Individual at Altcourse

Investigation into the death of a man, who was a
prisoner at HMP Altcourse, on 8 July 2005
Report by the Prisons and Probation ombudsman for
England and Wales
December 2005
This is the report of an investigation into the death of a man who died from
apparent natural causes on 8 July 2005 at HMP Altcourse. He was 28 years
old.
The man had been convicted on 24 May 2005 and sentenced to four months
imprisonment. It was his first conviction and his first experience of prison life.
This investigation has been undertaken by one of my investigators. I would
like to thank the Director of HMP Altcourse and his staff for their participation
in the investigation. The North Liverpool Primary Care Trust commissioned
two doctors to undertake a review of the man’s clinical care, and I appreciate
their assistance.
The loss of a loved one is always distressing and especially so in this case as
the man was due to be released the day that he died, and his girlfriend was
expecting their first child. I would like to add my personal condolences to
those already expressed by my Family Liaison Officer on behalf of this office.
Whilst I do not feel anything could have been done to prevent the man's
death, there are lessons to be learnt in the clinical management of patients in
prison. I endorse the four recommendations made in the clinical review.
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.
Stephen Shaw CBE
Prisons and Probation Ombudsman December 2005
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CONTENTS
Summary 3
The investigation process 4
Background 5
HMP Altcourse 6
Key findings 7
Issues raised by the family 9
Clinical review 11
Recommendations 12
ANNEXES
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Summary
1. The man was born in 1976 and was 28 years old when he died on 8 July
2005.
2. The man arrived at HMP Altcourse on 24 May 2005. He was received into
custody after being sentenced to four months imprisonment. At his first
reception health screen, it was noted that the man had taken a drug
overdose the previous year at a difficult time in his life, and that he had
previously used heroin. The man was due to be released on 8 July. He
was going to return to his mother’s house on Home Detention Curfew.
3. At 7:15am on 8 July, the man’s cell mate returned from breakfast. He was
unable to wake the man and informed staff. A Prisoner Custody Officer
entered the man’s cell and, as he also could not get a response from the
man, immediately summoned medical assistance.
4. Healthcare staff arrived at the man’s cell at 7:20am. They first moved the
man off his bed to the cell floor, before moving him on to the landing in
order to make a full assessment of his needs. As they were moving the
man out on to the landing, the prison doctor arrived. After a further
assessment, at 7:36am he declared that the man had died.
5. The clinical review noted that, although the man’s care was appropriate,
there appeared to be information which was not recorded in the man’s
medical records. The reviewers also concluded that the man’s care whilst
in prison could have been managed more efficiently.
6. On 15 August, one of my Family Liaison Officers contacted The man’s
family. Their concerns centred on the cause of the man’s death and the
possible implications for his children if it was a hereditary condition.
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The investigation process
7. My investigator studied all relevant prison records relating to the man.
These included his main prison record, his medical record and statements
from prison staff.
8. A clinical review was commissioned from North Liverpool Primary Care
Trust. I am grateful to the clinical reviewers for undertaking this review in
a most timely manner.
9. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner to
assist him in his enquiries into the man’s death.
10.One of my Family Liaison Officers contacted the man’s family who told her
of their concerns. These centred on the origins of the condition which
resulted in the man’s death. They enquired whether:
i the condition could have been identified beforehand;
ii it was a hereditary condition, and if his children were at risk;
iii it was caused by manipulation of The man’s neck after a recent
sports injury;
iv it was caused by a surgical procedure when he was a baby;
v The man was in the top bunk and if he had fallen out of the
bunk.
I hope the report provides the family with answers to their questions.
11.My investigator discussed aspects of the man’s treatment and the issues
raised by his family with both staff at Altcourse and Ms Whitby. The
clinical review found that, although the man’s clinical care was appropriate,
there were issues with the recording of information about medical
interventions in this case. I make a recommendation concerning this.
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Background
12.The man was born in the north of England in 1976. He was one of three
children. He had a brother and a sister.
13.The man had been married and was the father to three children, two boys
and a girl. His girlfriend was pregnant and was going for a pre­natal scan
of their baby on the day that he died.
14.The man had several jobs but found it difficult to settle in employment as
he got bored very easily. He had wanted to join the army but failed the
medical due to raised blood pressure and an enlarged kidney. He was,
however, allowed to join the Territorial Army. The man was a big football
fan and loved Liverpool Football Club.
