Individual at Birmingham

Investigation into the circumstances surrounding the
death of a prisoner at
HMP Birmingham, in June 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
November 2006
This is the report of an investigation into the circumstances of the death of a prisoner
in June 2006. The post mortem report indicates that the man suffered a heart
attack. At the time of his death, he was a prisoner at HMP Birmingham, having been
remanded there on 10 May following a failure to surrender to bail. He was aged 60.
The man who died collapsed during a meeting with his legal representative late in
May, and was taken to hospital by emergency ambulance. He had a family history of
heart disease, and had suffered a heart attack three years earlier. I would like to
extend my condolences to his family and friends for their unexpected and sad loss.
The investigation was carried out on my behalf by my colleague. A family liaison
officer provided liaison with the man’s family. In addition, an independent review into
his medical care and treatment was undertaken by a doctor on behalf of the Heart of
Birmingham Primary Care Trust (PCT). I am most grateful for his assistance. I am
also grateful to the Governor and staff of Birmingham for their ready co-operation
with this investigation.
This report makes two recommendations, both concerned with clinical matters. The
first relates to the way in which new prisoners with long term ill health should be
managed. The second refers to contacting prisoners’ GPs if they present with a
history of chronic illness.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2006
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CONTENTS PAGE
Summary 4
The investigation process 5
The man 6
HMP Birmingham 7
Key findings 8
Issues 10
Recommendations 11
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SUMMARY
The man who died was remanded to HMP Birmingham on 10 May 2006, having
failed to answer to bail. He had not been in prison before, but went though the usual
first night in custody procedures without reporting any concerns to staff. He was not
receiving any medication or other treatment, but did tell healthcare staff that he had
had a heart attack three years previously.
Once settled on the wing, the man did not make any close friends and was described
by staff as someone who kept himself to himself. He spoke briefly to his cell mate,
telling him he had lost his family and his home and felt he had nothing to live for.
The man was seen by healthcare staff on 15 May, when it was discovered he had
not been eating his meals. He explained to the doctor that he had nothing to live for
and was intent on starving himself to death. For this reason, he was then placed on
self harm monitoring procedures. On 24 May, following a period when staff reported
an improvement in his mood and condition, he was removed from this enhanced
monitoring.
A few days later, the man had a meeting with his solicitor. During the meeting, he
complained of pains in his chest. The solicitor put the man in the recovery position
and called for staff help. A nurse from healthcare soon arrived and an ambulance
was requested which took him to the hospital. The man died there early the next
morning.
The clinical review shows that the man’s history of coronary heart disease was
identified on his arrival at HMP Birmingham and during his subsequent General
Health Assessment in the Well Man Clinic. However, he was not receiving any
continuing care for his condition and he had said that he did not want any member of
the healthcare team to contact his GP regarding his health.
The post mortem shows that the man died from a heart attack.
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THE INVESTIGATION PROCESS
1. This investigation was formally opened on 6 June 2006 when one of my
investigators issued notices to staff and prisoners at HMP Birmingham. The
notices invited anyone who might have information relating to the man who
died to make themselves known. As a result, the man’s cell mate contacted
the investigator, and we were subsequently able to speak to him as part of our
enquiries.
2. My investigator visited Birmingham prison on 27 June 2006. She met the
Head of Safer Custody. She also met with a representative from the Prison
Officers’ Association (POA) and the Independent Monitoring Board (IMB) to
explain how the investigation would be carried out. During this visit, she
collected copies of the man’s prison files, including his main prison record, his
medical records and statements from prison staff, and was briefed about the
circumstances surrounding his death.
3. The Heart of Birmingham Primary Care Trust identified a doctor to lead a
review of the man’s clinical care. I am grateful to him for producing his report
in a timely manner.
4. 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. My investigator has also spoken to the
man’s solicitor and to a Detective Constable at the West Midlands Police.
5. One of my Family Liaison Officers contacted the man’s family to inform them
of this investigation and to provide an opportunity to contribute. They did not
wish to be involved and raised no concerns about the care he had received.
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THE MAN
6. The man who died was born in January 1946 in Stafford. On reception at
HMP Birmingham, he reported that he had been married for 30 years and had
two children. However, he explained that he had separated from his wife and,
as a consequence, he had been homeless for a time.
7. The man reported a history of heart problems in his family, and indeed that he
had suffered a heart attack some three years earlier. However, he said he
was not currently receiving any treatment.
8. He had not previously been involved with the criminal justice system until his
arrest on 10 May 2006, following a failure to attend court while on bail.
9. In prison, the man who died kept himself to himself. He did not come out of
his cell to work, attend education or association. At first, he had been
withdrawn and did not eat his meals, telling a doctor in healthcare that he had
nothing to live for, having lost his family and his home. However, he later
reported that he would ‘give things time to settle down’, and then try to contact
his wife through his solicitor.
