Individual at Blakenhurst

Investigation into the death of a man
at a hospital, on
10 September 2004, while a prisoner at
HMP Blakenhurst
REPORT BY THE PRISONS AND PROBATION
OMBUDSMAN FOR ENGLAND AND WALES
OCTOBER 2006
This is the report of an investigation into the death of the man who died in hospital,
on 10 September 2004, while a prisoner at HMP Blakenhurst. the man was 48 years
old when he died from pulmonary embolus and deep vein thrombosis.
My colleagues and I extend our sincere condolences to this man’s family and friends
in their sad loss.
This investigation was completed by one of my colleagues. I am grateful for the
assistance that my colleague received from the Governor of Blakenhurst, and his
staff including the residence governor, who acted as the establishment’s Liaison
Officer. I regret the delay in the issuing of this report. This was caused in part by a
delay of over 12 months before I received the clinical review commissioned by the
relevant Primary Care Trust.
A key objective of all my investigations is to make sure that the bereaved family has
the opportunity to raise any concerns and contribute to my inquiries. In this case, the
investigation team was able to meet with the man’s cousin. I am most grateful to him
for agreeing to this meeting at what must have been a very difficult and distressing
time.
No-one should under-estimate the difficulties of caring in a custodial environment for
a patient like the man who came into prison with a complex range of medical and
psychological problems. This report documents how HMP Blakenhurst rose to those
challenges. However, as with so many prisoners, the fundamental problem was that
prison was not really a suitable location for him at all.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN OCTOBER 2006
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CONTENTS PAGE
Summary 4 – 5
Background 6 – 9
The man
HMP Blakenhurst
Conduct of the investigation 10
The man’s time at Blakenhurst 11 - 18
Clinical review 19
Consideration and conclusions 20 – 21
Recommendations 22
Annexes 23
3
Summary
1. The man was born in July 1956 and was 48 years old when he died at Alexandra
Hospital, Redditch, from pulmonary embolus and deep vein thrombosis on 10
September 2004.
2. He had arrived at HMP Blakenhurst on 17 May 2004, following an assault on police
officers and threats to kill his mother. Staff were made aware that he had an
established history of epilepsy and mental health problems. This had meant that he
had frequently been admitted to psychiatric hospitals and was difficult to manage in a
community setting, where he had most recently lived with his mother. There were
over 100 episodes recorded when the man had violent outbursts against those
involved in his care.
3. Attempts were made by staff at Blakenhurst to manage the man appropriately.
There was continuity between his community psychiatric team and both the In-Reach
and Forensic Medical teams. For the first month, he was successfully managed on
the lower medical wing as an inpatient, but he was then moved to the segregation
unit following episodes of violent and abusive behaviour.
4. It was acknowledged early on by various people involved in the man’s care that the
segregation unit was not the most appropriate place to manage him. It was also
noted in his records that his mental health generally deteriorated when he was
located there. However, neither the normal location house blocks nor the lower
medical inpatient wing were considered appropriate locations due to his aggressive
behaviour. As his mental health continued to deteriorate, he had more frequent
assessments by his psychiatric teams. Attempts were made to obtain a suitable
placement for the man outside Blakenhurst, preferably in a secure psychiatric
hospital. It was difficult to find appropriate accommodation for him due to his history
of aggression and verbal threats to staff. There is documented evidence that he
tried to strangle a member of the care team, and that he had to be restrained on two
occasions by officers when he became violent.
5. F2052SH self harm warning forms were opened for this man twice, as he had
expressed thoughts of suicide, a desire not to be in prison and regrets about his
mother.
6. The man also sometimes refused to take his medication. Initially, he refused any
medication that was not to control his epilepsy, but by the end of August 2004 he
was also refusing that medication. His medical record shows that staff persistently
tried to encourage him to take his medication but he still refused. This led to an
increase in seizures and a deterioration in his physical health which resulted in him
being admitted to a nearby hospital, on 3 September, following repeated and
prolonged seizures that day.
7. At the hospital, the man was identified as having an infection on the right side of his
chest and associated heart arrhythmias (irregular heart rhythm), probably as a result
of toxic build up through the infection. During his time in the hospital he was not
always co-operative with the treatment provided, and he pulled out the device to give
him intravenous drugs and fluids. He also refused to take sufficient water and food.
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Staff found him difficult to manage and also tried to find a suitable location for him,
but were not successful. The man was also seen by his community psychiatric
team. I understand that a secure psychiatric hospital in Manchester was identified
as a possible location for him. Sadly, he died on 10 September before this was
investigated further and arrangements could be made to transfer him. The cause of
death was noted as pulmonary embolus and deep vein thrombosis.
8. The clinical review carried out concludes that all attempts were made by staff in
Blakenhurst to manage the man in an appropriate way. The review notes there was
continuity of care between the community psychiatric team and the in-reach and
forensic mental health teams.
9. One of my Family Liaison Officers contacted the man’s cousin. He expressed
concerns about the role of the various psychiatric teams involved in his cousin’s care
before he was located in Blakenhurst. He also complained about the role of the
hospital from when his cousin was admitted on 3 September until his death on 10
September. Both these issues are outside my remit.
