Individual at Belmarsh

INVESTIGATION INTO THE DEATH OF A MAN
AT A HOSPITAL ON 1 APRIL 2006,
WHILST IN CUSTODY AT HMP BELMARSH
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN
FOR ENGLAND AND WALES
October 2006
This is the report of an investigation into the circumstances of the death of a man.
He died at a hospital in London on Saturday 1 April at 9.30am. At the time of his
death, he was a sentenced prisoner at HMP Belmarsh and was aged 48 years.
I offer my condolences to those touched by this man’s passing.
A post mortem was carried out by a Home Office forensic pathologist on 3 April. The
pathologist concluded that death was due to: (1a) Intracerebral Haemorrhage, and
(2) Hypertensive Heart Disease and Diabetes Mellitus.
This investigation was carried out by one of my colleagues. A clinical review was also
commissioned to examine the medical care and treatment this man received at
Belmarsh. This has been carried out by the Head of Clinical Governance at
Greenwich Primary Care Trust, to whom I am most grateful.
I would also like to take this opportunity to thank the Governor of Belmarsh and her
staff for their full co-operation and assistance with this investigation.
Finally, I would also like to place on record my thanks and appreciation for the
dedication shown by prison staff in attempting to locate this man’s relatives. Sadly,
despite their efforts and those of police, no family member has been traced.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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Contents
Introduction
Summary
Investigation Process
HMP Belmarsh
The deceased
Events leading to the man being taken into hospital.
Conclusions
Recommendations and Good Practice
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Summary
The man arrived into custody on remand in July 2004. He had previous convictions
and had served other custodial sentences. He was sentenced in December 2004 to
five years imprisonment.
Whilst in HMP Belmarsh, he was located in the healthcare centre due to his complex
medical history. He suffered from renal and liver failure along with cardiac problems.
He required out patient appointments three times a week to receive dialysis. On
reception at Belmarsh, he also admitted to having a substance misuse problem and
underwent a methadone detoxification.
This man’s health deteriorated over the following two years. He was reliant on a
wheelchair, and needed oxygen day and night. He had several admissions as an
inpatient to hospital for recognised complications with his dialysis.
On 31 March 2006, he attended hospital as usual for his dialysis. On his return to
the prison, nothing abnormal was noted. However, during the night it became
apparent that this man was not well. Staff sought advice from the on call doctor and
manager. A 999 call was put out for an ambulance to attend the prison.
The man was taken as an emergency to a nearby hospital by a blue lighted
ambulance. On arrival he was seen and admitted. A bedwatch log was then started.
His prognosis was poor.
The following morning, after the consultant’s ward round, a decision was made to
turn off his life support. He died at 9.25am on Saturday 1 April.
No next of kin have been identified for this man. A solicitor has been the point of
contact.
The Prisons and Probation Ombudsman’s office was notified of the man’s death on 7
April. The delay in notification appears to have been an oversight by the National
Operations Unit, as the Incident Reporting System was up to date and the relevant
details were sent on the day he died.
I make five recommendations in this report and identify three examples of good
practice.
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Investigation Process
This investigation was opened on 12 April 2006, when two of my colleagues visited
Belmarsh and met with a member of staff from the secretariat office. She handed
over the man’s prison documents including his medical records. Original copies of
Notices to the Governor, staff and prisoners were given to her. These notices were
displayed around the prison. No members of the Prison Officers’ Association (POA)
or the Independent Monitoring Board (IMB) were present or had expressed a wish to
see my investigators.
My investigators were taken to the healthcare centre and shown around. They also
visited the cell that the man had occupied. No formal interviews were carried out
during this investigation.
A clinical review was undertaken by the Head of Clinical Governance and a medical
reviewer from Greenwich Primary Care Trust (PCT). The reviewers ascertained the
level of care given to this man whilst he was in Belmarsh. They also examined the
medical records, the quality of the entries made within them and any other matter
relating to his care.
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HMP Belmarsh
Belmarsh is a high security local prison which became operational on 2 April 1991.
The healthcare centre offers facilities for inpatients and outpatient clinics, and has a
purpose built therapy unit. The centre has an operational capacity of 32 beds, mainly
used for psychiatric care. There is also an Intensive care suite and special
observation room, both of which are single occupancy. The accommodation consists
of 20 single cells and 12 ward spaces. A clinical manager heads the staff
complement which comprises nursing grades, healthcare officers, discipline officers
and nursing assistants in conjunction with the psychiatric team. Outpatients facilities
include daily GP clinics and nurse led clinics (asthma, coronary care, diabetes, HIV,
hepatitis). All new patients receive a comprehensive health screen.
Healthcare is provided by officers and nurses employed by the Prison Service. GP
services are provided by Thamesmead Medical Associates (TMA) under a contract
arrangement with the prison, and psychiatric services are provided by Oxleas NHS
Trust.
