Individual at Birmingham

Investigation into the circumstances surrounding the
death of a prisoner at City Hospital, Birmingham while in
the custody of HMP Birmingham in December 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2008
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This is the report of an investigation into the death of a prisoner at HMP Birmingham
who died at City Hospital, Birminghamin December 2007. The man who died was
70 years old. Sadly, no family or friends were identified, despite efforts by the prison
and other agencies to trace them.
One of my investigators conducted the investigation on my behalf. In addition,
Birmingham Teaching Primary Care Trust was asked to provide a clinical review into
the man’s care whilst in custody.
I would like to thank the Governor of Birmingham, and his staff for their co­operation
and assistance with the investigation. I am particularly indebted to the Safer
Custody Governor at Birmingham, who ensured the relevant documentation was
made available to my investigator.
The man had been in custody for less than two months when he died. He had
already been admitted once to City Hospital for a short period when, in early
December 2007, he collapsed in the shower room. Other prisoners alerted staff who
responded quickly. The staff worked hard to resuscitate himand by the time
paramedics arrived, they had managed to get him breathing again. He went to City
Hospital where his condition was considered to be critical. He remained in the
intensive care unit until mid December when he was considered well enough to be
moved to the coronary care unit. Medical staff continued to monitor himclosely and,
in view of his improvement, the hospital made enquiries about him returning to the
prison’s healthcare wing. However, at the end of December, the man suffered a
further cardiac arrest and, despite the best efforts of medical staff, he failed to
respond to treatment and was declared dead at 3.42am.
The man was handcuffed during his initial period in hospital. The handcuffs were
removed when his condition deteriorated and he became immobile. However, once
he improved and was mobile again, restraints (an escort chain) were re­applied and
remained in place until his death. Management checks and risk assessments had
been conducted regularly. In response to my recommendation in a previous report
about strengthening the guidelines regarding prisoners who are gravely ill or dying,
the Prison Service has revised its guidance to take account of the needs of such
prisoners. I therefore make no further recommendation on this point in this report.
However, I have made a recommendation and highlighted good practice in relation
to electronic medical records. I would also like publicly to acknowledge the great
professionalism shown by those prison and healthcare staff who responded to the
man in early December 2007, and the sensitive way in which his funeral was
organised.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2008
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CONTENTS
Summary 4
The investigation process 5
HMP Birmingham 7
Key findings 8
Issues 12
Recommendation and good practice 14
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SUMMARY
The man was remanded into custody at HMP Birminghamin November 2007. On
his reception into custody, he had a routine health screen. Following this, a more in­
depth assessment of his medical condition was conducted. During these health
screenings, it became apparent that he was not a healthy man. He had a history of
chronic illness as well as of heavy drinking.
Staff recorded on reception documents that the man lived a transient lifestyle and
had moved around the country frequently in recent years. At the time of his remand,
he was of no fixed abode. Following his death, this made tracing a next of kin
impossible for the prison and other agencies despite various attempts to do so.
He was admitted to outside hospital in November after experiencing chest pains. He
remained in hospital for four days during which time tests were carried out. The
cardiology department gave himadvice about his heart condition and possible
medical interventions before he was discharged.
On a morning in early December, the man attended G wing for association and took
a shower there. He had just finished and was drying himself when he collapsed.
Other prisoners who were in the area at the time immediately notified staff who were
quick to respond. It was clear that he was not breathing and officers began cardio
pulmonary resuscitation (CPR). Nursing staff and other staff were quickly in
attendance and medical intervention continued. The man’s heart stopped ten times
before the arrival of paramedics. Through the efforts of staff, paramedics were able
to stabilise himbefore taking him to City Hospital, Birmingham.
He remained in intensive care where his prognosis was considered to be poor.
However, after around three weeks, his condition began to improve. The
improvements continued to the point where in late December the hospital was in
discussion with the prison about himreturning to the prison’s healthcare wing.
Unfortunately, the man suffered a heart attack the following day which was so severe
that medical staff decided that it was not in his interests to continue resuscitation.
