Individual at Acklington

Investigation into the circumstances surrounding the
death of a prisoner
at HMP Acklington in October 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
June 2007
This is the report into the death of a prisoner at HMP Acklington in October 2006.
He died in his cell, apparently of natural causes. He was 52 years old. The man had
been a prisoner at Acklington since 11 October 2004, shortly after he was sentenced
to seven years’ imprisonment by Teesside Crown Court.
I offer my sincere condolences to all those touched by his passing, especially his
wife.
This investigation has been undertaken by a member of my team. I would like to
thank the Governor of Acklington and his staff for their co-operation and active
participation. Special thanks go to the Ombudsman’s liaison officer for making the
arrangements for my investigator’s visit.
Northumberland Care Trust conducted a review of the care the man received whilst
in prison. My thanks go to the clinical reviewer for his invaluable contribution.
One of my Family Liaison Officers contacted the man’s wife to inform her of my
investigation and to offer her the opportunity to raise any concerns. I hope this
report answers any questions she or any other family member may have about the
circumstances surrounding the man’s death.
As well as suggesting that the Governor may wish to review a particular aspect of his
contingency plan following a death in custody, I make two formal recommendations
in this report. One concerns the apparent unreliability of the radios currently being
used at the prison. Whilst there is no suggestion that this would have helped to save
the man’s life, I am conscious that I made a similar recommendation to Acklington
following the death of a prisoner in 2004.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2007
2
CONTENTS
Summary 4
The Investigation Process 5
HMP Acklington 6
Key Findings 7
Issues 10
Recommendations 12
3
SUMMARY
The man who is the subject of this report was remanded into custody by Teesside
Crown Court on 9 August 2004. He was taken to HMP Holme House, where he was
given a full health screening. He disclosed to the nurse who assessed him that he
suffered from high blood pressure, epilepsy and depression, for which he took
prescribed medication. The nurse subsequently found out that he also received
medication for gout and alcohol misuse.
On 1 October, he returned to Teesside Crown Court and was sentenced to seven
years’ imprisonment. He went back to Holme House, where he remained until he
was transferred to HMP Acklington on 11 October.
The man adjusted well to life at Acklington and enjoyed positive relationships with
both staff and fellow prisoners. Having proved that he was willing to make the most
of his time in prison, he successfully applied to be relocated to J Wing where
prisoners are encouraged to manage their own lives.
Around 12.00pm on 31 October 2006, the man collected his lunch as usual before
returning to his cell. At 1.40pm, all the prisoners who worked were told to go to their
workplaces. He failed to report, so one of his fellow prisoners went to his cell to
investigate. A few seconds later, the prisoner came running to a member of staff
and said that the man was on the floor and he thought he was dead.
The member of staff accompanied the prisoner to the cell, went in and observed the
man lying prone on the floor. He was not breathing and, when checked, no pulse
could be found. The officer went to the wing office and raised the alarm, summoning
others including medical staff to help. Sadly, no signs of life could be detected.
Emergency resuscitation was not initiated because rigor mortis had already started
to set in.
The man was formally pronounced dead at 2.55pm. His family was informed of the
sad news later that day.
4
THE INVESTIGATION PROCESS
1. My investigator considered the man’s prison documentation, including his
clinical records, before formally opening the investigation on 9 January 2007.
2. Prior to my investigator arriving at Acklington, notices were issued to staff and
prisoners announcing the investigation and inviting anyone who had information
relevant to the man’s death to make themself known to the investigator. One
prisoner came forward and five members of staff were interviewed by prior
arrangement.
3. One of my Family Liaison Officers contacted the man’s wife to offer her the
opportunity to participate in the investigation process. I hope this report
addresses any concerns that she and other family members have about the
circumstances surrounding her husband’s death.
4. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of the investigation and to request a copy of the post mortem report.
Upon completion, this report will be sent to the Coroner to assist him in his
enquiries.
5. Northumberland Care Trust conducted a review of the clinical care the man
received whilst in custody.