Ms Anne Owers, Her Majesty’s Chief Inspector of Prisons, reported in an
unannounced follow up inspection of October 2005:
“Most of our 2003 recommendations about healthcare had not been addressed,
although prisoner perceptions about the quality of healthcare and the service from
doctors had improved. There was a very limited regime for inpatients, who had poor
access to regular exercise and limited association opportunities.”
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The man
The man was born on 29 April 1957 in Bulawayo, Zimbabwe. He was 48 years old
when he died. He was a keen artist and had decorated the healthcare centre with
some of his work.
He had been in custody since July 2004, first on remand then as a convicted
prisoner. He was sentenced on 16 December 2004 to five years imprisonment. He
had served two previous custodial sentences in Zimbabwe in 1975 and 1981. He
came to London in 1988, under an alias.. He served further custodial sentences in
1996 and 1998.
By the time of his reception to Belmarsh, he was already receiving dialysis three
times a week for chronic kidney failure in a hospital with appropriate facilities. In
addition, he had poor cardiac function and a past history of hepatitis C. He spent his
time in Belmarsh located in the healthcare centre. On his visits to hospital, he was
escorted by prison staff. On several occasions, he had been an inpatient at hospital
due to his complex medical history.
The chaplain at Belmarsh visited the man on a weekly basis. It appears that he had
no contact with any family. No family member was listed on his prison records, and
he received no visits and made no telephone calls of a personal nature whilst in
prison.
The chaplain believes that the man had been married in Zimbabwe and had a
daughter. The marriage ended and the man came to London. It is not known if he
ever divorced. After his arrival in London, he had another relationship and another
daughter. It is thought that the child was adopted.
Since his death, a firm of solicitors in London have been the point of contact. To
date, no family members have been identified. This apparently is in accordance with
the man’s own wishes.
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Events leading to the man’s death
The man was arrested on 19 July 2004 and held in police custody at Kentish Town
before being remanded to HMP Belmarsh. Whilst in police custody, he was seen
and assessed by a forensic medical examiner (FME). The FME recorded that he
suffered from liver failure, hepatitis C and congestive cardiac failure (CCF). He was
being cared for as an out patient at a London hospital (under the care of a consultant
nephrologist), where he received dialysis three times a week.
The man arrived at Belmarsh as a remand prisoner on 20 July 2004. Due to his
complex medical history, he was located in the healthcare centre. He was seen and
assessed on his arrival where the doctor noted that he suffered from liver and renal
failure. It was also noted that the man received dialysis on Monday, Wednesday and
Friday of each week. He also required the use of oxygen day and night.
He smoked, and was encouraged to reduce the amount of tobacco he consumed,
especially whilst receiving his oxygen. His first visit to hospital for dialysis occurred
the day after his arrival at Belmarsh On his return, his condition was recorded as
satisfactory.
Whilst in Belmarsh he commenced a methadone detoxification programme on 22
July. On his first reception health screen, he admitted to previously being an
intravenous drug user and currently abusing methadone. There was no history
recorded of self harm or mental health issues.
However, on 27 July a Form 2052SH (self harm monitoring form) was opened on
him. An officer was concerned after a search of the man’s property. During this
search, the officer came across a letter that stated “if things don’t improve I will ease
the pressures myself”. This letter was assessed in conjunction with the fact that, if
convicted, he would be facing a lengthy sentence. When the man was asked about
this, he said that he would “speak to his solicitors to ease the pressures”. The
F2052SH form remained open until 7 September 2004. Throughout that time there
were no incidences of self harm, and the man maintained that was never his
intention.
Over the next two years, he remained on the healthcare centre at Belmarsh. He
received his dialysis three times a week. The level of escort changed over a period
of time. Initially, it was felt that restraints should be used for public protection. During
the last months of his life, he attended a London hospital under escort but without the
use of restraints. It was felt that this was appropriate due to his poor prognosis and
his failing health which required him to resort eventually to using a wheelchair.
The man was a quiet prisoner who kept himself to himself; on the whole he did not
cause the staff any concern. A care package was in place to assist him with daily
routines, for example cleaning his cell and attending to his personal hygiene.
He had several admissions to hospital for short periods and these were due to
infections in his Hickman line (a fine plastic canula inserted into a vein to allow
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administration of drugs). Infections are a recognised complication of these lines.
The man was usually noted as being compliant with his medication. Over a period of
time his health deteriorated and his care plans were adjusted accordingly. Towards
the end of his life, he was extremely poorly.
On Friday 31 March 2006, this man attended the hospital for dialysis. His weight was
recorded as 60.9kgs pre-dialysis. Apart from complaining about toothache, there
was nothing abnormal noted about him on his return from hospital..
