Individual at Altcourse

Investigation into the circumstances surrounding the
death of a prisoner at HMP Altcourse
on 8 January 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
June 2006
This is the report of an investigation into the death of a prisoner. He was
aged 31, died in the Healthcare Centre at HMP Altcourse on 8 January 2006.
I would like to extend my sincere condolences to the prisoner’s family for their
untimely loss.
The man had been remanded into custody on 16 December 2005, and had
spent time in prison healthcare and outside hospital following a series of fits.
Despite extensive tests carried out at the request of the Coroner, it has not
been possible to establish the prisoner’s cause of death. The toxicology
results indicate that drugs or alcohol did not contribute to his death.
Notwithstanding the absence of a formal cause of death, I have judged that all
matters properly within my remit have now been covered. Other
investigations by the police and Coroner are continuing.
One of my Investigators, conducted this investigation. I am grateful to the
North Liverpool Primary Care Trust for undertaking a clinical review into the
prisoner’s care and treatment. I would also like to thank the Director of
Altcourse, and his staff for their help and co-operation during this
investigation.
I make four recommendations, the last of which reflects the very good practice
demonstrated by the prison’s family liaison officer.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2006
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CONTENTS
Summary
The investigation process
The prisoner
HMP Altcourse
Events from 16 December 2005 to 5 January 2006
Events from 7 January leading up to the prisoner’s death
Clinical review and post mortem
Issues considered during the investigation
Recommendations and Good Practice
Annexes:
A. The prisoner’s Medical Record
B. Bedwatch Logs for 28 December 2005 to 3 January 2006
C. Clinical review from the North Liverpool Primary Care Trust
D. Statements from staff involved in the prisoner’s care
E. Summary of interviews with staff.
F. Incident log for 8 January 2006
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Summary
At about 4.15am on 8 January 2006, the prisoner was pronounced dead by
paramedics in the Healthcare Centre at HMP Altcourse. He was 31 years old.
Despite extensive tests, his cause of death is not known.
The man had been remanded into custody at Altcourse on 16 December
2005. He told healthcare staff on his medical reception that he had been hit
over the head by police in their custody, after being arrested on 14 December.
He stated during his reception screening that he had experienced fits and
memory loss in the past, and that he had suffered a fractured skull in October
2003 also whilst in police custody. He had longstanding mental health and
alcohol problems, for which he had been receiving appropriate anti-psychotic
medication.
On 28 December, the prisoner experienced a series of fits and was taken to
the prison’s Healthcare Centre for further observation. Later that day, he was
taken by ambulance to an outside hospital for further tests which included a
head scan and x-rays. He was diagnosed as suffering from viral encephalitis
(infection in the brain). He remained in hospital under bedwatch by prison
staff until 3 January 2006 when he returned to the Healthcare Centre at
Altcourse. On 5 January, he was deemed well enough to return to a normal
residential wing.
At about 12pm on 7 January, the prisoner’s cell mate, alerted staff that he was
having a fit. In view of his recent history, it was decided to locate him in the
Healthcare Centre once again so that he could be observed. Whilst in
healthcare, the man did not experience any further episodes of fitting and
gave no further cause for concern to staff. During the night, he was observed
regularly. Staff noted that he was at first snoring heavily and then maintaining
a clear, loud and solid breathing pattern.
However, at about 3.45am on 8 January, the night nurse noted that she could
not hear the prisoner’s breathing. She looked through the open flap of his cell
door to discover that his chest was raised and he appeared not to be
breathing. His cell was unlocked immediately and Cardio-Pulmonary
Resuscitation began. An ambulance was called. During efforts to resuscitate
him, he bled from his mouth. Resuscitation attempts continued for about 25
minutes but were unsuccessful.
The clinical review concludes that the prisoner received timely, appropriate
and reasonable care and treatment whilst at Altcourse, and that he was
referred to outside hospital for prompt investigation and treatment. I hope his
family can take some comfort from these findings, and reassurance that he
received a level of care equivalent to that which he could have expected in the
wider community.
