Individual at Birmingham

Investigation into the circumstances surrounding the
death of a man at HMP Birmingham in March 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
September 2006
This is the report of an investigation into the death of a man who died from
apparent natural causes on 9 March 2006 at HMP Birmingham. He was 64
years old.
I would like to add my personal condolences to those already expressed by
one of my Family Liaison Officers on behalf of this office.
The investigation was undertaken by one of my investigators. I would like to
thank the Governor of HMP Birmingham and his staff for their active
participation and assistance during the investigation.
Two members of staff were identified by the Heart of Birmingham Primary
Care Trust to undertake reviews of the man’s clinical care, and I also
appreciate their assistance.
The principal clinical reviewer raises no concerns about the level of care that
the man received, but makes a number of recommendations about recording
and sharing information. I endorse all those recommendations.
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 September 2006
1
CONTENTS
Summary 3
The investigation process 4
HMP Birmingham 5
Key findings 6
Clinical Review 8
Issues raised by the man’s family 11
Conclusions 12
Recommendations 13
2
SUMMARY
1. The man was born in 1941. He was 64 years old when he died in
Birmingham prison on 9 March 2006.
2. The man had been received into custody after being sentenced to five
years imprisonment for firearm offences. He arrived at HMP Birmingham
on 3 February 2006. During his first health screen, it was noted that the
man had chronic obstructive pulmonary disease and severe asthma.
3. On 14 February, the man was taken to a local hospital. On 20 February,
following an outbreak of diarrhoea and vomiting on the wards near to
where he was staying, the man was discharged from hospital and returned
to Birmingham prison. On the following day, the man was moved to the
healthcare wing.
4. During the early hours on 9 March, the man complained to staff of being
breathless. He was given a nebuliser at 2:00am and 4:00am, and staff
carried out regular checks on the man throughout the night. When
healthcare staff checked on the man at around 7:30am on 9 March, he
was again short of breath and distressed. After healthcare staff entered
the man’s cell, he collapsed onto the floor. An ambulance was called and
staff immediately commenced cardio pulmonary resuscitation (CPR).
5. The prison’s medical officer and the ambulance crew arrived at the man’s
cell at the same time. The paramedics took an electro cardiogram (ECG)
which indicated that the man’s heart had stopped beating. Consequently,
there were no further attempts to resuscitate the man and he was
pronounced dead by the prison doctor at 8:16am.
6. The principal clinical review concludes that the man’s clinical care was,
overall, of an appropriate standard. However, it highlights a number of
areas where improvements could be made to systems of recording and
sharing information. The review makes ten recommendations, all of which
I endorse.
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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 records and
statements from prison staff.
8. Heart of Birmingham Primary Care Trust identified two staff to carry out
reviews of the man’s clinical care. I am grateful that these reviews have
been undertaken 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 met with the man’s family in the
company of my investigator. The family told them of their concerns which
are considered later in this report. I hope what I have written and the
contents of the clinical review will provide them with answers to some of
their questions.
11. My investigator discussed aspects of the man’s treatment with staff at
Birmingham prison and with the principal clinical reviewer.
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HMP BIRMINGHAM
12. Birmingham is a local prison for adult male prisoners. It serves the Crown
and Magistrates' Courts of Birmingham, Stafford and Wolverhampton and
the Magistrates' Courts of Burton, Cannock, Litchfield, Rugeley, Sutton
Coldfield and Tamworth.
13. The prison has recently undergone a period of considerable change as a
result of a multi-million pound investment programme by the Prison
Service. Some 450 additional prisoner places have been added together
with new workshops, educational facilities, a new healthcare centre and
gymnasium as well as extensions and improvements to existing facilities.
The prison is now well resourced and equipped to provide for its
population of around 1,450.
14. The provision of healthcare within the prison is the 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 hospital. The healthcare team comprises
doctors, nurses and healthcare assistants. Medication is administered on
a weekly and/or monthly basis to those prisoners who have been
assessed as capable of holding it in their own possession. It is
administered on a daily basis to other prisoners, when either they are
considered to be at risk or the medication is unsuitable to be held in their
cell.
15. There is an in patient ward where all cells have integral sanitation. The
ward is staffed by registered mental health nurses who provide care for
patients with mental health needs and those with physical needs requiring
24 hour nursing presence.
