Individual at Acklington

The Death of a man on 9 January 2005
in a Hospital whilst a serving prisoner at
HMP Acklington
Report by the
Prisons and Probation Ombudsman for England and Wales
September 2005
This is the report of an investigation into the death of a man. He was transferred
from HMP Acklington to a nearby Hospital where he died of pneumonia on 9 January
2005.
My office investigates the death of all prisoners in custody, including those due to
apparent natural causes. In this case the investigation was carried out by one of my
investigators. He commissioned an independent Clinical Review from the Prison
Lead for the Northumberland Primary Care Trust. The Clinical Reviewer has
assisted with a number of my investigations and I am again very grateful to him for
his assistance.
I extend my condolences to the man’s brother and family on their sad loss.
I would like to thank the Governor at Acklington and his staff for their ready
assistance throughout this investigation. I am satisfied that the man received good
medical treatment during his time at Acklington. However, this investigation ends
with some significant recommendations for strengthening procedures when prisoners
are moved from Acklington to nearby hospitals for ongoing inpatient treatment.
STEPHEN SHAW CBE
Prisons and Probation Ombudsman
September 2005
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CONTENTS
Page
CONTENTS 3
SUMMARY 4
CONDUCT OF THIS INVESTIGATION 5
PERSONAL INFORMATION ABOUT THE MAN 6
THE MAN'S PRISON HISTORY 7
THE MAN'S MEDICAL HISTORY AND TREATMENT IN PRISON 8
FOLLOW-UP TO THE MAN'S DEATH 11
THE MAN'S ESCORTS AT HOSPITAL 11
CONTACT BETWEEN THE HEALTHCARE CENTRE AND
THE HOSPITAL 12
THE NEED FOR APPROPRIATE AND RESPECTFUL
BEDWATCH LOG ENTRIES 12
CONCLUSIONS 14
RECOMMENDATIONS 15
3
SUMMARY
1. The man was received into custody at HMP Holme House on 25 February
2004 when he was 61 years old. On 27 February 2004, he was sentenced
to six years imprisonment for serious sexual offences committed between
1964 and 1977. He had no previous convictions. On reception at Holme
House, the man reported that he was suffering from hypertension and he
also indicated a family history of diabetes. He was a smoker who was
considerably overweight.
2. He was transferred to HMP Acklington in mid March 2004 and shortly
afterwards routine screening identified that he was diabetic.
3. In November 2004, he suffered temporary left-sided weakness and the
doctor who saw him considered it likely that he had had temporary
interruption of the blood flow to his brain.
4. On 17 December 2004, he became unwell on A Wing at Acklington and was
transferred to a nearby Hospital where he was admitted as an inpatient. His
condition deteriorated at the hospital and he died on 9 January 2005. The
cause of death reported to the coroner by the pathologist was firstly
pneumonia and secondly cerebral and myocardial infarction.
5. The medical care he received whilst a prisoner at Acklington was good, but I
make three recommendations in relation to the quality of support he received
from the prison after his transfer to Hospital.
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CONDUCT OF THIS INVESTIGATION
6. My investigator studied all the man’s relevant prison records. These
included his main prison record, Medical Record and the nine Bedwatch
Logs covering the period spent by him in Hospital between 17 December
2004 and 9 January 2005. My investigator also studied instructions at
Acklington on the arrangements to be followed when prisoners are escorted
outside the prison.
7. A Clinical Review was commissioned from Northumberland Primary Care
Trust and I am very grateful to the Care Trust’s Prison Lead for undertaking
that review. He is an experienced observer of prison clinical practice and he
has undertaken several Clinical Reviews for me in a number of different
prisons.
8. My investigator visited Acklington and discussed aspects of the man’s
treatment with a range of senior staff at the prison. These included the
Governor, Deputy Governor, Head of Operations and the Clinical Team
Leader.
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PERSONAL INFORMATION ABOUT THE MAN
9. He was born in December 1942 and at the time of his death he was 62 years
old. He was born in Middlesbrough and the address he gave when he was
first received at HMP Holme House in February 2004 was also a
Middlesbrough address.
