Individual at Usk and Prescoed

Investigation into the circumstances surrounding
the death of a man at
HMP Usk/Prescoed in January 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2009
This is the report of an investigation into the circumstances of the sudden death of
a man at Neville Hall Hospital, Abergavenny in January 2009. The man, a prisoner at
HMP Usk, was 72 years old and had suffered from several chronic conditions. The post
mortem found that he died from coronary artery thrombosis. An inquest into his death
was held on 27 January 2009 and concluded that he died from natural causes.
He had remained in contact with some members of his family. I am also aware that
staff and prisoners who knew him are saddened by his death. I would like to offer my
sincere condolences to all those who knew him and have been affected by his death. I
apologise for the lateness of this report.
My colleague conducted the investigation. An independent review of the man’s clinical
care was undertaken by the clinical reviewer, Review Manager Healthcare Inspectorate
Wales. I am very grateful to her for her valuable contribution. I would also like to thank
the Governor of HMP Usk and his staff for their cooperation. I am grateful to the prison
liaison officer for his assistance. The family liaison officer and a member of the
Independent Monitoring Board also made a very valuable contribution to the
investigation.
I make six recommendations. Five relate to healthcare matters and were recommended
by the clinical reviewer. The first two recommendations relate to the need to improve
the quality, legibility and accuracy of prison healthcare clinical record keeping at Usk.
The third recommendation asks that prisoners suffering from symptoms of hypertension
are treated in accordance with the National Institute of Clinical Excellence guidelines.
The fourth recommendation requires more detail to be provided in the event of requests
for hospital tests. A fifth recommendation suggests improvement in communication
between the prison and hospitals. The final recommendation is addressed to the
Governor and concerns compliance with Prison Service Order 2710 in respect of
holding debriefs following a death in custody.
My recommendations aside, I judge that the care the man received at Usk was
appropriate.
The prison service have accepted four and partially accepted two of my
recommendations and their response is documented on page 18 of my report.
This version of my report, published on my website, has been amended to remove the
names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman December 2009
2
CONTENTS
Summary
The investigation process
HMP Usk
Key findings
Issues
Recommendations
3
SUMMARY
In December 2004, the man was remanded into custody at HMP Gloucester. He
underwent a routine reception healthcare screen interview that day. He told the
healthcare worker that, in the past, he had depression, urine infections and acidity in his
stomach. He had a forthcoming hospital appointment at the Ear, Nose and Throat
Department at Gloucester Hospital. During an assessment with the doctor the following
day, he was noted to have a false left eye sustained through an accidental injury in
1954.
He was sentenced to eight years imprisonment on 11 April 2005 and, in May, he
transferred to HMP Usk. Healthcare staff at Usk made a thorough assessment of his
physical health. They concluded that he suffered from high blood pressure, he did not
have substance misuse issues or thoughts of self-harm, his diet was good and his
family history showed that there was a risk of diabetes.
Throughout his sentence he had a variety of medical ailments and visited the healthcare
department on a number of occasions. His blood pressure was regularly monitored. He
was assessed as suffering from hearing loss and, following a referral by a consultant
and after a lengthy wait, he was fitted with a hearing aid. Healthcare staff addressed his
back problems by prescribing paracetamol, providing a bed board and obtaining
permission for him to wear a surgical belt. He was well thought of by staff and worked
well as a cleaner until he was retired by the prison.
On 25 October, he was admitted to Nevill Hall Hospital, Abergavenny with chest pain.
Doctors diagnosed musculo-skeletal chest pain and discharged him the following day.
During April and May 2006, he continued to be treated for urinary tract infections, dizzy
spells, high blood pressure, an allergic reaction to amoxicillin, dermatitis (a skin
condition), skin irritation to his left calf and a strained ankle.
In February 2007, he received bad news from his family. He was told that his estranged
daughter had cancer. She died in September and he was very upset.
Just before his daughter’s death, he complained of vague chest pain and tightness to
his chest. He was taken to hospital but tests showed he had not suffered a heart attack.
From October 2007 to mid February 2008, he attended healthcare for various medical
complaints including problems with his right eye. In May, he again felt chest pain and
went to hospital. The chest pain was not related to his heart and he returned to the
prison. The clinical record said that an appointment for an exercise stress test was
awaited to see if he had angina.