10. The man’s cousin also raised specific concerns about the care and treatment of his
cousin by Blakenhurst which are addressed in this report.
11. This report makes three recommendations.
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Background
The man
12. The man was born in 1956. He was diagnosed with temporal lobe epilepsy at the
age of 11 years. He attended mainstream education. However, it is reported that
due to his father’s career, the family lived in many different places throughout his
childhood and his schooling was disrupted. As a teenager he apparently showed
promise in both academic subjects and sport. He had a long-standing history of
epilepsy and mental health problems. At the age of 21, the man’s mental health
deteriorated and he was eventually diagnosed with paranoid schizophrenia. In 1979,
he moved to live and work at a specialist centre for Epilepsy in Buckinghamshire,
returning home to his mother at the weekend. He lived there for ten years and then
returned to live permanently with his mother. His employment at the Centre had
ended when he attempted to attack a colleague with a knife whom he believed was
the son of the devil. There were also reports that he had hit his manager. After that
he was frequently admitted to hospital and at times he was detained under the
Mental Health Act.
13. On 9 August 2001, the man was admitted to hospital. On 31 August 2001, he was
detained under the Mental Health Act. In December 2001, he had a vagal nerve
simulator fitted as a method of controlling his epilepsy. On 18 October 2002, he had
a Care Programme Approach (CPA) assessment. It was noted that he had
aggressive and violent outbursts, against both his mother who was his main carer,
nursing staff and other patients. This had led to the police being called several
times.
14. The man remained an inpatient at the hospital until he was allowed home leave from
21 to 23 January 2004. He was allowed home permanently shortly after this but
remained as a day release patient at another hospital.
15. He was again admitted to the same hospital from 13 to 20 April 2004 and 22-23 April
for assessment as he appeared confused and muddled. A consultant psychiatrist,
Doctor F, noted that he settled and became more orientated. She saw him again on
19 April, when he had become aggressive and threatening towards staff. Police
were called and restrained him. He was not charged with any offence and later
apologised for his behaviour. A discharge planning meeting was held on 19 April
and the man was discharged back to stay with his mother. He returned to the
hospital on 22 April due to being agitated, talking about coincidences and whether he
was the Son of God. On 23 April, Doctor F discussed a management plan for him
with a consultant forensic psychiatrist, and several other members of staff including
the Medical Director. They concluded that the man did not have a chronic
psychosis. He returned to live with his mother and was monitored in the community
from 23 April, with reviews in the day hospital and assistance from a Community
Psychiatric Nurse CPN. His mother was advised that she should report any
incidents of aggression or violence towards her to the police.
16. On 14 May, the man threatened to kill his mother. On 17 May, there was an incident
at his home address in which his mother received a head injury from which she later
died. The man was taken into police custody on suspicion of murder and for
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assaulting police officers. However, before she died later the same day, the man’s
mother denied that he had assaulted her and said she had fallen. Consequently,
taking into account the man’s mental health problems, the Crown Prosecution
Service (CPS) concluded that there was insufficient evidence to support a charge of
murder and he was therefore charged with threats to kill. The man was remanded
into custody at Blakenhurst on 17 May from Leamington Magistrates’ Court.
17. Pre-convictions for the man indicate that he had one previous charge of criminal
damage caused between 12 and 18 November 2003 and a charge of threats to kill at
the same time, which seems to have been subsequently dropped. Prison records
show that he was remanded at HMP Leicester for one day.
18. The man’s cousin confirmed to my investigation team that his cousin had a long
history of mental illness and severe epilepsy. He said that he had attacked his own
mother on several occasions, and had also attacked his (the man’s cousin) mother in
the past.
19. The man’s cousin expressed concern generally about the man’s treatment for his
psychiatric problems before and during his imprisonment. He mentioned specifically
an occasion, before his cousin was located in Blakenhurst, when he had been
sectioned under the Mental Health Act and had been sent to a hospital in Leicester.
He was concerned that his cousin’s diagnosis was suddenly changed from
schizophrenia to anger management problems at that time and he was discharged
from the hospital. The man’s cousin said that the man was discharged with no help
to get anywhere, and returned home to his mother’s house where he lived for a
further four or five months. He said that his cousin’s mental health deteriorated
significantly from May 2004 and he began saying that he was the Son of God.
20. The man’s cousin said that, before the man was arrested on 17 May, he entered a
chemist’s shop and told the pharmacist that he needed help and needed to be
sectioned under the Mental Health Act or he was going to harm his mother. They
called the police who apparently said they could not arrest him as he had not broken
any law. This prompted him to assault a police officer to get himself arrested, which
is what happened. While in police custody he apparently told staff that if they
released him he would kill his mother. According to the man’s cousin, the mental
health team said the man could be discharged and he was released. He then
attacked his mother and it was after this attack that she died and he was arrested
and imprisoned. The man’s cousin said that the man’s mother was scared of her
son.
