Individual at Acklington

Investigation into the death of a man, a prisoner at
HMP Acklington, on 8 June 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
January 2006
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This is the report of an investigation into the death of a man who died from
natural causes at HMP Acklington on 8 June 2005. He was 68 years of age.
The man was convicted in March 2005 and sentenced to seven years
imprisonment. It was his first conviction and his first experience of prison life.
He was initially held at HMP Holme House but later transferred to HMP
Acklington, and it was there that he was taken ill and died.
The investigation has been undertaken by one of my investigators. I would
like to thank the Governors at HMP Acklington and HMP Holme House and
their staff for their help and co­operation during this investigation. A doctor at
Northumberland Care Trust was commissioned to undertake a review of the
man’s clinical care, and I also appreciate his assistance.
The loss of a loved one is always distressing. I would like to add my personal
condolences to those already expressed to the man’s family by my Family
Liaison Officer.
Whilst I do not feel that anything could have been done to prevent the man’s
death, there were aspects of the prison’s response to his being taken ill that
were inadequate. Whilst they do not appear to have been significant for the
man, it is important that the lessons are learnt.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2006
2
CONTENTS
Summary 3
The investigation process 5
Background 6
HMP Holme House 7
HMP Acklington 8
Key findings 9
Recommendations 13
ANNEXES
3
Summary
1. The man was born in 1937, and was 68 years old when he died.
2. He arrived at HMP Holme House on 4 April 2005. He was received into
custody after being sentenced to seven years imprisonment. He was
transferred to HMP Acklington on 26 May 2005.
3. At his first reception health screen at both prisons, it was noted that the
man had a number of health problems including angina, asthma and
circulatory problems.
4. Before his transfer to Acklington, the man had told his son that other
prisoners were bullying him at Holme House, but the man did not draw this
to the attention of prison staff.
5. After moving to Acklington the man volunteered to work and was allocated
a position in the tailor’s workshop. On 8 June around 8:20amthe man
entered Workshop 2 where he was employed as a tailor. The Instructional
Officers quickly noted that the man was not very well. He then collapsed
and one of the Instructional Officers left Workshop 2 to report this to the
Workshop Manager. The other Instructional Officer remained in the
workshop with the man and the other prisoners.
6. The Workshop Manager telephoned the healthcare centre at
approximately 8:25am to request assistance. After five minutes, the radio
was used to summon assistance, and medical staff arrived three minutes
later. In Workshop 2, prisoners had already placed the man into the
recovery position and were making him comfortable while awaiting medical
assistance.
7. When medical staff arrived at Workshop 2, they quickly assessed the
situation and requested that an ambulance be called. Cardio­pulmonary
resuscitation (CPR) was immediately commenced. The prison doctor, a
Senior Officer and the de­fibrillation equipment arrived just after CPR was
started. The Senior Officer de­fibrillated the man and the doctor continued
helping with the CPR. The man was pronounced dead at 8:43am after a
prolonged period of resuscitation.
8. The clinical review noted that the man had suffered four previous heart
attacks (the most recent in February 2004). The reviewer concludes that
the man was in poor health with a life threatening illness, and that he
would not be expected to survive a further myocardial infarction (heart
attack). The reviewer also concludes that the man’s care whilst in prison
was appropriate and the attempted resuscitation was handled well by
healthcare staff.
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9. On 30 June 2005, one of my Family Liaison Officers contacted the man’s
family. They expressed their concern about his care and the treatment
given to him both at Holme House and Acklington prisons. Their main
concern was that the man lived in the community for 15 years with his
heart condition, and yet died within a short time of entering prison. They
felt that being located at Holme House caused additional stress. This was
because it was in his home area, because he was allegedly bullied by
other prisoners, because his cell was on an upstairs landing and because
he had to wait outside for visits. His family think that all these factors
exacerbated the man’s condition. I hope this report provides answers to
some of their questions.
10.I make three recommendations.
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The investigation process
11.My investigator studied all relevant prison records relating to the man.
These included his main prison record, Inmate Medical Record (IMR) and
statements from both staff and prisoner witnesses.
12.A clinical review was commissioned from Northumberland Care Trust. I
am grateful to the reviewer for undertaking this review in a most timely
manner.