He continued to experience dizzy spells relating to high blood pressure. A prisoner who
shared his dormitory said that he recalled a few days before his death, he had suffered
dizzy spells and healthcare had treated him promptly.
4
In December 2008, he walked to healthcare from his dormitory as he, again, had chest
pain. He went to hospital as an emergency and his condition deteriorated. The hospital
advised the prison to contact his family as he was unlikely to survive. He was placed on
a life support machine but was unable to breathe unaided. At 4.45pm the following day,
the life support machine was switched off and he died in the presence of his family.
The Family Liaison Officer spoke with his sister. She invited the family to attend the
memorial service at the prison and to speak to staff and prisoners who knew him. The
family were very appreciative of how they were treated by the prison and spoke well of
the Family Liaison Officer.
My investigation has made five recommendations relating to healthcare matters and
another recommendation regarding the failure of the prison to hold a hot debrief in
accordance with Prison Service Order 2710. I conclude that, in spite of these
recommendations, the man received good care.
5
THE INVESTIGATION PROCESS
1. The Ombudsman was notified of the man’s death in January 2009. Terms of
reference and notices were issued to staff and prisoners at Usk telling them that an
investigation would be taking place, and inviting those who wished to see the
investigator to make themselves known. The investigator requested copies of his
core record, clinical record, and other records relevant to his time in custody and his
death.
2. The investigator also contacted HM Coroner to inform him of the nature and scope
of my investigation. The Coroner told her that the man had died from coronary
artery thrombosis. An inquest was held on 27 January 2009 and a verdict of death
by natural causes was recorded.
3. The investigator visited Usk in May 2009. She met and spoke at length with staff
and prisoners who knew the man. She visited the healthcare centre and saw the
wing and cell where he was located before he died.
4. A clinical review of the man’s clinical care was commissioned from Healthcare
Inspectorate Wales (HIW). The clinical review was conducted by the clinical
reviewer, Review Manager, HIW and appears as an annex to this report.
5. One of the Ombudsman’s Family Liaison Officers spoke with the man’s sisters.
They did not raise any concerns regarding his care at the prison. While they were
shocked at his sudden death, they said that other close family members had
suffered from heart problems.
6
HMP USK/PRESCOED
6. HMP Usk is a category C closed prison for prisoners convicted of a sexual offence
or offences, or who have a sexual element in their offending history. On arrival into
prison, prisoners are risk assessed and given a category based on their offence and
the risk that they pose to the public should they escape. There are four levels of
category: A, B, C and D, with category A prisoners being the most dangerous.
Category C prisoners are those who cannot be trusted in open prison conditions but
who would not have the ability or resources to make a determined escape. Usk is
located in Monmouthshire and is joined with HMP Prescoed, an open prison,
although both prisons are located separately. It has a maximum capacity of 256
prisoners.
11. Accommodation is provided in three double storey wings in a combination of single
and double cells and two dormitories. In May 2003, the Comber Unit opened on D
wing (where the man was located) and provides ground floor accommodation for 20
prisoners.
12. HM Chief Inspector of Prisons made a short unannounced inspection in early March
2008. She described both Usk and Prescoed as “good prisons” overall with
educational and vocational opportunities in both prisons judged as “impressive”.
13. She criticised healthcare accommodation. (Building improvements were awaited at
the time her inspection was conducted.) Healthcare is provided by permanent
nursing staff. A doctor attends the prison three days per week to deliver primary
health care to prisoners. Out of hours medical help is provided by an on-call system
after 4.30pm weekdays and at weekends.
14. The investigator spoke with a member of the Independent Monitoring Board1 who
told her that the prison was well run under a recently appointed governor. She
added that the Board received very few complaints regarding healthcare. She
described healthcare as very good especially as the population of Usk were older
than that of Prescoed and had higher health needs.
15. This is the fifth death through natural causes at Usk that the Ombudsman’s office
has investigated.
1 The Independent Monitoring Board members monitor the day-to-day life in their local prison and ensure that proper
standards of care and decency are maintained. Prisoners can complain to them using confidential access, they visit
the prison regularly and require responses from Governors on any points raised by prisoners. The Board is required
to produce an annual report on the prison to the Secretary of State, highlighting good practice and flagging up areas
of concern.