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I make four recommendations in my report. The first three relate less to the
death of the prisoner and more to issues that could be relevant in future
medical emergencies. The fourth highlights the way in which Altcourse liaised
with the prisoner’s family following his sudden, sad and untimely death.
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The investigation process
1. The investigation into the circumstances surrounding the prisoner’s death
was opened at HMP Altcourse on 9 January 2006. Notices were issued to
staff and prisoners informing them about the investigation and giving them
the opportunity to meet the investigator. My investigator visited Altcourse
on 16 February to speak with members of staff who had cared for him. No
prisoners came forward in response to my notice.
2. The Director and his staff produced the prisoner’s core record, his Medical
Record and a number of other documents for review.
3. North Liverpool Primary Care Trust was commissioned to conduct a
clinical review into the care and treatment that he received whilst in prison.
A doctor from the North Liverpool Primary Care Trust undertook the
clinical review. It is attached to this report as an annex.
4. One of my Family Liaison Officers, contacted the prisoner’s sister, the
family’s nominated representative, by telephone on 1 February. He
offered her the opportunity to meet with him and the investigator to discuss
the purpose of the investigation, and to raise any concerns or questions
that the family would like explored and addressed. The family liaison
officer and the investigator, met with his sister on 10 February when a
number of issues concerning the man’s care whilst in prison were raised. I
endeavour to address all these issues in this report.
5. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of the investigation and to request a copy of the post
mortem report. My final report will be sent to the Coroner to assist him
with the inquest into the prisoner’s death.
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The prisoner
6. The man was born on 6 December 1974. He was 31 years old when he
died. He was from a large family and is one of six siblings. He had a
particularly close relationship with his older sister, who described him as a
quiet, shy boy in his youth who was very protective of his family.
7. He left school at the age of 16 and became an apprentice in horticulture.
At about this time, he started to smoke drugs. His sister recalled that he
then went on to use heroin. He began to get into trouble when he became
involved in petty theft to pay for his habit. For some years, he lived with
his older sister and her children.
8. The man also misused alcohol and could be easily provoked under its
influence particularly by other members of his family.
9. The prisoner had an outstanding civil complaint against the police from a
previous arrest for another offence in October 2003. Whilst in police
custody, he sustained a fractured skull and other serious injuries whilst
being restrained. This matter was still being dealt with at the time of his
death. The prisoner’s family has maintained that, since the incident in
2003, he had been suffering from headaches and a degree of visual
impairment. The family is of the opinion that the injuries to his head could
have contributed to his death.
10. At the time of his arrest for his current offence in December 2005, he was
living with his partner at his mother’s home address. His mother was his
nominated next of kin. He was unemployed but had worked for a double
glazing company in the past. The prisoner and his partner had a young
son. However, at the time of his arrest, the relationship had broken down
and the child had been taken into care. The prisoner did not maintain
contact with his partner whilst he was in prison, and there is no record of
him using the telephone or requesting a visit from her.
11. This was not the man’s first experience of prison. He had previously been
at HMP Liverpool and HMP Altcourse for separate offences. Staff at
Altcourse found him to be an amenable person.
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HMP Altcourse
12. HMP Altcourse is a contracted prison in Liverpool, under the management
of Global Solutions Ltd – GSL. It was the first prison to be opened under
the Government’s Private Finance Initiative.
13. Altcourse’s population consists of sentenced and convicted adult males
from the Cheshire and North Wales area. It also holds young adults from
Cheshire, North Wales and Merseyside. The current operational capacity
(maximum crowded capacity) is 1,010. Approximately, one third of the
prisoners are on remand.
14. Until 31 January 2005, Primecare Forensic Medical provided the
healthcare services at Altcourse under a Service Level Agreement with the
prison. On 1 February, this contract transferred to a new provider, Veritas
Limited. The Healthcare Centre can accommodate up to 32 in-patients
and offers a good range of primary care services.
