Individual at Belmarsh

Investigation into the circumstances surrounding the death
of a man at HMP Belmarsh in September 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2007
The man had been remanded in custody for just over two weeks when he died in
September 2005.
Upon arriving in prison, he underwent a detoxification programme and was prescribed
several medications. He also took Warfarin to thin his blood when he was in prison.
The clinical reviewers consider that insufficient attention was paid to managing his use
of Warfarin within clinical guidelines.
The clinical review has concluded that the man’s death was the result of care and drugs
errors, along with inappropriate clinical management. It is suggested that there was an
imbalance between the attention paid to his drug problems and his general physical
health - with the greater emphasis being placed on his drug addiction.
The aim of my investigation was to discover whether the level of care provided by the
prison was appropriate, and whether any lessons could be learnt to help prevent a
similar death in the future. My investigation found several areas where practice could
be improved and I made a number of recommendations all of which were accepted.
Recommendations
1. Clinical management guidelines for patients on Warfarin therapy should be
urgently developed and training to health care staff given in them.
2. All patients arriving at HMP Belmarsh and reporting using complex or
potentially lethal drug therapies should be managed according to accepted
best practice and monitored as if starting these medications for the first
time. A list of suitable medications to be included within this plan should
be agreed by HMP Belmarsh Clinical Governance Committee.
3. A strategy and action plan for developing, adopting and implementing
evidence based clinical guidelines across all the activities of prison
healthcare should be written and actioned as part of the clinical
governance strategy and action plan.
4. Training in record keeping standards expected at the prison should be
made mandatory for all Healthcare staff, including the contracted GPs.
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