Tomasz Nowasad

1. 1. self-harm and suicide

   “In my opinion there ts a risk that future deaths will occur unless action is taken”

2. 2. over-reliance on prisoner's statements about no thoughts of self-harm or suicide

   “The context of this case has to be seen in the light of the fact that in 2019 two self- inflicted deaths happened at HMP Manchester There were four in 2018 and my records indicate that there have been 29 from the beginning of 2006 up to date In view of the evidential issues highlighted above it is suggested that there has been a repeated theme in the majority of these cases that there was an over reliance and emphasis on the assertions made by a prisoner that they "had no thoughts of self-harm or”

3. 3. inaccurate clinical record keeping

   “It is suggested that there was an absence of timely, full and accurate clinical record keeping by members of GMMH healthcare staff”

4. 4. inadequate documentation of risk factors when prison staff are present during healthcare interviews

   “It is suggested that whenever there is a healthcare interview and a member of prison discipline staff is present, records should be kept by GMMH and HMPS of who was there, but also HMPS staff should record separately within their records evidence and information relevant to the risk of self-harm or suicide”

5. 5. inadequate transfer of risk information during prisoner movement from HCC to ordinary cells

   “It ils suggested that whenever there Is a decision made to move a prisoner who Is subject to an ACCT from the HCC to another location in the prison, prison staff of the receiving wing should ensure that they attend any final case reviews prior to discharge so that they are familiar with the relevant history and risks that the patient prisoner presents, make appropriate documentary records and ensure that relevant information is handed over to colleagues”

6. 6. failure to review ACCT files upon prisoner arrival

   “It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide and how it has been managed to date and whether or not that needs to be reviewed on arrival Any concerns should be escalated”

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