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Report of the Prisoner Ombudsman
Nov 22, 2012
The Prisoner Ombudsman for Northern Ireland, Pauline McCabe, today published her report into the death of 23-year-old Frances McKeown, who died by suicide while in the custody of Hydebank Wood Women’s Prison on Wednesday 4 May 2011. Below are a number of excerpts from the report:
Frances McKeown was born on 28 April 1988. She was 23 years old when she died by suicide, on Wednesday 4 May 2011, whilst in the custody of Hydebank Wood Women’s Prison.
At around the age of 13, Frances was referred to community mental health services. She subsequently started to self harm. Frances’ family said that, throughout her secondary school years, she was bullied “quite badly”, but after leaving school she achieved a diploma in child care and had a part-time job.
At 18 years of age, Frances’ family said that she “drifted away” from them and she stopped engaging with community mental health services.
At 19, Frances met her husband and had their first child. Following the birth of their child and difficulties with their marriage, Frances and her daughter moved away from the family home. After the birth of Frances’ second child, she experienced further difficulties and her family said that they felt that she was suffering from post natal depression. As a result of these difficulties, both children were taken into care.
After Frances’ children were taken into care, and following an earlier allegation that she was the victim of sexual abuse, Frances’ mental health deteriorated and as a result she was admitted to Craigavon’s Bluestone Mental Health Unit. Frances was subsequently admitted to Bluestone on a further ten occasions. It was during these admissions that she was diagnosed with Emotionally Unstable Personality Disorder.
On 22 September 2010, Frances was remanded into the custody of Hydebank Wood. This was the first time that she had been in prison. Frances’ Prisoner Escort Record, which accompanies an individual committed from police custody, notes that she “suffered from depression and anxiety. Attempted self-harm 6-8 weeks ago. States currently feeling suicidal…”
There is no evidence that prison staff assessing Frances as part of the committal process received or considered this information. Staff did note Frances’ history of psychiatric hospitalisation; an attempted suicide six weeks previously; a history of illegal drug and alcohol misuse and that Frances had no “current thoughts of self-harm”. It was noted that Frances’ demeanour was appropriate, cheerful and co-operative. It was also recorded and confirmed with her GP, that she was taking Risperidone2 4mg daily prior to her committal. Her medical records were not, however, requested from her GP.
Frances was eventually seen by a mental health nurse on 8 November 2010. During her assessment, the mental health nurse noted that Frances had been a psychiatric patient 11 times, was currently an outpatient and had two infants in foster care. Frances disclosed a history of alleged childhood sexual abuse, domestic violence and self-harm and explained that she felt better on Quetiapine 125mg (an antipsychotic drug) and Fluoxetine 40mg (an antidepressant). The mental health nurse recorded on EMIS5 that a referral to psychiatry would be required, in order for Frances’ medication to be reviewed.
The day following her assessment, Frances was prescribed Fluoxetine by a prison doctor but, regrettably, the requirement for a referral to psychiatry was not actioned because of an oversight by the nurse.
Frances’ second SPAR booklet was opened on 13 November 2010, because Frances had thoughts of suicide and was considered to be “really at risk.” The following day, Frances had a SPAR assessment interview with a senior officer. The senior officer recorded that Frances clearly had a suicide plan and had felt suicidal during the night. She noted that Frances “gives me grave cause for concern as she is withdrawn,” and still appeared to be at high risk of suicide because she was “uncommunicative and morose…appears depressed and continued to voice negativity to all our suggestions.”
The investigation established that on 14 February 2011, a medication spot check was carried out and Frances was found not to have any of her prescribed medication in her possession. As a result, the prison doctor stopped her medication pending a mental health assessment and a referral form was completed. The doctor said, at interview, that because Frances couldn’t explain where her tablets were, she thought “if I didn’t know where the tablets were going wouldn’t it be better that she didn’t have any tablets than somebody coming up [and bullying her for them].”
The doctor was asked whether alternative options, such as placing Frances on daily supervised swallow of her tablets, was considered. She said “the nurses organise all of that. And sometimes the women don’t like that. How they give out the tablets is the nurses’ decision.” The doctor said also that she had thought that Frances would have a mental health assessment within a couple of days.
It is, in fact, the case that, in the absence of a doctor’s prescription, the nurses would be unable to give medication to Frances and could not, therefore, consider administering it in a different way.
On 2 March 2011, it is recorded that landing staff notified a nurse that they were concerned about Frances’ mood being low. The nurse recorded on EMIS that Frances had still not had a mental health review and requested that the doctor see her and recommence the antidepressant medication which had previously been stopped.
On 3 March 2011, landing staff recorded that Frances was “upset, tearful and feels her head is going….she feels she can hear voices and wants to go back to her old ways of cutting her arms.”
Although the doctor stated that she expected a mental health assessment to take place within a couple of days of stopping Frances’ medication on 14 February 2011, in the event, Frances was not seen by a mental health nurse until 4 March 2011 and was not put back on her medication until 5 March 2011. She was, therefore, without antipsychotic and antidepressant medication for 19 days.
Frances’ fourth SPAR was opened on 4 March 2011, following her period without medication. It was opened because of her low mood and thoughts of suicide and because she was “hearing voices in her head.” It is to note that, although SPAR booklets had previously been opened for Frances on 13 November and 5 December 2010, and she had further consultations with a mental health nurse on 6 December 2010, 10 December 2010 and 4 March 2011, the fact that she had not received her appointment to see the psychiatrist was not followed up.
On 4 March 2011, because Frances disliked being held in an observation cell, staff who were concerned that she was at risk of self harm, decided that she was to be
placed in an empty room with her own clothes and bedding and to be observed at intervals of no more than 30 minutes.
On 5 March 2011, it was agreed for Frances’ own safety and that of others that she would be moved to the healthcare centre “to give her time to re-coup her thoughts and re-adjust her thinking.” It was noted that “Frances is in a really bad place at present. She has stated that she will kill someone, maybe even herself”.
“… my problems are now things I haven’t suffered from since I was about fifteen. It’s the thoughts I’m having and the voices I’m hearing. I have non stop thoughts about seriously hurting people and even killing people. I think everything out to the finest detail of what I would do, and I don’t care if I get caught, I just want to hurt people including myself …”
“… the voices in my head are getting worse and more violent, they run me down and make me so angry. It’s like I’m sitting on my own but there is someone in the room with me telling me what to do and to hurt people and I have to fight it’s so hard, not to try and listen to it. At night when I am in my cell it is worst because I can’t distract myself from it all I can do is listen to it and the horrific things it tells me to do. Hell every day of my life and if I am dead it would all be over for me and I wouldn’t have to suffer anymore because I can’t put up with it any longer….
…in her suicide note, Frances made reference to a death of a young man at Hydebank Wood that occurred a few hours before her suicide. Frances was reported to be upset that the death of the young man resulted in her, once again, being locked. It is one possibility that the occurrence of this death may have affected Frances’ mood.
It is also a possibility that the fact that Frances was found, at autopsy, to have taken the non-prescribed antidepressant Trazodone, could have influenced her decision.