Mr Nicky Raymond Reilly · Prevention of Future Deaths report

On the 7th December 2018 I concluded the Inquest into the death of Mr Nicky Raymond Reilly (NR) also known as Mr Mohamed Saeed-Alim, who died on the 19th October 2016 in HMP Manchester. A jury reached the following findings and conclusion :

“In October 2016 the deceased was an inmate at HMP Manchester having spent 6 years at Broadmoor High Security Hospital. He had a diagnosis of Emotionally Unstable Personality Disorder and Aspergers. On the 19th October 2016 he was found hanging by a ligature in his cell. He was pronounced deceased at 14.43.

On the balance of probabilities the deceased died as a result of hanging whilst in HMP Manchester. It is more likely that not that he did not intend to end his life and he acted impulsively as a result of his Emotional Unstable Personality Disorder and Aspergers Syndrome.”

The circumstances leading up to NR's death are as follows:

In 2009 NR was convicted and sentenced to life imprisonment following an incident in May 2008 when he had attempted to detonate explosives in the Giraffe Café in Exeter. In the time prior to the incident NR had converted to Islam, changed his name and subsequently developed extremist views as a result of being radicalised. Prior to the incident NR had been diagnosed with Asperger’s Syndrome and had been under the care of Mental Health Services. He was subsequently also diagnosed with Emotionally Unstable Personality Disorder.

Following his conviction the Court imposed a life sentence as opposed to a hospital order.

During his remand he had been held in HMP Belmarsh on the healthcare unit, following his conviction a referral to the high security hospital was made and he was transferred to Broadmoor. He remained an inpatient in Broadmoor hospital for the next 6 years. In July 2015 NR and another inpatient assaulted members of staff, following which a clinical decision was made resulting in NR being transferred back to the prison estate.

A meeting was held between HMP Belmarsh and Broadmoor prior to NR's return to the prison estate. Subsequently he was referred to the Managing Challenging Behaviour Scheme and his care was overseen by the Central Management Group (CMG). A decision was made to transfer NR to the Specialist Interventions Unit at HMP Manchester in order for work to be undertaken in relation to his extremist views. The longer term plan was that he would be moved to the Westgate Unit at HMP Frankland when a place became available.

Whilst on the SIU the Court heard evidence with regards to the management of his care and the input of both the prison psychologists, part of (HMPPS) and the Mental Health In-Reach team, the prison mental health service provided by Greater Manchester Mental Health & Social Care Trust (GMMHIT).

The Court does not intend to repeat the evidence heard in relation to the contact with NR and sets out its concerns below.

HM Prison Service

• CPA

Whilst NR had been an in-patient at Broadmoor he had been subject to the Care Program Approach (CPA). There was no explanation as to why this was not continued when he was transferred back into the Prison Service. The lack of continuation of the CPA and the missed opportunities this presented, particularly in respect of earlier input from Psychiatry, for someone with such complex needs is of concern to the Court. Care plans relating to NR, as discussed below, should have had the benefit of Psychiatric input.

• Managing Challenging Behaviour Scheme and Challenge Support and Intervention Plan

The Court acknowledges that as of the 1st February 2019 the MCBS will be replaced by the new CSIP providing management of the prisoner to the individual establishment rather than with the CMG. Whilst recognising this significant development there were concerns heard during the course of NR’s Inquest which remain relevant. The Court also recognises the complexity of the challenging behaviour presented by NR in that he had a diagnoses of both emotionally unstable personality disorder, Asperger's and in addition, remained someone who held extremist views.

The Court heard evidence in respect of the quarterly meetings held by the CMG in respect of managing NRs care plan. The quality of documentary record keeping in respect of these meetings was limited. The absence of important multi-disciplinary attendees and lack of requirement of formal reports meant there was no-one who could provide full, accurate, informed information regarding NR, upon which decisions regarding his care could be made.

• Psychology Input

NR had been allocated a Psychologist ████████ to undertake the specialist extremism work. However this meant he did not have an allocated psychologist who was based within the SIU.

The evidence to the Court from several witnesses including the Psychologists and SIU staff showed there was confusion as to whom was NR’s allocated Psychologist. The reality was from May 2016, NR received no psychological input and did not have an allocated Psychologist in any meaningful form.

The Court received a copy of the psychology records kept by ████████ which the Court heard were the only Psychology records available. It was evident to the Court that there was little to no recording of information within the Psychology department. NR’s psychology medical records were at best, woeful. Moreover, as they were not kept in the Psychology department they were not available access to any other Psychologists.

The Extremism Risk assessment work had been concluded by ████████ in May 2016. Despite this, her report had not been completed at the time of NR’s death in October 2016 and she did not anticipate being in a position to complete the report until the New Year, some 8 months later. Whilst there is no evidence that in NR’s case this held up his referral to the Westgate Unit, given that a significant reason for his placement on the SIU prior to placement at Westgate, was to undertake this piece of work, a significant time had elapsed. In the meantime whilst waiting transfer, the Court heard no further Psychological input would be started with NR.

• Services available within Prison for Prisoners with Aspergers and/or Personality Disorder

The Court heard evidence as to the increase of prisoners within the Prison Service who potentially have a personality disorder or a degree of Aspergers and the limited services and places available. Of significance was the lack of training or guidance to staff on how to interact or accommodate someone with high functioning Aspergers such as NR. Please note the Court recognises the care provided by the SIU staff and the attempts some staff went to interact with NR, however there was no specific training or assistance given to them.

HMP Prison and Greater Manchester Mental Health & Social Care Trust

• Complete Separation of the Mental Health In-Reach Team and Psychology Team

The Court heard how the Mental Health team providing mental health services within HMP Manchester have a completely separate record keeping system (system 1) to the Psychology Team. Whilst acknowledging the Psychologists are employed by HMP Prison Service. However not all the psychologists were forensic psychologists as the Court heard ████████ was a clinical psychologist. There will inevitably be prisoners who require clinical psychological input for a range of diagnosis. Within a community setting such psychological services would be provided by the Mental Health Trust. Hence Psychologists would have access to the patients mental health records within the same Trust, where the same existed.

Where a prisoner is receiving both Mental Health input and Psychological input within a prison, there should be access to the appropriate medical records in order for each service to have a clear understanding of the patients clinical presentations and need. Having access to the totality of the information should then assist in appropriately assessing a patients risk to self and others.

Greater Manchester Mental Health & Social Care Trust

• Medication Refusals

The Court heard evidence as to the lack of action taken by staff following NR's refusal of medication. The Court heard the process which should happen but this is not clearly documented in one policy which covers the situation for both weekdays and also weekends. There remains a risk particularly at a weekend that an appropriate escalation process would not be actioned by staff.