7
KEY FINDINGS
1. On 14 December 2004, the man was remanded to HMP Gloucester having been
charged with a sexual offence. On the same day, he underwent a first reception
health screen interview with a member of the healthcare staff. He gave his home
address and the name of his community doctor. He said he had not been homeless
in the past year and confirmed that this was his first time in prison.
2. The man told the healthcare worker that he had seen a doctor for depression in the
few months before he came into prison. He also said that he had a hospital
appointment two days later on 16 December at the Ear, Nose and Throat
department of Gloucester Hospital.
3. The healthcare worker noted that the man had been prescribed Zoton2 medication.
He said that he had a problem with spicy food and suffered from urine infections and
related matters but no other health issues were recorded. He said he not received
medication for mental health problems and had not tried to harm himself. He asked
to see a doctor about his physical health.
4. The man saw the doctor the following day. The doctor recorded that he suffered
from reflux oesophagitus3 and queried whether he had undergone operations for
vagotomy4, pyluoplasty5 and pharyngeal pouch6. The man told the doctor that he
was sharing a cell with a prisoner who had similar health problems. He also
recorded that the man did not have thoughts of harming himself.
5. As the man had a variety of medical complaints, he visited the healthcare
department several times during the first three months of 2005. He also had a
history of hearing loss and was referred to a consultant. An Ear, Nose and Throat
(ENT) Registrar assessed the man on 24 February. Following that appointment, the
ENT Registrar wrote to the Senior Medical Officer at Gloucester prison on 1 March
to explain that he was arranging for the Audiology Department to fit the man with a
hearing aid.
6. On 11 April, the man was sentenced to eight years imprisonment at Gloucester
Crown Court. An entry in his clinical record shows that he told healthcare staff that
he would cope with his sentence but that he needed something to help him sleep
that night.
2 Zoton is prescribed for the relief of symptoms caused by a duodenal ulcer
3 Reflux oesophagitis is when acid from the stomach leaks up into the gullet. This can cause heartburn and other
symptoms
4 Vagotomy is the surgical cutting of the vagus nerve to reduce acid secretion in the stomach
5 This term does not match any known medical condition and is probably spelled incorrectly
6 The clinical reviewer in her review explains a pharyngeal pouch as a ‘weakening in the wall of the throat which can
cause a pocket to form in which food can get caught’.
8
7. A month later, on 12 May, the man transferred to HMP Usk. The Reception
Screening for Prisoners on Transfer form gives similar information to that of the first
reception health screen at Gloucester. The man added that he had had an
operation on his bladder but did not give a date. He said he did not wish to see a
doctor. He underwent a number of health assessments. He was assessed as
having high blood pressure and an action plan was put in place to monitor this until
the doctor’s review. He said that he was reducing his smoking levels. His
cholesterol level was tested and results were awaited. His diet was good and he did
not take drugs or drink to excess. The healthcare worker checked his family health
history and it was noted that his father and brother suffered from CVA/TIA7 and his
mother and sister were diabetic.
8. A few days later, the man signed a consent form giving healthcare staff permission
to apply to the ENT department of Gloucestershire Hospital for his medical records.
A letter from Gloucestershire Hospital Legal Services Department dated 31 May
shows that the hospital complied with the request.
9. An entry dated 18 May in the wing history sheet said that the man had been working
as a cleaner in the programmes department but was asked to leave over a difficulty
with programmes staff. However, this did not reflect upon the fact that “his work as
a cleaner was first class” and, as he was elderly, he retired.
10. Healthcare received a letter dated 30 June from the Audiology Department at
Gloucestershire Hospital telling them that the current waiting time for an
appointment (for a hearing aid) was 12 to 18 months.
11. In September, the man told healthcare staff that he had a bad back for which he was
prescribed paracetamol and a bed board was requested. The prison doctor sent a
memorandum to wing staff saying that the man had permission to wear a surgical
belt on medical grounds. He would be able to have the belt in his possession
following clearance from the security department.
