Investigations & Analysis - Northern Ireland
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Mother claims brain damaged son failed by prison service

01 MAY 2013

The mother of Mr C speaks exclusively to The Detail /

By Niall McCracken

THE mother of a man who was severely brain damaged after hanging himself in Maghaberry Prison has claimed the Northern Ireland Prison Service is not doing enough to ensure the safety of its inmates.

She has spoken to The Detail as the first near death in custody report by Prisoner Ombudsman Pauline McCabe is published in Northern Ireland today.

The 31-year-old prisoner is not identified in the report and his mother has asked that we also withhold her name.

The Prisoner Ombudsman’s investigation found that despite a requirement to check the prisoner’s cell in the Care and Supervision Unit every 15 minutes, there was a gap of almost half an hour between the previous check and staff realising that he was unresponsive in his cell in February 2012.

It then took a further five minutes before his cell door was unlocked to enable him to receive emergency medical treatment.

His mother says that important warning signs were missed and that her son was “crying out for help”.

The man’s girlfriend died from suicide in 2009, two weeks after their children were taken into care. After this he was admitted to a psychiatric hospital, having attempted to cut his throat and was noted to be “very depressed” with “suicidal ideation”.

The prisoner, referred throughout the report as “Mr C”, now remains under constant care in a nursing home as a result of his injuries. He is unable to speak or communicate his basic needs.

Speaking exclusively to The Detail, his mother said: “Sometimes it feels that death may have been the best thing for him and that makes me angry but it also makes me sad. I just want people to understand that my son was a prisoner, but he also had a name. He wasn’t just a number and he was crying out for help but nobody seen it.”

The Prisoner Ombudsman identified 44 areas of concern as a result of the investigation, including the approach taken by the prison service to caring for vulnerable prisoners.

Other key findings in the report include:

  • Despite having a history of mental health problems, Mr C was not given a mental health assessment when he was admitted to prison.
  • In response to a previous incident of self-harm by cutting, it took 42 minutes for Mr C’s cell to be opened by prison staff for medical help to be given.
  • There was a four and a half minute delay in requesting the ambulance when Mr C was found hanging in his cell due to “a misinterpretation of the radio message” sent by the senior officer at the scene.
  • The ombudsman concluded that prison care plans were not adequately responsive to Mr C’s “individual circumstances, needs and vulnerability.”
  • There were “significant communication breakdowns” resulting in a failure to properly consider important risk management related information.

THE REPORT

Given the vulnerability of Mr C, his mother says she wishes to remain anonymous to protect his identity, but agreed to speak to us as she believes lessons need to be learned.

She said: “I’ve yet to receive any kind of apology from anyone responsible for my son’s well being.

“He’s lying in a bed needing constant care and he doesn’t even know I exist. As far as I’m concerned the prison service need to learn how to take care of their prisoners.

“I haven’t slept since I read the report last week, my family have told me to put it down, but I keep reading it over and over again about the mistakes that were made and warning signs that were missed.”

The report states that Mr C’s records show that he tried to overdose three times in his late teens after he was victimised following his conviction for a sexual offence.

In 2000, Mr C was diagnosed with alcohol dependence syndrome and in 2008 had a serious fall which caused multiple fractures of the spine and pelvis. The ombudsman’s report notes that following his accident Mr C regularly used painkillers.

Separately the report notes that in December 2009 Mr C’s two children were taken into care and two weeks later his girlfriend, who was also the mother of his children, died by suicide.

On October 7 2011 Mr C was committed on remand to Maghaberry Prison and was sentenced to two years for a sexual offence.

The records analysed by the ombudsman’s office show that during his committal, Mr C was removed from Roe House to Bush House for his own protection after he alleged that he was being threatened by other prisoners.

The ombudsman‘s report highlights the fact that no decision was taken to refer Mr C for a mental health assessment when he was admitted to prison.

The clinical reviewer for the ombudsman, Dr Seena Fazel, a consultant forensic psychiatrist at the University of Oxford, concluded that someone with Mr C’s history should have been referred for assessment immediately.

In February 14 2012, five days before Mr C hung himself, a nurse noted in his medical records that a mental health referral marked “urgent” had been made.

When interviewed as part of the ombudsman’s investigation, the nurse said that he placed the written referral in the Mental Health Team’s ‘pigeon hole’ as he understood this to be the referral procedure.

However, the ombudsman’s investigation found that the person making the referral is also required to enter the patient’s name in the team’s diary, as this is the only way to access referrals.

The report states that as a result of this Mr C’s “urgent” referral was not considered by the mental health team and wasn’t prioritised at their weekly meeting.

At 9.56pm on February 15 2012, CCTV footage shows that Mr C broke a handle off a cup and intermittently slashed at his arms and wrists.

As he was in an observation cell at the time, staff saw what he was doing and phoned for a nurse.

At 10.13pm, an officer on the landing recorded that Mr C had cut his wrists but that it was “not that bad, ‘minor’, medic informed.”

At 10.38pm, 42 minutes after the incident began, a senior officer and a nurse arrived and the cell was opened for the nurse to bandage his arms.

Mr C’s mother believes this was a cry for help.

She said: “I can’t understand why he was left for over 40 minutes. Their excuse was that he was being monitored but to me that’s not good enough.

“At the end of the day I don’t think his fears around bullying and paranoid issues were properly addressed. As far as I’m concerned he should never have been in prison in the first place, he should have been in a mental health facility. In prison they were more concerned about punishing him than helping him.”

The family’s legal representative, Paul Pierce of KRW Solicitors, says the report raises very serious concerns over the way the prison service and the South Eastern Trust look after vulnerable prisoners in their care.

