Individual at Brixton

Investigation into the circumstances surrounding
the death of a man
at HMP Brixton in June 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
October 2007
This is the report of an investigation into the circumstances surrounding the death of
a man on 25 June 2006 at HMP Brixton. The man died as a result of a myocardial
infarction (a heart attack), secondary to coronary artery disease. He was 36 years
old.
My colleagues and I would like to extend our sincere condolences to
his family and friends for their loss.
Two of my investigators conducted the investigation. A Clinical Review was carried
out by a doctor on behalf of Lambeth Primary Care Trust.
I am grateful to the Governor of Brixton and his staff for their co-operation with my
investigators.
The sudden death of a relatively young man is always a great shock. However, I
have found no evidence to suggest that the prison authorities could have anticipated
or known that the man was suffering from heart disease.
At the request of the man’s family I delayed the issue of this report for some time as
they endeavoured to obtain legal representation.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2007
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CONTENTS
Summary
Investigation Methodology
HMP Brixton
Events leading up to the man’s death
Clinical Review
Conclusion and Recommendation
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SUMMARY
The man who died was sentenced to seven years imprisonment in February 2003,
following a conviction for armed robbery. During the course of his sentence, he
moved around many prisons across the country, mainly due to his challenging
behaviour. At the time of his death, he was in HMP Brixton.
On 25 June 2006 at about 8.30am the man was found on the floor of his cell by a
fellow prisoner. He had seen the man on the floor via the observation panel in the
cell door. The prisoner called for help, alerting officers who arrived promptly.
Healthcare staff attended, but the man who is the subject of this report was clearly
dead and resuscitation was not appropriate. Formal certification of death was made
by the doctor present at 9.44am.
A post mortem was carried out by another doctor, a Home Office pathologist, on 26
June. He concluded that death was due to a myocardial infarction (heart attack)
secondary to coronary artery disease. Toxicology tests were also carried out and
the man tested positive for Dihydrocodeine and Cyclizine (both of which were
prescribed medications).
The doctor’s clinical review indicates that the care the man received in custody was
comparable to that which he would have received in the community.
I make one recommendation relating to Brixton’s family liaison arrangements.
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INVESTIGATION METHODOLOGY
1. One of my investigators visited Brixton on 28 June 2006. He was given access
to the man’s prison records and shown around the wing where he was located.
In September 2006, another investigator took over the investigation. She has
reviewed the available documents and has liaised with Brixton Police and HM
Coroner. She herself went on maternity leave in May 2007 and this report has
been issued by my Assistant Ombudsman.
2. Notices to staff and prisoners were sent to the Governor 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.
Neither of the Investigators was made aware of anyone wishing to see them.
3. As part of my investigation, a prisoner was identified as a possible witness.
However, it has not been possible to interview him as he has been released
from custody. He is part of a travelling community and his present
whereabouts are not known.
4. Lambeth Primary Care Trust (PCT) was invited to commission a review of the
clinical care that the man received while in custody.
5. One of my family liaison officers made contact with the man’s brother. She
explained the nature and scope of this investigation and the family was invited
to raise any concerns or questions they had. The family complained about the
frustrations they encountered when trying to obtain the man’s personal
belongings. They also wanted the investigation to establish if he received
appropriate medical care whilst in custody.
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HMP BRIXTON
6. Brixton is a local prison, serving mainly the Inner London and Southwark Crown
Courts. It holds remand and convicted prisoners. There are four main
residential units and a healthcare centre.
7. Her Majesty’s Chief Inspector of Prisons carried out an inspection of Brixton in
February 2004. The inspectors had some concerns about reception
procedures, but described improvements in first night and induction
arrangements. They said that healthcare staff were able to assess new
prisoners and give basic information on the availability of healthcare services.
However, the Chief Inspector’s report said that the healthcare staff who worked
in reception were under considerable pressure.
8. Brixton’s operational plans for a death in custody were last updated in October
2003. They say that when dealing with the apparent death of a prisoner, the
communications room is to contact ‘Hotel 6’ (the healthcare officer carrying the
emergency radio) to indicate that urgent medical assistance is required, and
then call an ambulance. The Communications Officer must not wait for further
details before calling an ambulance.
9. Brixton also has healthcare protocols for medical response codes. These say
that in a Code 1 emergency, Hotel 6 should attend, assess the patient, and
decide whether an ambulance is definitely required. A Code 1 emergency is
defined as life threatening, including situations where a prisoner is hanging and
not responsive.
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EVENTS LEADING UP TO THE MAN’S DEATH
10. When the man arrived at Brixton on 28 September 2005, his general health
was assessed, as it had been in previous prisons. He gave a detailed history
which included cholecystectomy (removal of gall bladder), arthritis, short
achilles tendon, fracture of an ankle, possible peptic ulcer, Marfan’s syndrome
and drug dependence. His weight and height were both recorded and some
routine blood tests were arranged.
