HMP Durham has been ordered to make changes after a second man died after being found hanging in his cell, according to a report into his death.
Ahmed Alshbli, 35, was found in his cell at HMP Durham on November 2, 2022, after being remanded in prison earlier that day for offences including harassment and assault on his partner. It was his first time in prison.
He died at University Hospital North Durham a week later, on November 10, 2022, having sustained a brain injury caused by lack of oxygen due to the incident, a post-mortem concluded. His inquest in October concluded that Alshbli died by suicide.
He was the second person in three days to die after being found hanging in their cell at the prison.
And now a Prisons and Probation Ombudsman (PPO) report, published on February 20, has called on the prison to make a number of improvements, having found similarities between the two deaths and how the men’s admission to the prison was handled.
The PPO report said Alshbli arrived at the prison with a suicide and self-harm warning form after punching and banging his head against a wall and tying a jumper around his neck at court. He also wrapped his seatbelt around his neck en-route to prison.
But when he presented to HMP Durham he told staff that he had not intended to harm himself in court and was just trying to avoid being sent to prison.
The report ruled that this appears to have influenced the supervising officer’s decision that suicide and self-harm prevention procedures (known as ACCT) monitoring was not necessary, despite documents advising that Alshbli was at risk of harming himself. The supervising officer has since left the prison service.
Alshbli, a Syrian national who had been living in the UK since 2018, was then assessed by nurses in reception who did not have access to the digital documents advising of his risk, the report said. He told the nurse that he had no history of self-harm or mental health issues but was tearful. The nurse did not have any serious concerns and did not start ACCT procedures, the report added.
It went on to say that Alshbli was later assessed by a mental health nurse, who also had no access to Alshbli’s forms. During his meeting with the nurse he mentioned low mood and thoughts of suicide but said he had no intention to act on those feelings. The mental health nurse began ACCT procedures with checks at least once every 30 minutes.
At 8pm that evening, Alshbli was found to have obscured the view into his cell and had tied something to his bed, which he claimed was to rest his legs and he had no intention of harming himself. The obstruction was removed by staff and Alshbli was told not to obscure the view or tie anything to the bed.
The PPO report found that staff did not reassess his risk, and observations were not increased.
At 10pm Alshbli was found hanging in his cell. Paramedics who were already at HMP Durham due to a separate medical incident attended within one minute of the emergency call being raised. Alshbli was taken to University Hospital North Durham, where he died on November 10, 2022.
The PPO report concluded that the governor and head of healthcare at the prison should review reception procedures to ensure that all staff supporting individuals and completing initial risk assessments have access to relevant information and documents.
It also ruled that the Governor and Head of Healthcare should ensure that staff responsible for ACCT procedures comply with national policy requirements, including, assessing a prisoner’s risk based on their risk factors and not solely their presentation, and reassessing risk and observation levels after any indication of increased risk.
The findings follow an earlier investigation into the death of a prisoner who died just three days before Alshbli after being found hanging in his cell. The report found that the prisoner, Russell Irvine, had not been identified as an increased risk of suicide and was not subject to any additional monitoring, despite him being managed under ACCT and refusing food on several occasions during his time in prison.
The report also found that staff did not have appropriate access to vital digital information, such as documents outlining a prisoner’s risk of self harm. In the report, published on July 8, 2024, the Governor and Head of Healthcare was asked to review reception procedures to ensure that all staff have access to and consider relevant information.
Following the review into Alshbli’s death, the HM Prison & Probation Service (HMPPS) has published an action plan addressing the PPO’s recommendations and has taken a number of steps to improve its reception and ACCT procedures.
It sates that improvements to reception procedures include better joint working between the Governor and Head of Healthcare and updated processes to ensure timely healthcare access for new arrivals, as well as regular reviews to make sure all risk information is available and used.
While improvements to ACCT procedures have included staff training on identifying risks and not just relying on prisoner behaviour, clear documentation of decisions and use of a safety checklist when remand prisoners arrive in prison. It also includes new roles and a focus in the safer prisons team to improve risk assessment, as well as ongoing training for both prison and healthcare staff.
A HMPPS spokesperson said: “We have addressed the PPO’s recommendations at HMP Durham, including improving our processes for new prisoners and boosting staff training to better identify and manage risks.”
The full PPO report can be viewed here and the HMPPS action plan can be found here.
View news Source: https://www.chroniclelive.co.uk/news/north-east-news/hmp-durham-must-improve-after-31130075