As noted, the prison was unable to identify any family or friends. The Governor
therefore assumed responsibility for the funeral arrangements and he was given a
respectful and decent funeral.
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INVESTIGATION PROCESS
1. My investigator conducted the investigation on my behalf. In February 2008, he
contacted Birmingham’s appointed liaison officer, the Safer Custody Manager.
The Governor and the Safer Custody Manager provided the man’s prison
records for examination, including his medical record. Notices were issued to
staff and prisoners to inform them of the investigation process and to give them
the opportunity to speak with my investigator. No responses were received.
2. I asked Birmingham Teaching Primary Care Trust to conduct a clinical review
into the medical care the man received while in custody, in accordance with my
Terms of Reference.
3. The prison made enquiries in order to trace a next of kin but no one was
identified. There were also attempts by other external agencies to trace family,
again with no success.
4. The investigator wrote to HM Coroner to inform him of the nature and scope of
the investigation.
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HMP BIRMINGHAM
5. HMP Birmingham is a local prison for adult male offenders, holding up to 1,450
prisoners. It has recently undergone a programme of refurbishment that has
provided new workshops, educational facilities, a new healthcare centre and
gymnasium. Improvements to existing facilities have also been made.
6. Heart of Birmingham Primary Care Trust (PCT) is responsible for the delivery of
healthcare. General Practitioners (GPs) deliver primary care clinics. The
inpatient facility is staffed by registered nurses, mental health nurses and
discipline officers during the day, and a nurse and discipline officer at night.
7. Since I took over responsibility for investigations into all deaths in prison
custody in April 2004, there have been seven previous deaths at Birmingham
from natural causes.
8. An announced inspection by HM Chief Inspector of Prisons, Ms Anne Owers,
was carried out in February 2007. The inspection concluded that:
"Birmingham was suffering from many of the pressures of an
overcrowded prison system. Those pressures made it much more
difficult to deliver safe, decent and purposeful outcomes for prisoners.
It was a credit to staff and managers that the prison remained a much
better place than it had been in 2000, and the scale of the task should
not be underestimated. But this inspection found that the prison was
not responding sufficiently proactively and robustly to the challenges it
now faced, and indeed that some of the old culture was now
reasserting itself. We do not underestimate the difficulty of sustaining
progress, with increased pressures and increased expectations of
delivery. The fact that Birmingham was not performing sufficiently well
against three of our four key tests is a measure of the challenge facing
its managers.”
9. The Independent Monitoring Board (IMB) at Birmingham published their 2007
annual report in which they said of A wing and G wing where the man who died
was housed for part of the time:
“A wing houses 147 prisoners, consisting mainly of those on remand or
awaiting trial. Because of its proximity to G wing (Vulnerable
Prisoners), A2 is used as an overspill area for Rule 45 prisoners. This
is unsatisfactory, as the prisoners suffer from being part of the regime
on neither wing. They are regarded as ‘separate’ on A wing and have
to be kept apart from normal A wing residents because of verbal
taunting and threats from other prisoners.
“On G wing, where most of their regime should take place, they are
again, because they have no base there, regarded as ‘separate’.
Efforts are continually being made to resolve the situation.”
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KEY FINDINGS
Events leading up to the man’s death
10. The man was remanded into custody to HMP Birmingham on a charge of
burglary in November 2007. A nurse saw him on his reception to complete a
health screen. During the screen, it was established that he had a history of
chronic illness and was taking a combination of medicines to manage this.
When asked about his alcohol consumption, he indicated that he had been a
heavy drinker prior to coming into custody and a referral was made for him to
be seen by the doctor. The prison GP saw him later that day and prescribed
medication to help with his alcohol detoxification. The GP also diagnosed him
as having Type 2 diabetes mellitus, chronic obstructive pulmonary disease
(COPD), essential hypertension and alcohol dependence syndrome. The
following day, he was seen in the Well Man Clinic and a more in­depth
assessment of his medical history and condition was completed. The man told
nursing staff that he had a history of heart disease and in October had
undergone an angiogram (this is a technique where x rays are used to examine
blood vessels in any part of the body and is very useful for diagnosing heart
problems).
