Individual at Wealstun

Investigation into the circumstances surrounding the
death of a man
at HMP Wealstun in January 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2011
This is the report of an investigation into the death of a man at HMP Wealstun in
January 2010. He was 35 years old. I offer my sympathy and condolences to his
partner, his children and his parents, and to all those others affected by his death.
The post mortem found that the man died because of acute heart failure due to the
anomalous origin of his right coronary artery. It is a rare condition and one which he
would have been born with. There was no indication that he was going to die and it
would have been very sudden.
The investigation was carried out on my behalf by one of my colleagues. An
independent review of the man’s medical care in prison was conducted by a clinical
reviewer on behalf of Leeds Primary Care Trust. I am most grateful to the clinical
reviewer for his assistance.
I would also like to thank the Governor and staff of Wealstun for their co-operation
during the course of the investigation.
The clinical reviewer makes four recommendations, all of which I endorse, in his
clinical review. The man had been in prison for a number of years and was held at
HMP Durham and HMP Lindholme before he moved to Wealstun. The reviewer’s
recommendations concern prescribing practices at all three prisons and so I will
send my report to each. I have an additional recommendation to reflect my concern
about the length of time that seems to have elapsed before the staff established that
the man had died.
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
Acting Prisons and Probation Ombudsman June 2011
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CONTENTS
Summary
The investigation process
HMP Wealstun
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was sentenced on 13 October 2006 to an indeterminate sentence for public
protection (IPP) and ordered to serve a minimum of four and a half years before he
could be considered for release. In December 2009, the Parole Board decided not
to direct his release from prison because work to reduce the risk of re-offending was
still required.
When he came into custody at HMP Durham in July 2005, the man told the nursing
staff that he suffered from asthma and had a family history of cardiac problems. In
October of the same year, he reported at the wing clinic that he suffered from high
blood pressure and asked for his blood pressure to be taken. Although variable, his
blood pressure was regarded as high but the doctors decided against treatment with
medication at that stage.
The man was granted bail in 2006 and, whilst on bail, he was investigated in hospital
for chest pain. On returning to prison, the doctor contacted the hospital who
reported that the man had been investigated for cardiac problems but no treatment
was necessary. His GP confirmed that he had not been taking any medication.
In August 2006, the man had acute chest pain and was prescribed pain relief. He
told the doctor in November that he was not sleeping and felt depressed. An anti
depressant was prescribed by the doctor and seems to have continued for the
remainder of his time in prison. Medication to treat hypertension was prescribed in
March and April 2007, after which his blood pressure stabilised.
In August 2008, the man transferred to HMP Lindholme and in November 2008 to
HMP Wealstun. On reception at Wealstun, he told nursing staff that he had suffered
two heart attacks in 2006 and was due to see a cardiologist. He was offered a GP
appointment but did not attend.
In January 2009, the man saw the doctor and said that he had recently suffered two
episodes of crushing chest pain. Medication to prevent chest pain was prescribed
and he was referred to the local hospital. The hospital diagnosed a particular
abnormality of the right coronary artery. He did not have any significant coronary
heart disease and no past evidence of any heart attacks. The hospital did not
suggest any treatment and discharged him back to the care of Wealstun.
The man reported in July that he was suffering from chest pains. The doctor
prescribed medication to reduce acid content and reassured him about his heart.
The man made no further complaint of any chest problems. He continued to receive
his medication and his blood pressure was generally normal.
On the morning of the man’s death, a prisoner standing by the man’s cell door
alerted prison staff. Officers found the man on the floor of his cell with dried blood
near his mouth. An officer summoned medical assistance, including an ambulance.
Paramedics attended and confirmed that the man was dead. They suggested that
his death had occurred some four to six hours previously. I am concerned that so
much time passed before the alarm was raised.
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The post mortem report establishes that the cause of death was acute heart failure
due to the anomalous origin of the right coronary artery (one of the most important
arteries supplying the heart muscle itself). The clinical reviewer notes that there
would have been no indication that his death was imminent.
The clinical reviewer observes that there are two related issues that remain
unresolved. They concern the potentially high levels of medication reported in the
toxicology report, and the discrepancy between the medication that should have
been in the man’s possession but was not found in his cell
The clinical reviewer makes a number of recommendations in his clinical review, all
of which I endorse, and I make an additional recommendation.
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THE INVESTIGATION PROCESS
1. This investigation was undertaken by one of the investigators from this office.
He first visited Wealstun on 21 January 2010 and was given access to the
man’s prison records. The investigator visited the residential unit where the
man had been found collapsed on the day he died. He was also shown
around other parts of the prison, including the healthcare unit.
2. During this initial visit, the investigator met members of the Independent
Monitoring Board (IMB) and the Prison Officers Association (POA). He invited
them to provide any information regarding the prison or the circumstances
surrounding the man’s death that they felt pertinent to my investigation. (Each
prison has an Independent Monitoring Board. IMB members are independent
and unpaid. They monitor day-to-day life in the prison and ensure that proper
standards of care and decency are maintained. The IMB produces an annual
report of its work.)
