mr Lucas raised the issue of not having a kettle, telephone or television on his first
night. These items were important for his well-being and could have affected his
risk to himself. An officer provided him with a kettle the next morning and another
prisoner found him a television and telephone later that day. We are concerned
that these items were not immediately available to Mr Lucas. At the time of
interview, the Head of Safety had recently taken over responsibility for induction
and the first night centre. He said he was aware of this issue and that he had tried
to ensure prisoners were always provided with these items as soon as they arrived
on the First Night Centre. He said it had not been raised as an issue since the
death of Mr Lucas.
The Governor and Head of Healthcare should ensure that staff manage
prisoners at risk of suicide or self-harm in line with national guidelines,
including in particular that:
• reception staff all have access to, and consider, information relevant to risk
from PERs and suicide and self-harm warning forms;
• ACCT assessment interviews and the first ACCT case review are conducted
separately, in line with PSI 64/2011;
• all known risk factors are considered when determining the level of risk of
suicide and self-harm;
• ACCT reviews determine the required frequency of conversations with the
prisoner, as well as the required frequency of observations;
• ACCT observations take place as specified, are unpredictable and are
recorded accurately;
• all staff receive appropriate ACCT training;
• ACCT reviews are held whenever an event occurs that could mean a prisoner
is at increased risk;
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• all relevant information about risk is documented in the ACCT document; and
• caremaps contain meaningful actions to address an individual’s risks and
make use of protective factors.
The Governor and Head of Healthcare should share this report with SO A,
Nurse A, CM A, Officer C and CM B and discuss the Ombudsman’s findings
with them.
Mental healthcare
118. The clinical reviewer concluded that the mental healthcare Mr Lucas received was
not of the required standard and therefore not equivalent to that which he could
have expected to receive in the community. She noted that risk assessments and
clinical reviews were not informed by evidence which should have been available,
and a care plan was not put in place to effectively support Mr Lucas with his suicidal
thoughts. The clinical reviewer concluded that she could not say that Mr Lucas’
death could have been prevented if suicide risk assessments had been more
rigorous and informed by all the information, but it might have been.
119. On 11 May, the mental health team received an email from the liaison and diversion
service outlining their concerns about Mr Lucas. This noted that he had several
NHS numbers which should have prompted healthcare staff to consider if he had
other medical records. These other records detailed Mr Lucas’ intention to kill
himself and outlined the circumstances of his arrest. An administrative assistant
uploaded the email to Mr Lucas’ clinical record the next morning. A psychiatrist
also replied to say that they would assess Mr Lucas over the following days. The
Mental Health Team Leader said that the administrative assistant was covering
three roles at the time. She said that she should have sent a task to the mental
health team about the email for that day’s duty worker to consider.
120. We are concerned that the information contained in the email was not considered
by the mental health team. The receipt of the email should have triggered an ACCT
review. The clinical reviewer also concluded that healthcare staff should have
implemented a care plan to support Mr Lucas with his suicidal thoughts.
121. In addition to this, a referral to the mental health team asking them to see Mr Lucas
as soon as possible took three days to be actioned by the team, by which time Mr
Lucas had already taken his own life. We note that this had not been properly
marked as urgent (the appropriate box had not been ticked) but we still regard it to
be an urgent referral. The expected NHS England timescale for an urgent mental
health referral is 48 hours to see a prisoner. The Mental Health Team Leader said
that the team can receive up to around 50 referrals each day and due to this high
volume of referrals and a staff vacancy, they cannot review all the referrals they
receive the day they arrive.
122. We note that the NHS review after Mr Lucas died indicated that they intended to
ensure that prisoners with multiple NHS numbers had their records merged or
linked within 24 hours of arriving at Wandsworth. This would have ensured that
healthcare staff could have accessed Mr Lucas’ recent and previous psychiatric
history immediately.
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123. We make the following recommendations:
The Head of Healthcare should ensure that any new information received by
the mental health team from the liaison and diversion services after a
prisoner has arrived at Wandsworth must inform a review of the level of risk
and plan of care.
The Head of Healthcare should ensure that all prisoners with multiple NHS
numbers have their records merged within 24 hours of arriving at
Wandsworth.