12. A discharge summary dated 8 November 2005 from Nevill Hall Hospital, said that
the man had been admitted on 25 October and discharged the next day. He was
diagnosed with musculo-skeletal chest pain. He had been taken to hospital because
he had suffered two episodes of sharp central chest pain. Tests showed that he had
not suffered a heart attack and he was given pain relief. (There is no corresponding
entry in the clinical record to confirm that he was taken to hospital with chest pain.)
On 29 October, an entry in the clinical record suggested that he might have a chest
infection. He was given amoxicillin (an antibiotic similar to penicillin) and
omeprazole for acid reflux.
13. The man was treated for a variety of health complaints during April and May 2006.
They included urinary tract infections, dizzy spells, high blood pressure, an allergic
reaction to amoxicillin, dermatitis (a skin condition), skin irritation to his left calf and a
7 CVA/TIA is a cerebral vascular accident (stroke related); TIA is a temporary ischaemic accident (heart related)
9
strained ankle. In July, healthcare staff submitted a Special Diet Request form to
the catering department to advise them that he could not tolerate onions or spicy
food and had been advised to choose non-spicy food items from the menus.
14. The man received an appointment to have his hearing aid fitted on 1 September
2006. A handwritten note on the letter said “no staff” and “transferred to Gwent”. It
is not clear what this means or whether the appointment took place.
15. An entry dated 1 December 2006 on the man’s wing history sheet says that he
continued to conform to the prison rules and regime and had completed the
Enhanced Thinking Skills course. On 29 November, he moved to the quieter
Comber Unit. He continued to do well and wing staff found him “very positive and
upbeat about his future.” He was making plans for his release including considering
where he wanted live. He was also a Listener8.
16. The wing history sheet says that on 7 February 2007 the man received a visit from
his sisters and they had given him bad news about his daughter having treatment for
cancer. An officer noted that the man was worried and upset and he advised him to
speak to the prison chaplain. The officer also told wing staff and the Orderly Officer9
of the man’s situation. He attended healthcare on 9 February as he was unable to
sleep. He was prescribed Zimovane10 for three nights to help him sleep.
17. The clinical reviewer noted that the man lost a piece of his hearing aid on 3 July and
needed to return to the hospital for a repair. He was advised by the hospital to
attend the drop-in clinic. On 9 August, healthcare contacted the Nevill Hall Hospital
to ask if the man had been to hospital and the matter was passed back to ensure an
appointment was made.
18. The man’s blood pressure was checked regularly throughout September and
October 2007. The prison doctor reviewed the man on the night of 15 September
because he complained of vague chest pain and tightness to his chest. His blood
pressure and temperature were taken and he was given oxygen. The prison doctor
contacted the hospital accident and emergency department, however there is no
evidence that the man was sent to hospital for further tests or treatment.
19. On 22 September, the man told an officer that he had learned that his daughter had
died. It is not clear how he knew or who had told him. The funeral had taken place
the previous day, before he became aware of his daughter’s death. The man was
seen to be quite upset and the chaplain and the orderly officer were told.
20. An entry in the wing history sheet dated 1 December 2007 says that the man had
been allocated a probation officer. This would suggest that the parole process had
8 A Listener is a trusted prisoner who listens and assists other prisoners when they are in crisis. They work on a one
to one basis day or night. They are vetted and trained by the Samaritan organisation who supervise the Listeners
Scheme.
9 The Orderly Officer is the discipline officer who is in charge of the day to day running of the prison wings.
10 Zimovane ;The clinical reviewer defines this as treatment for insomnia
10
started. This is confirmed in the next entry dated 14 June 2008 when the parole
dossier11 was completed.
21. From October 2007 to mid February 2008, the man went to healthcare on 9
occasions for various medical conditions including urine infections. He had stopped
smoking. The clinical record shows that on 20 February, he had a further urine
infection caused by urethral stricture. (The clinical reviewer has described this as a
narrowing in the urinary tract.) On the same day, he returned to healthcare
complaining of problems with his right eye, pain behind his ear, blurred vision and
dizziness. Healthcare staff contacted the prison doctor (who had seen him earlier
that day) and he prescribed co-codamol.12 The prison doctor advised healthcare
staff to review this should he suffer from shortness of breath. An electrocardiogram
(ECG) was used to monitor his heart and result was normal.