15. A report of an announced inspection by Her Majesty’s Chief Inspector of
Prisons (HMCIP) in February 2005 confirmed the widely held view that
Altcourse is a very good local prison. The Chief Inspector concluded that
Altcourse was “a safe prison with good interaction between staff and
prisoners”. The report also highlighted that good links had been
established with the North Liverpool Primary Care Trust and that a survey
of prisoners revealed all aspects of healthcare were highly rated.
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Events from 16 December 2005 to 5 January 2006.
16. On 14 December 2005, police were called to his mother’s address where
he was arrested for threatening to kill his mother and resisting arrest. He
appeared at Magistrates’ Court on 16 December and was remanded in
custody until 16 January 2006.
17. On reception at Altcourse, he underwent an initial medical screen. This
established that he had seen his GP in the previous 12 months in respect
of a wound to his penis. He was also being treated for a stomach ulcer.
The prisoner had a history of mental health problems including psychotic
episodes and schizophrenia. He said he was being treated by a
Consultant Psychiatrist and was receiving Quetiapine and Diazepam.
When asked if he had contemplated self-harm, he admitted that he had
attempted this approximately 18 months previously. The initial health
screen also indicated that he had suffered from fits in the past. He also
told healthcare staff at reception that he had been hit over the head with a
baton or a fist during his most recent arrest. However, the health screen
determined that he was not suffering from any serious physical problem.
The prisoner stated that he had not taken drugs for many years.
18. Following his health screen, he was referred to the prison doctor and the
Mental Health In Reach Team because of his history of mental health
problems. He was deemed suitable to share a cell with another prisoner.
He was placed in a shared cell with another prisoner who was on remand.
19. On 17 December, it was recorded in his medical record that the prisoner
was prescribed the appropriate medication for his mental health problems.
On 20 December, he was seen by the Mental Health In Reach Team.
Confirmation of his current medication was also received by fax from his
GP. The prisoner complained at the time of being unable to urinate
properly because his penis was split. Examination did not discover
anything untoward.
20. On 21 December, he was seen by a Registered Mental Health Nurse
(RMN). The medical record indicates that he agreed to comply with his
medication regime.
21. The prisoner’s cellmate recalled speaking to him on 22 December and
being told that he was not getting the right medication for his psychotic
illness and that he was getting pains in his head. The prisoner also told
his cellmate that the root cause of his problem was that he had been
assaulted by police during his recent arrest, when he had sustained a hit
to the head with a truncheon. In a subsequent statement to the police, the
cellmate said that he had told him that he had not suffered fits prior to
being arrested by police on 14 December 2005. However, the initial health
screen noted that the prisoner had in fact experienced fits prior to being
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arrested in December 2005. During this investigation, it emerged that the
man had told staff that he had experienced fitting episodes outside of
prison. In a letter sent to his brother before Christmas, he said that he had
received a beating by police when he was arrested on 14 December. This
letter also contained an apology to his mother for the outburst leading to
his arrest.
22. At about 2am on 28 December, the prisoner’s cellmate rang the cell bell,
having observed him with foam coming out of his mouth. The cellmate,
who had some experience of people who suffered with fits, placed him on
his side so that he could not swallow his tongue. Healthcare staff entered
the cell within 10 minutes, after authority was received from the Duty
Operations Manager (DOM). They noted that the prisoner was sitting on
his bed talking incoherently. The cellmate was removed from the cell so
that he could be treated. The medical record states that at 2.15am he was
observed to fit again and was turning blue. He was given oxygen. During
the course of being treated, he fitted twice more. At 3am, he was admitted
to the Healthcare Centre for further observations. He was then taken by
wheelchair as he was unable to stand.
23. The medical record further states that, at about 5.30am, the prisoner
experienced a mild fit that lasted for about 30 seconds. Staff reassured
him and kept him under observation. At about 8.50am, he vomited a small
amount of blood and was seen by a doctor. The record then indicates that
at 9.30am he vomited a small amount of partially digested food. By 10am,
he was described as incoherent, and at 11.30am he was drowsy and
vague. The man had also complained of a headache and stated that he
was feeling unwell. Investigations at Altcourse confirmed that he had not
taken any additional medication or illicit alcohol. (Whist he was in the
Healthcare Centre, the prisoner told a nurse that outside prison he was a
heavy drinker and that he had experienced similar episodes of fitting about
18 months previously.)
