MARK ANTHONY DOYLE · Prevention of Future Deaths report

On 5 April 2017 an investigation was commenced into the death of Mark Anthony Doyle, aged 45 years old. The investigation concluded at the end of the inquest on 12 December 2017. The jury found that Mr Doyle died on 28 March 2017 at University College London Hospital, as a result of injuries earlier sustained when he suspended himself from the bars of his cell window at HMP Pentonville with a ligature. The jury made a narrative determination that his intention at the time was unclear; and that his death may have been caused or contributed to by errors in the identification and recording of the anniversary of his son’s death on his ACCT; his inappropriate transfer from F Wing; and the undue delay in responding to his cell bell on the evening of 21 March 2017. The medical cause of death was found to be: 1a post cardiac arrest hypoxic ischaemic brain injury; 1b ligature compression to the neck.

See section 3 above: Mr Doyle was found suspended by a ligature attached to the bars of his cell window on the evening of 21 March 2017. Following emergency resuscitation he was taken to University College London Hospital, where he remained until his death on 28 March 2017 from injuries sustained by his suspension with the ligature.

(1) Although recent developments regarding multi-disciplinary involvement in ACCT case reviews and quality assurance ACCT checks are encouraging (as described to me by ████████, Head of Safer Custody), I remain concerned that the following failings were apparent in the ACCT case reviews concerning Mr Doyle conducted on 10 and 20 March 2017, but are not addressed / adequately addressed by the recent initiatives (including the new Weekly Quality Assurance Check):
• Insufficient appreciation of the importance of identifying and recording trigger factors for a particular prisoner on their ACCT inside front cover;
• Officers undertaking case reviews without reading recent entries on the ACCT daily record relevant to risk;
• Officers determining the frequency of observation levels for an ACCT prisoner without considering relevant material in the ACCT file;
• The ACCT reviewer failing to appreciate the value of involving at least one member of the prison staff who knows the prisoner; and
• Circumstances in which a prisoner’s family could or should be contacted as part of the ACCT review process were poorly understood.

(2) Although, ████████, Head of Healthcare, described how healthcare staff have received recent encouragement to make entries on a prisoner’s ACCT in relation to matters that could bear on risk, I am concerned that this does not go far enough to change past practice and ensure that relevant information is shared, in light of the prison staff’s lack of access to System One records and the infrequent occasions that Care UK staff made entries on Mr Doyle’s ACCT daily record.

(3) Decisions that prisoners are fit to be transferred from F Wing are made and conveyed to prison staff by the charge nurse on duty that morning annotating by hand a list of the prisoners on the Wing. There appears to be no clear criteria for assessing when a prisoner is fit for transfer; the information that should be considered in making this determination is left to the discretion of the decision maker; and there is no process for recording the decision, the reasons for it or the identity of the decision maker in the prisoner’s records or otherwise.

(4) There is no mandatory first aid training for existing (as opposed to new) prison officers. I was informed that Orderly Officers and OSGs have / are being provided with first aid training, but I am concerned this remains a serious lacuna. I appreciate it is a nationally made resourcing decision and that it has been raised previously, but I raise it for further consideration; in light of the limited number of prison and nursing staff on duty overnight, there is a real prospect of medical emergencies arising where no trained first aider is available.