22. The man continued to attend healthcare for blood pressure reviews and to deal with
his acid reflux condition. The clinical record shows that on 14 May he complained of
feeling “chest pressure”, breathlessness and pain in the back of his neck. However,
he did not complain of pain in his jaw or down his arm which might have suggested
a heart attack. Blood was taken for tests and he went to hospital for further tests,
returning to the prison the following day. (There is no record of the outcome of the
blood tests.)
23. The hospital found that the man’s chest pain was not related to his heart. However,
an appointment for an exercise stress test was arranged to see if he had angina.
There is no recorded information about this appointment. The hospital discharge
letter said that he was investigated for “cardiac chest pain” and his tests were
normal. Therefore, the hospital discharged him back to the care of the prison with
no follow up arranged. The investigator was unable to clarify the entry relating to the
exercise stress test as the member of staff who recorded it was on long term sick
leave. Therefore, the appointment for the test remains unexplained. He was
advised not to take any exercise and to “have a quiet week”. A healthcare review
was set for the following week.
24. Throughout May and June, the man felt unwell. Healthcare staff continued to
monitor his blood pressure and manage his various symptoms including dizziness
and dermatitis.
25. Healthcare staff were called to the gym on 18 July because the man felt unwell. His
blood pressure was raised and he “appeared very anxious”. They told him to go
back and rest in his cell and they would check up on him later in the morning. This
is no entry in the clinical record to confirm whether they did so.
11 The parole dossier is a bundle of reports from internal and external probation officers, wing staff, healthcare and
other prison professionals involved in the man’s sentence. This is then submitted by the prison parole clerk to the
Parole Board of England and Wales for their consideration as to whether he could be released on licence into the
community.
12 An analgesic used for pain relief.
11
26. No further entries are made in the clinical record until 29 August when the man’s
blood pressure was taken and no problems were identified. In September, he
continued to have difficulty with acid reflux and blood was taken for his annual
hypertensive check (high blood pressure). During October, his ear problems were
identified and treated appropriately.
27. A fellow prisoner remembered that the man had complained of experiencing pins
and needles and a numbness in his leg a few days before his collapse. He was
sitting in his chair in the dormitory he shared with the prisoner, but he felt unwell and
had to lay on the bed. The prisoner recalled that “two or three times, he [the man]
had little turns and felt faint” and healthcare “checked him out”.
Events in December
47. The prisoner who shared a dormitory with the man told the investigator that before
the man went to work that morning, he was stitching a tapestry rug and that he was
getting on well with it. At 10.00am, the prisoner noticed that he was standing at the
sink, in pain and with his arms out holding on to the sink. The man left the dormitory
two minutes later.
48. The investigator spoke with a second prisoner who also shared the dormitory with
the man. He was waiting in healthcare in the morning to see healthcare staff when
he saw the man walk in clutching his chest. A prisoner banged on the nurses’ door
to ask for help. The nurses took him into the room. There was no doctor there at
the time because the doctor only visited the prison three days each week.
49. The clinical record shows that nursing staff saw the man at 10.10am and he had
chest pain. He was given an ECG and the reading said there was an abnormality
with his heart. Oxygen was given and an emergency ambulance was called at
10.17am. A paramedic arrived at 10.42am and the ambulance arrived at 11.00am.
50. A risk assessment for the man’s attendance at hospital was completed by
healthcare and security staff. It concluded that he was not a security risk and there
was no evidence in the past that he had tried to escape from custody. The security
assessment was that he should be accompanied by two officers and placed in a
single handcuff linked by a chain to one escorting prison officer. This was to be
used on the journey to the hospital and on return to the prison.
12
Events at the hospital
51. The man’s journey and events after he arrived at Nevill Hall Hospital are recorded in
the Prisoner Escort Record form (PER). The ambulance left the prison a few
minutes after 11.00am and arrived at Nevill Hall Hospital at 11.30am. Paramedics
handed him to hospital care at 11.35am and medical staff asked for the handcuffs to
be removed at 11.41am. The prison staff immediately complied.
52. At 11.45am, the man was “rushed to Crash Room”. The Nursing Sister asked the
bedwatch officers13 to tell his relatives that he was gravely ill. An officer, one of the
officers on bedwatch duty, telephoned the prison and asked a senior officer to
contact the man’s family.
