Individual at Birmingham

INVESTIGATION INTO THE CIRCUMSTANCES
SURROUNDING THE DEATH
OF A MAN AT HMP BIRMINGHAM IN JULY 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
October 2007
This is a report into the circumstances surrounding the death of a man at HMP
Birmingham on 25 July 2005. He was just 32 years old when he died, apparently
from natural causes.
The man who died had been remanded into HMP Birmingham on 26 March 2005,
four months before his death. He had received a three year custodial sentence in
June 2005.
On reception, he was noted to be a substance misuser and was receiving support
from the local drug service providers. He later applied for a transfer to the
therapeutic community at HMP Channings Wood to address his offending behaviour.
He appeared to have an unremarkable time at Birmingham. Whilst he had a
diagnosable mental health need, it was well controlled with the medication he was
receiving. The clinical review, commissioned as part of my investigation, identified
two learning opportunities. However, I am aware that these have been considered
locally and do not propose to repeat them here.
The man was found to be unrousable on the morning of 25 July and, despite the best
efforts of staff, resuscitation was not possible. The post mortem following his death
was inconclusive. Low levels of heroin and prescribed medication were found in his
blood, but these were not thought to have contributed to his death. The inquest into
the man’s death was held in May 2006 and recorded a verdict of natural causes.
I very much regret the very late completion of this report. My office’s handling of this
case had been unacceptable, and has shown disrespect to his family, the Coroner
and the staff at HMP Birmingham. I offer an unqualified apology to all concerned.
In light of the failings on the part of my office, I ordered an urgent review of our
systems and procedures. This has resulted in changes in both policy and practice
that I hope will prevent any recurrence.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2007
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CONTENTS
Summary
Methodology
HMP Birmingham
Key Findings
Clinical Review
Recommendations
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SUMMARY
The man who is the subject of this report died unexpectedly on 25 July 2005. He
was just 32 years old.
The man had been received into HMP Birmingham just four months before he died.
He was subsequently sentenced to three years in prison for robbery. He had been in
prison before.
On reception, he was identified as schizophrenic and as a substance misuser. He
was prescribed appropriate medication to manage both conditions. The records
indicate that he was responding well to both courses of treatment and that his
schizophrenia was well controlled.
The man appears to have had an uneventful few months in Birmingham. He was
receiving support from the local drug services and had applied to join the therapeutic
community at Channings Wood.
On 25 July 2005, he was found to be unconscious when staff went to wake him to go
to work. Staff immediately commenced resuscitation. Sadly, this was unsuccessful
and he was pronounced dead.
An autopsy was carried out following his death. The initial findings were unable to
determine the cause of death. Eventually, in February 2006 my office was informed
that toxicology indicated that the man had a small amount of heroin in his system,
indicating he was likely to have used some within 48 hours of his death. Other
prescribed medications were found in his system, but were noted to be within
therapeutic limits. The pathologist concluded the levels of drugs found would not
have had any direct bearing on his death, and recorded the cause of death as
unascertained - probably acute viral pneumonia.
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METHODOLOGY
1. The investigation was begun in July 2005 by one of my investigators, who
handed over the investigation to my Deputy Ombudsman to conclude. My
Deputy has completed this report using the limited information available.
2. Notices to staff and prisoners, terms of reference and the Governor’s
notification letter were sent for distribution and display around the prison.
They announced the investigation and invited staff and prisoners to submit to
my investigator any concerns or views they wished to express. No staff or
prisoners came forward.
3. A clinical review was commissioned from Heart of Birmingham Primary Care
Trust. The Associate Dean at the West Midlands Postgraduate Medical and
Dental Deanery, undertook the review on their behalf. I am grateful for his
contribution,
4. My investigator contacted the man’s family at the start of the investigative
process. They have not brought any concerns or issues to the attention of my
office.
5. Management oversight and communication failures meant that this
investigation unacceptably slipped through the net. I offer an unreserved
apology for the shabby way in which the man’s family, the Birmingham
Coroner, and the staff at HMP Birmingham have been treated as a result. I
also wrote personally to the man’s father in June 2006.
6. The Coroner concluded the inquest into the man’s death in May 2006. A
verdict of natural causes was recorded.