3. Leeds Primary Care Trust (PCT) was asked to undertake a clinical review of
the care that the man received whilst he was in custody, particularly during his
time at Wealstun. They appointed a clinical reviewer to undertake the review
on their behalf. The investigator asked the clinical reviewer to consider
particularly medication issues that might have impacted on the cause of the
man’s collapse and any actions that should or could have been taken in
respect of his heart problems.
4. One of my family liaison officers contacted the man’s father, as his listed next
of kin, to inform him of my investigation and to invite his family to ask any
questions or raise any issues for consideration as part of my investigation. I
hope that my findings help the man’s family better understand what happened
following his collapse and address any concerns they may have about the
care he received.
5. The 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 of this investigation, a copy of my report will be sent
to the Coroner to assist his enquiries into the man’s death.
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HMP WEALSTUN
6. HMP Wealstun is a category C training prison for adult men. It opened on 1
April 1995, following the amalgamation of HM Prisons Thorp Arch and
Rudgate.
7. Wealstun was a large and complex establishment when it was two prisons
within one operation. When Her Majesty’s Chief Inspector of Prisons made
her announced full inspection visit in 2008, she said:
“On our previous visit, we were critical of the complexity of the site, which
included an open prison. On our return, the open side was empty and in
the process of being converted into additional closed training places.
Wealstun was clearly benefiting from the single focus that these changes
had brought about. Improvements were visible across the board, with
particular progress having been made in resettlement provision.
“There had been significant improvements at Wealstun since our previous
visit. The prison had clearly benefited from the increased clarity of role
that had come with the closure of the open prison, leaving it to focus fully
on its category C training function.
“Bullying and violence reduction arrangements had also developed,
although more individual work was needed with bullies and their victims.
Drugs remained a significant problem, but security arrangements had
been tightened proportionately to address the issue.”
8. As part of my enquiries, I endeavoured to consult the current annual report by
the IMB, but discovered that no reports are available for the period after May
2007.
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KEY FINDINGS
9. The man was remanded into the custody of HMP Durham on 21 July 2005 for
an offence of conspiracy to commit arson and harassment charges. He was
transferred to HMP Holme House for a short time, but returned to Durham on
31 August. He was released on bail in March 2006, and remanded back into
custody on 14 July. On 17 July, at a Crown Court he was convicted of the
charges. He appeared on 13 October at a further Crown Court and was
sentenced to an indeterminate sentence for public protection (IPP) and
ordered to serve a minimum of four and a half years before he would be
considered for release.
10. On his first reception health screen undertaken at Durham in July 2005, the
man told the nursing staff that he suffered from asthma and had a family
history of cardiac problems. He was a non-smoker and took regular exercise.
He had no alcohol or substance misuse problems but, because he said he
had suffered from chest pains in the past, he was given an appointment to
see the doctor. Unfortunately, the clinical records from any consultation that
may have taken place are missing.
11. On 4 October, the man presented himself at the wing morning clinic asking if
he could have his blood pressure taken because he said he was known to
have high blood pressure. The nurse obliged his request and recorded the
man’s blood pressure as being 198/105 (which is a high reading). He was
given an appointment later that day to be seen by the doctor.
12. An unidentified doctor saw the man later that day and measured his blood
pressure twice. The first reading was 154/84 and the second reading was
recorded as 133/92. Neither result was considered by the doctor to be of
concern. He reassured the man and suggested that he should have his blood
pressure checked annually.
13. The man again asked for his blood pressure to be checked on 14 December.
The nurse made two recordings, one from the man’s left arm (148/110) and
one from his right arm (150/100). The significance of these readings is that
they are broadly similar and both would be considered quite high. A nurse
advised that the man should have his blood pressure monitored over the next
few days and be seen by the doctor if it remained high.
14. The man was seen again on 17 and 21 December, when his blood pressure
readings were again recorded as high (139/92 and 174/108 respectively). A
prison doctor at Durham wrote to the man on 21 December explaining that he
was reluctant to begin what would be a lifetime of medication and so he would
have an appointment in the New Year (2006) to discuss alternative options.
In the meantime he wanted additional blood pressure readings to be obtained.
15. Unidentified healthcare staff took the man’s blood pressure on 10 January
2006 (168/116), 12 January (142/102), 25 January (169/120), 27 January
(142/108) and on another unclear date in January when it was ‘so high as to
be unrecordable’. During this time the man had blood taken for investigation.
8
He also supplied urine samples and was referred to the local hospital for a
chest x-ray. Nothing abnormal was discovered in the blood investigations
although some protein was found in his urine, indicating that he might have a
slight infection. The blood tests did not indicate the need for any treatment.