13.My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner to
assist him with his enquiries into the man’s death.
14.One of my Family Liaison Officers and my investigator met with the man’s
family and were told their concerns about his care at Holme House and
Acklington prisons.
15.My investigator visited Acklington and discussed aspects of the man’s
treatment with both staff and prisoners. My investigator also discussed
with staff, at both Acklington and Holme House, the issues raised by the
man’s family about his care whilst in prison. The clinical review found that
the man’s clinical care was appropriately managed while he was in
custody. However, I do have concerns that, in emergencies, assistance
cannot be readily summoned by staff in the prison workshops.
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Background
16.The man was born in a pit mining village in the north of England in 1937.
17.The man worked in the chemical industry and after he retired through ill
health, his main interest was computers and he did voluntary work
assisting with the set up of computer systems. The man had been married
and had one son.
18.Before being arrested and sentenced, the man had suffered four heart
attacks.
19.This was the man’s first experience of prison life. Due to his age and ill
health, he did not find it a very easy experience but had appeared to be
overcoming these difficulties at Acklington shortly before his death.
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HMP Holme House
20.Holme House is a purpose built prison, which opened in May 1992. It
expanded in the late 1990s with the building of two further house blocks
providing 235 additional places. It has an operational capacity of just
under 1,000. The prison serves the communities of Tees Valley, South
West Durham, East Durham and North Yorkshire. The accommodation
consists of six self contained living units with integral sanitation, with a
mixture of single and double cells.
21.Holme House holds convicted, sentenced and un­convicted male adults,
and also a small number of un­sentenced young male adults for HMYOI
Castington. The regime offers prisoners a variety of employment
opportunities within its modern workshop complex. These are
complemented and supported by a purpose built education department
offering both part time and full time classes.
22.The prison healthcare is in a two storey, purpose built building. The top
floor is used for primary care and outpatients services.
23.A first night centre has been established – a safer custody initiative that
provides support to prisoners when they are first received into the
establishment. A ‘Listener’ scheme operates on a 24 hour basis and is
fully integrated into prison arrangements for those in need of support.
(The scheme, which operates in almost all prisons, is a prisoner peer
group support system, with each Listener receiving training from the
Samaritans).
24.Her Majesty’s Chief Inspector of Prisons (HMCIP) carried out an
announced inspection of Holme House in April 2005. Her report described
that the prison was carrying out ‘good work in detoxification and
healthcare, where uniformed and specialist staff were working together to
produce excellent outcomes’ and went on to say that ‘more prisoners told
us that they felt safe in Holme House than in comparable establishments’.
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HMP Acklington
25.HMP Acklington opened as a prison in 1972 and is on the site of a former
RAF station. It has an operational capacity of 882.
26.A man’s cell was situated on the ground floor of A wing, which is in one of
the wings for vulnerable prisoners. Prisoners in the wing share double
cells and there are 12 cells in the spur where the man lived. Each prisoner
has a key to their own cell and uses a shared bathing and toilet area within
the spur. There is a locked metal gate at the end of the spur, with an
office from which staff can see down the corridor through the middle.
Each prisoner has a single bed, table and wardrobe, together with a
lockable bedside cupboard for the storage of their valuables and
medication.
27.The prison’s healthcare is provided by Northumberland Care Trust, who
employ nurses during the day, seven days a week. They work with a
medical officer, providing primary health care and weekly or monthly
administration of medication to prisoners who have been assessed as
capable of keeping it in their own possession. They administer medication
on a daily basis to other prisoners, when either they are considered to be
at risk or the medication is unsuitable to be held in their cell. Prisoners
who require in­patient nursing care are transferred to outside hospital or to
another prison.
28.HMCIP carried out an unannounced inspection of Acklington in April 2003.
Her report described a ‘safe prison’ and went on to say that ‘the low levels
of self harm and the absence of self inflicted deaths reflect well on the
proactive approach taken by staff’.
29.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. At the time of this investigation, the
clinical team leader was exploring the possibility of introducing clinics for
specialist conditions, such as those experienced by older people.