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HMP BIRMINGHAM
7. HMP 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
Service’s website records that 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.
HMP Birmingham now holds 1,450 prisoners.
8. 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 nurse and 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.
9. The prison was last inspected by HM Chief Inspector of Prisons, Ms Anne
Owers, 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 be better coordinated.
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KEY FINDINGS
10. The man was received into custody in late March 2005, charged with robbery.
He received a three year custodial sentence in mid June. His conditional
release date would have been in mid September 2006, with a sentence expiry
date of 23 March 2008.
11. On reception into custody, he was seen for a healthcare assessment. He said
that he had no physical health concerns. However, he did tell the healthcare
worker that he had been diagnosed as schizophrenic. This had resulted in
him spending a period of time in a psychiatric hospital. He had then been
prescribed Amitriptyline and Zopiclone to manage his condition in the
community. These medications were continued when he arrived at HMP
Birmingham.
12. He also admitted to a drug habit. His main drug of choice was heroin, but he
also used crack cocaine. He said he spent £1,400 per week on drugs and
used crime to fund his habit. He was referred to the substance misuse team
for assessment and management, and consented to a Subutex detoxification.
He commenced his detox on 29 March 2005 and completed it 12 days later.
13. The man was also referred to and seen by the Counselling, Assessment,
Referral, Advice and Throughcare (CARAT) team. An initial assessment was
completed. A care plan assessment was also conducted, in which he
identified his wish to change his life style and address his addictive and
offending behaviour.
14. Following sentence, he applied to join the Therapeutic Community at HMP
Channings Wood. On 13 July 2005, he received a letter informing him that he
had been successful with this application. He was hoping to transfer to
Channings Wood at the end of July.
15. Whilst in prison, the man appeared settled and had gained employment on
the wing servery. There are no significant entries in his history sheet and
nothing in the wing observation books. All of this indicates that he was
compliant with the routines and had not come to the attention of staff.
16. At about 8.45am on Monday 25 July, an officer went to his cell to collect him
and his cellmate to go to work on the servery. They were due to take the
trolleys back to the kitchen. When the officer arrived at the cell, the man’s
cellmate was sitting on his bed watching television. The officer went to wake
him up and realised there was a problem. The officer then checked him and,
realising that he was not breathing, summoned additional support including
healthcare staff.
17. On arrival, the healthcare staff commenced cardio pulmonary resuscitation
(CPR). Paramedics were called and arrived at about 9.05am. Staff continued
to administer CPR with the paramedics until 9.29am. A clinical decision was
taken to stop resuscitation at this point. The man’s death was verified by the
duty doctor.
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18. Following the man’s death, contact was made with his next of kin. Some
members of the family were able to visit the prison and spent some time with
the chaplaincy. The governor offered financial assistance towards the cost of
the funeral.
19. The initial post mortem examination was unable to provide a conclusive cause
of death. Samples were sent for toxicology. These later provided evidence
that the man had a low level of heroin in his system, indicating he was likely to
have used within 48 hours of his death. That said, the pathologist concluded
this was not a factor in his death, nor were the other prescribed medications
found in his blood. These were noted to be within therapeutic limits.
20. The pathologist therefore concluded that the cause of death was
“unascertained – probably viral pneumonia”.
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CLINICAL REVIEW
21. The clinical review was carried out by the Associate Dean at the West
Midlands Postgraduate Medical and Dental Deanery. His review records that
the man was a known schizophrenic and substance misuser. He says that,
whilst in prison, the man received appropriate opiate substitution therapy to
manage his withdrawal from illicit drugs. Records indicate that he tolerated
this well.
22. Whilst no psychiatric opinion was sought, the clinical reviewer says the
records indicate that the man received appropriate medication for his
schizophrenia. Those records suggest that his condition was stable and well
controlled.
23. At the time of completing his review, the clinical reviewer made two
recommendations. One concerned the availability of equipment in the event
of an emergency, and the other was regarding the computerisation of medical
records. I am aware that both of these matters have been addressed in the
interim, and therefore do not propose to repeat them in this report.
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RECOMMENDATIONS
24. I make no recommendations in respect of the death of the man who is the
subject of this report.
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