5
HMP ACKLINGTON
6. HMP Acklington opened in 1972 as a category C prison. The jail is situated on
a former Royal Air Force base near Amble in Northumberland. It has the
capacity to hold 882 prisoners.
7. One of the wings is J wing, which is a unit for non-smoking prisoners who have
shown that they can comply with the prison regime without constant staff
supervision. Prisoners on the wing are granted a degree of freedom within the
physical confines of the unit, on the understanding that they will be returned to
the main prison if they break the rules.
8. Northumberland Care Trust provides healthcare to the prison. Nurses are
employed to deliver primary healthcare during the daytime, seven days a week.
Prisoners who require in-patient nursing care are transferred to an outside
hospital or another prison.
9. Her Majesty’s Chief Inspector of Prisons carried out an unannounced inspection
of Acklington in April 2003. The Chief Inspector, Ms Anne Owers, found
Acklington to be a safe prison and commented that “low levels of self-harm and
the absence of self-inflicted deaths reflect well on the proactive approach taken
by staff”. However, the inspectorate highlighted concerns about the needs of
older prisoners, and those with health conditions requiring a level of care that
could not be provided at Acklington.
10. Since August 2004, there have been nine deaths at Acklington, including that of
the man who is the subject of this report. Six of these were due to natural
causes and three were apparently self-inflicted. Investigations into all nine
deaths have been carried out by my office. One previous investigation has
highlighted problems with the prison radios. I was disappointed to learn that
this issue does not appear to have been resolved.
6
KEY FINDINGS
11. On 9 August 2004, the man who later died appeared at Teesside Crown Court
and was remanded into custody. He was taken to Holme House, where he
underwent a full health screening. He disclosed that he suffered from
hypertension (also known as high blood pressure), epilepsy and depression.
The nurse who assessed him contacted his General Practitioner (GP) and
found out that he received a combination of medications for his health
problems. These were Atenolol, Bendrofluazide and Nifedipine for his
hypertension, Epanatin for his epilepsy and Paroxetine for his depression. The
GP also told the nurse that the man was in receipt of a Vitamin B supplement
for alcohol misuse and Alluplurnol for gout.
12. On 1 October, the man appeared again at Teesside Crown Court and was
sentenced to seven years’ imprisonment. He was returned to Holme House,
where he remained for ten days before being transferred to Acklington on 11
October.
13. Upon his arrival at Acklington, he was subject to another health screening. No
further issues were identified by the nurse who reviewed him, although it was
documented that his blood pressure should be regularly monitored.
14. On 15 September 2005, the man was admitted to Wansbeck General Hospital
for an operation to strip a varicose vein in his right leg. He remained at the
hospital overnight and was discharged back to Acklington, as planned, the
following day. In the days after his discharge, his progress was systematically
followed up by healthcare staff who noted that the wounds were clean and dry,
and healing well. The man experienced no further problems with varicose veins
after the operation.
15. Over the next 12 months, the man’s contact with healthcare staff was limited to
collecting his prescribed medication and routine checks related to his
hypertension and epilepsy. At the same time, he made positive progress
through the prison and secured himself a cell on J Wing.
16. At around 12.00pm on 31 October 2006, the man joined the lunch queue on J
Wing. He chatted with his fellow prisoners before collecting his meal and
making his way to his cell on the first floor. One of the prisoners told my
investigator that the man climbed the stairs in his usual brisk manner, taking
two steps at a time. He turned to the prisoner and said he would see him later,
then continued on to his cell, J2-17.
17. Around 1.40pm, staff on J Wing started labour movements, which is when the
gates inside the prison are opened to enable prisoners to attend work and
education classes. After about ten minutes, an officer, who was one of two
officers on the wing at the time, noticed that the man had failed to come down
from his cell for work. He mentioned this to one of the prisoners on the wing,
with whom he was conversing at the time. The prisoner offered to go up to the
man’s cell to check on him. He made his way up to the first floor landing,
7
pushed the door ajar (the cell doors on the wing do not have conventional
prison locks) and looked inside. He came running back down the stairs to the
officer, and said that the man was on the floor and appeared to be dead.