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Key Findings
30.When the man first arrived at both Holme House and Acklington, it was
decided that he should be given Vulnerable Prisoner status because of his
age and the nature of his offence. The man had a number of health
problems including angina, asthma and circulatory problems and he had
previously suffered four heart attacks. It was good practice that a Well
Man assessment was carried out by Acklington’s healthcare team.
31.My investigator investigated the concerns raised by the man’s family about
his treatment at Holme House. The prison did locate the man in a cell on
an upper floor for 11 days, before moving him to a cell on the ground floor.
The man was initially located at Holme House as it is the local prison
serving the court where he had appeared. The prison stated that the man
would not have been made to wait outside whilst waiting for a visit as he
would have been placed in a holding room which is in the middle of the
visits building. Holme House could not find any records of complaints of
bullying being made by the man and neither could my investigator
substantiate this allegation.
32.After the man was convicted, he was moved at the earliest opportunity to
Acklington, where he was allocated ground floor cells, initially in H wing.
After his induction, he was moved to A wing.
33.Because of his age, the man did not have to work. However, the man
volunteered to do sedentary work, and joined the tailor’s workshop. A
prisoner described meeting the man at the workshop and showing him
how to complete their allotted tasks. The prisoner described the man as a
likeable old gentleman and “a really nice lad” who got on with his work.
34.It was alleged in an interview with one of the prisoners that on 8 June 2005
before the man left his wing he told one of the officers that he did not feel
well enough to attend work. The prisoner also alleged that this comment
was ignored by the officer who still sent the man to work. When
interviewed, the officer denied the allegation and pointed out how he been
supportive to the man after he had moved to A wing. My investigator
could not find any evidence to substantiate this accusation and an alleged
witness identified by the prisoner, stated that he was not present at the
time of the alleged comment.
35.At 8:20am on 8 June, the man entered Workshop 2 to commence work as
a tailor. He sat down at a table near one of the Instructional Officers. A
fellow prisoner was asked to collect the man’s scissors from the tool store,
as he did not look very well.
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36. When the prisoner returned, another Instructional Officer was standing
next to the man. The man told her that he wanted to work but he could
not. One of the Instruction Officers stated that she thought that the man
should return to his wing, but he was too out of breath to move at the
current time. Both Instructional Officers carried keys, but neither carried a
radio.
37.The prisoner returned with the scissors and asked the man if he wanted a
drink. He then went to fetch him a glass of water. As the prisoner walked
away, he heard one of the Instructional Officers shout and saw the man
getting up from his chair and then falling, face first, onto the workshop
floor.
38.The prisoner ran back to the man and turned him onto his right side. The
man was unconscious and his face was badly damaged. He was bleeding
very heavily from nose and mouth. One of the Instructional Officers
immediately reported to the Workshop Manager and informed him that the
man had collapsed. The Workshop Manager telephoned the healthcare
centre and informed them of the situation. The other Instructional Officer,
who was still in the workshop, was not involved in dealing with the
emergency.
39.In his interview, the Workshop Manager said that he did not consider using
the radio to summon assistance even though he carried one. Although
the clinical review states that the time between the Workshop Manager
alerting healthcare and medical assistance arriving was not significant to
the man, it could be critical to another prisoner. The Workshop Manager
also stated that instructional staff do not currently have to carry radios but
he added that this is under review at the moment and that all new staff will
now carry radios.
The Governor should review arrangements to ensure that staff are
trained and equipped to recognise an emergency and call for
immediate assistance using the standard prison emergency
procedures.
40.Two other prisoners had come to help when the man collapsed. Together
they put the man into the recovery position and put a cushion of towels
under his head. Another prisoner also assisted. One prisoner held the
man’s head, another held his arms and another listened to his chest and
checked his carotid artery for a pulse. One of the prisoners felt a weak
pulse on the man’s neck but believed that the man’s heart was in arterial
fibrillation (that is a very irregular rhythm and at time banging). By this
time the Assistant Workshop Manager andWorkshop Manager were
present. The Workshop Manager informed the staff and prisoners that
healthcare staff were on their way.