16. The Head of Primary Care Services at HMP Durham saw the man on 3
February and noted his history of high blood pressure. Because he was
asthmatic, the doctor said that beta blockers should not be prescribed
immediately. He wanted to await the results of the recent chest x-ray. They
arrived at the prison on 21 February and showed nothing abnormal. The
man’s blood pressure continued to be monitored throughout the following
weeks, showing varying degrees of being higher than it ought to be.
17. On 20 March, the man was released from prison on bail. He returned to
Durham during his trial in July 2006. At that time he was seen by a nurse who
in turn contacted the man’s doctor in the community. The man’s doctor in the
community responded that the man was not prescribed any medication, but
had been given an inhaler, even though he was not asthmatic, because ‘it
makes him feel better’. The man also revealed that he had been sent to the
Rapid Access Chest Pain Clinic (RACPC) at outside hospital with recurrent
chest pain. A copy letter to the man’s doctor in the community from the
hospital arrived at the prison with the results of tests carried out sometime in
mid August.
18. The man started work as a cleaner on 28 July although the officer writing his
weekly report recorded that he required a little more motivation than others.
No other problems were reported.
19. On 10 August, the man was seen by a number of healthcare staff following an
episode of acute chest pain. His blood pressure was taken a number of
times, and showed slightly high readings. He was reassured and prescribed
some pain relief, but no further action was deemed necessary.
20. The man was moved to B wing on 11 August. Two days later, his cellmate
harmed himself. There are no details regarding this incident, save that the
man was required to move cells during the night. On 18 August, he moved
cells again, this time to C3 landing.
21. The letter from the RACPC clinic stated that the man had attended and been
investigated for cardiac problems. He had been given an Exercise Tolerance
Test (ETT) which monitors a patient’s cardiac rhythms whilst they undertake
exercise on a treadmill. The man was said to have had ‘jumped off treadmill
as he was breathless’ and had not reached a point in the exercise programme
where staff at the Chest Pain Clinic could measure any changes in his cardiac
rhythm. The hospital concluded from this and other tests that he had no
cardiac problems that warranted any treatment. This information was relayed
to the man in a letter from the Head of Primary Services at Durham on 17
August. He suggested that they should continue to monitor the man’s blood
pressure regularly.
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22. The man asked wing staff to arrange for him to see a nurse on 17 September.
When the nurse arrived, he refused treatment stating that he had waited too
long for their arrival.
23. On 20 September, the man was upgraded to Enhanced status on the
Incentives and Earned Privileges scheme (IEP). (IEP is a system to reward
good behaviour in prisons. There are three tiers – basic, standard and
enhanced, with enhanced being the highest level of rewards available.
Incentives can include more visits and opportunity to spend more private
cash.)
24. From August until November, the man’s blood pressure was monitored in
response to requests from healthcare staff and the man himself. On almost
all occasions, his blood pressure was raised.
25. On 6 October, the man started working in the waste management unit of the
prison. The following week, on 13 October, he was sentenced to an
indeterminate sentence for public protection with a minimum tariff of four and
a half years to be served before any release from prison could be considered.
26. An entry in the man’s wing history sheet was written on 21 October. (The
history sheet is a record of important events applicable to a prisoner is kept on
the wing where they are located. An entry is usually made at least weekly as
a summary of an individual’s behaviour during the preceding week.) The entry
says ‘Give credit to this inmate when he had to move location at short notice
due to unfortunate circumstances’. There is no indication as to what the
circumstances were or when they occurred.
27. The man completed the Challenging Offending Behaviour course on 3
November. He was sacked from his job in the waste management unit on 5
December after blaming another prisoner for the presence of a magnet on the
wing. No further details of the incident are given in his wing history sheet, but
the entry for two days later records that the man was eager to be in work,
there were no problems with discipline and he was polite and respectful. He
appears to have remained unemployed throughout December. He was given
a written warning on 21 December because his newspaper was found strewn
over the entrance to the wing. The man claimed that he had not thrown the
paper out of the window, but had lent it to another prisoner. Despite some
staff believing his version of events, the written warning stood.
28. The entries in both the man’s clinical record and wing history sheet from
December 2006 until August 2008 are fairly consistent throughout. In January
2008 he was assessed as suitable to hold his own medication in his
possession rather than it being administered daily by healthcare staff.
29. The clinical record has numerous entries recording his blood pressure
readings, most of which could be described as high. His history sheet
predominantly contains entries that describe the man as a cooperative
prisoner who had no problems with self harm or resettlement issues. He
remained on the enhanced level of the IEP scheme. He undertook a business
10
course through the education department and worked in the workshops. He
also participated in a relationships course and was reported to be enjoying
and benefiting from the Father and Child visits scheme.
