Individual at Blakenhurst

Investigation into the circumstances surrounding the death of
a male prisoner in July 2005 at HMP Blakenhurst
Report by the Prisons and Probation Ombudsman for England
and Wales
March 2006
This is the report of an investigation into the circumstances of the death of
a male prisoner. He died from natural causes in July 2005 at HMP
Blakenhurst. He was 51 years of age.
My colleagues and I would like to extend our condolences to his family and
friends for their loss.
One of my investigating officers conducted the investigation. I would like to
thank the Governor of Blakenhurst, who ensured that all relevant information
was made available to my investigator.
I am also grateful to the clinical reviewer, who carried out an independent
clinical review on behalf of the Redditch and Bromsgrove Primary Care Trust.
My report makes one recommendation and identifies one example of good
practice. The clinical reviewer makes ten recommendations.
My report also commends the duty governor and the detective in charge of
the police investigation for the way in which they arranged for his family to be
informed of his death.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2006
Contents
Page
Summary 4
Investigation Methodology 5
Background 6
HMP Blakenhurst 6
Events leading up to the death of the prisoner 7
Events of 16 July 2005 9
Issues considered during the investigation 11
Clinical Care 11
Management of his cellmate 12
Breaking the news to his family 12
Findings and Conclusions 13
Recommendations 14
Good Practice 14
Summary
The prisoner died on 16 July 2005 at the age of 51, while in custody at HMP
Blakenhurst. He had been in custody since June 2004, initially on remand
and then as a sentenced prisoner.
He died from a myocardial infarction as a result of a coronary embolus. Along
with his history of diabetes, he smoked and was overweight, and was
therefore considered at higher risk of coronary disease.
The prisoner had a history of diabetes, hypertension and an enlarged heart for
which he was receiving treatment prior to arriving at Blakenhurst. His General
Practitioner reported that his condition had been poorly controlled whilst in the
community.
In January 2005, he had been seen by medical staff when he complained of
chest pains.
Prison staff were alerted on the morning of 16 July to the prisoner by his cell
mate, who called for staff assistance. Staff arrived almost immediately and
tried to resuscitate him. They continued to care for him and assist the
paramedics. However, despite their efforts the paramedics decided that he
had died and ceased all activity at 7.25 am.
I criticise the treatment of his cellmate who was taken from the cell and locked
in the second floor showers while resuscitation attempts were made. I
conclude that this was unacceptable.
I commend the duty governor and the detective in charge in charge of the
police investigation for the way in which the prisoner’s family was informed of
his death.
In addition to the recommendations made by the clinical reviewer, I make one
recommendation of my own.
Investigation Methodology
1. All the indications were that this was a death from natural causes.
2. My investigator, was given access to all the prisoners prison records,
including his medical records.
3. Notices to staff and prisoners were sent to the Governor of
Blakenhurst, to be displayed around the prison. These announced the
investigation and invited staff and prisoners to submit to my investigator any
concerns or views they wished to express with regard to his death.
4. My investigator did not conduct any formal interviews during the
course of the investigation, but he did correspond with a prisoner and one of
the officers involved.
5. One of my family liaison officers, contacted the prisoner’s family who
decided they did not need to meet with my investigator. They would prefer to
wait for my report to be made available to them.
Background
HMP Blakenhurst
6. HMP Blakenhurst is located on the outskirts of Redditch in
Worcestershire. It is a category B local prison, serving a number of courts in
the West Midlands area. It first opened under private management in 1993,
but since 2001 was has operated under the management of the Prison
Service.
7. In September 2005, Blakenhurst had an operational capacity (total
crowded capacity) of 856 men held principally on four identical house blocks.
Most prisoners are held in double cells. There are separate specialist units,
including the healthcare centre and a segregation unit. Roughly a third of the
population are unsentenced.
Events leading up to the death of the prisoner
8. The prisoner was remanded into custody at Birmingham Crown Court
on 16 June 2004. He was convicted and sentenced to five years
imprisonment on 14 April 2005.
9. On 30 June 2004, he reported to healthcare staff that he had a history
of raised blood pressure, diabetes and an enlarged heart. His medical
records identified the prescribed medication that he was taking, and noted
that he smoked 15 cigarettes a day as well as being a social drinker.
10. He was then seen on 1 July by the prison doctor, and treatment
commenced for hypertension and diabetes control. A record of his blood
pressure was also taken at this time. Recommended action from this
consultation was a weekly review of his blood pressure and prescribed
medication. Background information was to be requested from his GP.