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KEY FINDINGS
16. The man arrived at Birmingham on 3 February 2006. During his health
screen it was noted that he had chronic obstructive pulmonary disease
(COPD) and severe asthma. The man asked to see a doctor during his
health screen. The prison doctor assessed the man as being fit for normal
cell location and sharing a cell but stipulated that, for medical reasons, he
should be accommodated on one of the lower levels
17. During the evening on 13 February, the man was short of breath and
healthcare staff were called to his cell. He was given oxygen and an
appointment slip to see the prison doctor the following day.
18. During the early hours of the following morning, staff were again called to
the man’s cell. The man was complaining of chest pains and shortness of
breath. When treatment did not alleviate the man’s symptoms, he was
immediately referred to the local hospital. After the man arrived at
hospital, he collapsed and had to be resuscitated. When healthcare staff
contacted the hospital at 9:10am on 14 February they were told that the
man was sedated, ventilated and had been prescribed medication to
stabilise his blood pressure. The man’s condition was described as critical
and it was noted that he was being kept in the Intensive Care Unit (ICU).
19. The man remained in ICU until 18 February when he moved onto a
general ward. Once the man’s condition improved, the security risk
assessment identified that a closeting (escort) chain should be used. This
was entirely appropriate and enabled the nursing staff to have easy
access when they carried out their duties. Whilst the man was a patient at
the hospital, a bedwatch was carried out by prison officers.
20. The discharge letter of 20 February indicates that the man had recovered
well. He was prescribed a nebuliser for 24 hours and then “discharged to
inhalers”. As there was also an outbreak of diarrhoea and vomiting (D&V)
on nearby wards, it was felt to be in the man’s interest to return him to
prison. A non-smoking cell was recommended. On the following day, the
man was moved to the healthcare wing.
21. Entries in the nursing record indicate that the man settled back into prison
life. One describes him as “pleasant, mixes well with fellow inmates”. He
complied with his medication, but continued to cough and complained of
breathlessness on 2 and 8 March.
22. During the early hours on 9 March, the man complained to healthcare staff
of being breathless. The man had asked to be let out of his cell for some
fresh air, but this request was refused as the prison was in night patrol
state at the time. The man was given a nebuliser at 2:00am and again at
4:00am and staff carried out regular checks on him throughout the night.
6
23. When a nurse checked on the man at around 7:30am, he was again short
of breath and distressed. After the nurse entered the man’s cell, he
collapsed onto the floor. An ambulance was called and staff commenced
cardio pulmonary resuscitation (CPR). Staff applied a defibrillator which
stated that there were no signs of circulation and to continue with CPR.
24. The prison’s medical officer and the ambulance crew arrived at the man’s
cell around 8:15am. The paramedics took an electro cardiogram (ECG)
which indicated that the man’s heart had stopped beating. There were no
further resuscitation attempts and the man was pronounced dead by the
prison doctor at 8:16am
25. The Duty Governor and a representative from the prison chaplaincy visited
the man’s family to inform them of his death and to offer condolences and
support.
26. Contact was maintained with the family and the prison assisted with the
arrangements for the funeral.
27. The post mortem states that the cause of death was due to natural causes
as a consequence of an acute bronchial asthma attack which was caused
by chronic obstructive airways disease.
7
THE CLINICAL REVIEW
28. The principal clinical review records that the man suffered from significant
long-term chronic diseases (chronic pulmonary obstructive disease and
asthma) which had appeared settled. The review draws attention to a
number of issues which are also noted below.
29. The review finds that prison staff were unable to download a record from
the defibrillator used in the attempt to resuscitate the man. This meant
that an assessment of the resuscitation attempt could not take place.
The defibrillator used in any resuscitation incident (successful or
not) should be immediately quarantined by the healthcare manager
and passed to the resuscitation team as quickly as possible, so that
the information stored on the defibrillator is downloaded and
assessed. This will allow the resuscitation team and subsequently
the clinical review team to review the actions taken and make
recommendations if improvements are needed.
30. The medical records for the man were in a disorganised state, and did not
include the nursing records from the in patients wing. It is essential that
all the clinical records for a patient are kept together so that each clinician
reviewing the care has all the available information.
The standard of record keeping must be improved including the
information being recorded, to ensure that all entries are recorded in
the same folder so that it is accessible to all staff, and that additional
forms such as prescriptions are filed in the appropriate records.
31. There is no section in the medical notes for recording the name, signature
and designation of each member of staff using them. This is particularly
important for a department which uses a significant number of locum and
agency staff.