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41.None of the staff who were present at this time had a first aid qualification,
and they did not attempt first aid and were content for the prisoners to
continue to assist the man. I commend the actions of the prisoners to
assist the man, but believe staff working in the workshop should have
appropriate training to enable them to manage emergency situations
appropriately.
Consideration should be given to providing first aid training for all
staff who have contact with prisoners.
42.At 8:30am, the Assistant Workshop Manager requested over his radio for
urgent medical assistance from prison healthcare staff (a Code Blue). The
Control Room informed healthcare of this request. At 8:33am, two
members of healthcare staff arrived and an ambulance was called. Cardio­
pulmonary­resuscitation (CPR) immediately commenced with the aid of an
ambubag to blow air into the man’s lungs.
43.At 8:36am, the prison doctor, a Senior Officer and the de­fibrillation
equipment arrived. The Senior Officer defibrillated the man. At 8:43am,
the prison doctor pronounced that the man was dead, just before the
paramedics arrived. The paramedics and medical staff left the workshop
at 8:55am.
44.The duty governor was immediately informed of the man’s death. A
member of the prison chaplaincy and another member of staff,
representing the Governor, immediately contacted the family to offer their
condolences and support to the man’s family.
45.The prison maintained contact with the family and offered to assist with
arranging the funeral and providing financial help. The man’s funeral took
place on in June 2005.
46.The post mortem report states that the cause of death was due to natural
causes as a consequence of a coronary artery atheroma (a degenerative
change in the inner and middle coats of the arteries in the heart).
47.The Clinical Reviewer concluded that the man’s care while he was in
prison was appropriate and that medical issues were dealt with in a timely
manner. He drew attention to the fact that Holme House had obtained a
summary of the man’s General Practitioner’s records. The Reviewer also
drew attention to the fact that although there may have been a delay in
summoning medical assistance, it was unlikely that the outcome was
affected as the man received qualified assistance much sooner than he
would in the community.
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48.My investigator noted that Acklington does not have medical staff on duty
24 hours per day, and as the man’s death occurred at the beginning of the
working day, some medical staff were in the process of commencing their
duties. Nevertheless, the use of a radio to summon assistance might
have resulted in a more rapid response to the emergency. This would
have been especially so in the case of prison medical staff who were
already on duty and who could have been contacted via the radio. I
acknowledge that this would not have made any difference to the outcome
so far as the man was concerned.
49.Some of the prisoners who attended to the man complained that the staff
in the workshop appeared content to allow them, the prisoners, to look
after the man after he was taken ill. From interviews with staff and
prisoners, it is doubtful whether the man’s care could have been better
managed with a more pro­active participation by staff in the workshop, as
the prisoners who assisted had some first aid knowledge. However, I
have already stated that I think that consideration should be given to
providing first aid training for all staff who have contact with prisoners.
50.The man entered prison with very serious diagnosed physical health
problems and had already suffered four heart attacks. The man’s
condition was being monitored and assessed regularly by the prison
healthcare staff. As the man was taking a lot of medication related to his
angina, asthma and circulatory problems, his dosages were carefully
observed due to the relative complexity of the case and the potential for
adverse reactions. Even with the limitations imposed by his health, the
man was deemed fit enough to do sedentary work and was allocated work
in the tailor’s workshop.
51.The man did not have to work as he was over retirement age but he
wanted to keep himself occupied. In his interview, one of the prisoners
commented on how the man had taken to the work and seemed to enjoy it.
52.From comments made by staff and prisoners at Acklington, it seems that
the man was a respected and well liked prisoner. It would have also
appear that he had put behind him his experiences at Holme House and
was starting to settle down into prison life.
53.I would like to commend the actions taken by the prisoners who went to
the man’s assistance when he was taken ill. Their actions meant that he
was immediately being looked after and supported in what transpired to be
his final moments.
The Governor should arrange for letters of commendation to be sent
to those prisoners who assisted the man in his final moments.
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Recommendations
Consideration should be given to providing first aid training for all staff who
have contact with prisoners.
The Governor at Acklington should review arrangements to ensure that staff
are trained and equipped to recognise an emergency and call for immediate
assistance using the standard prison emergency procedures.
The Governor should arrange for letters of commendation to be sent to those
prisoners who assisted the man in his final moments.
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