11. His blood pressure was not checked again for over three weeks. A
letter was received on 5 July from his community General Practitioner. This
listed his medication and also confirmed that he suffered from diabetes and
hypertension, which were both rather poorly managed prior to arriving at
Blakenhurst. During this time, he was seen at the Well Man clinic and had his
blood glucose monitored.
12. He was advised about nutrition on several occasions, as well as being
reminded to take his medication.
13. On 1 September, the prisoner medication was reviewed. The clinical
reviewer says it would appear that medication reviews were often conducted
without the patient being seen by the doctor. On this occasion, it is not certain
if he was seen or not. The clinical reviewer suggests that his medication was
changed. However, it would appear from prescription sheets that his original
medication was not stopped and he ended up with two similar drugs being
given at the same time.
14. His blood pressure was checked regularly throughout the rest of the
year and his hypertension remained steady at 180 over 105 but was not at the
expected level for a man of his age and condition. The clinical reviewer
concludes that his hypertension was therefore uncontrolled. During this
period, there were two recordings of non­compliance with medication and a
failure to attend for appointments.
15. On 20 January 2005, he returned from court complaining of chest
pains, which he had been experiencing for approximately three hours. He
was seen by one of the prison medical officers who recorded his blood
pressure and asked that blood tests be done. One test was to identify an
enzyme marker, found in the blood following a cardiac event, and which is
routinely used to identify whether those with chest pains have had a heart
attack. The blood was taken on 21 January but it would appear that the
enzyme test was not carried out as the nurses were not aware of one of the
tests required, and they had not been trained in its diagnostic properties.
Along with the blood test, the clinical reviewer states that an Electro Cardio­
Gram (ECG) should have been requested, but there is no record that one was
asked for or that one was performed.
16. During January 2005, the prisoner was frequently attending court and
most days would be out of the prison. On a daily basis, his medical record
noted that he was fit to go to court. The clinical reviewer comments that this
is just a routine procedure carried out by the nurses and that it would be
extremely rare for a prisoner to be considered unfit for court. My investigator
was concerned, however, that following this episode of chest pain he was still
considered to be fit without his blood pressure being regularly rechecked, or
there being any record of him being asked about his symptoms.
17. On 14 February, his blood test results were reviewed and they were
considered to be within normal limits. During the remainder of February and
March it would appear that he attended court on a daily basis. There is no
record of his blood pressure being checked throughout that period of time.
18. His medical records show that another review of his medication took
place on 23 March, but it is not possible to read who carried out the review.
However, whoever conducted the review noted some confusion over his
medication and felt that a more in depth review was urgently required.
19. There are no further entries in his medical record until 2 June 2005,
when his blood pressure was checked and recorded. The following week his
blood pressure was taken and recorded again.
20. On 16 June 2005, he was seen by one of the doctors, although the
signature is illegible. The medical records are very difficult to read but it
would appear that the focus of the consultation was whether he could stop
some of his medication at his own request, as he had reported feeling weak at
times. His blood pressure was taken and recorded. The recommendation
from this consultation would appear to be general lifestyle advice, and that his
blood pressure should be reviewed in two to three week’s time.
Events of 16 July 2005
21. At approximately 6.09am on 16 July, the night patrol officer, who was
a new member of staff, started to do routine checks on the wing. At 6.18am,
she noticed that a cell call light at cell B219 was lit. She went to the cell to
see why the light was on. Upon arrival at the cell door, she opened the
observation flap and could see two prisoners. One was standing near to the
door while the other was lying on his bed foaming from his mouth and nose.
He appeared to be having a severe asthma attack.
22. The night patrol officer immediately called to a second night patrol
officer that was also on the wing. At 6.20am, the second officer went straight
to the cell and when he saw the prisoner lying on the floor, he immediately
called for help using his prison radio and the term Code Yellow. The term
Code Yellow is used when calling for assistance in a medical emergency. At
this point, the other prisoner in the cell was clearly distressed and both night
patrol officers remained at the door to reassure him. They did not enter the
cell as they were waiting for the orderly officer to arrive. I judge that this was
appropriate in the circumstances as it could have been unsafe to enter the cell
without the support of fully trained staff.