11. The man was located on D wing. Due to the state of his health, medical staff
decided that he should be ‘located flat’ (this is a term used in prisons to
describe someone who requires a cell on the ground floor), and the induction
process was started. During his induction, he told staff that he had been
released from custody in Liverpool within the previous six months and that he
had been in custody at least ten times before. There were no other significant
points raised during the induction and he was moved to K wing. The day after
he arrived onto K wing, the man asked to be placed on Rule 45. (This is a Rule
whereby prisoners who feel vulnerable either because of the nature of their
offence or other reasons can be separated from the rest of the prison
population.) However, following a discussion with staff, he opted to remain on
ordinary location.
12. In mid­November, the man told staff that he had fallen off a chair in his cell
during the night and had hurt his back. An officer therefore took him to be seen
by a nurse. He told the nurse that he had fallen against the toilet. On
examination, he had redness to his upper back and pain. The nurse gave him
paracetomol and told him to come back if the pain persisted. After two days he
was still experiencing backache and was prescribed more paracetomol as he
said it had worked previously. An appointment was also made for himto be
reviewed by a nurse after the weekend.
13. The following day, a nurse went to see himon the wing as he was complaining
of chest pains. The nurse checked his blood pressure and provided him with a
saline nebuliser (a machine that creates a mist of medicine, that is then
breathed in through a mask or mouthpiece). A referral was also made for him
to be seen by the doctor that afternoon. Around lunchtime, after complaining of
continuing chest pain, the man again saw a nurse who took his blood pressure.
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14. The prison GP saw himin the afternoon and recorded that he had been having
chest pain for two hours prior to her examination. The doctor decided to
transfer himto the healthcare centre for 24­hour observations. However, due
to continuing pain and given his previous medical history, the man was taken to
the local hospital. Following an examination, he was admitted and placed in
the care of a consultant. Tests were carried out and a course of warfarin (an
anticoagulant medication) was started. The Cardiology Department advised
the man that he should consider having a coronary artery bypass graft (CABG)
and he said he wanted to think about it.
15. He returned to the prison after a few days. On his return, he again requested to
be placed on Rule 45. He believed that he was at risk from prisoners to whom
he owed money outside of prison. A governor interviewed himand, after
listening to his reasons for the request, the decision was taken for the man to
be placed on Rule 45. Normally prisoners requesting Rule 45 are located on G
wing but, when no spaces are available, A wing is used as an overflow. While
segregated on Rule 45, the man was located on A wing and attended G wing
for exercise and association.
16. At the start of December, the man went to G wing for association. While he
was there, he took a shower. Other prisoners using the shower at the time
recalled seeing him. They said that he had just finished his shower and was in
the process of drying himself when he collapsed onto the floor. The other
prisoners then immediately alerted staff who were out on the landing.
17. Staff responded immediately and found himlying on the floor of the shower
recess. There was a cut to the back of his head that appeared to have been
sustained in the initial fall, and he was bleeding heavily. On examination, it
became apparent that he was not breathing. The staff proceeded to administer
cardio pulmonary resuscitation (CPR), with officers giving mouth to mouth and
other officers performing chest compressions. Officers made a request for
nursing staff to attend and also for additional staff support to look after the other
prisoners who were out on association. The staff attending to the man
managed to get him breathing again and placed him in the recovery position.
18. Once informed, the nursing staff were quickly in attendance. Nurse 1 collected
emergency equipment from the office on G wing and requested an ambulance.
Nurse 2, who had attended with Nurse 1, checked the man and found that he
had stopped breathing again and that no pulse could be detected.
19. Other staff had arrived to assist the nurses and CPR resumed with Nurse 2
being assisted by four officers. Nurse 1 had collected a defibrillator and this
was connected to the man. The defibrillator assessed himautomatically and
delivered five shocks at regular intervals. By the time the ambulance staff
arrived, nurses and officers giving first aid had resuscitated the man ten times
although he remained unconscious. The determination and success of staff in
administering first aid made it possible for ambulance staff to stabilise him
before taking himto City Hospital.