24. The medical record states that at 12.25pm, following observations and
abnormal test results, he was seen by the prison doctor who decided to
refer him as an emergency case to a local Hospital for further assessment.
25. At 2pm, the prisoner arrived at hospital under escort and handcuffed in line
with the prison’s security and operating procedures. He was seen by a
doctor at 2.15pm and was described as confused and with a high
temperature. The bedwatch log (an observation log completed by the
escort officers) states that, at about 3.10pm, he was becoming agitated,
distressed and delirious. The escort officers were concerned that he might
take out his frustrations on the medical staff.
26. At 4.09pm, the bedwatch log indicates that the escorting officers had to
restrain him as he was becoming very agitated and violent towards staff as
doctors were trying to treat him. At 4.40pm, he was seen by a doctor who
suspected that he might have an infection and that an x-ray and blood
tests were required.
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27. The prisoner needed intravenous treatment and accordingly his handcuffs
were removed. However, in light of his propensity for violence and his
behaviour towards staff earlier on, a third officer was deployed to help
supervise him. At about 6.17pm, the bedwatch log indicates that the
doctors treating the prisoner wanted to sedate him in preparation for a
brain scan. They were concerned at his abnormal blood test results which
indicated that there might be a problem with his heart. By 6.30pm, his
condition was deteriorating. One of the escorting staff contacted the
prison control room asking that his next of kin should be contacted in light
of his deteriorating condition. An entry in the bedwatch log indicates that
the prisoner’s condition might have been attributable to a head injury.
28. By 8.30pm, he was intubated, fully sedated and had undergone a chest x-
ray and other medical tests. An entry in the bedwatch log at 9.50pm
enquired whether his next of kin had been informed of his condition.
There was no evidence that this had been done in the prison records. My
investigator also found that the prisoner had told his escort officers that he
did not want his family told of his condition, although there was no
documentary evidence to support this. Since his death, Altcourse has
revised its documentation. This now prompts escorting officers to ask the
prisoner if they would like their next of kin to be informed in the event of
being kept in hospital, and to record the response
29. The prisoner remained fully sedated until 9.50am on 29 December. He
was then informed that he might have to undergo further neurological tests
in a Neurological Unit. At 3pm, he was transferred under escort to the
Neurological Unit where he had a brain scan. Following the scan he was
taken back to hospital. He was described by staff as fully compliant.
30. At 9.50am on 30 December, the bedwatch log entry indicates that the
scans on him were normal and that he was to be transferred to a normal
ward as a bed became available. At 4pm, he was seen by a doctor and
told that he would be in hospital for several more days. He had been
receiving antibiotic treatment. Whilst in hospital, the prisoner continued to
be handcuffed and supervised by two Prison Custody Officers.
31. By 1 January 2006, the bedwatch log indicates that he was becoming
increasingly frustrated at the lack of information from medical staff with
regard to his condition, although he remained compliant and raised no
concerns with his prison escorts.
32. On 3 January 2006, the prisoner was discharged from hospital and
returned to the Healthcare Centre at Altcourse. He had been diagnosed
as suffering from possible viral encephalitis (an infection in the brain) and
was due to be reviewed in three months time. His brain scan was normal.
It emerged during the investigation that following his discharge from the
hospital, although the prison received notification with detail of the
diagnosis, they did not receive a discharge letter which is used to
formulate an appropriate care plan. The Healthcare Manager stated that
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this was by no means unique to the prisoner’s case and that, despite
previous attempts to obtain discharge letters from the hospital through the
Primary Care Trust, a system for sending letters to the Healthcare Centre
had not been implemented. The Healthcare Manager and her staff were
frustrated by this. The clinical review concludes that this is a universal
problem, although healthcare staff would have been able to contact the
hospital at any time if they were concerned.