23. At approximately 6.25am, the orderly officer arrived at the cell along
with two Nurses. They entered the cell to attend to the prisoner. At this time,
the staff took the cellmate from the cell and he was located in the shower
room on the second floor landing. After approximately 30 minutes, the
cellmate was taken to be supported by a Listener (a prisoner who has been
trained by the Samaritans to support other prisoners). Once inside the cell,
the orderly officer sent a radio message to the control room and requested
that an emergency ambulance be called.
24. The nurses checked the prisoner’s vital signs and put in place an
airway to assist with his breathing. The nurses tried to use the small suction
pump to remove the copious amounts of foam coming from his mouth and
nose but this was unsuccessful. A nurse and one of the night patrol officers
then went to the medical block to collect a portable suction pump that was
powered electrically. When they returned to the cell, they began suction to
help clear his airway.
25. The heart start monitor was connected to the prisoner and it displayed
that no shock was required and there was a regular steady heart beat. The
nurse returned again to the medical block to collect some more oxygen while
the other nurse maintained his airway until the paramedics arrived at 6.38am
and took over. The paramedics continued to care for him. At 7.10am, they
commenced Cardio Pulmonary Resuscitation (CPR) as well as connecting
defibrillation pads to him.
26. The paramedics requested assistance from staff to move the prisoner
onto the floor. Three officers entered the cell and placed him on the floor. At
7.15am, the paramedics who were continuing with CPR noted that he had no
readable heartbeat and the nurses were unable to intubate.
27. At 7.25am, the paramedics ceased all resuscitation attempts and
decided that he had died. The cell was vacated and sealed by staff.
28. At 7.35am, the doctor was contacted and informed of the prisoner’s
death. He was asked to attend the prison, but he declined to attend until the
Police Scenes of Crime Officer had attended. He was contacted again at
7.55am, but still declined to attend. The prison liaison officer confirmed that
the doctor was expected to attend the cell prior to the Police Scenes of Crime
Officer.
29. At 8.45am, the doctor arrived at the cell and confirmed that the
prisoner had died. At 9.17am, Bromsgrove CID and the Police Scenes of
Crime Officer arrived, entering the cell at 9.19am and leaving at 10.30am.
The Coroner’s Officer arrived at the cell at 12.42pm to remove the body from
the prison.
30. Following a discussion between the duty governor and the detective
in charge of the police investigation, it was decided that the Imams would
inform the family of the prisoner’s death. This would take place in the
presence of the Police Family Liaison Officer. A Police Constable was
identified as the most suitable as he was a trained Family Liaison Officer and
a Muslim. The Imams met with the two police constables and travelled to the
home of the prisoner’s brother. The Imam informed the prisoner’s family of
his death. Both Imams returned to the family at approximately 8.00pm the
same evening and attended the funeral.
31. The post mortem report concluded that the prisoner died of a heart
attack.
Issues considered during the investigation
Clinical Care
32. Standards of healthcare in prisons are intended to mirror those
available in the outside community. It is considered that all appropriate
actions were undertaken in the attempted resuscitation.
33. The clinical reviewer found that the care and treatment on the day of
his death were of a proper standard, with staff and paramedics making all
appropriate attempts to resuscitate him.
34. Prior to his death, the prisoner had a number of medical conditions for
which he was being treated. The clinical reviewer has stated that changes
need to be made with prisoner care to ensure that a better healthcare service
can be offered.
35. The recommendations of the clinical review are:
§ The PCT should put in a place a policy in relation to non­
compliance with requests to attend for medical checks or
screening.
§ Where prisoners do not attend for appointments, this should be
recorded in the medical records.
§ The National Service Framework for Coronary Heart Disease
recommends that ‘if a suspected heart attack, with 30 minutes
plus of central chest pain, a 999 call should be made for
assessment.’ It is not clear from the records whether there was
a serious concern of a suspected heart attack. However, it is
recommended that these guidelines should always be followed.
§ Prisoners who report chest pain should have an ECG to exclude
cardiac events.
§ When writing in the medical / health care record all entries must
be dated, legible and signed. Where there is a significant event
a time should be added as well as date.
§ The pharmaceutical contract should be reviewed to establish
why it took three days to get emergency stock of a
straightforward potassium replacement medication.
§ Records must make it clear whether the in­patient is actually
seen.
§ Systems must be put in place to ensure patients are followed up
as requested by either medical officer or nurse.
§ Where there are clinical issues such as uncontrollable
hypertension, the records must clearly state what clinical plan is
in place to resolve the clinical problem.