10. He was received at Holme House on 25 February 2004 at the beginning of
his trial at Teesside Crown Court. On 27 February 2004, he was sentenced
to six years imprisonment for a number of indecent assaults on two young
females committed between 1964 and 1977. He had never been in prison
before and, although he was sentenced to a lengthy term of imprisonment,
no pre-sentence report was written. It is normally possible to find a good
deal of written information about a man, like the deceased, who was serving
a long-term of imprisonment. But in this case, such information was not
available.
11. My investigator made contact with the man’s brother who told him that the
man had worked for British Steel until taking early retirement around the age
of 55. He then became a night watchman. According to his brother, the
man spent much of his time in the local British Legion Club. He never
married and, when his parents died, he continued to live in the family home.
The man apparently suffered from angina before going to prison and he was
deaf in one ear due to an industrial injury. The man was described by his
brother as being a “big lad” who weighed 18 to 20 stones.
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THE MAN’S PRISON HISTORY
12. As already indicated, he first entered HMP Holme House on 25 February
2004. On that date a standard First Reception Health Screen was
conducted by a nurse. He was asked if he was currently receiving
medication. The nurse recorded that he was confused about the
medications or what they were for. However, the nurse found a recent
prescription from his doctor and was therefore able to record the medication
that was currently being prescribed. He was asked if he suffered from a
number of conditions including asthma, diabetes and chest pains. He
answered ‘No’ to all these questions, with the exception of chest pains where
he spoke of suffering panic attacks.
13. A Secondary Health Assessment was also completed by the same nurse on
25 February 2004. His weight was recorded as being 123 kilograms and he
said that he smoked but did not wish to give up. When asked if there was
any history of illness running in his family, he referred to diabetes. He
answered ‘Yes’ to the question “Do you have any problems with your heart,
high cholesterol or high blood pressure?” Although the nurse did not tick any
of the Planned Action boxes at the end of the Secondary Health Assessment
form, he was seen by the Medical Officer at the prison on 2 March 2004.
14. On 16 March 2004, he was transferred from Holme House to HMP
Acklington. Acklington is in Northumberland near the seaside town of
Amble. It is a Category C adult male training prison with an operational
capacity of 882. He remained at Acklington continuously until his transfer to
Hospital on 17 December 2004.
15. An Initial Reception Healthcare Assessment was conducted at Acklington on
the day of his arrival. He was again asked a number of questions about his
health. The nurse recorded that diabetes was not an issue, but his high
blood pressure was highlighted. Acklington was one of the first prisons in
the country where clinical care is directly commissioned by the National
Health Service. The objective is that the standard of healthcare received by
prisoners should be as good as that received by citizens in the community.
The Clinical Review cites an example of good practice at Acklington as
follows:
“The computerisation of medical records at Acklington made (my) Medical
Review simpler (and the entries legible). It is possible to see at a glance the
summary of care which makes it much less likely that key issues are
overlooked when organising patient care.”
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THE MAN’S MEDICAL HISTORY AND TREATMENT IN PRISON
16. The Clinical Review states in the opening summary that he was overweight
when received at Holme House and he was also suffering from hypertension
for which he was receiving treatment. Shortly after his transfer to Acklington
in mid March 2004, routine screening also identified that he was diabetic.
17. The medical history section of the Clinical Review provides more detail about
his medical condition. The doctor notes that, at the time of the man’s arrival
at Holme House, his blood pressure was not properly controlled. He was
taking anti-inflammatory drugs and analgesics following a road traffic
accident which caused him back pain. The Clinical Reviewer writes that a
family history of diabetes was identified and the man was a smoker who was
considerably overweight.
18. Arrangements were made to monitor his blood pressure. He was advised to
stop smoking and had blood tests to check his blood fats. The Clinical
Reviewer describes all these actions as appropriate in view of his
hypertension.
19. In relation to diabetes, the Clinical Reviewer writes:
“Surprisingly, the possibility that he might be diabetic does not seem to have
been considered, despite his positive family history and the fact that he was
significantly obese.”
20. Monitoring of the man’s blood pressure showed it to be sustained at an
unacceptably high level and so his anti-hypertension medication was
increased and more satisfactory control was achieved.
21. Once he had been transferred to Acklington, he was referred to the GP, the
Well Man Clinic and the Chronic Disease Management Clinic at the prison.