33. Whilst he was in healthcare, he told a nurse that he had no recollection of
the events leading up to his admission to hospital and stated that this was
not the first time that he had experienced a loss of memory. The nurse
recalled that he had told her that sometime in 2005, whilst outside prison,
he had collapsed at a bus stop and was taken to hospital. He described
the experience to the nurse as “a bit of a blitz” and had been told by
medical staff that he had fitted. She also told my investigator that the
prisoner was on a high dosage of Quetiapine. Because of this, his
medication was always double checked during its administration. The
nurse also said that, during her conversation with the prisoner, he had told
her that he had been assaulted by six police officers.
34. He did not suffer any further recurrence of fits and, having been assessed
by the prison doctor on 5 January, he was deemed fit to be moved back to
a normal residential location. The prisoner returned to the same cell on
the wing that he had been sharing with his cellmate. In a statement to
police following his death, the cellmate said that the prisoner was subdued
and complaining of headaches. The cellmate also said that the prisoner
attended the Healthcare Centre in order to receive his medication.
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Events from 7 January leading up to the prisoner’s death
35. The prisoner’s cellmate said that at about 11.30am on 7 January, he and
the prisoner were playing cards in the cell when the prisoner began to fit.
His eyes were rolling and he was coughing froth and some blood. The
cellmate alerted discipline staff who entered the cell. Healthcare staff
were then alerted and attended the cell within minutes. After attending to
the prisoner, staff noted in the medical record that he was uncoordinated
and unable to respond to various commands and was not aware of his
surroundings. It was also established that he had bitten his tongue whilst
fitting as there was some blood. In view of his previous medical history, he
was admitted to the Healthcare Centre once again and placed in a double
cell for further observation and assessment by the prison doctor. The cell
is located adjacent to the nurses’ office.
36. At about 9pm, the Nurse, the Healthcare Assistant, and Prison Custody
Officer had reported for night duty. A verbal handover between the day
and night staff had taken place and confirmed that the prisoner was back
in the Healthcare Centre following a fit earlier that day. The healthcare
staff were aware of the prisoner’s previous history of fitting. The nurse had
been told that he had been on association with other prisoners, had
watched television and played snooker. He had also collected his
medication between 6pm and 7pm. It was also reported by staff that he
had eaten very well that day, and given no cause for concern.
37. At 9pm, prisoners are locked up for the night. Each Prison Custody Officer
has a set of sealed keys, but cells must only be opened with the authority
of the Duty Operations Manager. (This procedure is designed to ensure
that security is not compromised during the night.)
38. During lock up, the nurse toured the Healthcare Centre and looked
through the door flap of each cell to assure herself that prisoners were
okay. The Healthcare Assistant had asked the prisoner to place his
mattress on the floor of his cell in order to prevent further physical injury
should he experience a fit during the night. The prisoner complied with the
request.
39. Staff told my investigator that regular observation of prisoners in
healthcare took place during the night, irrespective of whether prisoners
were on specific observation regimes to prevent self-harm. The nurse
stated that checks were cursory and consisted of approximately five
checks during the hour in which staff look through the cell door flap to
ensure that the prisoner is okay. Staff are not required to keep a record
unless the prisoner is subject to the formal suicide prevention regime. The
prisoner was not the subject on any formal observation regime and
consequently the checks on him were not recorded. However, the nurse
told my investigator that these quick checks on the prisoner did take place.
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40. Staff also told my investigator that during the night he was snoring loudly,
and that he gave them no cause for concern. At about 1.00am, the nurse
looked again into his cell and noted that he had just been to the toilet. The
prisoner was standing with hands on his hips and appeared to be stable
on his feet. The nurse asked if he was okay and she received an
affirmative response.
41. Later on in the night, the nurse noticed that he had stopped snoring loudly
and was maintaining a clear, nice and deep level of breathing. The nurse
stated that, in light of this change in his breathing pattern, she lowered the
flap to the cell door and left it open so she could hear any change in his
breathing pattern. Healthcare staff told my investigator that, at night time,
sounds resonate very clearly in the Healthcare Centre.