21. The man’s cousin said that he visited the man on several occasions in Blakenhurst
and noticed a marked deterioration in his condition with each visit. He said he
challenged the staff about the clothes his cousin was wearing, which he felt were too
big for him and humiliating to wear as he was not eating and had lost a lot of weight.
The man’s cousin said that he asked prison healthcare staff, the man’s solicitor, and
the Community Psychiatric team on several occasions to get him moved from
Blakenhurst to a psychiatric hospital for treatment. He said that nobody listened to
him or did anything in this respect. He is aware that the man refused to take his
medication and said that he felt he had lost the will to live after what he had done to
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his mother. In his opinion, the assistance offered to his cousin by a nurse was
insufficient to deal with his problems.
22. The man’s cousin said that when he saw the man in hospital, he was appalled by
what he saw. He alleged that his cousin was beyond recognition, chained to the bed
in a nappy and looked like he was being treated like an animal. Three prison officers
were present at all times. He said that this sight upset him and his wife and he could
not believe a human being was treated like this. The man’s cousin said that, after
three days, the man came around a bit and recognised him. He said that the man
was not eating or drinking, but hospital staff told him they could not put a drip on him
because he refused the treatment. As he had not been sectioned under the Mental
Health Act, they could not impose treatment.
23. The man’s cousin said that he was informed about the man’s death by the police and
had not been contacted at all by Blakenhurst. He alleged he had had no
possessions back, no letter of condolence, nor an offer of funeral costs.
8
HMP Blakenhurst
24. HMP Blakenhurst is located on the outskirts of Redditch in Worcestershire. It is a
local prison, serving a number of courts in the West Midlands. In September 2004,
Blakenhurst had an operational capacity of 856 adult males held principally within
four identical houseblocks. (Most prisoners are held in double cells with separate
specialist units including the healthcare centre and a segregation unit. Roughly a
third of the population are unsentenced remand prisoners.)
25. In September 2004, healthcare was provided by a Healthcare Manager, two G grade
nurses, two F grade nurses, 14 E grade nurses, five A grade nurses, two clerical
staff and one E grade nurse on nights. There was a total of three full time and one
part time Registered Mental Health nurses, RMN’s, supported by agency staff when
required. There were 29 inpatient beds and one gated cell. Some specialist mental
health input was provided by a psychiatric consultant from a Psychiatric Clinic,
Birmingham, and also from a forensic psychologist. Blakenhurst now has a forensic
team comprising of a consultant with two specialist registrars, plus the forensic
psychologist. They also have a much larger team of RMN's providing cover for their
24 hour healthcare centre and for out-patient clinics. The mental health in-reach
team also attend the prison. They only have 21 beds now.
26. Her Majesty’s Chief Inspector of Prisons (HMCIP) carried out an unannounced
inspection of Blakenhurst in April 2002. The inspection report described Blakenhurst
as ‘a dynamic prison which was working towards becoming a healthy prison’.
9
Conduct of the investigation
27. My investigator studied all relevant prison records relating to the man. These
included his main prison record and his Medical Record.
28. A Public Health Consultant from Redditch and Bromsgrove Primary Care Trust
(PCT) carried out a clinical review.
29. 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. A copy
of the post mortem report dated 20 September 2004 was received and recorded the
cause of death as pulmonary embolus and deep vein thrombosis.
30. One of my Family Liaison Officers contacted the man’s family. His cousin raised
concerns about the man’s treatment for his mental health problems and epilepsy
both prior to his arrest and whilst in custody.
31. My investigator visited Blakenhurst and discussed aspects of the man’s treatment
with a range of staff at the prison. These included the Deputy Governor and the
Head of Healthcare. My investigator also met the Chair of the local branch of the
Prison Officers’ Association (POA), and representatives of the Independent
Monitoring Board (IMB), to tell them about the investigation process.
32. The clinical review found that ‘all attempts were made to manage the man in an
appropriate way. There was continuity between his community psychiatric team and
both in-reach and forensic mental health teams.’
10
The man’s time at Blakenhurst
33. The man was remanded into custody at Blakenhurst on 17 May 2004 and was
immediately located in the lower medical ward in the healthcare centre.
34. On 19 May, a Medical Disruptive Prisoner risk assessment and management plan
was completed by a registered mental health nurse (RMN). He noted that further
information was obtained from the man’s Community Psychiatric Nurse (CPN) and
psychiatrist, which stated that he had a history of violence with over 100 unprovoked
and unpredictable incidents recorded. A three officer unlock was implemented as a
result of the assessment. (That is, the man could not be unlocked without three
members of staff present.) This was later reduced to a two officer unlock on 25
August.
35. A self-harm warning form, F2052SH, was opened by a nurse on 27 May after
concerns were expressed by a senior probation officer, following a MAPPA meeting
(Multi-Agency Public Protection Arrangements). Their concerns were that the man
might self-harm when he realised that his mother had died. The care plan for the
man was Level 3 Observations, access to nursing staff, weekly visits by the CPN,
and bereavement counselling. (Level 3 observations are hourly observations at
irregular intervals.) There is no evidence that the man saw a counsellor specifically
to deal with his bereavement.