All decisions regarding the care and location of prisoners must be
recorded in the medical records, including who made them and why
they were made.
The medical records should record the printed name, designation
and signature of every person who makes an entry, so that they can
be identified if further questions are needed.
All records produced by clinical staff must be recorded in a single
file. This includes daily nursing records.
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32. The medical records did not include the prescriptions for medication
provided to the man prior to his transfer to the local hospital. However,
the record of attendance to the man on the wings shows that he had his
medication in his possession. It is important that when the prescription
charts are finished they are filed with the medical record. The pharmacy
records showed that the man received his medication on 7 February 2006
and that it was consistently provided during his time in prison.
When they have been completed, all prescription charts must be
filed in the medical record so that clinicians can review them when
they consider the patient’s future care and treatment.
It is essential that all patients who require medication are provided
with it as soon as possible after they enter the prison, irrespective of
weekends and holidays.
33. There does not appear to be any record of discussions between the
hospital and prison healthcare regarding the man’s return into prison. The
only record is the discharge information provided by the hospital itself.
34. The man was received back from the hospital onto B wing, which is close
to the primary care nurses who could therefore monitor his progress.
Whilst the clinical reviewer could not find a record of the short period the
man spent on the wing, he could see no indication that the man’s
treatment was not appropriate.
Clear documentation for the acceptance and receipt of patients from
Hospital or other institutions must be made so that there is a record
of the circumstances and advice given when the prisoner arrives.
This is especially important if limited information is provided in the
discharge letter.
35. In response to issues raised by the man’s family, the clinical review states
that records following the reception screening suggest the man was seen
by a GP who probably prescribed him medication. As the man was living
in the community when he came into prison, and had been managing his
own medication, it is probable that the man would not have been
recommended for in patients by the examining doctor although there is no
evidence to support that assertion.
The records of the reception screening process need to show all the
interactions and recommendations made.
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36. It is believed that the move from ITU was on 18 February 2006, as the
prison medical records identify that ward staff were unable to update them
on his condition on that day. When they did receive the information the
following day, the medical record simply reads as if the man was moved
that day.
37. The local hospital had a number of outbreaks of diarrhoea and vomiting
(normally caused by a virus and very easily spread) on the wards in
February, but not where the man was being treated. The fact that
diarrhoea and vomiting was circulating in the hospital appears to have
been a consideration, albeit not the only one, in the decision to discharge
the man.
38. The clinical reviewer refers to comments made by the consultant who
dealt with the man in the local hospital. The consultant reported that
during a diarrhoea outbreak the hospital will take action to treat each
affected patient individually, with separate facilities as far as the ward
environments will allow. Patients with diarrhoea will be kept on the ward
until the infection has cleared, treated in a side room where this is
possible and staff will be advised of the potential risk of spread and use
appropriate infection control procedures to minimise the risk of spread.
The consultant noted that the diarrhoea outbreak at the time did not
adversely affect the clinical management of the man’s condition.
39. The consultant’s review of the man when he was discharged from hospital
stated, “Clinical examination showed that he was fully conscious, there
were very few rhonchi on his chest with good air entry, his pulse was 77
per minute, which is normal, with normal temperature. He was not on any
IV fluids or intravenous antibiotics, he was mobilizing well and deemed
safe to be discharged. Overall his clinical picture revealed excellent
recovery and we planned his discharge”.
40. The introduction of an electronic patient record could resolve a number of
issues relating the recording of patient information and should be
implemented as soon as possible.
The introduction of an electronic patient record should be
implemented as soon as possible.
41. The man’s collapse appears to have been sudden and unexpected.
Given that the man underwent a comparable respiratory arrest in the local
hospital less than four weeks previously, it would appear to have been a
potential risk wherever he happened to be. From the clinical reviewer’s
experience of the West Midlands Asthma Mortality Audit, this is not an
uncommon cause of sudden death in asthma patients, both at home and
in hospital. Certainly, the man had access to more trained care and
attention in the prison than he would have had at home and he was
already on appropriate maintenance treatment, including oral steroids.
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ISSUES RAISED BY THE MAN’S FAMILY
42. From comments made by his family, it seems the man was a well loved
father and grandfather.
43. His family was surprised that, given his medical history, the man was not
immediately admitted to the prison’s healthcare wing after his first health
screening. However, as the clinical review concludes, there was no
indication in the screen that he should be admitted to hospital. The man
was managed in his own home whilst in the community and there was no
initial clinical indication that he should not be managed in a normal
environment whilst in prison. The prescription of an oxygen cylinder for
emergency use at home did not warrant immediate assessment in the
prison’s healthcare wing. The view expressed by the clinical reviewer is
reinforced by the records indicating that the man was not unwell during his
first days in custody.