15.The man had a history of minor offences and it was a culmination of these
that led to him being given a short custodial sentence. The man was due
to be released on 8 July on Home Detention Curfew to his mother’s
address.
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HMP Altcourse
16.Altcourse opened in 1997 and is a privately managed prison run by Global
Solutions Ltd (GSL). It has an operational capacity (maximum crowded
capacity) of 1,010. The prison has six main houseblocks, each divided
into two units. Approximately a third of the prisoners are on remand and
the remainder convicted and sentenced or awaiting sentence. The full
facilities and regime of the prison are available to all prisoners.
17.After the evening roll call which is held at 9:00pm to confirmall prisoners
are accounted for, the prison enters what is called patrol state. This is
defined as ‘Prisoners are locked up and staff numbers are reduced to the
minimum needed to patrol. The main role of staff at this time is to maintain
the security of the prison.’
18.When the Night patrol arrives on the wing a hand­over is given by the
officer on evening duty and a sealed packet containing keys is given to the
Night patrol officer. The keys in the sealed packet are only to be opened in
an emergency. When the Officer who is on duty during the next day
arrives, they are given a hand­over from the Night patrol officer and a roll
check is carried out before the Night patrol officer is relieved and leaves
the wing.
19.From when Altcourse opened until 31 January 2005, Primecare Forensic
Medical provided the healthcare service. On 1 February, the contract for
healthcare services was transferred to a new provider, Veritas Limited.
The healthcare unit can accommodate 32 prisoners and offers a range of
primary care services.
20.Her Majesty’s Chief Inspector of Prisons (HMCIP) carried out an
announced inspection of Altcourse in February 2005. Her report described
Altcourse as a safe prison with good interaction between staff and
prisoners.
21.There have been five deaths at Altcourse since the beginning of this year
– two from natural causes and four apparently self­inflicted deaths.
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Key Findings
22.The man arrived at Altcourse on 24 May 2005 and was allocated a cell on
the Furlong residential unit, which is the induction and detoxification unit.
During his initial health screen interview, it was noted that the man had
recently seen a doctor concerning addiction to heroin. The man requested
detoxification (reduction or removal of the toxic properties of a drug) as he
had previously been receiving prescribed medication (Subutex) to help him
with his withdrawal from heroin. The man also told staff that he had
previously taken an overdose and, as he later threatened to harm himself,
he was placed on an open Suicide and Self Harm (SASH) observation
regime.
23.On 26 May, the man was admitted to healthcare for observation because
of chest pain, shortness of breath and high blood pressure. He also told
staff that he had a pre­existing heart condition, a hole in the heart. The
man’s blood pressure subsequently settled and he was discharged from
the health care centre the following day. On 1 June, The man’s blood
pressure was checked and it was noted that it was no longer high.
24.The SASH observation regime was closed on 2 June after a multi­
disciplinary case review decided that The man was no longer at risk of
self­harm.
25.On 22 June, the man reported to healthcare due to a football injury. On
examination, there was found to be limited movement in his neck. The
man’s blood pressure was checked again and the reading was high. The
man was admitted to healthcare the following day for bed rest and
observation. The man then requested to return to the Furlong unit. There
was no plan for further monitoring of his condition, and there was no
further review of his blood pressure.
26.On 25 June, the man told staff that he had a headache and was given
paracetamol.
27.On 28 June, a prison doctor saw the man as his neck was still painful. He
advised the man to keep it mobilised.
28.On 8 July at 7:15am, the man’s cellmate returned from breakfast to their
cell in the Furlong unit. The cellmate found the man still in bed and, as he
could not rouse him, he informed prison staff. A Prisoner Custody Officer
entered the man’s cell. He also failed to get a response from the man and
immediately summoned urgent assistance via his radio.
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29.Prison medical staff responded to the request for medical assistance and
arrived at the man’s cell within five minutes. They initially moved the man
off his bed to the cell floor. As the man had no pulse and was not
breathing, they decided to move him to the landing, which had been
cleared of prisoners, so that a full assessment of his needs could be
carried out. It was at this point that the prison doctor arrived at the cell. At
7:36am, the prison doctor certified that the man had died. The man was
then returned to his cell which was secured.
30.The Duty Director and a representative from the prison’s Chaplaincy
contacted the man’s family to inform them of his death and to offer their
condolences and support.
31.The Chaplaincy maintained contact with the family and offered to assist
with arranging the funeral and providing financial help. The family were
invited to visit the prison to see the man’s cell. While they were in the
prison, the family also met the man’s cellmate. The man’s family told my
Family Liaison Officer that they felt that the prison had handled these
matters sensitively. I am pleased to share that commendation more widely
through the medium of this report.