30. One entry in his history sheet is worthy of mention as it contains information
regarding his medical condition. On 25 July 2008, an officer wrote that the
man was keen to move to the prison (HMP Lindholme) to which he had been
allocated as part of his sentence plan. The officer wrote: ‘If he has heard
nothing by Monday from healthcare re appointment he will sign disclaimer and
get medical hold removed’. On 14 August, the man was transferred to
Lindholme.
31. When the man first arrived at Lindholme he was located on K wing, but on 9
October he told staff that he was about to be assaulted by other prisoners.
He was initially moved to J wing and then to HMP Wealstun on 28 November.
32. During the first reception health screen undertaken at Wealstun on the day of
his arrival, the man told the nursing staff that he had hypertension, had
suffered two heart attacks in 2006 and had an outstanding hospital
appointment to see a cardiologist. It was also recorded that he had a history
of chest pain, and was asthmatic. His medication was recorded as
amitriptyline (an antidepressant), ramipril (anti-hypertensive medication) and
aspirin. The clinical review establishes that the man was able to receive a full
28 day supply of all his medications in possession from January 2008
onwards until his death in January 2010. The man declared that he had used
illicit drugs, which was cocaine in 2005. There was no declared mental health
problem. He confirmed that he wished to see the GP and was duly referred to
the GP clinic but did not attend the appointment made on 1 December.
33. Following another request by the man to see a GP, he saw a doctor on 13
January 2009. The man told him that, over the preceding fortnight, he had
had two episodes of a crushing central chest pain. One episode of pain had
lasted over 40 minutes. His blood pressure was taken and recorded as
normal (120/80). He was prescribed atenolol (which prevents chest pain
caused by ischaemic heart disease), and given a glyceryl trinitrate spray to
use should he suffer an acute attack of chest pains. Blood tests were taken.
The doctor referred the man as an urgent referral to the cardiology
department at outside hospital. In his referral letter of 13 January, the doctor
indicated that the man was taking ramipril and aspirin but did not mention that
he was also prescribed amitriptyline medication.
34. On 26 January, the man reported to nursing staff that he was feeling chest
pain. He was seen by a doctor and tested for troponin levels to exclude the
possibility of an acute heart attack. The man’s cholesterol level was also
measured as total cholesterol 5.8mmol/L, HDL 0.9 mmol/L). This was
regarded as high and he was prescribed simvastatin (a medication that helps
to reduce cholesterol and prevent heart disease in people at high risk and
those who have already had a heart attack or stroke). A blood pressure
reading was taken which showed that it remained at normal (120/80). The
man did not go to his GP appointment on 2 February or an appointment with
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the nurse on 10 February, although he did see the GP that day. His blood
pressure reading was the same as before (120/80).
35. The man was seen by a consultant cardiologist at outside hospital on 12
February. The consultant cardiologist noted there was no evidence to support
the man’s self declared past history of myocardial infarction (heart attack) as it
was not consistent with the echocardiogram (ECG) findings. The consultant
cardiologist wrote to the doctor at Wealstun proposing that the man should
have a diagnostic angiogram (a test to visualise the coronary arteries
supplying the heart muscles).
36. On 19 February, the man told the nursing staff that he suffered from a
migraine once a month, and that morning he had awoken with a headache
and dizziness. He said he was not suffering chest pains, his blood pressure
was taken (130/90) and he was prescribed paracetamol.
37. The man had a coronary angiogram test at the heart centre at outside hospital
on 12 March. In his report written on the same day, the consultant
cardiologist said the test showed that his right coronary artery was aberrant,
meaning that it was out of place. The man was noted to have “good cardiac
function/LV systolic function” which meant that his left ventricle heart muscle
was working well. The consultant cardiologist proposed that a more
specialised test, a coronary CT angiogram, should be undertaken to provide a
more detailed observation of the route of the aberrant right coronary artery.
(Computed tomography [CT] is a medical imaging method which uses an
imaging computer to reveal a three dimensional image of the body’s interior,
in this case the heart.)
38. The man went to outside hospital for the coronary CT angiogram on 27 April.
The consultant cardiologist provided a report of his findings to the doctor at
Wealstun, on 25 June. He confirmed the particular abnormality of the right
coronary artery. The report concluded
“In summary, this gentleman [the man] does not have any significant
coronary artery disease. Moreover, there is no past evidence of any heart
attacks. He should continue with medical therapy and I am discharging
him back to your care.”
39. The consultant cardiologist also wrote to the man: “I am pleased to report that
no significant narrowings were found in the coronary arteries. All this is
satisfactory”. He added that he would not need to see the man again.
40. There are entries in the clinical record recording that the man’s blood
pressure was regularly monitored whilst he was at Wealstun. Except for one
occasion, his blood pressure was consistently normal (in fact below average).
He was seen by medical and nursing staff on several occasions for minor
conditions, when asking for his medication and to review test results.