44. HMP Birmingham has acknowledged that they did not notify the man’s
family of his discharge from hospital and have apologised to the family for
the omission. The family was also concerned that their attempts to
arrange a visit to the man after he left hospital were hampered by the
limitations of the prison phone system for arranging visits. Visits may be
booked by telephone, by e-mail or by asking a member of staff to contact
the visits centre. Family members may also attend the visitors centre in
person to make a booking. However, the prison accepts that having only
one telephone line can lead to difficulties and have agreed to review the
system. (I welcome the prison’s action. From my investigations into both
complaints and fatal incidents, I am well aware of the difficulties members
of the public face in booking visits or otherwise making contact with a
prison.)
45. The man’s family was also concerned that, when the man’s heath
improved in hospital, mechanical restraints were re-applied. The use of
physical restraints on those in hospital, especially those prisoners whose
condition is life-threatening, understandably causes distress. However,
the Prison Service also has a duty to prevent escapes and protect the
public. My investigation has confirmed that the re-application of restraints
on the man was properly carried out following a security risk assessment,
and I have no criticism of the result.
46. In general, the security arrangements at the hospital seem to have been
appropriate, and struck a good balance between public protection and
sensitivity to the man’s circumstances. In reviewing the bedwatch log, my
investigator concluded that the staff involved with the man’s care behaved
with sensitivity.
47. The family also drew attention to some of the positive practices employed
by the prison. These included handing back the man’s belongings in a
timely manner and assisting with the costs for the man’s funeral.
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CONCLUSIONS
48. The post mortem report concludes that the man died from natural causes.
49. In light of the findings of the clinical review, and my own investigation, I
judge that the man’s medical care was appropriate and satisfactory.
However, clearer, more detailed recording would have provided further
evidence in support of such a conclusion.
50. The principal clinical review makes ten recommendations, which I
endorse.
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RECOMMENDATIONS
Medical
The defibrillator used in any resuscitation incident (successful or not)
should be immediately quarantined by the healthcare manager and
passed to the Resuscitation team as quickly as possible, so that the
information stored on the defibrillator is downloaded and assessed.
This will allow the resuscitation team and subsequently the clinical
review team to review the actions taken and make recommendations if
improvements are needed.
Accepted - This will be done by the Healthcare Manager unless the police
seize the defibrillator as evidence before he has an opportunity to download
the information.
The standard of record keeping must be improved including the
information being recorded, to ensure that all entries are recorded in
the same folder so that it is accessible to all staff, and that additional
forms such as prescriptions are filed in the appropriate records.
Accepted - Written into Performance targets for Practice Manager.
All decisions regarding the care and location of prisoners must be
recorded in the medical records, including who made them and why
they were made.
Accepted - Written into Performance targets for Practice Manager.
The medical records should record the printed name, designation and
signature of every person who makes an entry, so that they can be
identified if further questions are needed.
Accepted - Written into Performance targets for Practice Manager.
All records produced by clinical staff must be recorded in a single file.
This includes daily nursing records.
Accepted – In patient nursing notes will be filed in IMRs (Inmate
Medical Records).
When they have been completed, all prescription charts must be filed in
the medical record so that clinicians can review them when they
consider the patient’s future care and treatment.
Partially Accepted - Logistically difficult for management of supervised
medications. Prescription charts have to be available in ‘hatches’ and
therefore separated from IMRs. EMIS development will solve problem
13
It is essential that all patients who require medication are provided with
it as soon as possible after they enter the prison, irrespective of
weekends and holidays.
Accepted - Facility available for prescription medication to be available to
prisoners following initial health screen.
Clear documentation for the acceptance and receipt of patients from
hospital or other institutions must be made so that there is a record of
the circumstances and advice given when the prisoner arrives. This is
especially important if limited information is provided in the discharge
letter.
Accepted – Lead nurse to review and introduce appropriate documentation.
The records of the reception screening process need to record all the
interactions and recommendations made.
Accepted - EMIS development will address this action.
The introduction of an electronic patient record should be implemented
as soon as possible.
Accepted - Funding for EMIS system agreed. Project plan finalised. Mental
Health Trust signed up to use of EMIS.
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