Drugs
124. Mr Lucas had a large quantity of suspected drugs taken from him in reception. It is
impossible to know how and when he acquired these drugs. He had gone from
hospital, to police, to court and finally to prison. Police told the investigator that Mr
Lucas was subject to a general custody search when arrested. There was no
information to suggest that he had drugs secreted on him, so the police were not
prompted to do a more thorough search at that point.
125. When the drugs were found in reception, Officer A said that he communicated the
confiscation of the suspected drugs to managers in the prison at the time, although
they told us they could not recall this conversation. Since Mr Lucas’ ACCT had not
yet been opened (although the need to open one had already been identified), this
information was not recorded on his ACCT. However, CM A said that he was
aware of this information when he did the immediate action plan although he did not
record it on the ACCT and the information was not passed on to staff doing the
ACCT assessment or case review the following day. Officer A did not make an
entry in Mr Lucas’ prison record as he should have done. Another officer did this
the following day, after the ACCT review had taken place.
126. CM B said that the information should have been communicated to her by noting it
in the wing observation book and by logging it on the daily report sheet. This daily
report sheet would then be communicated with all managers at the morning
meeting. She also said that safer custody should have been informed.
127. HMP Wandsworth’s Approach and strategy for tackling prisoners who have
swallowed or secreted items only relates to prisoners who are suspected to have
items secreted on them. It does not have any instructions for those who have had
the illicit items taken from them. The policy does indicate that once a prisoner is
suspected to have drugs secreted inside them, staff must consider what level of
healthcare or other observations are necessary and any other issues concerning
their segregation and management, for their risk to themselves, their mental health
and physical wellbeing. We consider that the policy needs to be updated to include
reference to the body scanner in reception and instructions on what to do when a
prisoner has illicit items taken from them.
128. In addition, the clinical reviewer concluded that healthcare staff in reception need to
be informed when prisoners are in possession of drugs, even if they give them up.
There are associated risks from ingesting substances which may remain after the
item has been retrieved; the presence of drugs may indicate substance misuse
issues, or the prisoner may be at an increased risk of bullying, harassment or
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coercion. All of these may negatively impact a prisoner’s mental health and may
have done so in Mr Lucas’ case.
129. It should be noted that when staff telephoned Mr Lucas’ next of kin to inform him of
his death, the first thing she said, before realising he was dead, was that she would
pay his debts. This suggests that she was aware of Mr Lucas’ involvement in the
illicit economy and the possibility that he might have been in debt in prison.
130. The seizure of the drugs may have left Mr Lucas in significant debt to other
prisoners. There is no evidence that staff considered how the confiscated item
might have affected Mr Lucas’ risk to himself. Mr Lucas may also have been at risk
from other prisoners as a result of this and that could have been the reason that he
did not want to share a cell. We are concerned about the lack of clarity in the
prison’s own policy and the poor communication in this case, which could have
increased Mr Lucas’ risk. We make the following recommendation:
The Governor and Head of Healthcare should review the Swallowed and
Secreted Items Policy to include prisoners who have had illicit items taken
from them and ensure any information about secreted illicit items is
communicated and considered appropriately.
Emergency response
131. We are satisfied that the emergency response was swift and appropriate in the
circumstances. The clinical reviewer has made some minor comments about the
response which the Head of Healthcare will want to note.
132. Our only concern is that when staff in the control room requested an ambulance,
they told the 999 operator that Mr Lucas was unconscious but breathing. This was
not the case. The member of staff said that they could not give the 999 operator
any further information as they were not “on the scene”. In Mr Lucas’ case the
incorrect information did not delay the despatch or arrival of an ambulance, but in
other cases it could result in the ambulance being given a lower priority and could
therefore make a critical difference in an emergency.
133. Following our recommendations in previous investigations, PSI 3/2013, Medical
emergency response codes, was amended in September 2021, to require that
control room staff get specific information from those at the scene of the emergency
as soon as possible, to include information about what has happened and whether
the prisoner is breathing, or resuscitation has been started. We make the following
recommendation:
The Governor and Head of Healthcare should ensure that accurate
information is given from the scene of an emergency incident to staff in the
control room about the condition of a prisoner.
Inquest
134. The inquest into Mr Lucas’ death finished on 12 September 2025 and concluded
that Mr Lucas died due to suicide contributed to by neglect.
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OFFICIAL - FOR PUBLIC RELEASE