41. On 30 July, the man told a nurse about chest pains he said he had been
suffering. He said that the pains had occurred on about 12 occasions in the
12
previous month and he had to use his glyceryl trinitrate spray six times. He
also complained of nausea and sweating whilst suffering the pain. The man
said that he had been drinking Gaviscon in excess (Gaviscon is taken to treat
excess acid in the stomach.) The nurse reported the concern to a doctor.
42. The doctor saw the man the next day, 31 July. She diagnosed oesophagitis
(inflammation of the gullet due to stomach acid which often causes spasmodic
chest pain). She prescribed an alternative to Gaviscon, namely lansoprazole,
which reduces acid content in the stomach, and advised the man to continue
the medication for a month. An ECG test was done as well as a blood
pressure check (145/98). The doctor reassured the man about his heart, but
she advised that he should continue his medication for blood pressure.
43. The clinical record indicates that between August and December 2009, the
man was seen by staff approximately once a month when he asked for and
collected his repeat medication. He was also seen by nursing staff in regard
to toothache and minor backache. There is no record of the man complaining
about his health such that he needed to see a doctor, and no indication that
he complained about any further chest problems. The last occasion when he
asked for his medication (a repeat prescription) was on 22 December 2009.
He collected the medication on 1 January 2010.
The day of the man’s death
44. On a morning in January 2010, a prison officer came on duty at 6.50am to
relieve the night staff on the wing where the man’s cell was located. The
officer conducted a roll check. The roll check is the physical count of the
number of prisoners on each wing within a prison. Roll checks take place at
specified times during the day and night, usually at shift handovers, and staff
must sign that the roll is correct.
45. In interview with my investigator, the officer recalled that he saw the lower half
of a prisoner lying on the floor of his cell and did not notice whether he was on
a mattress. He was not alarmed because he knew that a number of prisoners
felt more comfortable on the floor ‘’if they’ve got a bad back or something like
that’’. He continued the roll check and reported that the number of prisoners
was correct.
46. Although there is no record, the weekend routine includes the cells being
unlocked at 9.00am.
47. Two officers said that, at approximately 10.30am, they were spoken to by a
prisoner. The prisoner was standing outside the man’s cell and he asked the
officers to go there immediately. On reaching the cell, they saw that the man
was lying on the floor covered in a blanket. A substance, which appeared to
be dried blood, had run from the left corner of his mouth. One of the officers
tried to find his pulse but was unable to do so and he said that the man was
cold to the touch.
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48. Wealstun’s Incident Log records that the officer who had conducted the roll
check that morning used his radio at 10.30am to call for assistance from
healthcare and Oscar 1. (Oscar 1 is the senior officer on duty who can be
contacted by radio to respond to emergencies.) The two officers who had
earlier been spoken to by a prisoner told the investigator that two staff from
healthcare responded to the call and came to the man’s cell ‘within seconds’
as they were already on the wing. The staff nurse examined the man but
could not find a pulse. He noted that he was not breathing, was cold to the
touch and that rigor mortis had set in. The two officers who had earlier been
spoken to by a prisoner said that the principal officer, who was the Oscar 1
officer, arrived within two minutes of the call being made to her.
49. The staff nurse told the investigator that he radioed the Control Room asking
for an ambulance to be called. The Incident Log records the time that the
request was made as 10.32am, with Control Room staff calling the ambulance
three minutes later at 10.35am. The Control Room asked the staff with the
man whether their request was a Code Blue or Code Red. (Code Blue
indicates a person has breathing /respiratory problems and Code Red that the
person is bleeding. The codes allow the medical staff to respond with
appropriate equipment.) The staff nurse explained that it was in order for
paramedics to attend the prison to certify death.
50. The Incident Log records that the ambulance arrived at the prison at 10.52am.
(The prison Death in Custody record sheet records the time of arrival as
10.42am and two paramedics entering the cell at 10.49am, but I consider the
Incident Log timing to be more reliable as the log was maintained
contemporaneously.) The paramedics confirmed that the man was dead and
told Oscar 1 and the nurse from healthcare that they considered that he had
died between four to six hours earlier.
51. The prison family liaison officer made arrangements for the man’s family to be
informed. He asked for assistance from staff at HMP Acklington (which is
nearer to their home) and they confirmed, at 1.23pm on the day of the man’s
death, that two of their family liaison officers would visit the next of kin. The
following day, the Governor of Wealstun wrote to several family members to
express her condolences, indicating that she was able to assist with the
funeral expenses. She wrote to the Acklington family liaison officers that the
man’s father had been impressed by their sensitive handling of his son’s
death and appreciated the advice and information that they gave when they
visited him.
52. The post mortem report recorded the cause of the man’s death as acute
cardiac failure due to the anomalous origin of the right coronary (one of the
important arteries supplying the heart muscle).