36. On 30 May, there is a note that the man was to remain in the healthcare centre, but
there was a risk of him becoming violent. The F2052SH was closed on 6 June
following a review by a governor and a nurse. It was closed as the man had not
made any attempts at self-harm during that time and there were no concerns from
nursing staff. There was no support plan put in place when the F2052SH was
closed.
37. On 13 June, there is a note that the man was at times abusive and threatening
towards staff. The man was still located in the healthcare centre during this time and
generally complied with medication and food and drink intake. However, on 16 June
his behaviour started to deteriorate and he was re-located to the Segregation Unit on
19 June. This was following several episodes of being verbally abusive to staff,
flooding his cell, throwing his food and barricading his cell door.
38. On 24 June, the man was seen by a Community Forensic Psychiatric Nurse (CFPN),
and Doctor A, a Senior House Officer. They said that he was much more articulate,
and was co-operative, but did become verbally intimidating at times. He was not
physically aggressive and was fully aware of why he was in the segregation unit.
There is a note that he talked throughout the night on 27 June about God and Jesus
Christ. The man was seen again by the CFPN on 1 July. He said that the man was
not psychotic and his behaviour was seen to be reasonably well controlled. He said
that the man had felt suicidal, and had tried to pierce his throat with a plastic knife,
but no marks were noted on his neck.
39. The man fell out of his bed on 3 July and suffered a minor cut over his right eye and
a raised lump with bruising over his left eye. It was noted that his behaviour was
bizarre and he said he was the Holy Spirit.
11
40. There is evidence that the man’s behaviour continued to deteriorate during June and
early July. On 8 July, he was very agitated and said that he would put in a charge of
attempted murder against staff. He had to be restrained by two officers when he
attempted to get out of his cell during a doctor’s rounds. There were no injuries
noted to the man and he was pushed back into his cell. Doctor B, a Senior Prison
Medical Officer, said that in his opinion up until the beginning of July the man had
been reasonably settled and appeared not to be having seizures. He was on five
different anticonvulsants to control his epilepsy. Doctor B noted that the man’s
behaviour had recently changed distinctly and he appeared to have had at least one
seizure, suffering abrasions on his forehead as a result. He also noted that the man
had begun to neglect himself and his cell. He said that previously he had not
considered there were any mental health problems to address with the man, but now
felt that the segregation unit had adversely affected him mentally and that he needed
to be reassessed. Doctor B referred the man for a further mental health assessment
and he saw Doctor C, a Consultant Psychiatrist for Worcestershire Mental Health
Trust, on 16 July.
41. The man remained in the segregation unit and a segregation review was held on 12
July. The review concluded that, although the segregation unit was not an ideal
location for the man, he would need to stay there due to his unpredictable and
violent behaviour. The Deputy Governor asked that the matter be raised with the
Psychiatric Team regarding the possibility of a hospital placement.
42. The MARC (Multi-Agency Risk Conference), which had been held on 11 June,
recommended that a F2052SH should be opened and remain open irrespective of
the man’s mood and behaviour. This had not happened and the F2052SH was
reopened on 15 July by a nurse. The reason given for reopening the F2052SH was
that the MARC had identified the man as at risk of self-harm once he realised that he
was likely to be charged with the death of his mother. The advice of the MARC was
that the F2052SH was to remain open for the foreseeable future. The nurse did not
feel it appropriate to explain to the man the whole reason for opening the F2052SH.
It was noted that he had not given any indication to segregation staff that he
intended to self-harm. The support plan was to continue with Level 3 observations
and to have healthcare input into F2052SH reviews and segregation reviews, which
did happen.
43. On 16 July, Doctor C undertook a psychiatric reassessment as requested by Doctor
B. He recommended that the man should be moved back to the healthcare centre
as an inpatient. He felt that being in the segregation unit may have led to a
deterioration in the man’s mental health. He concluded, ‘I will ask Doctor D to see
him due to the risks involved. It may be that he should be moved back to Lower
Medical on a 2 or 3 man unlock to help stabilise him.’ (Doctor D is a Consultant at
the Psychiatric Clinic, Birmingham).
44. The man had a self harm case review on 19 July, by a nurse and Doctor B. It was
noted by Doctor B that the man had not given any indication that he intended to self-
harm. He noted that the man could be returned to normal location. This did not
happen and the man remained in the segregation unit, although he did return briefly
to the healthcare centre on 11 August. On 19 July, the Healthcare Manager noted
12
that she had taken part in a specific case review to determine the man’s future
location. She wrote, ‘Viewing the IMR there seems to be no clinical indication for
admitting him to healthcare, but segregation staff are concerned about his mental
health deteriorating if he remains in their unit. I have suggested that he could be
managed in a structured regime on the houseblock but this is currently unavailable. I
will discuss with other healthcare staff a way to take this forward and it may be
allowing him to associate in lower medical and being housed in segregation for the
time being.’