22. Further blood profiling confirmed that he was suffering from Diabetes
Mellitus. The Clinical Reviewer observes it is probable that this condition
had been present for some time. The man’s medical record indicates that
the diagnosis of Diabetes Mellitus was made on 13 April.
23. The Clinical Reviewer notes that the man had lost weight since entering
prison and further weight loss was encouraged. He was given medication to
help control his diabetes and regular monitoring of both his hypertension and
diabetes was undertaken.
24. There is an entry on 1 October in his medical record which states that he
collapsed at work and that his right leg and arm went numb. His speech had
been slurred but, when he was examined in the GP surgery at the prison
later that day, he had full feeling in his leg and his speech appeared to be
normal, although he still had some numbness in his right side.
25. On 12 October, he commenced Simvastatin as a preventive measure to
reduce his blood lipid levels. The Clinical Reviewer explains that the man
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was at risk of a heart attack as he had diabetes, hypertension and was a
smoker. The Clinical Reviewer also writes that in such circumstances raised
blood lipids should be controlled if possible.
26. On 20 November, the man “suffered a transient left-sided weakness” which
resolved spontaneously. On 22 November, he was seen by a doctor who
considered it likely that the man had had a transient ischaemic attack
(temporary interruption of cerebral blood flow).
27. On 17 December, the man suffered a further episode of left-sided weakness
and the nurse who attended him on the wing could not record his blood
pressure. The Clinical Reviewer notes that she correctly decided to refer
him to the Accident and Emergency Department at a Hospital near the
prison. He was diagnosed as having had a left-sided stroke so was admitted
to the hospital and investigated by CT scan.
28. In the ward, he developed a chest infection and his condition deteriorated.
According to the Clinical Reviewer, “this was attributed to an extension of his
original cerebral vascular accident”. On 9 January 2005, the man
deteriorated rapidly with a falling level of consciousness and increasing
sepsis from his chest infection. A Senior Officer recorded in Bedwatch Book
9 that the man passed away at 8:22pm on 9 January.
29. He appears to have died from natural causes with the pathologist reporting
the cause of death to the coroner as:
1A pneumonia
1B cerebral and myocardial infarction.
30. The Coroner for North Northumberland has kindly made available to me a
copy of a letter sent to him on 11 January 2005 by the Specialist Registrar in
Elderly Medicine at the Hospital where the man was a patient. He reported
to the coroner that the man was admitted to hospital on 17 December 2004
with left-sided weakness and slurred speech. He also informed the coroner
that the man’s past medical history included diabetes, hypertension and
hypercholesterolaemia.
31. After the Clinical Review had been completed, the coroner sent me a copy of
the post-mortem report he had received from the Home Office pathologist for
the North Eastern region based at the Royal Victoria Infirmary in Newcastle.
The pathologist’s commentary at the end of his report to the coroner is as
follows:
‘’The post-mortem in this case has shown that this man has probably died as
a result of a terminal infection involving the substance of the lungs,
pneumonia. This infection has arisen as a result of debilities imposed upon
the patient because of extensive damage to the brain and the heart brought
about by degenerative vascular disease. These conditions between them
are thus properly considered the underlying cause of death in the case.
There were no marks of violence.’’
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FOLLOW-UP TO THE MAN’S DEATH
32. Bedwatch Log Book 9 indicates that his condition began to deteriorate
markedly during the afternoon of 9 January 2005. The consultant at the
Hospital asked the officer who was accompanying the man that day for
information that would enable contact to be made with the man’s family in
Middlesbrough. An entry in the Bedwatch Log at 18:10 shows that by that
time his brother had been contacted by the hospital authorities. He
explained that the family would be unable to get to the hospital.
33. The Duty Governor at the prison that day was the Head of Operations. The
man’s brother in Middlesbrough had already received news of his death from
the Hospital by the time the Head of Operations telephoned him. The Prison
Service Order on Follow-up to a Death in Custody states that ideally the
news of a prisoner’s death should be conveyed in person, but I am entirely
satisfied that in this case it was appropriate for the Head of Operations to
make telephone contact instead. In the first place the man was a patient in
Hospital at the time of his death and the hospital authorities therefore
correctly took on primary responsibility for breaking the news of his death to
his next of kin. Secondly, the significant distance between Acklington and
Middlesbrough would have led to the man’s household being disturbed in the
very late hours of 9 January or the very early hours of the following morning
for the news to be given in person by the Duty Governor.