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ISSUES
When the man was found
53. In an interview with my investigator, the officer who had conducted the roll
check on the morning of the man’s death confirmed that on that day he
arrived at approximately 6.50am to take over from the night staff on the wing
where the man was located. He told my investigator that he completed the
roll check (counting the prisoners in their cells) by opening the flap of each
cell door and satisfied himself that there was a person in the cell.
54. In the man’s cell, the officer saw the lower half of a person on the floor and
thus was able to physically count the prisoner’s presence. He said that he did
not notice anything untoward at that time. My investigator asked the officer
whether he considered it unusual to see a prisoner lying on the floor. The
officer said that he did not because some prisoners found the beds
uncomfortable. (The prisoner who alerted staff and the officer who conducted
the roll check that morning both told my investigator that the man was lying on
his back covered in a blanket in what appeared to be a natural sleeping
position.)
55. My investigator asked the officer who had conducted the roll check that
morning if there was a mattress on the cell floor and he replied:
‘’I didn’t see him on a mattress but I saw him on the floor and I saw, as
far as I can remember I saw his feet and his belly. And the rule of
thumb is that as long as you see somebody in there you can account
for that person.’’
56. The investigator also asked the officer to explain the weekend morning
procedure that follow the roll check. The officer explained that the cells of
prisoners on cleaning duty are opened at approximately 8.40am to 8.45am.
All the remaining cell doors are unlocked at 9.00am. The procedure at
weekends differs from that on weekdays because breakfast is not served as a
meal. Instead it is given to prisoners the previous evening for them to eat
when they like.
57. The officer who had conducted the roll check that morning told my investigator
that there is not necessarily any interaction between prison staff and prisoners
when the roll check is carried out. Similarly, no contact is required when the
cells are unlocked unless the prisoner leaves his cell and approaches a
member of staff. As some prisoners sleep until lunchtime, that may be the
first time they are spoken to at the weekend. The officer added “generally
people don’t actually go into the cells and wake them [prisoners] up”. He
confirmed that this was normal custom and practice on the wing where the
man was located.
58. The man was discovered lying on the floor in his cell by a fellow prisoner who
alerted prison staff to his concern. The fellow prisoner told my investigator
that he raised the alarm somewhere between 10.20 am and 10.45 am. (This
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has subsequently been noted as close to 10.30 am.) There is little doubt that,
in this particular case, had the man been discovered at 7.00am when the roll
was checked or 9.00am when cells were unlocked, there would have been no
difference to the outcome. The paramedics who attended at 10.52am judged
that the man had died between four and six hours earlier which was before
both the check and the unlock.
59. However, I consider it unfortunate that it was a prisoner, rather than a
member of staff, who found the man and that the discovery was not made
until approximately an hour and a half after the cell was unlocked.
60. In a number of previous investigations I have reported on significant delays
between cells being unlocked and the discovery that a prisoner has died. I
believe that clearer or renewed guidance is required about the actions to be
taken by prison officers when unlocking cells, particularly at morning unlock.
In a previous report I quoted from the Prison Officer Entry Level Training
(POELT) manual, which states:
“Prior to unlock, staff should physically check the presence of the
occupants in every cell. You must ensure that you receive a positive
response from them by knocking on the door and await a gesture of
acknowledgement. If you fail to get a response you may need to open the
cell to check. The purpose of this check is to confirm that the prisoner has
not escaped, is ill or dead.”
61. In view of the apparent delay before the man was found I recommend:
The Governor should review the guidance to staff at Wealstun on
unlocking arrangements to ensure that the well-being of prisoners is
adequately addressed.
Starting treatment for raised blood pressure
63. The clinical reviewer raised a number of concerns, together with
recommendations, in his report that I address below. He is of the opinion that
some medical practitioners would have started treatment for the man’s high
blood pressure at an earlier point.
64. Two prison doctors at Durham had considered the possibility of starting
treatment at an earlier stage, but for different reasons had concerns. One of
them set out his reservations in a letter to the man of 21 December 2005. He
said, "You are only a young man and once you start on blood pressure
treatment it is a lifetime commitment." At that time, the doctor proposed more
basic tests which he would discuss with the man.
65. In a letter of 15 February 2006 addressed to his GP in the community (in the
expectation of the man’s imminent release), the Head of Primary Care
Services at HMP Durham said;
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"I have held off putting him [the man]] on any medication
partly because of the fluctuation in the levels of his blood
pressure and partly because a beta-blocker, which I would
have thought fairly appropriate, is contraindicated as he has
asthma.”
He went on to say that he was uncertain whether the man’s blood pressure
should be treated or not.
66. The clinical reviewer concludes that the investigations conducted by the
medical staff at Durham, which included referral to hospital for a 24 hour
blood pressure reading, appear to have been appropriate and sensible. He
acknowledges that the time the man spent outside prison on bail (March 2006
to July 2006) interrupted the continuity of care provided by Durham.