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HMP BIRMINGHAM
10. Birmingham is a local prison for adult male prisoners. It serves the Crown and
Magistrates' Courts of Birmingham, Stafford and Wolverhampton and several
Magistrates' Courts in the surrounding areas. The prison has recently
undergone a period of considerable change as a result of a multi-million
pound investment programme. Some 450 additional prisoner places have
been provided, together with new workshops, educational facilities, a new
healthcare centre and gymnasium, as well as extensions and improvements to
existing facilities.
11. The provision of healthcare within the prison is the commissioning
responsibility of the Heart of Birmingham Primary Care Trust. Primary
care clinics are delivered by GPs and visiting consultants. The
healthcare centre has the opportunity to draw upon the broader expertise and
range of healthcare services at the local City Hospital. The primary healthcare
team comprises doctors, nurses and healthcare assistants. There is an in-
patient facility, which is staffed by registered mental health nurses and a
healthcare assistant during the day, and a trained nurse and a healthcare
assistant at night. They provide care for patients with primary mental health
needs and those with primary physical health needs, requiring 24 hour nursing
care.
12. The prison was last inspected by HM Chief Inspector of Prisons in May 2004.
Her unannounced inspection found that Birmingham had improved in all four
key areas that the Inspectorate assesses: safety, respect, purposeful activity
and resettlement. However, some areas for development were identified,
particularly the relationships between staff working in different parts of the
prison. For example, work between healthcare and wing staff needed to
become more joined up.
13. The man’s death is the tenth death (the seventh from apparently natural
causes) to have occurred at Birmingham since April 2004 when my office
became responsible for the investigations. I have identified no common
themes between this investigation and the other nine.
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KEY FINDINGS
14. The man who died was remanded to Birmingham prison on 10 May 2006,
having failed to surrender to bail. He arrived at the prison at 5.12 pm. On his
Personal Escort Record (PER), the medical box is highlighted - indicating that
this was an area of concern. Staff noted that he had had a heart attack three
years previously. It is also recorded on this form that the man had refused his
lunch. A Cell Sharing Risk Assessment was carried out on reception. This
concluded that he was not a risk to himself or to others and was suitable for
shared accommodation.
15. His First Reception Health Screen remarks that the man had been registered
with a doctor in the community, but had not visited him in the months before
he came into Birmingham prison. He told staff that he had been homeless for
a few months, and confirmed that he did not have any outstanding hospital or
GP appointments, was not receiving any prescription medication, and had no
history of recent physical injury. The man said that he had not been in prison
before. As there were no health problems, he was admitted directly to D wing.
16. On 11 May, he was seen by a nurse who carried out a more general health
assessment. At this point, the man said he did not want his medical
information to be shared with anyone, and declined consent to contact with his
own GP for his past medical history. However, he again reported that he had
a heart attack about three years earlier. When asked about his current
situation, he said he did not have any concerns about his health at present.
17. The man was seen by a doctor on 15 May, following the discovery that he had
not been eating his meals. The doctor recorded that there was no history of
psychiatric ill health, and the man appeared neat, engaged well and was
pleasant. At this consultation, he told the doctor that he had no reason to live
any more. He said he had lost his wife, family and home, and was committed
to starving himself to death. The doctor recorded that he discussed this with
the man, who was fully aware of the implications of his actions and who said
he was not happy with the idea of medical intervention if he became physically
unwell. The doctor recommended that the man be placed on the self harm
monitoring procedures (Assessment, Care in Custody & Teamwork – ACCT),
on a constant watch.
18. The ACCT observations started immediately. A senior officer met with the
man and conducted a thorough interview with him. At the end of the interview,
the senior officer and the man agreed a plan of his care.
19. Several further reviews of the man’s position were conducted. These were
well documented and show that he was able to speak to staff about his
concerns and to obtain practical help with some of the issues that were
troubling him. The ACCT observation entries were also thorough and indicate
a high level of staff interaction.
20. The next day (16 May), the man was again seen by the same doctor. He said
that he had changed his mind about starving himself to death, and said he
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would not contemplate suicide as he was not a violent man and believed
suicide to be a violent act. He also reported that he intended to let things
settle down, and perhaps approach his wife, through his solicitor, in a few
months’ time. Although this seemed positive, the doctor noted that staff
needed to be cautious of the reasons for such a sudden change in the man’s
resolve and the constant observations were to continue. He also suggested
some psychiatric input if the man was willing to consider this. On 24 May,
following a period of observation during which time the man’s mood and
condition seemed improved, the ACCT document was closed.
21. Another prisoner shared a cell with the man for a few weeks. He told my
investigator that the man did not leave his cell for anything except to collect
his meals. He said he did not seem to bother with anything - he did not go to
work or education and he did not seem to be interested in life. The man who
died had told him that he had nothing to live for now; his cell mate said that he
seemed totally “shut down”. He said that he knew that the man had previously
not eaten for five days. However, he said that he was eating when they
shared a cell - albeit very little. On the morning of his legal visit, the man’s cell
mate said that the man seemed his normal self, but felt he would have been
worried. When he spoke to the investigator, the cell mate said he was in the
same position as the man who died. He had spoken to him about that and
urged him to think positively about things. However, he was not sure whether
the man was able to do this.