32.From comments made by staff at Altcourse, it seems that the man was a
respected and well liked prisoner. This was demonstrated by the fact that
£400 was collected by the prisoners on his wing after his death, and also
from the letters of support received by the man’s family.
33.The post mortem states that the cause of death was due to natural causes
as a consequence of a subarachnoid haemorrhage and a ruptured
intracranial aneurysm (a ruptured artery in the brain).
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Issues raised by the family
34.The man’s family asked whether the cause of his death was a condition
that could have been identified beforehand. The Clinical Reviewer stated
that the man received appropriate care following his presentation to
healthcare staff. In retrospect, the reviewer stated that it would have been
difficult for the healthcare team to link the symptoms and signs with which
the man presented, namely headache and raised blood pressure, to what
turned out to be the actual cause of death.
35.The family stated that the man suffered from migraine and wondered if
this was connected to his cause of death. The Clinical Reviewer stated
that the man did not tell healthcare staff that he suffered from migraines,
and that he was treated appropriately when he said that he had a
headache. The reviewer added that headaches may or may not have
been relevant to the cause of death but this would be impossible to
determine.
36.The family pointed out that the man’s aunt died of the same condition and
asked whether it is hereditary as his children may be at risk. The reviewer
stated that this condition can be hereditary and recommended that the
family seek guidance from their family doctor on this matter.
37.The man had told his mother in a telephone call that he had hurt his neck
playing football a couple of weeks prior to his death, and had reported it to
medical staff who said they would manipulate his neck. The family
wanted to know if the manipulation could be linked to his death. The
reviewer stated that the man’s football injury was treated and monitored
appropriately. The reviewer added that there was nothing in the clinical
records to suggest that the man’s neck had been manipulated, although
he was advised to keep his neck mobilised.
38.When the family visited the prison, the man’s cellmate had asked the
family if the man’s death could have been caused by a knock to his head
during the football game when he injured his neck. The clinical records
confirm that the man did sustain an injury following a football game.
However, it is impossible to determine whether this is directly linked to his
cause of death.
39.The family also asked whether it was possible that having a drip put into
his head when he was a baby could have had any impact on his death.
The reviewer stated that there was no evidence that this had any bearing
at all.
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40.The family also asked whether the man had fallen out of his bed. My
investigator noted that, although the man did occupy the upper bunk in his
cell, there was no evidence that he fell out of his bed. I do not think his
death was attributable to falling from height.
41.My investigator also noted that Altcourse were in the process of fitting all
upper bunks with top railings to prevent accidental falls before the man’s
death.
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Clinical Review
42.The clinical review concluded that, although the man’s care was
appropriate, there appeared to be information that had not been properly
recorded in the man’s medical records.
43.During the First Reception Health Screen, the man reported no significant
concerns in relation to his physical health. On 26 May 2005, the man was
admitted to the healthcare centre because of chest pain, shortness of
breath and high blood pressure. The plan was to monitor the cause and
effect of the chest pain and to relieve the pain with effective interventions.
Observations were to be carried out half hourly. On the same day, he
received a once only prescription for Atenolol. The man’s blood pressure
subsequently settled and he was discharged from the healthcare centre
the day after.
44.The man’s blood pressure was checked again on two further occasions on
1 June and 22 June; the latter reading was elevated. No plan for further
monitoring was apparent. The man then sought medical assistance on 25
June with a headache and was given paracetamol. His blood pressure
was not reviewed at this time. Differential diagnosis does not appear to
have been illustrated in relation to the man’s chest pain.
45.No entries in the clinical notes were signed and some entries were difficult
to read.
46.The reviewer also drew attention to issues concerning the management of
The man’s care. These included:
i. the absence of a differential diagnosis, which is a list of the
possible diagnoses for symptoms and signs, from which the
correct diagnosis can be extracted after further investigation;
ii. recording blood pressure monitoring in cases where it is
indicated;
iii. better maintenance of medical records.
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Recommendations
Healthcare
I accept the recommendations of the clinical review, which are summarised
as:
1 The standards in relation to clinical records should be reviewed,
particularly the legibility and signing of some individual entries.
2 The RMN progress notes should be amended to include space to
record the date.
3 Care should be taken to record all blood pressure monitoring.
4 A differential diagnosis should be carried out and recorded in the
clinical notes.
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