Geraldine Liege Kilborn · Prevention of Future Deaths report

On 3rd December 2013 I commenced an investigation into the death of Geraldine Liege Kilborn aged 37 years. The investigation concluded at the end of the inquest on 5th December 2014.
The Jury could not determine the Deceased’s intention when she hung herself. The Jury concluded that following an ACCT review, the deceased was not appropriately located at the time of her death and that she would not have ended her life when she did, irrespective of her location.

Immediately upon entry into HMP Low Newton, the reception screen nurse deemed the deceased to be of high risk of self-harm and advocated a constant watch. Over the next 22 days prior to her death the deceased self-harmed repeatedly with many of the attempts being deemed by staff as being genuine attempts to take her own life. There were a series of ACCT reviews. For a time she was on constant observations, on normal location, in healthcare safer cell and healthcare normal cell. One ACCT review had no mental health input after when such staff had asked to be present and somewhat incredulously, in evidence the ACCT case manager stated that he did not know that mental health care staff were available to attend on the day in question. At the time of her death mental health care staff did not work weekends and at two critical ACCT reviews, there was no mental health input into the reviews. Several mental health witnesses described tensions between mental health and wing staff, one such witness calling wing staff “dinosaurs”. Senior key members of the last two ACCT reviews were unaware of the detailed entry made in system one notes by a Consultant Psychiatrist and did not take her views into account. On one of these two key reviews, which was attended by a senior general nurse, she did not share with the other review team members the knowledge that she had of the said system one Consultant Psychiatrist entry. The Jury was critical of the Prison’s care of the deceased.

(1) There was a clear breakdown in sharing of information known to the mental health team with other members of some ACCT reviews. Evidence was given that there has been a change in service provision contracts since the death of the deceased and that mental health staff will now work weekends. Nevertheless, it is vital that in appropriate cases where a prisoner is on an ACCT and has had substantial mental health input that they both attend relevant ACCT reviews and their opinions are given sufficient weight. It is noted that mental health nurses never chair such ACCT reviews as case manager and in this case has revealed that even in attendance, their views might not be given sufficient weight.
(2) Witnesses confirmed that they often did not read much of the ACCT document prior to the ACCT review and relied more upon input of other attendees who might know the prisoner and opined their face to face assessment of the prisoner at the time. In this case, some ACCT review members had limited day to day experience of the deceased, whose temperament and presentation could change “like a light switch” and therefore face to face presentation could well be misleading. Thus in cases where the ACCT review was dealing with a particularly complex challenging prisoner and where an enhanced review was called for, it would seem appropriate for further consideration to be given to the question of review panel membership generally as well as, as above, mental health input in particular.