11. On 17 October, a psychiatric referral was made by a prison doctor. He
questioned whether the man would benefit from being prescribed an
antipsychotic drug.
12. On 26 October, the man was seen by a visiting psychiatrist from a nearby NHS
Trust. This consultation recorded that the man had Post Traumatic Stress
Disorder (PTSD ) and a psychological disorder. The psychiatrist thought that
this was as a result of serving in the army. The man described his problem in
the following words: “I sometimes get depressed and my head goes.”
13. A prison psychologist made an entry in the man’s medical record on 29
November. She noted that he was currently undergoing a course of
counselling. He was keen to engage in any help offered, but reported that he
would not take any medication.
14. The man saw the psychiatrist again on 7 December. At the end of the
consultation, the psychiatrist suggested that he should continue to see the
psychologist to explore difficulties he might be having. No further out patient
appointment was required.
15. On 28 December, the medical records show that the man complained of
abdominal pain. The doctor who saw the man queried if he had pancreatitis or
peritonitis. An ambulance was called and the man was taken to hospital. He
was discharged on 18 January 2006 following a diagnosis of gallstone induced
pancreatitis. He had a laparascopic cholecystectomy (removal of gallstones)
as treatment for this.
16. There is little else of note in the man’s medical records. There are several
other consultations, but they pertain to him arguing with doctors about his
medication. The man was prescribed medication on a daily basis. The doctor
who carried out the Clinical Review says that the man was prescribed
dihydrocodeine. This is confirmed by toxicology at post mortem.
Sunday 25 June 2006
17. At 8.27am, after prisoners on the landing had been unlocked, a prisoner made
his way to the man’s cell (A1-37) to collect a cigarette. The man’s cell door
was still locked, so the prisoner looked through the cell observation window.
He saw the man lying on the cell floor beside his bed.
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18. The prisoner immediately called for staff. A Senior Officer went straight to the
cell, and called a Code 1 on his prison radio. (A Code 1 emergency is defined
as life threatening and alerts other staff that assistance is required). Two
Nurses, who were in A wing treatment room, heard the call and went to the cell
straight away. It was apparent to the nurses arriving at the cell that the man
had been dead for some time. Rigor mortis had set in and there was dried
blood and vomit around his mouth. It was very clear to both nurses that
resuscitation would have been to no avail.
19. A Governor arrived at the man’s cell shortly after 8.30am. The London
Ambulance Service was called and arrived at 8:40am. The prison’s on call
doctor was also called and arrived to pronounce life extinct at 9:44am.
20. Following the man’s death, a letter of condolence was sent to his family,
including an offer to help with funeral expenses. However, I am aware that the
man’s brother experienced a delay in retrieving his belongings from the prison.
This caused unnecessary distress at what was already a difficult time. The
man’s brother made several approaches to the appointed prison FLO (family
liaison officer) to obtain these belongings. In the end, out of frustration, he
contacted my Family Liaison Officer for assistance with this matter.
I recommend that the Governor ensures that a prisoner’s personal
belongings are returned to his family in a timely manner.
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CLINICAL REVIEW
21. A clinical review was commissioned by Lambeth Primary Care Trust.
22. The doctor who carried out the Clinical Review found that the medical records
for the man were easy to follow and would meet standards set out in the GMC
(General Medical Council) “Good Medical Practice”. The doctor said that it is
difficult to make an absolute judgement about completeness and it does appear
that some of the hospital correspondence may not have been filed. However, it
would be straightforward for any practitioner to have taken over the man’s care.
The difficulty for doctors involved with the man throughout his time in custody
was that he never allowed them to have access to his community medical
records. This is clearly evidenced within the man’s medical record (it was
entirely within the man’s rights to withhold this consent).
23. The doctor who carried out the Clinical Review noted that it was not possible to
clearly establish the history behind the possible diagnosis of Marfan’s
syndrome, due to a lack of access to the man’s medical records. Whilst in
custody, the man saw two hospital consultants, including a cardiologist and the
diagnosis of Marfan’s syndrome was disputed by both.
24. In relation to ischaemic heart disease, the doctor says that the post mortem
identified this condition, although it was clearly not made while he was alive.
The medical records show that, whilst in Parkhurst in 2005, the man had a two
day admission to hospital for investigations following chest pain.
Musculoskeletal rather than cardiac pain was diagnosed.
25. The man had a range of physical health problems. It is clearly unfortunate that,
despite investigations, a diagnosis of ischaemic heart disease was not made.
That said, the doctor’s opinion is that such a diagnosis would have been very
unusual for a man of his age, and the more so considering the investigations in
2005 were negative.
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CONCLUSION AND RECOMMENDATION
26. I conclude that the care the man received was compatible with the level of care
he would have received in the community and make just one recommendation
regarding the return of personal possessions.
I recommend that the Governor ensures that a prisoner’s personal belongings
are returned to his family in a timely manner.
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