Individual at Wayland

Investigation into the circumstances surrounding the death of
a man at HMP Wayland on 21 May 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2005
This is the report of an investigation into the circumstances of the death of a
life sentence prisoner at HMP Wayland. He died on 21 May 2004 in outside
hospital following a stroke.
The investigation was led by one of my Senior Investigators. A clinical review
into the man’s care and treatment was commissioned from Southern Norfolk
Primary Care Trust (PCT).
We would like to extend our condolences to the family for their loss. I would
like to thank the Governor of HMP Wayland and his staff for their help.
This version, published on my website, has been amended to remove the
names of the deceased, his family and those staff and prisoners involved in
my investigation.
Stephen Shaw
Prisons and Probation Ombudsman December 2004
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Contents
SUMMARY .................................................................................................................................4
INVESTIGATION PROCESS .....................................................................................................5
BACKGROUND .........................................................................................................................6
THE EVENTS OF 19-21 MAY 2004 ...........................................................................................7
LEVEL OF COMPLIANCE .........................................................................................................8
THE FAMILY ..............................................................................................................................9
FINDINGS ................................................................................................................................ 10
CONCLUSION AND RECOMMENDATIONS ......................................................................... 11
GOOD PRACTICE .................................................................................................................. 12
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Summary
The man died aged 57 at the Norfolk and Norwich University Hospital on 21
May 2004. He was taken there by ambulance from HMP Wayland on 19 May
after being found in his cell unconscious but breathing. He subsequently died
from a stroke. His death was not connected to the fact that he was in prison or
to the level of care that he received there.
The man suffered a brain haemorrhage in 1998 and since that time had been
placed on the International Subarachnoid Aneurysm Trial under the Radcliffe
Hospital in Oxford. His condition meant that he was liable at any time to suffer
a spontaneous and fatal rupture of blood vessels in his brain and there would
be no prior warning.
The Governor and staff at HMP Wayland responded to his short illness and
sudden death with professionalism and sensitivity to his family. Some care
was taken to put out a further notice when it became apparent that the family
were going to visit Wayland.
There are few recommendations arising from this investigation. The clinical
review [not published] highlighted some procedural considerations for the
dispensing and recording of medication.
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Investigation process
My practice in investigations into a death from apparently natural causes is to
conduct an initial review to determine the extent of investigation required.
My investigator visited HMP Wayland on 28 May 2004. She met the Governor
who provided her with the man's prison record and copies of the notices,
reports and other paperwork associated with his death. She visited the wing
and cell where he had lived, and the Healthcare centre where she spoke to the
clinical nurse manager and the prison doctor.
She also gathered details of the man's next of kin, the Coroner, the police
liaison officer and the appropriate contact in the Southern Norfolk Primary
Care Trust (PCT). One of my Family Liaison Officers subsequently contacted
the family.
No formal interviews with staff were conducted. This report is based upon informal
discussions with the Governor and staff at Wayland, a thorough review of all relevant
paperwork and the findings of the clinical review.
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Background
The man who died was a life sentence prisoner and had been in prison since
1989. He had been at Wayland since 6 September 2002 where he seemed to
have settled well.
He had suffered a brain haemorrhage in 1998 leaving him vulnerable to a
future fatal haemorrhage. He received medication for his condition and was
tested regularly as part of a trial conducted by the Radcliffe Hospital. The trial
took the form of filling in a questionnaire. He arrived at Wayland on this
treatment and it was reviewed monthly, but not altered, during his time there.
The most recent trial was in April 2004. The prison doctor told my investigator
that he had completed the trial with the man and that he had not reported
anything untoward. The doctor observed that the man's condition had meant
that his death would be sudden and with no warning as he would suffer a
spontaneous rupture.
On arrival at Wayland in September 2002 the man was passed 'labour three'
which meant that he was deemed unfit for gym and heavy work. Despite his
condition, he was not a regular visitor to healthcare. Most of the entries on his
Inmate Medical Record (IMR) relate to his repeat prescriptions. In addition it is
noted that he suffered from tendonitis in his wrist and smoked 25-30 cigarettes
a day.
The clinical nurse manager told the investigator that the man liked to read and
write. She said he was a polite man and always co-operated with healthcare
staff. She felt that he found the mental slowness, which he had as a result of
his previous stroke, frustrating. He had made friends at Wayland and
attended the Introduction to Alcohol Awareness course in education. He was
employed as the library orderly.
He had only limited contact with his brothers and sisters during his time in
prison.
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The Events of 19 - 21 May 2004
On 19 May 2004, the man attended the Introduction to Alcohol Awareness
course between 2pm and 4.30pm. A fellow prisoner remembered walking
back to the wing with him and laughing and joking about the next session. He
said that the man was in good spirits and had not reported feeling unwell.