42. At approximately 3.45am, the nurse was in the nurse’s office opposite The
man’s’s cell. She said that she could not hear him breathing and walked
across to his cell to look through the open hatch of the door. The prisoner
was lying on his mattress. She noticed that his chest was raised and that
he might start fitting. After a few seconds of further observation, she then
saw that he was not breathing. The nurse shouted to the PCO and her
colleague, the Healthcare Assistant, who were nearby and requested
access to the cell immediately.
43. The PCO informed the Duty Operations Manager, that healthcare staff
needed access to the prisoner’s cell and that the sealed pouch containing
cell keys would need to be broken. The Duty Operations Manager who
was in the Care and Separation Unit at the time, conducting his routine
supervisory checks, told the PCO that he would make his way to the
Healthcare Centre in order to assess the situation. Whilst the Duty
Operations Manager was making his way to the Healthcare Centre, the
PCO unlocked the cell and entered it with Healthcare Assistant. The
nurse went to get the emergency bag. The prisoner was unconscious,
unresponsive and cyanosed [a blue colour to the skin]. He showed no
vital signs. His mattress was repositioned on the floor to allow for ease of
access and medical treatment. The Healthcare Assistant and the PCO
then began Cardio-Pulmonary Resuscitation (CPR).
44. The nurse returned to the cell in seconds with oxygen and a mask. She
told my investigator that the prisoner began to vomit and, as he was turned
on his side to obtain a clear airway, he suffered two large haematemasis
(vomiting blood from the stomach or oesophagus) that resembled ground
coffee.
45. Staff confirmed to my investigator that they were up to date in their CPR
training. They continued CPR until the paramedics arrived. The nurse
quickly put in an airway to administer oxygen. A defibulator was attached
to the prisoner that indicated to staff that CPR should continue.
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46. During the resuscitation attempt, the Duty Operations Manager arrived in
the cell and contacted the control room via radio to request an emergency
ambulance. As the Duty Operations Manager, he then left the wing to
open the prison for the paramedic team. He also contacted the Duty
Director, and informed him of the situation.
47. The ambulance was called at 3.50am, and paramedics arrived in the cell
at about 3.58pm to assist healthcare staff with resuscitation. CPR
continued for a further 15 minutes. The ambulance was parked on grass
close to the Healthcare Centre. Sadly, the efforts to resuscitate the
prisoner were not successful and he was pronounced dead at 4.15am.
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Events after the prisoner’s death
48. At about 4.25am, the Duty Director arrived in the prison and was briefed
on the events leading up to the prisoner’s death. Altcourse then followed
its contingency plan in the event of a death in custody. This included
informing the Prison Service’s National Operations Unit (NOU), the
Coroner, the prison’s Independent Monitoring Board, and the police. Staff
who dealt with the prisoner were also requested to complete
contemporaneous notes. They were offered support by the care team.
49. The incident log indicates that, following his death, the ambulance that had
been parked on grass outside the Healthcare Centre sank into the ground
and could not be moved. Later on that day it had to be towed away. In
the event, this did not have a direct effect on the prisoner’s treatment or
care, although it could have had serious consequences for him had he
been resuscitated and needed to be transferred to hospital. Manifestly, it
could also have serious consequences for other patients in the future.
50. Altcourse nominated a governor as the prison’s Family Liaison Officer.
The decision was taken for the liaison officer together with the chaplain, to
visit the prisoner’s mother’s address. The family was told of his death at
about 10.45am. The family are highly critical and suspicious that he died
as a result of the police having used excessive force in his arrest. It also
became clear that there was a long and acrimonious history between the
family and the Police in respect of a previous allegation of improper use of
force.
51. After the news of his death had been broken, the family went to view the
body at the hospital. They were accompanied and supported by the
prison’s family liaison officer and the prison chaplain.
52. The funeral took place in late January 2006. The prison offered and paid
the cost of the funeral. The chaplain attended the funeral as the
representative from Altcourse.