During a night time check at 11.15pm, the man complained of left sided numbness
and appeared distressed. When asked if he was in pain he said “no” but his
reactions indicated something different. His observations (pulse and blood pressure)
were taken. The prison’s on call doctor, was contacted, and the advice given was
that he should be taken to the Accident and Emergency Department at a nearby
hospital.
An entry to reflect the above was recorded in the healthcare centre’s observation
book: “Whilst doing intermittent watch on prisoner he was seen to be unwell. He was
unlocked so staff could check on him. Obs were done and duty doctor and manager
were called. Blue light ambulance called and prisoner has been taken to A&E.” This
entry was written by an officer.
The incident log sheet shows that at 11.51pm the ambulance was called. It arrived at
midnight and left for the hospital at 00.29am. At approximately 1am, a nurse
assessed the prisoner and stated that he would be admitted.
In attendance were two Officers. They commenced a bedwatch log. The man
Was in restraints at this time but they were removed at the request of a doctor at
2.45am. A call was made to inform the prison that this was the case. At 4.20am, he
went for a CT scan. He was then moved to the ITU (intensive care unit). The
prognosis was not good and he was expected to die. The restraints were never
reapplied. Another officer took over the bedwatch at 9am after being briefed by the
night staff.
On the morning ward round made by the consultant, the decision was made to turn
off his life support. The man passed away at 9.30am.
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Issues
Was the man appropriately screened on reception to Belmarsh?
The clinical reviewer has concluded that there are inappropriate entries made within
the initial medical screening form. Under the section “record any health related
observations about the prisoner’s physical appearance’’ the words “appears a
physical wreck!” have been written. The reviewer finds that this entry, along with
others, is unhelpful, inappropriate and insulting and suggests that the prison takes a
trivial approach to health screening. It is recorded that the man was receiving weekly
dialysis and medication at a London hospital. He was appropriately placed within the
healthcare centre. There was regular dialogue between the prison and the hospital
where he had been receiving dialysis to ensure that his medical needs were met.
Did the man receive quality physical care?
The clinical review concludes that histories were taken from the man to establish the
nature of his many health problems. The medical records contain evidence of a
caring approach by prison staff and the visiting GP service. Regular appointments
with secondary care were kept up during the man’s confinement at Belmarsh so that
appropriate care could be provided.
Did the man receive equitable healthcare?
The clinical reviewer finds that the care provided to the man was equitable with the
care that might have been provided had he not been a prisoner.
Conclusions
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Bedwatch Entries
This bedwatch ran for approximately 9 hours in total. The entries in the log are to
relay information about the prisoner from staff to staff. They should be decent and
respectful of the patient. All of the entries complied with the instructions given to
officers.
Use of Restraints
The man had been attending hospital for over two years. He had not been in
restraints for some time due to his ill health. I therefore question the use and
necessity of the restraints used to convey him to the Accident and Emergency
Department on 31 March (they were removed after two hours or so at the request of
the hospital doctors) However, it must be appreciated that the Orderly Officer
(person in charge of the prison at night with limited staff on duty) made a decision in
difficult circumstances and without prior knowledge of this man. I accept that his
decision was appropriate in the light of the limited information he had at the time.
Record Keeping.
There was regular communication between the hospital where the man received
dialysis and Belmarsh relating to the man and the care he required. His medical
records were kept up to date, although names are not printed alongside the
signatures of medical staff as they should be. The clinical review concludes that the
standard of record keeping was not acceptable. I would also suggest that the
Governor, in conjunction with the PCT, considers the prospects for computerising
medical records as this is becoming more and more the norm.
Recommendations
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• The Governor should remind all healthcare staff that entries in a prisoner’s
medical record must be signed and accompanied by the author’s name in
print.
• I and the clinical reviewer would urge the Governor to think about the
implementation of computerised medical records. They would be especially
useful for a man like this who had such complex medical issues over a long
period of time. They also allay any problems with identifying staff and reading
entries that are not clear.
• The Governor should remind healthcare staff that use of inappropriate
language is unacceptable. Entries in medical records should not be of a
degrading or flippant nature.
• It is regrettable that this man was restrained on his final journey to hospital
when more humane arrangements had already been in operation for several
months. I recommend a review of relevant procedures in the healthcare
centre with a view to ensuring that decisions about the use (and non-use) of
restraints are consistent.
• I endorse the clinical reviewer’s recommendation regarding dialysis. The
Governor and PCT should consider the benefits of “Home dialysis” on an
individual basis for all prisoners requiring dialysis treatments.
Good Practice
• Healthcare staff at Belmarsh managed this man’s complex medical issues with
patience and sensitivity.
• Communications between the hospital and prison health services seem to
have been appropriate and are well documented. There is evidence of regular
and ongoing correspondence between the services involved to ensure
effective and safe treatment.
• There is evidence that this man’s death was anticipated and that he had joined
in discussions about dying with his GP at the prison and the chaplain.
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