At about 4.50pm, an Officer reported that he was locking up the wing for tea
time roll check. He said he saw the man lying on his bed and failed to get a
response from him. He called another Officer who used his radio to summon
medical assistance. The second Officer reported that the man was lying on
his back with one leg rigid and his right arm in spasm. He said that he was
breathing regularly but did not respond to any stimulus.
Shortly afterwards the doctor arrived at the cell with two healthcare officers.
After a short examination, the doctor decided that the man had suffered a
stroke and asked for an ambulance to be called. The ambulance was called
immediately at 5.07pm. A further call was made at 5.25pm and staff were
advised that the ambulance would be another 10 minutes. The ambulance
arrived at 5.38pm and left at 6pm taking the man to Norfolk and Norwich
University Hospital. While waiting for the ambulance, staff gave him oxygen
and continued to monitor his condition.
Once at hospital, the man was intubated, ventilated and had a CT scan of his
brain. The scan revealed a large left-sided intra cranial haematoma. The scan
was discussed with the neurosurgical unit at Addenbrooke's Hospital and it
was decided that this was not an event that he would survive. He was
transferred to the Intensive Care Unit but showed no signs of neurological
recovery.
On arrival at the hospital, the escorting staff rang the prison for advice on the
use of handcuffs. The Governor advised that, for the preservation of dignity,
these should not be used. The Governor told the investigator that he did not
pursue an application for release on compassionate grounds because hospital
staff advised him that death was imminent.
The man died on 21 May at 1.30pm. His family were present at the hospital
and agreed that his kidneys could be used for donation. They were
subsequently transplanted.
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Level of Compliance with Prison Service Requirements
The decision to not use any form of handcuff or restraint was entirely
appropriate given the circumstances. I think the Governor made the right
decision, and commend him for it.
HMP Wayland followed its contingency plan relating to deaths of prisoners.
Statements were taken from staff, the Independent Monitoring Board were
informed and notices to staff and prisoners were put out. The post-incident
response was fully compliant with Prison Service instructions and policies on
managing a death in custody.
A further notice was put out in advance of a visit to the prison from the family.
This is good practice and again the prison should be commended.
When my investigator arrived at Wayland, she found that all relevant
information had been gathered together and sealed. Arrangements were
made for the investigator to speak to relevant members of staff and the
Governor personally escorted her around the prison.
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The Family
The man had three brothers and a sister. He had not been in regular contact
with them for some years. The Governor managed to contact two of his
brothers on19 May and they travelled to Norfolk that evening. They spent the
next day in the hospital with their brother and on Friday 21 May they gave their
permission for doctors to turn off his ventilator.
The brothers met the Governor at the prison on the afternoon of 21 May. They
were offered the opportunity to walk around the grounds but did not want to.
They collected the man's property and staff promised to deliver the remainder,
which was in store at Branston.
One of my Family Liaison Officers, tried to contact the brothers on several
occasions but it appears they did not wish to have contact with this office
concerning the investigation.
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Findings
The clinical review did not find any deficiencies in the man’s medical treatment
while at Wayland. It seems clear that he had a medical condition that was
likely to become acute at any time and without warning. He was on regular
medication and was monitored as part of a trial at the Radcliffe Hospital. His
records indicate that he was otherwise in pretty good health and did not visit
the healthcare centre regularly other than to collect his medication.
He seemed settled in Wayland, had made friends and was attending courses.
I have seen no evidence to suggest that he had any other issues that were
affecting his mental or physical health. On the day he died, the last person to
see him remembers that he was laughing and joking and looking forward to
the next session on his course.
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Conclusion and Recommendations
There was no extra preventative action or treatment that would have caused
the man to live longer. There was nothing that staff who found him and
attended him in his cell on 19 May could have done to save his life.
The only recommendations that I make are taken from the clinical review:
1. Prisoners at HMP Wayland should sign for their medication on receipt
from the dispensary.
2. The practice of recording medication monthly in the IMR should be
reviewed since all prescribed medication is already recorded on the
prescription chart.
3. A records audit should be undertaken to ensure that standards for
record keeping are met.
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Good Practice
The Governor put out notices to staff and prisoners on 21 May informing them
of their fellow prisoner’s death. The man's brothers were able to visit the
Governor that afternoon. A further notice was put out in advance of this to
staff and prisoners on the man's wing and the wing on which he attended his
course. This explained the circumstances of the family visit and asked
everyone to let the family party approach people if they wanted to rather than
questioning them. I consider this to be good practice. It shows sensitivity to
the family who would be in an unfamiliar environment at a difficult time and
might not want to be approached.
I was also pleased to note the Governor’s decision that there was no need to
use handcuffs or any form of restraint when he was in hospital.
Earlier in this report, I have commended the Governor for both examples of
good practice.
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