22. The man’s solicitor, visited him as previously arranged. She said when she
went into the visits area she was told by one of the officers that the man was
not feeling very well. As she approached him, she asked him what was the
matter and he told her he had pain in his chest, and pins and needles in his
arm. She said she was concerned and told the officer she thought the man
might be having a heart attack, and asked that a doctor should be called.
Staff told her that the doctor would not be in the prison until 9.00 am, but a
member of healthcare had been contacted and was on the way. She then
returned to the man, who was seated in a chair holding his chest. She
suggested he might be more comfortable lying down, and she helped him get
into the recovery position.
23. A senior officer was in charge of visits that morning. He said that at about
8:00 am he was told by an officer that the man was having chest pains, and
that his solicitor was with him and had put him into the recovery position. The
senior officer said he called for medical assistance and informed the duty
governor over the radio about what was happening. The control room log
times the call at 8.20 am. The senior officer said he then helped to get the
man comfortable and, sensing the urgency of the situation, contacted the duty
governor again to say that he was calling an ambulance. He said the
response nurse soon arrived, as did the duty governor, and they took over the
situation.
24. The nurse who was the emergency response nurse that morning had been
called to attend ‘Legal Visits’ immediately. When she arrived, she found the
man who died lying on his right side. He told her he had a left sided chest
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pain and a numb left arm. She also noted he was of a poor colour. She gave
him oxygen and sprayed glyceryl trinitrate (GTN), a treatment that relieves the
symptoms of angina, under his tongue. After checking he was not allergic,
she also gave him 300mg of aspirin. The nurse explained that the man said
he had suffered a heart attack five years previously. She said that, whilst he
was still experiencing pain, he told her that it was not getting any worse. She
also requested a blue light ambulance. Records show that the ambulance
was called at 8:25am, arrived at 8:35am, and departed the prison at 8:58am.
25. At about 11.30 am, the nurse spoke to the staff nurse at the local hospital and
was advised that the man was being assessed by medical staff.
26. Staff who accompanied the man to the hospital contacted the control room at
9:45pm that evening. They reported that there was no improvement in his
condition and he remained on life support. At 12:50am, they contacted the
control room again, informing them that the man’s kidneys had failed. At
4:00am, a senior officer contacted control again to say that the man had died.
27. At 4:01am, the control room log shows that the contingency plans for a death
in custody were activated and followed appropriately. The relevant people
were contacted and informed and the staff involved were debriefed and
supported.
28. Following the man’s death, the police informed his family. The Governor
visited the family on the same day. He provided contact numbers for himself,
other governors at the prison, and the chaplain. He also explained the
procedures that would now take place, including this investigation. On 14
June, the Governor visited the family again to return his belongings and
personal effects.
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ISSUES
The man’s medical care
29. The clinical reviewer makes detailed observations on the man’s medical care
and I endorse the recommendations arising from his report.
30. It is evident that in the short time the man was at Birmingham he was, in the
main, appropriately cared for. However, his history of a previous heart attack
and strong history of family heart problems should have triggered a routine
referral to a doctor after his initial General Health Assessment.
Where new receptions are identified as having any long-term ill health at
their initial health screen or general health assessment, arrangements
should be made for the prisoner to be seen by a member of the GP team
at the next available appointment. A policy for the clinical management
of such prisoners should be developed in agreement with the Prison
Clinical Governance Committee.
31. I note that the man did not give consent for his GP in the community to be
contacted. Nonetheless, I agree with the clinical reviewer and believe there
should be consideration for some system whereby a prisoner’s previous
medical history can be made available to prison medical staff. As the man
who died was not apparently receiving any treatment for heart disease, and
said he was not on prescribed medication, it seems that healthcare staff felt
there was no need for any further action.
Where a prisoner is identified on reception or in the Well Man Clinic as
having a long-term illness, but is not receiving any care or treatment for
that illness, the prisoner’s registered GP should be contacted and care
needs discussed, subject to prisoner consent. The consent procedure
should be reviewed and amended as appropriate to ensure that this
functions effectively.
32. The man had a condition that could have become acute at any time. I am
satisfied that, when he experienced pain just before he died, staff were
alerted, a member of healthcare was quickly summoned, and an ambulance
was called soon afterwards. It is unlikely that assistance could have come
any quicker had the man not been in prison. Indeed, it could well have taken
longer.
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RECOMMENDATIONS
1. Where new receptions are identified as having any long-term ill health at their
initial health screen or general health assessment, arrangements should be
made for the prisoner to be seen by a member of the GP team at the next
available appointment. A policy for the clinical management of such prisoners
should be developed in agreement with the Prison Clinical Governance
Committee.
2. Where a prisoner is identified on reception or in the Well Man Clinic as having
a long-term illness, but is not receiving any care or treatment for that illness,
the prisoner’s registered GP should be contacted and care needs discussed,
subject to prisoner consent. The consent procedure should be reviewed and
amended as appropriate to ensures that this functions effectively.
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