53. Altcourse has maintained contact with the prisoner’s family since his death
and have given family members the opportunity of visiting the
establishment. Arrangements were also in hand to ensure that his
property was returned to his family. The prison’s family liaison officer
endeavoured to answer any questions or concerns and the family have
been most appreciative of his efforts and the sensitivity of the prison in this
matter.
54. On 10 February 2006, my Family Liaison Officer and the investigator
visited the prisoner’s sister at her home address. It was clear that the
family remained deeply concerned and mistrustful of the way in which he
was arrested by police in December 2005. In conjunction with a previous
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incident involving the police, they believe that he may have sustained
injuries that could have contributed to his death. However, this issue is
outside the remit of this particular investigation and remains the subject of
a separate police inquiry.
55. The family also raised some issues in respect of the prisoner’s time at
Altcourse. First, the family wanted clarification on whether he was
receiving his medication for his mental health problems, and whether any
change in his medication was a factor in his untimely death. The family
was also concerned that he might have been discharged prematurely from
hospital and that, whilst in the care of the prison, normal and frequent
observations on him were not maintained. Lastly, the family wanted to
know whether he had been bullied whilst in prison and had therefore
sustained any further injury that caused him to suffer from fits. (My
investigator has found no evidence to suggest that the prisoner was
bullied.)
56. Staff who dealt with the prisoner were asked if they had received the
appropriate care and support following his death. Whilst most staff are
satisfied with the level of support they had been given, this was not
universal. My investigator established that a staff debrief for those
involved in the prisoner’s care had not taken place.
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Clinical review and post mortem
57. The clinical review undertaken by the North Liverpool Primary Care Trust
has determined that the man’s care appears to have been comprehensive
and thorough during his stay at Altcourse. His chronic and acute health
problems appear to have been managed in an appropriate and timely
manner. The review states that he received his anti-psychotic medication
from 19 December. He was also given Diazepam, prescribed for his
anxiety, although this was stopped two days after his arrival at Altcourse.
The review states that stopping this medication abruptly could have
lowered the threshold for seizures. However, it is noted that it was 10
days after this medication was stopped before he was observed fitting.
58. In regard to the prisoner’s discharge from hospital, the clinical review
states that this was reasonable, particularly as he was returning to a 24-
hour healthcare facility within the prison. The review highlights that no
formal discharge letter was received by prison healthcare and that this is
often the case. However, the review states that prison healthcare staff
would have been able to contact the hospital at any time if they were
concerned.
59. Following further observations where no further fits occurred, he was
deemed fit to return to a normal location. The review goes on to state that
whilst he was in the Healthcare Centre on the night preceding his death,
the man was observed at the appropriate frequency.
60. The clinical review notes that the prisoner had a previous history of fits
and, although these are recorded in his general practice notes, this does
not appear to have been investigated at any time prior to his detention at
Altcourse. As such, it is impossible to relate this to recent alleged
episodes of head injury. The clinical review concludes that the history of
fits should have been the subject of further investigation in primary or
community services. These issues are also subject to a separate, ongoing
investigation by the police.
61. A post mortem was carried out and extensive tests were made on the
prisoner’s brain at the request of the Coroner. However, the cause of
death is unascertained and will never be known.
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Issues considered during the investigation
The prisoner’s history of fits
62. The prisoner’s psychiatric history was noted when he entered Altcourse
and he continued to receive the appropriate anti-psychotic medication. It
was documented that he had suffered episodes of memory loss. He also
admitted to members of staff that he had suffered from fits in the past,
although this was not known to his family. The clinical review also notes
the history of fits, including a head injury following a fit in August 2005.
Although these are recorded in his general practice notes, this does not
appear to have been investigated at any time prior to his detention at
Altcourse.
63. The prisoner was prescribed Diazepam for anxiety although this was
stopped two days after his arrival in Altcourse. The clinical review states
that stopping this medication abruptly could have lowered his threshold for
seizures, although it was 10 days after this medication was stopped before
he was observed fitting.