67. In early 2007, the man was diagnosed with borderline persistent hypertension
and mildly raised diastolic blood pressure. In March 2007, he was prescribed
Bendrofluazide (water tablet) and the following month in addition ramipril (an
anti-hypertensive medication). Bendrofluazide was subsequently omitted
from his prescription. The clinical reviewer finds that:
“… by the middle of 2007 more acceptable readings were being seen
on treatment. The care given for this particular problem thereafter is
good and I have no particular further comments regarding the control of
his blood pressure in the prison setting.”
Investigation of chest pain
68. The man complained intermittently of experiencing pains in his chest. He was
referred to cardiologists on a number of occasions by doctors in Durham,
Lindholme and Wealstun. The investigations led to the discovery of the
anomalous origin of his right coronary artery. The clinical reviewer reports
that his research led him to conclude that an anomalous origin of the coronary
artery can lead to, amongst other things, sudden death. He adds:
“… there does not appear to be a beneficial or specific treatment [for
this problem], and although coronary artery resiting or grafting has
been tried, it was not considered or offered in the case of [the man].
The clinical reviewer also observes that no explanation was given by the
cardiologists as to the cause of the chest pains. On the last occasion when
the man was seen by a cardiologist, no further treatment was suggested and
he was discharged back to the care of Wealstun.
69. The clinical reviewer concludes that the man’s chest pains were fully
investigated from a cardiological point of view. He finds the care provided by
Wealstun:
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“was good and particularly thorough in commencing new medication,
performing useful investigations and making an urgent referral to
cardiologists”.
Prescription of amitriptyline
70. With regard to the man being prescribed amitriptyline to treat depression, the
clinical reviewer says in the Commentary Section of his clinical review
“There appears to have been scant attention paid to his [the
man’s] regular prescription for amitriptyline other than just to
dispense it to him. … there appears to be no medication
review for this particular drug [amitriptyline] and no
indication of why it was being prescribed on a regular basis. If
the medical officers and healthcare staff believed it was being
prescribed for chronic depression then there should have been
at least some sort of formal depression review in the 13
months of custody at Wealstun.”
71. The clinical record says that the man was prescribed amitriptyline to treat
depression (initially also insomnia), and he was being monitored as a result.
The clinical reviewer has, however, been unable to find any record either of a
diagnosis of a depressive illness, or an assessment of the effectiveness of the
drug. He is not convinced that the man had any significant depressive illness
and considers that the medication may have been prescribed instead of
sleeping tablets (as a substitute for the sleeping tablet, zopiclone, which had
been prescribed to the man in July and August 2006). The clinical reviewer
regards the use of amitriptyline for this purpose as 'poor practice'.
72. I endorse the following three recommendations made by the clinical reviewer.
The Heads of Healthcare at HMP Durham, HMP Lindholme and HMP
Wealstun should ensure that the standard guidelines for the treatment
of depression are used such that assessment, treatment and review are
clearly followed and documented in the medical records.
Medication reviews should be undertaken within three months of
transfer, and then on at least a six monthly basis for all regularly
prescribed medications.
Indications for starting regular treatment and its continuation (at
medication reviews) should be clearly documented.
In Possession medication
73. I share the clinical reviewer’s surprise:
“that the decision to allow in possession medications [amitriptyline] was
not formally reviewed and especially in view of the possible diagnosis
of depression”.
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He acknowledges that there was appropriate discussion and assessment
when it was initially agreed, in January 2008, that the man could keep his
medications in possession. However, he has been unable to find a record of
any review after the initial decision was made in January 2008.
74. The absence of another risk assessment is especially important in the light of
the amount of medication found in the man’s cell after he died. Significant
amounts appear to be missing. The clinical reviewer estimates that there
should have been at least 28 days supply of amitriptyline tablets left in the
man’s cell whereas none were found. On 22 December 2009, the man made
a request for medication and the following day a repeat prescription was
completed for 28 amitriptyline tablets each of 50mg and 25mg, one each to be
taken daily and 28 aspirin, one daily. The man collected the medication on 1
January 2010. There was an empty packet of amitriptyline 50mg tablets
found in the cell and, though not explicitly stated, the implication is that no
packet of 25mg amitriptyline tablets was found. As well, several months
supply of atenolol was discovered, even though this ceased to be prescribed
to the man by July 2009. The absence of some tablets and the presence of
others may indicate that the man did not follow the instructions for his
medication.
75. The clinical reviewer finds that the absence of any amitriptyline tablets in the
man’s cell is an unresolved issue.
76. A serious untoward incident report, required by the Primary Care Trust in
circumstances such as this, was written soon after the man’s death. It refers
to “all outstanding medication has been recovered from the patient’s cell and
accounted for”. In view of the discrepancy between the clinical reviewer’s
comments in the clinical review and the extract from the serious untoward
incident report quoted above, the investigator asked Wealstun further
questions in November 2010. He was told that there is no list of the
medication removed from the man’s cell which would support the assertion in
the serious untoward incident report that all medication had been accounted
for.