53. Around 45 minutes later, the Nursing Sister told the Bedwatch officer that the man’s
condition had deteriorated and he was being put onto a life support machine. The
man’s sister and brother-in-law arrived at the hospital at 3.41pm and spoke with
medical staff.
54. The nursing staff told the bedwatch officers that, if the man went into cardiac arrest
again, he would not be resuscitated. The bedwatch officers kept the prison informed
of his condition throughout the night.
55. In January 2009 nurses told the bedwatch officers that they were waiting for
instructions from the consultant to withdraw medication and turn off the life support
machine to see if the man could breathe on his own. The bedwatch officers gave
this information to the prison.
56. At 11.30am, the man’s family returned and they were joined by other family
members at midday. The bedwatch officers telephoned the Governor at 1.20pm to
tell him that the life support machine would be switched off when all the family were
present. The chaplain also visited during this time. The family were consulted
before the machine was switched off at 4.45pm and the man died in the presence of
his family.
Events after the man’s death
57. The investigator spoke with the prison’s family liaison officer. She said that she was
not on duty when the prison contacted her after the man’s death but she was ‘on
call’ as a family liaison officer. She understood from the Governor that the man’s
sisters were away from home. She contacted them the following day and, together
with the chaplain, she visited them at home in Gloucester.
13 A Bedwatch Officer is a prison officer who accompanies prisoners when they go to hospital and remains with them
at all times.
13
58. The prison’s family liaison officer returned the man’s property to his sisters during
the visit. One of his sisters told my family liaison officer that the prison “have been
very good”. She said she could not fault either the chaplain or the prison’s family
liaison officer whom she thought had been “especially good” as she had taken a lot
of pressure from the family. The prison had offered to pay for the funeral and the
family had accepted. The family were invited to a memorial service at the prison
and were asked if they wished to have the opportunity to speak to staff and
prisoners. The man’s sister spoke highly of staff and said that they were always
treated well when they visited him every month.
59. The prisoner who shared a dormitory with the man was surprised at his death and
said a wing officer had kept prisoners informed of his condition. The Governor told
my investigator that staff on D wing were aware that the man had gone to hospital.
He said that prisoners were told individually of his death. He spoke on the
telephone to one of the man’s sisters who lived in Germany and was shocked at the
news.
60. There is no evidence that a hot debrief14 for staff was held as required by Prison
Service Order 2710, Following a Death in Custody. The Death in Custody Action
Plan says that the two prisoners who knew the man were identified as those who
might need counselling as they shared a dormitory with him and knew him well.
The Governor said that the prison’s family liaison officer contacted the bedwatch
officers and offered them support, although they did not take up the offer.
14 A hot debrief is a meeting held by management for staff involved in a serious incident. It is an opportunity to
share learning, review procedures and provide support for staff who need it.
14
ISSUES
The clinical review
61. The clinical review was undertaken by a clinical reviewer, Review Manager,
Healthcare Inspectorate Wales. Her review is based on the man’s prison clinical
record, reports and letters from other healthcare professionals and records of
interviews with prison staff. She makes a number of recommendations which I
endorse and, in some instances, recast.
Record keeping
62. The clinical reviewer has judged that the clinical records were generally in good
order. However, some entries were illegible, unsigned and with abbreviations used
throughout. I endorse her finding. An entry in the clinical record dated 15 May 2008
says that the man awaited an appointment for an exercise stress test. There is no
evidence in any other healthcare record of such an appointment and whether it took
place and healthcare staff were unable to explain it to the investigator.
63. There were periods within the record where, in the clinical reviewer’s opinion, it was
not clear what care and treatment the man was receiving including admissions and
visits to hospital in relation to his hearing aid.
The Head of Healthcare should ensure that all healthcare staff are reminded of
the requirements to keep accurate, legible, signed records in accordance with
Nursing and Midwifery Council Guidelines and that abbreviations should not
be used.
The Head of Healthcare should ensure that all dates of admission to hospital
and attendance at clinics are recorded, including the reason for them.