He said: “The content of this report is very disturbing, particularly so for the family.

“This was a vulnerable prisoner with a history of mental health issues. The trust and the prison service were aware of that background but were unable to properly treat and assess his needs.

“The failures in the report are unacceptable and of such significance that immediate steps should be taken to ensure it doesn’t happen again. Their focus and repsonsibilty should be on care and treatment rather than a fixation on punishment."

DELAYS

At 6.34pm on the day of the hanging incident (February 19 2012), CCTV shows that Mr C’s cell door was opened for 23 seconds whilst he was seen by a nurse and given his medication.

Although Mr C was required to be observed at 15 minute intervals, the ombudsman found that his next observation was 29 minutes later, at 7.03pm.

At interview the officer who checked through his door flap said that he could only see Mr C from the knees down and could not get a response from him. The officer also said that he was upstairs in the office catching up on paperwork at the time of the missed observation and hadn’t realised that the time had lapsed.

From the time that the officer found Mr C and called for assistance, it took a further five minutes for an emergency unlock of the cell to be carried out with a senior officer. Mr C was found to be suspended by a ligature.

The senior officer cut Mr C down and placed him on the floor of the cell. It was established that Mr C’s airway was clear but that he was not breathing. They began chest compressions with the assistance of two nurses. A defibrillator was used and it was established that Mr C had a pulse and was still alive. It was recorded that CPR continued for a further 10-15 minutes until Mr C started to breathe himself. Paramedics arrived at 7.31pm and entered Mr C’s cell.

The ombudsman noted that there was a four and a half minute delay in requesting the ambulance due to a misinterpretation of the radio message sent by the senior officer at the scene.

Edward Brackenbury, a consultant cardiothoracic surgeon at the Royal Infirmary of Edinburgh, was asked by the ombudsman for his opinion on the findings as part of the report.

He said: “The delays in the quarterly hour checks and the five minute delay in opening the cell door and commencing CPR in theory could be relevant to the final outcome of the resuscitation attempt.

“The brain is a highly oxygen-dependent organ and can become severely damaged after only three or four minutes of hypoxia (when the body is deprived of oxygen) at normal body temperature.

“Even the smallest delay in rescue will be important in determining the success, or otherwise, of resuscitation following hanging.”

The ombudsman’s report states that there is evidence that some staff considered that Mr C may have been threatening self harm in order to manipulate a move and this may have inappropriately influenced their approach to assessing his needs and developing a care plan.

The ombudsman concluded that case reviews carried out by staff did not properly consider the underlying cause of Mr C’s self harming and care plans were not adequately responsive to his “individual circumstances, needs and vulnerability.”

The investigation also found that there were “significant communications breakdowns” resulting in a failure to properly consider important risk management related information.

Mr C’s mother says more should have been done to help her son.

She said: “When I read about the delays in getting him the help he needed, it breaks my heart. My son is now lying in bed, brain damaged. He’s so thin, he can’t talk, is fed by tubes and is in and out of hospital because his body can’t fight infections anymore. I go home and I cry myself to sleep and that’s when I can sleep.”

On 21 August 2012 – six months after the hanging incident – the Prison Service advised that the Parole Commissioners had directed that Mr C could be released from custody, because he did not pose as a risk to the public or of an unaided escape.

FUTURE REPORTS

In their official response to the ombudsman’s report the Chief Executive of the South Eastern Trust said they accepted the recommendations raised by the report and that appropriate action would be taken. The trust also outlined that it now assesses all new prisoners with mental health issues within 72 hours.

Prison Service Director General Sue McAllister said It was clear from the report that ‘Mr C’ was a vulnerable individual and his final spell in custody was both challenging and difficult.

She said. “The Prison Service accepts that while he was the subject of 15 minute observations, 29 minutes had elapsed from the time of ‘Mr C’s’ last observation to the time he was found in his cell in a near death state.

“The ombudsman notes that prior to this final check, all other observation checks on the prisoner had been carried out consistently in line with his care plan.

“There are important issues raised by the ombudsman in relation to the overall approach to caring for vulnerable prisoners and I will pay close attention to this in my overall consideration of the report in collaboration with the South Eastern Health and Social Care Trust.”

In recent years Prisoner Ombudsman, Pauline McCabe, has published a number of death in custody reports, but this marks Northern Ireland’s first “near death” report.

The Northern Ireland Prison Service’s Standard Operating Procedure on Self Harm and Suicide Prevention 2011 states that an investigation by the Prisoner Ombudsman will occur when a prisoner self-harms to the point where:

(i) without immediate intervention the prisoner would have died;

(ii) as a result of the incident the prisoner has suffered permanent or long term serious injury;

(iii) as a consequence of the long term injuries sustained the individual’s ability to know, investigate, assess and take action in relation to the circumstances of the incident has been significantly affected.

In an interview with The Detail, Mrs McCabe said while the investigation found that the implementation of Supporting Prisoner at Risk protocols was, in general, to a higher standard, the investigation had raised concerns about the level of care provided to vulnerable prisoners.

She added: “This investigation has emphasised the importance of near death investigations in highlighting issues of concern and providing learning and service improvement opportunities for both the Prison Service and the South Eastern Health and Social Care Trust.

“I have always considered the Prison Service’s criteria for triggering a near death investigation to be unduly restrictive and I believe that any serious incident resulting in permanent physical and/or mental impairment should warrant investigation by the Prisoner Ombudsman. I am therefore pleased that the Director General of the Prison Service has now given a commitment to review this.”

© The Detail 2013