77. Nevertheless, in the light of all these circumstances, I endorse the
recommendation made by the clinical reviewer:
The Heads of Healthcare at HMP Durham, HMP Lindholme and HMP
Wealstun should ensure that reviews of 'in possession' medication are
undertaken at appropriate intervals and risk reassessed at these times.
Prison record keeping
78. As noted earlier, a clinical review was conducted by a clinical reviewer on
behalf of the Leeds Primary Care Trust. He reviewed the medical records for
the man from his reception into Durham on 21 July 2005 until the date of his
death in Wealstun in January 2010. The clinical reviewer finds that the
documents relating to the reception screening at HMP Holme House (where
the man had been transferred for a short time) were incompletely copied. The
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record made available to him does, however, clearly show that neither the
man nor healthcare staff at Holme House had any particular concerns about
his health.
79. The clinical reviewer finds that most records for the period between July 2006
and July 2008 when the man was at Durham were complete and relatively
comprehensive. However, the first reception screening documents (relating to
July 2006 when the man returned there after a period on bail) were
incompletely copied. Some of the records were made in both handwritten and
computerised form by the same medical practitioner on the same day, which
the clinical reviewer considers is unnecessarily confusing and “not good
practice”.
Toxicology Report
80. A toxicology report concludes that "both paracetamol and codeine
concentrations were higher than expected within the therapeutic range" and
the amitriptyline concentration found in the blood samples taken at post
mortem examination “may have represented high therapeutic range use”.
81. Codeine had not been prescribed to the man and paracetamol was last
prescribed on 4 October 2009, for toothache. The clinical reviewer states
that interpretation of the data provided in the toxicology report on the levels of
amitriptyline found in the man at post mortem is beyond his expertise. The
potentially high levels of prescribed and non prescribed drugs found in the
man’s blood at post mortem remain an unresolved issue.
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CONCLUSION
82. The man had the potential for serious cardiac problems because of his family
history of heart disease, the undiagnosed anomalous origin of his right
coronary artery and his high blood pressure.
83. Although he had a long history of complaining of chest pain, which was
thoroughly investigated by various specialists, he had not complained of any
health issues requiring review by doctors in the five months prior to his death,
and the clinical reviewer says “there was no indication at all that a sudden
cardiac related death was imminent”.
84. The clinical reviewer concludes:
“[The man] probably died of natural causes” having suffered a sudden and
major arrhythmia (an interruption of the normal heart rate) of such severity
that this led to a massive and catastrophic loss of normal cardiac output
due to acute cardiac failure. Death would have been very sudden.”
85. Two issues remain unresolved. The first is the discrepancy between the
medication that should have been still remaining in the man’s possession, but
was not found in his cell. The second is the information in the toxicology
report that after the man’s death both potentially high levels of amitriptyline,
which had been prescribed, and codeine, which had not been prescribed,
were found in his body.
86. Finally, I am concerned that the man apparently lay dead in his cell when the
roll was checked and later when the door was unlocked. The staff carrying
out these duties are not required to communicate with prisoners and neither
officer noticed anything untoward. By 10.30am, when the man was found by
a fellow prisoner, the paramedics estimated he had already been dead for
between four to six hours. I appreciate that it was the weekend, when some
prisoners like to lie in, but nevertheless I recommend that the Governor
reviews the unlocking arrangements to make sure that these circumstances
are not repeated.
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RECOMMENDATIONS
The following recommendations were made in the draft version of the report. The
service’s response is included in italics following each recommendation.
To the Governor of Wealstun
1. The Governor of Wealstun should review the guidance to staff on unlocking
arrangements to ensure that the well-being of prisoners is adequately
addressed.
Service response: Recommendation accepted. A notice was sent to all staff,
reminding them that they must get a response from each prisoner at roll
check.
To the Heads of Healthcare at Durham, Lindholme and Wealstun
2. The Heads of Healthcare at HMP Durham, HMP Lindholme and HMP
Wealstun should ensure that
• the standard guidelines for the treatment of depression are used such
that assessment, treatment and review are clearly followed and
documented in the medical records.
• medication reviews should be undertaken within three months of
transfer, and then on at least a six monthly basis for all regularly
prescribed medications.
• indications for starting regular treatment and its continuation (at
medication reviews) should be clearly documented.
Service response: Recommendations accepted. The Governors of all
three prisons have confirmed that policies and national guidelines are in
place to cover all aspects of the above recommendations and all staff have
been reminded.
3. The Heads of Healthcare at HMP Durham, HMP Lindholme and HMP
Wealstun should ensure that reviews of 'in possession' medication are
undertaken at appropriate intervals and risk reassessed at these times.
HMP Durham Safer Custody Team Lead sent a response in regard to the
above recommendation that he had confirmed with the Head of healthcare
that polices and national guidelines were in place.
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