34. The Governor sent a prompt letter of condolence to the family and he also
ensured that staff and prisoners were quickly informed of the man’s death.
35. A senior Governor at Acklington made suitably early telephone contact with
the man’s brother and the prison offered to send a representative to the
funeral. This offer was declined by the family.
36. The prison also offered to contribute towards the cost of his funeral, but his
brother told my Family Liaison Officer that the man’s solicitor was dealing
with a number of issues, including funeral costs, and the family had therefore
not accepted the prison’s offer in relation to funeral expenses. A number of
items of clothing were sent by the prison to the man’s brother and safely
received by him on 24 January 2005. My investigator has also seen an
exchange of correspondence between the prison and a Law Firm in
Middlesbrough in relation to a sum of money and two bags of property
belonging to the man. I take the view that the prison has behaved
professionally and sensitively in its handling of matters after the man’s death.
10
THE MAN’S ESCORTS AT HOSPITAL
37. As a result of good work both by prison officers and nursing personnel, he
was transferred rapidly to Hospital from Acklington on 17 December 2004.
The gravity of his medical condition on that date meant that he was admitted
to the hospital. He was serving a relatively lengthy sentence for sexual
offences and the prison conducted a risk assessment on 17 December to
establish the appropriate level of escort. The decision by the then Head of
Operations at Acklington was that the man should be escorted by two prison
officers and that he should be handcuffed up to and immediately following
any consultation, examination and treatment. If he was admitted to Hospital,
an escort chain was to be used at all times. The risk assessment stated that
ROTL (Release on Temporary Licence) could not be granted.
38. A further seven days went by and then a second risk assessment was
conducted on 24 December 2004. Bedwatch Log No. 3 indicates that on 23
December the man had been complaining about his handcuffs and “kept
asking for them to be removed”. The previous entry in the Bedwatch Log at
14:15 on 23 December made by one of the escort Officers states:
“Remove cuffs, allow staff to put the man in hoist then on to toilet. Now sat
up in chair. Reapplied cuffs.”
39. On the morning of 24 December, a Principal Officer made a management
check at the hospital. As the Security Principal Officer he had both the
authority and expertise to review the man’s escort conditions and make
recommendations. At Part 2 of the Risk Assessment for Escorts form, the
Security Principal Officer wrote that he had discussed the patient’s condition
with the ward sister. The prisoner was immobile due to paralysis on his left
side. The revised Risk Assessment indicated that the escort should be
reduced from two prison officers to one. At Part 4 of the same form, the then
Head of Operations agreed that the staffing should be reduced to one officer
and he also instructed that restraints should no longer be applied. He wrote
that the Duty Governor should be advised immediately if there was any
indication of increased prisoner mobility or any event indicating difficulty in
managing the man with a single escort.
40. This second Risk Assessment again indicated that ROTL could not be
granted.
41. There are two aspects of the time that the man spent at Hospital which
require further comments:
(i) contact between the Healthcare Centre at Acklington and the
Hospital;
(ii) the quality of some entries made in the Bedwatch Log while the man
was an inpatient at Hospital.
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CONTACT BETWEEN THE HEALTHCARE CENTRE AND THE HOSPITAL
42. On 17 December 2004, a nurse attended the man on the wing and noted in
his medical record that he was complaining of left-sided weakness. His
mouth was drooping, his arm had little grip, he was complaining of pins and
needles, and his leg was heavy. An Officer wrote in the A Wing Observation
Book on the same date that the man had had a stroke down his left side.
43. The man spent three and a half weeks in Hospital between his admission on
17 December and his death on 9 January. During that period there was just
one recorded contact between the HCC at Acklington and the Hospital. On
4 January 2005, two and a half weeks after his transfer to hospital, a nurse
called Ward 9 at the Hospital to ask about him. The medical records do not
indicate any information about what the nurse was told when she asked
about his condition.