45. On 20 July, a further MARC meeting was held to discuss the man. It was noted that
during the review the man appeared calm but asked why he was in prison. The
Deputy Governor explained that his mother had died and he replied, apparently in a
detached and matter of fact way, ‘I’m sorry if I killed my mother.’ There were no
current issues about refusing food or drink.
46. Another F2052SH review was held on 21 July. The support plan was to maintain
Level 3 observations, review appropriate location, and maintain interaction. On 21
July, the CFPN and a social worker discussed the man’s management plan. Their
opinion was that the segregation unit was not the most suitable location for the man
and that his behaviour was unpredictable. They noted that he had previously been
managed in a more open environment, either in a hospital or in the community.
They felt that he did respond to firm, but calm management, and that being in the
Segregation Unit for a prolonged period might increase his hostile behaviour.
Initially, the man might be challenging to manage if allowed out of the segregation
unit, but they felt that could be achieved and that he would eventually settle.
47. On 23 July, Doctor D saw the man. He concluded that the man did not need to be in
the Segregation Unit and could be managed on normal location where staff would be
aware that he could be confused briefly after a seizure. There was no evidence to
indicate that the man had suffered any seizures during the previous three weeks that
Doctor D had been observing him.
48. On 26 July, another F2052SH review was held for the man. The man said he did not
have any intention of self-harm and did not recall shouting or being violent towards
staff. It is recorded that he admitted killing his mother during the review, but said he
did not recall what happened. The review panel were concerned that the F2052SH
was being kept open just because of the decision of the MARC panel. The man’s
support plan was for Level 3 observations to continue, for him to comply with
medication and to have continued support from the CFPN. There was also a
segregation review the same day. This was documented by a nurse who noted that
the man became annoyed when his previous volatile behaviour was mentioned. He
apparently maintained that he had never been violent and then said that his epilepsy
had been ‘visited upon by those who were sons of the devil’ and that he was under
the influence of the devil when he killed his mother.
49. During another F2052SH case review on 28 July, the man said he had no thoughts
of self-harm and a governor explained to him that the F2052SH was open as there
were concerns that he might harm himself if he remembered what had happened to
his mother. The F2052SH was to remain open until contact was made with the
Multi-Agency Public Protection (MAPP) team. The support plan was for Level 3
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observations to continue and for him to be encouraged to take his medication. A
F2052SH review held on 4 August noted that he looked as healthy as he had ever
been. The support plan was for him to remain on Level 3 observations, take his
medication and for staff to continue to interact with him. The 29 July segregation
review notes that the man behaved ‘largely normally and appropriately’ and ‘had no
mental health needs to address although it is difficult to see him settling amongst the
general prison population.’ He requested occasional sedation which the doctor did
not feel was unreasonable while he was in the segregation unit.
50. There are letters dated 3 and 4 August from Doctor D to Doctor B, and the
Consultant Forensic Psychiatrist respectively. Doctor D had been reviewing the man
for several weeks. The letter to Doctor B recommended that the man should be
admitted to the healthcare centre for an assessment over two weeks, as it was
considered that there had been deterioration in his mental state over the preceding
week. He said that he would liaise with the Consultant Forensic Psychiatrist.
Between them they would look at devising a comprehensive management plan over
the two weeks to give them a better indication of where the man would be best
located within the prison.
51. On 7 August, the man was seen by a RMN, who noted that his right elbow was
swollen and felt soft and palpable and a little hot to touch, possibly because of an
infection. There was no known cause and the man was not complaining of any pain.
A bruise was also noted to the inside of his upper left arm. He was referred to see a
doctor. He was seen by a doctor on 9 August, signature illegible, who noted, ‘has
some bruising on his right upper arm and tingling of his right 5th finger. Seg staff
report a change in his manner and speech over the last few days. Not sure if he has
had a fit but this is the most likely explanation for a right elbow injury’. The support
plan was to continue to observe him. It is not clear whether the man’s elbow was
examined further or treated.
52. A segregation review was also undertaken on 9 August. A note prepared by the
RMN said that staff suspected that the man might have had a seizure over the
previous three days, but this was not witnessed by anybody. There was discussion
about re-locating him to the healthcare centre for a period of assessment as
recommended by Doctor D. From a nursing perspective, it was felt that this was not
appropriate and would not be of any therapeutic value to him. It was noted that
Doctor D was to refer the man back to the Consultant Forensic Psychiatrist to
establish a care plan. There was reluctance within healthcare to receive the man
back to the healthcare centre because he was difficult to manage and had violent
outbursts. However, he was moved there on 11 August after he returned to
Blakenhurst from an outside hospital visit to Doctor E, a Consultant
Neuropsychiatrist, regarding his epilepsy.
53. During the evening of 11 August, the man began to destroy his cell. Two officers
entered his cell to try to calm him down. The man is reported to have punched one
of the officers in the face. Control and restraint (C&R) immediately took place during
which the man is reported to have headbutted the officer and he was returned to the
segregation unit. The man sustained minor injuries during the initial restraint and
relocation from the healthcare centre to the segregation unit, a cut to his top lip and
redness over his back area and wrists. His left leg was grazed and red below the
14
knee cap. He was seen by a nurse and did not require any medical treatment. His
behaviour continued to fluctuate and he remained agitated.