18. The officer and the prisoner quickly made their way to the man’s cell, followed
shortly afterwards by another officer, who was guarding the gate that separates
the wing from the outdoor compound. The first officer went into the cell and
saw the man lying prone on the floor. He did not respond to any verbal
commands, and so the officer checked for a pulse. He could not find one and
promptly left the cell to return to the wing office. The officer who first went to
the man’s cell telephoned the communications centre, and asked them to put
out an emergency call over the prison’s radio network. The officer told my
investigator that he had a radio in his possession, but it was not working
properly because the battery was going flat, and so he had to go to the wing
office to make the call.
19. According to Acklington’s Incident Log, a code blue call was transmitted over
the radio network at 1.50pm. (Most prisons in England and Wales now use a
code system for indicating different types of emergencies. Code blue is the call
sign used to signify that a prisoner’s breathing may be compromised, and this
helps staff attending to the emergency to decide what equipment might be
needed to deal with it.)
20. Whilst the first officer went to the wing office, the officer who was previously
guarding the gate went into the cell. He saw that the man’s lunch lay
untouched on the bed, and that he was lying on the floor in an unnatural,
uncomfortable looking position. He called out to the man, asking whether he
was okay, but did not receive any response, verbal or otherwise. He saw that
the man’s eyes were wide open, his skin had a greyish/white hue, and that he
had apparently urinated and wet himself. The office believed that the man was
dead, and he briefly left the cell before returning to check for a pulse. The
officer is trained in first aid, albeit not recently, and he told my investigator that
he would expect to be able to find a pulse. He said that he could not detect any
sign of a pulse, and then left the cell and stood outside.
21. Two minutes after the code blue call, at around 1.52pm, a senior officer and
another prison officer arrived at the cell from their normal location on H Wing,
next to J Wing. They asked the officer who had been previously guarding the
gate what he had found, and the senior officer asked him whether he was
alright.
22. At the same time, another senior officer arrived at the cell, and also asked the
officer who had earlier been guarding the gate what had happened. The senior
officer went into the cell to check the man’s vital signs. Like the officer who had
been guarding the gate before the man was found in his cell, he could find no
signs of life.
23. At some point between 1.55pm and 2.00pm, two nurses arrived from the
healthcare centre. They brought with them a range of emergency resuscitation
8
equipment including a defibrillator. As they arrived on the wing, and prior to
going to the man’s cell, they asked a member of the wing staff (my investigator
has been unable to establish whom) to telephone 999 and request an
ambulance.
24. The two nurses went to the cell on the first floor landing and conducted checks
for signs of life. Despite not being able to find any signs, they attached the
defibrillator machine to the man in order to establish whether his heart was
emitting any electrical signals. The defibrillator recorded that an electrical
shock should not be administered, and recommended that they administer
Cardio Pulmonary Resuscitation (CPR). However, as the man’s left arm was
stiff, and rigor mortis had clearly already set in, the nurses decided not to
commence CPR.
25. At 2.20pm, the ambulance arrived and the paramedics confirmed death. A
local GP arrived at Acklington shortly afterwards and formally pronounced the
man dead at 2.55pm.
26. The prison subsequently activated its contingency plan for dealing with a death
in custody. The other prisoners on the wing were asked to return to their cells.
The officer who had been guarding the gate prior to the man being found was
stationed outside cell J2-17 to ensure that only authorised personnel,
specifically those involved in removing the man’s body, entered. He told my
investigator that he did not consider it appropriate for him to be assigned this
duty as he had been involved in checking the man’s vital signs after he was
found. Acklington has accepted that allocating this task to this officer was not
best practice and has decided to implement a policy so that staff who are
directly involved in fatal incidents are not required to remain at the scene any
longer than necessary. I welcome this initiative.
27. A memorial service took place on the wing later in the day, and prisoners sent a
card to the man’s widow. Support was offered to the prisoners, and most of the
officers said that they were also offered support.
28. As part of the contingency plan, and because of the distance to the man’s
family home, North Yorkshire Police were contacted and asked to inform his
next of kin of his death. This did not happen until 8.10pm, and unfortunately the
police officer did not give the relative the name or contact details of the person
to contact at Acklington.