44. To Acklington’s credit, my investigator discovered when he visited the prison
in late February 2005 that arrangements are in hand to improve systems of
contact. He discussed existing arrangements with the Clinical Team Leader
at Acklington. She said there were no written systems at the time of the
man’s death, but showed my investigator a draft document which requires
much more regular contact by a member of the nursing team once a prisoner
is in outside hospital.
I recommend that written guidance should be issued and implemented
without delay requiring much more regular contact by the nursing team once
a prisoner is in an outside hospital.
It is very important for contact to be maintained and documented by HCC
staff once a prisoner is being cared for as an inpatient at an outside hospital.
This is because of the prison’s continuing duty of care to any such prisoner
and because decisions about security matters need to be based on reliable,
up-to-date information about the patient’s condition. Information from the
Healthcare Manager is critical for decisions by the Governor about such
issues as the use of restraints and whether ROTL may be granted.
The need for appropriate and respectful Bedwatch Log entries
45. My investigator carefully studied the nine Bedwatch Logs completed by
Acklington prison officers during the time that the man spent at Hospital
between 17 December and 9 January.
46. My investigator was shown a copy of the published guidance made available
to staff from Acklington who are undertaking escorts outside the prison.
Section 1 of the guidance states that, if the escort develops into a
“bedwatch”, they should contact the Communications Room at the prison
and maintain an Occurrence Log. They are referred to Section 3 of the
guidance for requirements about what is to be entered into the log, but when
my investigator asked to see Section 3 it was blank. The job description for
officers on a bedwatch states that they have three prime functions, the third
12
of which is “to maintain an Occurrence Log of all events, i.e. visits from
prisoner’s family, changes of location and staff, etc.”
47. There is very detailed guidance about how escorting staff are to maintain
security, but there is no corresponding guidance about what the Occurrence
Log should or should not contain nor about the language and tone of their
entries.
48. The job description for the Duty Governor at Acklington sets out a list of
general responsibilities. The second responsibility on the list is to arrange
for a manager to visit the bedwatch during the course of the day if there are
any prisoners in outside hospital. The seniority of the manager who should
make such a visit is not specified.
49. The vast majority of the entries made in the nine Bedwatch Logs are
appropriate and suitable, but a few are lacking in respect and decency.
50. I accept that officers staffing the bedwatch at Hospital were not to know that
the man’s life was nearing its end, but they should certainly know that it is
unremarkable for seriously ill patients to lose control over their bodily
functions. There are several examples of log entries that I consider
disrespectful and lacking in common humanity. They use pejorative
language, exclamation marks and refer disrespectfully to incontinence.
These entries were made by two senior officers and two officers on 18 and
20 December and 3 and 5 January.
51. I consider a review of procedures should be undertaken to include improved
guidance and training for staff on what to write and how to write it when on
bedwatch duty. The review should also reflect on the question of who
should make management visits and whether any additions are required to
the existing Visiting Manager’s Bedwatch Checklist.
I recommend that staff should be reminded of the need to ensure that entries
in prisoner records should be accurate, factual, sensitive and respectful.
I recommend that the Governor should review and strengthen existing
procedures at Acklington for management checks and the monitoring and
support of staff on bedwatch duty.
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CONCLUSIONS
52. I conclude that the man had a number of health problems when he was first
admitted to prison in February 2004, although his diabetes was not
diagnosed until he was transferred to Acklington. He received good medical
care at Acklington, then on 17 December 2004 he was referred to the
Accident and Emergency Department at a nearby Hospital. According to my
Clinical Reviewer that was a correct decision. Although the man remained in
outside hospital for over three weeks until the time of his death, there was
just one formal contact between the HCC at Acklington and the hospital
during that period. Some of the entries made in the Bedwatch Logs by
prison staff were lacking in respect and decency.
53. Representations were made to me about my bedwatch logs conclusion in
the preceding paragraph when I issued my draft report to the Prison Service
for consultation. I decided not to accept these representations.
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RECOMMENDATIONS
Written guidance should be issued and implemented without delay requiring much
more regular contact by the nursing team once a prisoner is in outside hospital.
Staff should be reminded of the need to ensure that entries in prisoner records
should be accurate, factual, sensitive and respectful.
The Governor should review and strengthen existing procedures at Acklington for
management checks and the monitoring and support of staff on bedwatch duty.
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