Hypertension management
64. The clinical reviewer has identified that although the man’s blood pressure was
repeatedly measured as higher than normal, he was not given any hypertensive
medication. She considers this unusual considering the symptoms he displayed
including dizziness, generally feeling unwell, tiredness and chest pain.
The Head of Healthcare should ensure that prisoners suffering from
indications of hypertension are treated appropriately according to the National
Institute of Clinical Excellence Guidance – Hypertension: Management of
Hypertension in Adults Primary Care.
65. The clinical reviewer found that tests and investigations into the man’s health were
ordered and the prison doctor was waiting for the results. However, it was not clear
15
from the records what some of these tests were, whether they were undertaken,
what the results were or if treatment started.
The Head of Healthcare should ensure that medical staff properly record the
circumstances and details of tests as well as the outcome and any treatment.
66. The clinical reviewer is concerned that the man had to wait over a month to get his
hearing aid fixed when the hospital had said that he could go to any drop-in clinic
Monday to Friday between 9.00am and midday. The clinical reviewer has judged
that this had been arranged but the records are not clear.
The Head of Healthcare should improve communication between the prison
and hospitals in arranging appointments.
67. There is no evidence that a formal hot debrief15 was held for all the staff who were
involved in the man’s care and the events leading up to and following his death. A
hot debrief is a requirement of Prison Service Order (PSO) 2710 and should follow
every death in custody. Paragraph 5.3 of the PSO says that there must always be a
hot debrief immediately after the incident and provision should be made in the local
contingency plans. A senior member of staff must act as debriefer and a duty care
team member must also attend.
The Governor should ensure that formal hot debriefs take place in accordance
with PSO 2710 and are documented.
Conclusion
68. The man was an older prisoner. During his four years in prison, he reported and
was diagnosed with a number of ailments, including chest pain. Hospital and prison
tests revealed no heart abnormalities but he was treated for other conditions. His
condition suddenly deteriorated in December 2008 and an ECG showed an
abnormality of his heart. He was admitted to hospital where he died the following
day.
69. My recommendations aside, I judge that the medical care the man received for the
conditions he disclosed to healthcare staff was comparable to that which he would
have received in the community.
16
RECOMMENDATIONS
1. The Head of Healthcare should ensure that all healthcare staff are reminded of
the requirements to keep accurate, legible, signed records in accordance with
Nursing and Midwifery Council Guidelines and that abbreviations should not
be used.
Accepted. All nursing staff have been reminded of the need for accurate recording,
which is also legible and not abbreviated.
2. The Head of Healthcare should ensure that all dates of admission to hospital
and attendance at clinics are recorded, including the reason for them.
Accepted. Nurses have been reminded to record admissions to hospital in the HC
record. Attendance at out patient clinics is already recorded on the outpatient’s
appointment sheet.
3. The Head of Healthcare should ensure that prisoners suffering from
indications of hypertension are treated appropriately according to the National
Institute of Clinical Excellence Guidance – Hypertension: Management of
Hypertension in Adults Primary Care.
Accepted. Nurses are fully aware that any patients showing indication of
hypertension are referred for assessment to the GP who then makes his clinical
assessment of the most appropriate treatment.
4. The Head of Healthcare should ensure that medical staff properly record the
circumstances and details of requested tests as well as the outcome and any
treatment.
Accepted. The GP has been informed of the need for such records. Correct
recording should greatly improve with the introduction of the Prison Health
Information Technology (PHIT).
5. The Head of Healthcare should improve communication between the prison
and hospitals in arranging appointments.
Partially Accepted. The clinical reviewer has indicated that, “The clinical reviewer
has judged that this had been arranged but the records are not clear.” This appears
to be a recording issue and not a need to improve communication between the
prison and hospitals. Nonetheless evidence of such communication will be retained.
6. The Governor should ensure that formal hot debriefs take place in accordance
with PSO 2710 and are documented.
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Partially Accepted. Staff on duty at the time of the man’s death were all briefed by
the Senior Officer on duty. The two escorting staff that were in attendance at the
hospital at the time of death were contacted by the establishment Care Team and
offered support but both declined.
All prisoners located on D wing were spoken to personally and informed of the man’s
death. However, contingency plans will be reviewed to ensure when the ‘hot debrief’
takes place it is recorded.
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