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20. On arrival at hospital, the man was taken immediately into the resuscitation
room. Medical staff found that he had arrested again on arrival at the hospital
and proceeded to attempt resuscitation. The man had to be resuscitated a
further five times before he was eventually stabilised. The doctor attending to
himdecided, along with the other medical staff, that resuscitation would not be
attempted if he arrested again as it was considered not to be in his best
interests.
21. Hospital records show that on his admission he was suffering from ischaemic
heart disease and chronic obstructive pulmonary disease (COPD). Once his
condition had stabilised, the man was moved to the intensive care unit (ICU).
22. During the afternoon, the man was taken for x­rays. He was also seen by a
heart specialist, who told the escort staff that he would require surgery at some
point. However, this depended on his condition improving. Due to the man’s
condition, the staffing on the bed watch was reduced to one officer and
restraints (handcuffs) were not applied.
23. The prison contacted the ICU the following day to obtain an update on the
man’s condition. The GP from the prison, who made the call, was informed that
he had suffered a severe myocardial infarction (heart attack). As a result he
was being ventilated and given medication to support his heart. The prognosis
given by the hospital was poor. Despite this, plans were in place for himto be
operated on if his condition stabilised.
24. Over the next couple of days, there was no significant change in the man’s
condition which was described as ‘stable’. He remained unconscious and
heavily sedated. Nursing staff continued to monitor him closely. They informed
prison staff that the plan was to take himoff the ventilator to see if he could
breath unaided which would increase his chances of survival.
25. At around 6.30am on the fourth day, the man woke up for a few minutes. This
was the first time that he had been conscious since being admitted, and he was
able to respond to questions by nodding his head. Nurses attending to him
made plans to remove the breathing tubes later that day as he was now able to
breathe unaided.
26. Throughout the morning, he drifted in and out of consciousness. A consultant
informed the escorting officer that he considered the man’s condition to be
improving. The consultant and a physiotherapist examined him. The breathing
tube was removed and as the day progressed he became more alert and
talkative. Another consultant informed himthat he had suffered a heart attack
and that he might need surgery in a few days to clear blocked arteries.
27. During that afternoon, he was able to get out of bed and sit in a chair. This
surprised hospital staff. The escorting officer kept the prison updated on the
man’s condition and improvement. A management check by the prison was
carried out later that day. The manager who conducted it concluded that as he
remained immobile there was no increase in risk. As a result, the escort
remained at one officer to be kept under daily review.
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28. With the continued improvement in the man’s condition, a review of the risk
assessment the following day increased the bed watch to two officers.
However, he remained free of restraints to enable medical attention to be
unhindered. The man had developed a chest infection and this was causing
him some breathing difficulties. For this reason, escort staff were informed that
he would remain in the ICU for the time being.
29. He remained there for a further week before being moved to the coronary care
ward. The escort staff notified the prison and arrangements were made for the
risk assessment to be reviewed in relation to restraints. The day after arriving
on the ward, in line with the outcome of the new risk assessment, an escort
chain was applied to him. He had no concerns about this and remained
talkative with both hospital and prison staff.
30. Over the next week, with the help of the physiotherapist, the man’s mobility
continued to improve but he still was experiencing breathing difficulties. After
three days, arrangements were made for him to be given a full body scan to
determine whether a pacemaker (a medical device to regulate the beating of
the heart) needed to be fitted. However, as he was experiencing a lot of pain,
this and a follow up treatment planned for the following day had to be
cancelled.
31. Over the following week, the man continued to receive treatment for the pain
and wheezing in his chest and made good progress. He was also seen by the
physiotherapist to continue work on his mobility. In late December, a Senior
Nurse recorded that the man would be returning to the prison’s healthcare wing
on the following Monday.
32. However, the next day, the man suffered a further cardiac arrest. Medical staff
attempted to resuscitate him without success. In view of his previous cardiac
arrest and other medical history, the team decided that it was not in his best
interests to continue resuscitation. The Senior Registrar, declared the man
dead at 3.42am. He had remained in restraints (the escort chain) up to the
point of his death.
