HMP Humber prison to step up procedures after inmate dies following fall in protest over missing medication

An investigation by the Prisons and Probation Ombudsman, was published this week more than four years after the death of 42-year-old David Atkinson at HMP Humber, where he was serving a 26 week sentence for assault and breaching a restraining order.

The report states Mr Atkinson's death was an accident but found there "deficiencies" in the way staff treated him before the fall on January 5, 2018 - just days before he was due to be released from prison.

Mr Atkinson had a history of self-harm and had been monitored previously under suicide and self-harm procedures, known as ACCT (Assessment, Care in Custody and Teamwork). He took methadone and was deemed suitable to keep other medication in his possession, including pregabalin, used to treat anxiety and nerve pain.

He told several officers and a mental health nurse on a number of occasions it was missing but was told a GP would re-prescribe it and an appointment was needed. He threatened to kill himself and was taken back to cell. There was some discussion about whether a nurse or prison officer should start ACCT procedures, which were not progressed.

At 4.28pm, the nurse sent an electronic task to ask prison GPs to review Mr Atkinson’s medication but it was actually sent to healthcare administration team, who did not open it until two days after Mr Atkinson’s fall. The nurse sent another task to the prison’s pharmacist who said medication would be prescribed when it was next due on his release date, or a GP appointment would be needed. Half an hour the task was closed with no appointment made.

Mr Atkinson made further requests to nurses before "storming off" and going to the first floor landing, climbing over the rail and resting on an alarm bell. The report says he had heard that another prisoner had got what they wanted in such a way.

However, the bell gave way under his weight and he fell to the ground. He died on January 16.

The Ombudsman report said: "There were deficiencies in the way that staff managed Mr Atkinson in the days before his death. He was agitated and in a volatile state, banged his head on a desk and threatened to kill himself. Staff took a decision that they would not formally monitor his risk of suicide and self-harm but, having made that decision, did little to understand or address the underlying causes of his agitation.

"This was compounded by the actions of healthcare staff who, when Mr Atkinson reported that his prescribed medication had gone missing, failed to refer him for a review of his medication or deal with his continuing frustration and agitation at lack of access to his medication. Humber will need to review its guidance and procedures on tradable medications and the actions that staff should take when prisoners report that their medication is missing."

Three recommendations were made which say the Governor should ensure that staff start ACCT procedures if a prisoner has risk factors and if not, clear reasons should be stated; the Head of Healthcare should ensure clinical staff refer prisoners to GPs when they report medication missing so prompt decisions can be made and the administration of pregabalin and other tradable medications is completed as a matter of urgency.