9
ISSUES
Management of the man’s health problems
29. It is the opinion of the clinical reviewer that the man’s chronic diseases, namely
epilepsy and hypertension, were well managed by Acklington. I therefore make
no recommendations about Acklington’s management of his health problems.
Prediction of the man’s death
30. My investigator found no evidence to suggest that the man’s death could have
been predicted. Just minutes before it is likely he collapsed in his cell, he was
engaged in conversation with a fellow prisoner who then observed him dashing
up the stairs to the first floor landing taking two steps at a time. He had had no
contact with the healthcare department for two weeks, and this was for nothing
more than a routine blood test.
Response to the man’s collapse
31. Given that the man’s lunchtime meal, which he collected around 12.00pm, was
found untouched on his bed, it is probable that he collapsed shortly after
returning to his cell. By the time he was discovered, more than an hour and a
half later, it is highly unlikely that CPR or any other form of emergency
intervention would have made any impact whatsoever. Indeed, members of
staff who went to the cell after the man was found told my investigator that his
limbs had started to go stiff, indicating that rigor mortis had set in. Initiating
CPR at this stage would have been futile. Indeed, it would have been
disrespectful both to the man’s memory and to the staff expected to carry it out.
32. I therefore have no recommendations to make in relation to how Acklington
managed the man’s health problems or how his collapse was dealt with by the
staff who attended to him in the minutes after he was found.
Failure of the officer’s radio
33. Despite the fact that the man was sadly beyond resuscitation when he was
discovered in his cell, I am concerned that the first member of staff to arrive
was unable to summon help over the radio network because his radio failed.
The officer told my investigator that this is a persistent problem. Whilst there is
no evidence to indicate that faster assistance would have saved the man’s life,
there might very well be instances in the future when prisoners’ lives can be
saved through a rapid response.
34. A previous investigation conducted by my office into the death of a prisoner at
Acklington made a recommendation that the condition of UHF radio batteries
should be reviewed and a battery protocol should be implemented. Whilst there
now exists a written procedure for the management of UHF radio batteries at
Acklington, it would appear there are still problems. I therefore urge Acklington
10
to revisit its written protocol to check whether it is sufficiently robust to eliminate
problems on the frontline.
The Governor should review whether further steps are necessary to
ensure that the prison radios work effectively.
Informing the man’s next of kin of his death
35. My office believes strongly that it is more respectful for the families of prisoners
who die in custody to be informed of the death in person. Ideally this should be
done by a senior member of prison staff who is knowledgeable about the
circumstances of the death. Where this is not possible, for instance when the
prison is too far away from the next of kin’s home, it is reasonable for a prison
to contact the local police to pass on the news (although best practice would be
to ask the staff of another prison). As Acklington is more than 80 miles away
from the man’s family home, I think it was understandable that the prison chose
to ask the North Yorkshire Police to inform his family.
36. However, I am concerned that the family was not told until more than six hours
after he was found. I am also worried because the police officer did not provide
either a name or contact details for the prison. It is beyond my remit to make
recommendations to the police. However, the Governor may wish to review
this aspect of his contingency plan. Following any future death, I think it would
be far better if Acklington itself, or another prison, takes responsibility for
informing the bereaved family. If for one reason or another this is not possible,
then every effort should be made to ensure the police have all relevant details
and are impressed with the need for the news to be delivered without delay.
Returning the man’s possessions to his family
37. For reasons that my investigator has been unable to establish, the man’s
possessions were only returned to his wife in late December, some seven
weeks after he died. I know that this delay caused the man’s wife considerable
distress. This should have been avoided.
Acklington should review its policy on dealing with deaths in custody to
ensure that the personal possessions of prisoners are returned promptly
to their next of kin.
11
RECOMMENDATIONS
To the Governor
1. The Governor should review whether further steps are necessary to ensure that
the prison radios work effectively.
2. Acklington should review its policy on dealing with deaths in custody to ensure
that the personal possessions of prisoners are returned promptly to their next of
kin.
12