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ISSUES
Healthcare
33. It was discovered on the man’s reception into Birmingham that he was not in
very good health and the necessary follow up appointments were scheduled.
In November, when the man informed staff that he had fallen in his cell, he was
again seen by medical staff. The follow up care that he received and the earlier
information that had been recorded meant that he was referred quickly to
outside hospital when his symptoms persisted. I consider that this
demonstrates the benefits of both sharing information and recording it correctly.
The clinical reviewer has also recognised this and says:
Healthcare interventions delivered at HMP Birmingham were well
documented on the electronic medical records system (EMIS).
The clinical review highlights this as an area of good practice which I endorse.
34. Contact between the prison and the hospital following the man’s admission in
December was not regular or at least not recorded as such. The clinical review
says that his medical record does not demonstrate that contact with the hospital
occurred consistently between him being admitted and the man’s death. The
clinical reviewer makes the following recommendation, which I endorse:
All EMIS entries need to have the time logged consistently to facilitate the
establishment of a timeline between episodes of healthcare interventions.
More robust systems need to be established to ensure that regular
updates are ascertained from external agents delivering healthcare to
prisoners of HMP Birmingham.
Staff intervention
35. Following the man’s collapse, both discipline and healthcare staff acted quickly
and professionally to assist him. They worked tirelessly to keep his heart going
until the arrival of the ambulance staff. These actions enabled the paramedics
to stabilise himbefore transferring him to hospital. Although the onus was on
response staff to maintain resuscitation until paramedics arrived, for the staff
involved in this case it must have been particularly traumatic and exhausting.
The man was bleeding quite heavily and his heart stopped ten times. I am
aware that the staff involved have already been commended for their actions. I
share that view of their actions and would ask the Governor to share my
observations with his staff.
Actions after the man’s death
36. The man had no identifiable next of kin. Therefore, the prison made
arrangements for his funeral which was attended by members of the senior
management team and chaplaincy. There is no national guidance on prisoners
like this man where there are no family contacts. In spite of this, staff at
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Birmingham, most notably the Safer Custody Governor, ensured he had a
respectful and decent funeral. Although a rare occurrence, it might benefit
prisons were Headquarters to consider issuing guidance for local contingency
plans where a prisoner has no identifiable next of kin. Acting without the
benefit of such guidance, I commend the way in which this was handled by
HMP Birmingham.
Use of restraints
37. The balance between public protection and the compassionate management of
seriously ill or dying prisoners is a difficult one to strike and one that I frequently
address in my reports. In four recent reports on deaths of prisoners from
Birmingham, Gartree, Maidstone and Norwich, I have been critical of the lack of
flexibility in local policies on bed watches. There are, of course, many factors
to consider when arranging a bed watch. I also appreciate they require
discretionary judgements. In this case, the management checks and risk
assessment reviews were carried out frequently and in accordance with the
National Security Framework (NSF) guidelines. I also acknowledge that there
were times when his condition appeared to be improving significantly.
38. In addressing these matters in earlier reports, I have suggested that
consideration be given to incorporating into the NSF explicit instructions on how
to deal with gravely ill or dying prisoners in outside clinical environments. The
Prison Service accepted this recommendation. In addition, a review of the use
of restraints on hospital escorts and bed watches has been undertaken
following the case of ‘G’ in the High Court in November 2007. The policies
within the NSF have been amended to take account of prisoners who are
seriously or terminally ill, and the sensitive nature of balancing their changing
physical condition against the need to provide the public with adequate
protection. The revised guidance was to be issued to all Governors during
February 2008. In view of this, I make no further recommendation on this point.
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RECOMMENDATION
All EMIS entries need to have the time logged consistently to facilitate the
establishment of a timeline between episodes of healthcare interventions.
More robust systems need to be established to ensure that regular updates are
ascertained from external agents delivering healthcare to prisoners of HMP
Birmingham.
GOOD PRACTICE
Healthcare interventions delivered at HMP Birmingham were well documented
on the electronic medical records system (EMIS)
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