54. A prisoner at Blakenhurst at the same time as the man expressed concerns to my
investigator about the man’s treatment during this restraint and generally by a
specific officer. A report of the man’s restraint was produced at the time and detailed
the circumstances and minor injuries he sustained. The Officer in question no longer
works for the prison service so it would not be practical for the Governor to pursue
this further by way of investigation, although he may wish to review the management
of restraint procedures overall.
55. On 12 August, the man had a visit from the CFPN and the CPN. He was described
as co-operative, but said he was frustrated with the prison system. He said that he
wanted to kill himself and was sorry for killing his mother. They noted that he had
various injuries to his body: his right arm was swollen, his elbow was bruised and his
left large toe was swollen. On 13 August, Doctor D reviewed him in the segregation
unit with another doctor. He noted that the man had some bruising to his body,
which he said he sustained while he was being restrained. He said that he did not
have any thoughts of self-harm. The care plan was for the man to remain in the
segregation unit if feasible and to be reviewed by a doctor on a regular basis.
56. On 16 August, the man had a segregation review which was recorded. This said
that the man was calm, talkative and rational and went to chapel that day. The plan
was to continue to slowly integrate him into normal location.
57. On 21 August, Doctor D saw the man in the segregation unit. He noted that the man
was becoming increasingly preoccupied with numbers, behaviour which was
bordering on psychotic. He said that he had been told by the Consultant Forensic
Psychiatrist that a contact of Doctor F’s was trying to locate a bed for the man in a
secure psychiatric hospital. Doctor D noted that he would write to Doctor F about the
matter.
58. On 22 August, the man was again seen by a RMN for a segregation review. It was
noted that he was agitated and aggressive and was naked in his cell. He refused his
morning medication. It was also noted that, if he continued to refuse his medication,
he was to be referred to the doctor. The note in his medical record says, ‘Again
refused medication at midday, despite great effort to explain its necessity. Behaviour
becoming increasingly bizarre and hostile. Talking about being God and says that
the prison staff are disciples to the devil.’ The care plan was to encourage the man
to take his medication and, if he continued to refuse, to refer him to the doctor. His
possible admission to the healthcare centre was to be kept under review. He was
also to have had a F2052SH review on 22 August, but it was noted, ‘unable to
convene a review with the man because of his present condition, pacing the cell
naked and talking in a bizarre fashion. He has grabbed at staff, possibly in an
attempt to leave the cell. Having read his file there is apparently information which
we are unaware of which may require further case reviews and so we decided to
keep the form open.’ The support plan was to continue with Level 3 observations,
and to arrange a meeting to draw up a management plan as soon as possible.
15
59. On 23 August the man was seen by a doctor (no signature) in the segregation unit.
He had been swallowing paper in what was seen as a suicide attempt. He appeared
very disturbed, possibly psychotic and there were concerns about the ‘poor’
treatment for his epilepsy. It was recommended by the doctor that Doctor D should
pursue a bed in a psychiatric hospital for the man. In the meantime, the man should
be transferred back to the healthcare centre. The man had started to refuse any
medication that was not to control his fitting. By the end of August, he started to
refuse to take all his medication including his medication for epilepsy. Records note
that staff persistently tried to encourage him to take his medication. It appears that
he was transferred to the healthcare centre on 24 August, but this is unclear from the
records.
60. On 25 August, another Medical Disruptive Prisoner Risk Assessment was
undertaken. A management plan was implemented for the man which was for him to
have a two officer unlock, with a member of healthcare staff present, to exercise on
his own in the exercise yard, and to have a regular mental health review. A record of
all his behaviour was to be maintained.
61. By 27 August, there are notes in the man’s medical record that he had become more
psychotic, which was possibly linked to his temporal lobe seizures due to his refusal
to take his medication. He was seen by Doctor D and Doctor F. Doctor D noted that
the man was clearly psychotic and was probably having temporal lobe seizures. He
noted that the man told him he was the ‘Son of God’, that he was ‘special’ and
thought that a picture was talking to him. According to the notes, the man did not
remember what had happened over the previous three months and did not
remember that his mother had died.
62. Throughout August, records indicate that the man was seen frequently by
psychiatrists, the forensic team, and community and in-reach psychiatric nurses. He
became increasingly preoccupied with a combination of numbers and coincidences.
He also indicated that he had thoughts of suicide, did not want to be in prison and
regretted ‘killing his mother’.