§ Where medications are complex or not having the desired effect,
it may no longer be appropriate to issue in possession
medications
Management of his cell mate
36. The cellmate promptly alerted staff to the condition of the prisoner
when he woke up on the morning of 16 July. The cellmate was clearly
distressed by the situation he found himself in. The night patrol officers
remained outside his cell providing reassurance until other staff arrived and
the cell could be safely opened. I judge this was appropriate in the
circumstances.
37. It is evident that by 6.25am there were at least five staff in the cell
treating the prisoner including two nurses. However, his cellmate was locked
in a shower room and left alone for about 30 minutes. He was later moved to
a new cell where he was supported by a Listener. I believe it would have
been more appropriate to move the cellmate immediately into a cell with a
Listener or for a member of staff to have remained with him until such time as
a Listener could be identified.
38. At approximately 10.20am, the prison says that the cellmate was
located in a crisis suite with a friend and a Listener, both of whom are Punjabi
speakers. The prison says that, prior to this, the Imam saw him and that he
was seen on two further occasions.
39. A letter received from the cellmate states that he felt unsupported by
the prison. He further says that he was placed with a Listener, but that the
Listener did not speak his language therefore causing him more stress. The
cellmate feels that he has not been offered any continued support and has
had to cope on his own.
The Governor should remind staff that, when a prisoner has been
involved in a distressing situation, they should be offered support
without delay. The use of a Samaritans phone or direct support from
staff must be considered until a more detailed support plan can be put
in place.
Breaking the news to the prisoner’s family
Prison Service Order 2710 makes clear that it is best practice for the prison
itself to inform the next of kin of a death in prison custody. In the case of the
prisoner a decision was taken that the Imams along with a Police Liaison
Officer would inform his family. A Police Constable was identified as the most
suitable as he was a trained Family Liaison Officer and a Muslim. The Imams
met with two police officers at Trinity Road Mosque and they travelled to the
home of the prisoner’s brother, where the Imam informed the prisoner’s family
of his death. Both Imams returned to the family home at approximately
8.00pm the same evening and attended the funeral.
Findings and Conclusions
40. The Post Mortem records that there was evidence of the prisoner’s
suffering previous minor heart attacks and more recent ones. The clinical
reviewer considers that he reported chest pains in January 2005 could have
been managed more appropriately at that time. In particular, an ambulance
should have been called if there were serious concerns that he was suffering
a heart attack. The reviewer includes that if he had been transferred to
hospital, the outcome might have been different.
41. In my view, the treatment of the cellmate who was locked in the shower
room while attempts were made to resuscitate the prisoner was unacceptable.
He should have been offered support without delay.
42. I commend the actions of the duty governor and the detective in
charge of the police investigation for the way in which they arranged for the
family to be informed of the prisoner’s death.
Recommendations
I make one recommendation:
§ The Governor should remind staff that, when a prisoner has been
involved in a distressing situation, they should be offered support
without delay. The use of a Samaritans phone or direct support from
staff must be considered until a more detailed support plan can be put
in place.
The recommendations made by the clinical reviewer are as follows:
§ The PCT should put in a place a policy in relation to non­compliance
with requests to attend for medical checks or screening.
§ Where prisoners do not attend for appointments, this should be
recorded in the medical record.
§ The National Service Framework for Coronary Heart Disease
recommends that ‘if a suspected heart attack, with 30 minutes plus of
central chest pain, a 999 call should be made for assessment.’ It is not
clear from the records whether there was a serious concern of a
suspected heart attack. However, it is recommended that these
guidelines should always be followed.
§ Prisoners who report chest pain should have an ECG to exclude
cardiac events.
§ When writing in the medical / health care record all entries must be
dated, legible and signed. Where there is a significant event a time
should be added as well as date.
§ The pharmaceutical contract should be reviewed to establish why it
took three days to get emergency stock of a straight forward potassium
replacement medication.
§ Records must make it clear whether the in­patient is actually seen.
§ Systems must be put in place to ensure patients are followed up as
requested by either medical officer or nurse.
§ Where there are clinical issues such as uncontrollable hypertension,
the records must clearly state what clinical plan is in place to resolve
the clinical problem.
§ Where medications are complex or not having the desired effect, it may
no longer be appropriate to issue in possession medications.
Good Practice
§ The use of the term Code Yellow to summon help to medical
emergencies is good practice as this alerts everyone carrying a prison
radio and those within hearing distance that urgent medical assistance
is required.