64. The clinical review observes that the history of fits should have been the
subject of further investigation in primary or secondary services in the
community and is not a reflection on his care in prison. The prisoner’s
healthcare in the wider community is outside the scope of the
Ombudsman’s investigation.
65. The medical record does not show that the man entered prison with any
obvious physical injury, although he had told his cellmate and a nurse that
he had been assaulted by police during his arrest in December 2005 and
sustained a bang to his head.
Information sharing between the hospital and prison healthcare
66. On 3 January 2005, the prisoner was discharged from hospital back to the
Healthcare Centre at Altcourse. He had been diagnosed with possible
viral encephalitis and was due to be reviewed in hospital in a further three
months. However, during the investigation the Healthcare Manager was
concerned that a formal discharge letter was not received by Altcourse.
This would have been useful in confirming and determining an appropriate
and continuous plan of care for him. However, the clinical review
concludes that this did not contribute to the prisoner’s death, and it seems
to be a continuing source of frustration to healthcare staff when they refer
a prisoner for treatment to an outside hospital.
The Director and the Healthcare Manager should continue their
efforts with the North, South and Central Liverpool Primary Care
Trust to ensure that formal discharge letters are received every time
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a prisoner returns from hospital, to ensure continuity of treatment
and the formulation of an appropriate care plan.
Emergency access
67. In the event, the ambulance was not required to take the prisoner to
hospital. However, the vehicle had been parked on soft ground outside
the Healthcare Centre and became bogged down in the ground. Although
this did not have a bearing on the events surrounding the death of this
man the inability to transfer a patient to hospital for immediate and
potentially life-saving treatment could have serious consequences in
similar circumstances. (Or could have done in this instance, had he been
resuscitated.)
The Director should ensure that staff direct ambulances attending
the establishment to an appropriate hard standing in order to prevent
vehicles from becoming bogged down in soft ground.
Alleged injuries sustained during arrest
68. Although the prisoner had stated during his medical screen that he had
received an injury to his head during his arrest in December, the post
mortem indicated that this was not a contributory factor to his death.
However, he had also sustained a fractured skull and other injuries in
October 2003 during a previous arrest. In view of this, the Coroner had
requested further tests on the prisoner’s brain in order to determine
whether this could have been a cause of death. However, following
investigations the cause of death will remain unknown. The circumstances
of his arrest in October 2003 are being investigated as a civil complaint by
the family against the Police.
Post incident de-brief
69. The investigation highlighted the need to provide adequate debriefing to
staff following a death in custody in line with Prison Service Order 2710.
This enables timely discussion and early identification of potential learning
opportunities.
The Director should remind senior colleagues of the importance of a
timely formal debrief of key staff following a death in custody or
other serious incident.
Family liaison
70. It was clear that Altcourse has dealt with the man’s family in a very
sensitive and compassionate way, and has provided both comfort and
reassurance to the family during a traumatic time. The efforts of the
prison’s Family Liaison Officer, should be highlighted as an example of
good practice.
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The Director should commend the Family Liaison Officer, for the way
in which he broke the news of the death of the prisoner to his next of
kin and the high level of sensitivity, professionalism and compassion
that has been displayed and commented on by members of the
family since his death.
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Recommendations and good practice
1. The Director and the Healthcare Manager should continue their
efforts with the North, South and Central Liverpool Primary Care
Trust to ensure that formal discharge letters are received every time
a prisoner returns from hospital to ensure continuity of treatment
and the formulation of an appropriate care plan.
2. The Director should ensure that staff direct ambulances attending
the establishment to an appropriate hard standing in order to prevent
vehicles from becoming bogged down in soft ground.
3. The Director should remind senior colleagues of the importance of a
timely formal debrief of key staff following a death in custody or
other serious incident.
4. The Director should commend the Family Liaison Officer, for the way
in which he broke the news of the death of the prisoner to his next of
kin and the high level of sensitivity, professionalism and compassion
that has been displayed and commented on by members of the
family since his death.
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