63. Attempts were made to try to locate suitable accommodation for him both within a
nearby town and further afield. There is a letter from Doctor F, dated 3 September,
to the consultant forensic psychiatrist, which details what recent consideration had
been given to the most appropriate location for the man. The letter states that
Doctor F and the Consultant Forensic Psychiatrist had spoken about the man on 9
August, 17 August and 2 September. During the telephone call on 9 August, after
the Consultant Forensic Psychiatrist had visited the man at Blakenhurst, they had
discussed whether there were any residential units for epilepsy sufferers which
would be able to cope with the man’s episodes of aggressive behaviour. Doctor F
notes in the letter that she subsequently spoke to a Consultant Neuropsychiatrist
from Stoke, who did not know of any such unit and said that managers were wary of
accepting patients who might assault staff. Doctor F states in the letter that she also
spoke to Doctor E, who was reviewing the man regarding his epilepsy, and who had
recently been working at a residential unit for patients with epilepsy. He did not think
that unit would be able to manage the man, but said he would make further enquiries
and let Doctor F know.
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64. Doctor F notes that she spoke to the Consultant Forensic Psychiatrist on 17 August,
after a meeting when the CFPN had suggested that Doctor F refer the man to a
medium secure mental health hospital. Doctor F notes that she then contacted
Doctor G, a consultant rehabilitation psychiatrist in Leicestershire. Both she and
Doctor G felt that they could not consider detaining the man long term, under section
3 of the Mental Health Act, as they considered his mental health was relatively stable
when his fits were controlled. They concluded that he would benefit most from
independent living, with a support package to help him establish himself.
65. Doctor F writes that the CPN had visited the man on 25 August and found him
confused and disorientated, as he had not been taking his anticonvulsants regularly.
Doctor F records in her letter that she spoke to the Consultant Forensic Psychaitrist
on 2 September, after she had visited the man with Doctor D on 27 August, and they
found his speech rambling with little recall of recent events. In view of this, Doctor F
concluded that it was appropriate to transfer the man to a low secure private hospital
under section 48 of the Mental Health Act, and a forensic case manager was to look
for a suitable placement. Doctor F noted that, once the man’s mental health was
stabilised, his long term placement would need to be reconsidered. Meanwhile, it
appears that the man remained in the healthcare centre at Blakenhurst, although this
is not certain from the records.
66. During August, it was also noted that the man had started having more frequent
epileptic fits which were more severe. On 1 September, the man refused to take his
medication and he was found lying under his bed. On 2 September, he was found
having been incontinent of urine, although nobody saw him having an epileptic fit.
He had slept most of the night under his bed. He was later seen by the CFPN and
another CPN, but was not sure whether he had had a seizure during the night. He
complained of a painful left leg, which was warm and a little swollen, and he was
unable to stand. He said that he was well cared for in the healthcare centre and was
stupid not to take his medication. He saw a doctor that afternoon (signature illegible)
who noted that his left leg had felt hot and painful when he woke up, but was ‘a lot
easier now’. The doctor was concerned that the man might have suffered a fit the
previous night. There was no further mention of the problems with his left leg.
67. On 3 September, the man suffered a series of ‘grand mal’ seizures, repeated
seizures which were difficult to control and long lasting, and was admitted by
ambulance to hospital. At the hospital, signs of infection were identified on the right
side of his chest and his white cell counts were raised, also indicating an infection.
The diagnosis was thought to be status epilepticus (prolonged or repeated epileptic
seizures, without recovery of consciousness between attacks) with a lower
respiratory tract infection. Both these conditions were complicated as the man was
found to have an abnormal heart beat. He was treated with intravenous antibiotics
for the infection, antiarrhythmic therapy for the abnormal heart beat, and
anticonvulsives to control the seizures.
68. The man’s ongoing management was complicated by his agitated and erratic
behaviour. It was difficult for staff to examine him properly and obtain a clear
medical history. He repeatedly pulled out his intravenous antibiotics and sometimes
refused to take his oral medication. He also refused to take adequate fluid and
nutrition. Following a risk assessment by the prison authorities in which all the
17
necessary information was considered, the man was handcuffed to an officer and
accompanied by two other officers at all times. The post mortem states that the
cause of death was due to natural causes as a consequence of pulmonary embolus
and deep vein thrombosis.
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Clinical Review
69. The Clinical Reviewer concluded that all attempts were made by staff in Blakenhurst
to manage the man in an appropriate way. There was continuity of care between the
man’s community psychiatric team and the in-reach and forensic mental health
teams.
70. My investigator asked the PCT to conduct the review on 29 September 2004 but it
was not received until 4 October 2005.
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Consideration and conclusions:
71. The man presented with a range of complex physical and psychological difficulties
when he was located in Blakenhurst and many staff were in charge of his care. It is
not clear whether any effort was made to ensure that he took exercise and it appears
that he spent most of his time lying down in his cell. In view of his medical condition
and the medication he was taking, it would have been important for him to take
exercise although it is impossible to say what difference this would have ultimately
made to the man’s wellbeing.
72. The man’s cousin expressed concern about the role of the various psychiatric teams
involved in his cousin’s care before he was located in Blakenhurst. He also felt that
the police acted inappropriately in arresting the man considering his obvious mental
health problems. The man’s cousin criticised the role of the hospital from when the
man was admitted on 3 September until his death on 9 September. He questioned
why the man was allowed to refuse medication, food and water, and whether he
should have been sectioned under the Mental Health Act to ensure he complied with
his treatment. These issues are outside my remit, but the family may decide to
pursue them via the NHS complaints system.
73. During his time in hospital, the man was handcuffed to a prison officer and,
generally, two other officers were present at all times. The man’s cousin was
unhappy that his cousin’s freedom of movement during his last days was curtailed in
this way. I can appreciate that this must have been very distressing for the family,
but I am satisfied that the prison authorities undertook a proper risk assessment
based on the necessary and available information. I believe that the risk
assessment was appropriate in view of the man’s previous violent behaviour.
74. The man’s cousin also expressed disappointment at the lack of contact from the
prison after the man’s death. When this report was produced in draft form, my
investigator had not yet received a full reply from the prison to her inquiries about the
alleged lack of contact. Nevertheless, the prison maintain that there was contact
with the family and that funeral expenses were paid. Given the time that has already
elapsed since the man’s death, I do not wish to increase the delay in issuing this
report still further.
75. The man’s cousin was very concerned that the man was in prison and not located in
a secure psychiatric hospital. He said that he spoke to the man’s solicitor and
healthcare staff on several occasions to ask whether the man could be transferred to
a secure psychiatric hospital, but nobody took any action. It is clear (and was
acknowledged by various people involved in the man’s care) that the segregation
unit was not the most appropriate place to manage the man. It was also noted in his
records that his mental health generally deteriorated when he was located there.
However, neither the normal location house blocks, nor the lower medical, were
considered appropriate locations due to his aggressive behaviour.
76. As his mental health continued to deteriorate, the man had more frequent
assessments by his psychiatric teams. As detailed earlier, attempts were made to
obtain a suitable placement for the man outside Blakenhurst, preferably in a secure
psychiatric hospital. Given the man’s physical and mental health difficulties, the
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decision about where to locate him was difficult to make and finely balanced. Given
the evidence of what attempts were made to find a placement for him outside the
prison, I conclude that those efforts were reasonable.
77. There is no doubt that the symptoms of mental illness the man was exhibiting
became the focus of concern, and I can readily appreciate why this was. However, it
is impossible to say whether earlier treatment would have prevented his death. I
note that the man had complained of a sore arm on 7 August and a sore leg on 2
September. But it is not clear from the records whether he received treatment for
either complaint, and he had a chest infection by the time he was admitted to
hospital. It does not appear either that he saw a counsellor specifically to deal with
his bereavement as identified in his care plan. It is also difficult to identify from the
records exactly when he was located in healthcare at the end of August.
78. I recommend that healthcare staff endeavour to provide a more holistic
approach to care to ensure that all the patient’s needs are met - clinical and
psychological - including counselling, if appropriate.
79. I recommend that healthcare staff are reminded of the need for clear, concise
and contemporaneous record keeping in accordance with the Nursing and
Midwifery Council guidelines for records and record keeping. A clinical audit
system must be put in place to monitor compliance with these standards for
records and record keeping.
80. The Governor should remind all staff of the need to ensure that
contemporaneous prisoner records are maintained and updated particularly to
reflect decisions taken or considered and all prisoner movements.
81. A F2052SH was opened when there was concern during a MAPPA meeting about
the man’s possible reaction to the realisation that he had been responsible for his
mother’s death. It was closed after about 10 days before being re-opened five days
later at the advice of the MARC team. I have considered whether the F2052SH
should have been closed at all. However, at that time the man had not expressed
any suicidal or self harm intentions and there were no other indications that he was
at risk. Consequently it was appropriate for staff to close the form. Nevertheless, I
have detailed at length the range of issues involved in caring for the man in a
custodial environment. My overriding view is that prison was not a suitable location
for him.
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Recommendations:
OPERATIONAL:
The Governor should remind all staff of the need to ensure that
contemporaneous prisoner records are maintained and updated particularly to
reflect decisions taken or considered and all prisoner movements.
HEALTHCARE:
I recommend that healthcare staff endeavour to provide a more holistic
approach to care to ensure that all the patient’s needs are met - clinical and
psychological - including counselling, if appropriate.
I recommend that healthcare staff should be reminded of the need for clear,
concise and contemporaneous record keeping in accordance with the Nursing
and Midwifery Council guidelines for records and record keeping. A clinical
audit system must be put in place to monitor compliance with these standards
for records and record keeping.
The Prison Service has accepted all the recommendations. The man’s cousin
responded to the draft report and maintains that there was no contact from the prison
after the man’s death and has also said that he has not received reimbursement for
the funeral costs. The man’s cousin asked what had happened to money left in his
cousin’s prison account and finally he believed there should be some books
belonging to his cousin at the prison.
The prison does not have a record that anybody from the establishment contacted
the man’s family after his death. With regards to the funeral cost, the Governor has
agreed to pay the amount requested and is liaising with the man’s cousin about this
matter. When the man died, he had a balance of £51.58 in his account, which is
held in a suspense account at the prison. The prison could not find any books
belonging to the man at the establishment.
I would remind the prison that in future, they should allocate a Family Liaison Officer
and such matters should be dealt with in a timely and sensitive manner and suggest
that the cash in the man’s account should also be reimbursed.
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