Individual at Bronzefield

The Death in Custody of
a woman at
HMP Bronzefield in October 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2006
This is the report of an investigation into the circumstances surrounding the death
of a woman in hospital on 20 October 2005. Her death was caused by cerebral
compression due to a brain abscess. She was 30 years old. At the time of her
death, the woman was a prisoner at HMP Bronzefield.
I extend my sincere condolences to the woman’s family and friends for their loss.
The investigation was carried out by one of my colleagues. A clinical review into
the woman’s care and treatment was carried out by a qualified nurse and who
also works for my office. In addition a Nurse Consultant on Substance Misuse,
carried out a review of the management of the woman’s detoxification
programme. Her review also comments on other aspects of the woman ’s care
and treatment.
I would like to thank the Director of Bronzefield, and her staff for their help. I
would also like to thank the Director and the contractor, UKDS, for action already
taken following early disclosure of an interim draft of this report.
The condition from which the woman died is not common, but it is one with which
clinicians should be aware and is treatable. The two clinical reviews are very
critical of the clinical care and treatment afforded to the woman. She had been at
Bronzefield for just over three weeks by the time of her death, but it was only in
the final hours of her life that she was recognised to be unwell and sent to outside
hospital for further assessment. By then, it was too late.
I have made 20 recommendations, all of which are taken from the two clinical
reviews obtained in this case.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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SUMMARY.......................................................................................................4
INVESTIGATION PROCESS...........................................................................6
HMP BRONZEFIELD.......................................................................................7
THE WOMAN...................................................................................................8
THE EVENTS OF 27 SEPTEMBER TO 19 OCTOBER 2006..........................9
THE NIGHT OF 19 OCTOBER AND THE DAY OF 20 OCTOBER 2006 ......11
THE WOMAN'S CAUSE OF DEATH.............................................................15
CONTACT WITH THE WOMAN'S FAMILY...................................................16
FINDINGS AND CONCLUSIONS..................................................................17
RECOMMENDATIONS..................................................................................20
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SUMMARY
On 27 September 2005, the woman was received into HMP Bronzefield after
being convicted for breach of a community order. At that time, she was awaiting
sentencing.
Upon arrival at Bronzefield, she saw a nurse who carried out a first reception
health screening assessment. During this assessment, the woman reported that
she used heroin, cocaine and methadone. She also reported that she had
consulted her GP in the previous few months about a groin abscess and a severe
headache. She said on the form that she was concerned about her headache.
Although the woman supplied the name of her doctor, Bronzefield did not make
contact with the GP.
The following day, 28 September, the woman was seen by a local GP providing
primary medical services to Bronzefield. In their consultation the woman did not
mention any concern about headaches and so the GP did not explore that
condition with her. The GP prescribed medication for drug detoxification and
antibiotics for the woman’s groin abscess. Treatment for her drug detoxification
commenced without delay, but six days went by before the antibiotics were
issued by the prison pharmacy.
A friend of the woman said that she continued to suffer with headaches and was
also having ‘drop’ (fainting) fits. However, from 29 September to 19 October, the
only reference to either condition in the woman’s custodial and medical records
was when she fainted in the gym on 29 September.
At about 10pm on 19 October, the woman pressed the call bell in her cell and told
a Prison Custody Officer (PCO) that she had a headache. The woman was told
that, at night time, nurses did not usually visit prisoners who were only
complaining of a headache. At around 5am the following morning, the woman
pressed her call bell again and told the PCO that her headache was now more
severe and the pain was also running down the side of her body. This time the
woman was told that nurses did not visit prisoners after about 4am in the
morning.
When the day staff came on duty at 7.30am, a Senior Prison Custody Officer
(SPCO) saw that the woman had been complaining through the night about a
headache. He arranged for her to be first to see the nurse who would be issuing
the morning medication.
As the woman was walking to the medication room at around 8am, the SPCO
saw she was unsteady on her feet, so she was given a chair to sit on. A nurse
tried to question the woman about her symptoms, but she was not very
responsive. The woman was given two paracetamol tablets. After this, the
woman’s friend was asked to stay with her to keep a check on her condition.
For the next two hours, a PCO made frequent visits to see the woman. He did
not notice any deterioration in her condition and said that she made no
complaints to him that she was in pain. The woman’s friend said the woman’s
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arm was going numb, she was losing consciousness and she was incontinent.
She said that she was told by a PCO that the staff were waiting for healthcare to
arrive on the wing. The woman’s friend’s account is not consistent with that
given by the PCO.
At about 10.30am, a pre-arranged fire drill took place. Two other prisoners
supported the woman as they walked to the assembly point – a small courtyard
just outside the prison wing. The woman was unsteady on her feet and she sat
on a low concrete plinth. After about 15 minutes, the officers decided that the
woman should be checked by a nurse. A nurse came to see her. The woman
was able to converse with the nurse and to answer the questions she was asked.
The nurse decided to take the woman to the healthcare unit for further
observation, but at interview with the investigator said that she did not think that
the situation was serious.
When they arrived in healthcare, the nurse took clinical observations of pulse and
blood pressure and checked the woman’s pupils. These checks did not give the
nurse any cause for concern and so she left her while she carried out other
duties. When the nurse returned to the woman’s room at around midday, she
was sitting on the floor and had been incontinent of urine. On checking the
woman’s eyes, the nurse saw that her right pupil was dilated (enlarged) and was
sluggish in reacting to light. The nurse asked the GP to check the woman and he
quickly decided that she should be transferred to outside hospital. The
ambulance service was contacted at 12.25pm.
The woman arrived at hospital at about 1.15pm. Her condition deteriorated very
quickly from then on and at 6.30pm it was noted that the hospital doctors had
advised that she would not survive. The woman died at around 9.30pm. The
cause of death was cerebral compression caused by a brain abscess.
The condition from which the woman died is not a common one and would not,
perhaps, be the first diagnosis that would come to a clinician’s mind in dealing with
a patient. However, based upon the findings from the two clinical reviews
obtained in this case, I judge that opportunities were missed during the woman’s
time in Bronzefield that meant that the clinicians involved did not put themselves in
the best possible position to reach the correct diagnosis at an earlier stage.
I have made 20 recommendations.
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INVESTIGATION PROCESS
The investigation was opened on 27 October 2005, when my investigator visited
Bronzefield and met the prison’s Security Manager who liaised closely with the
woman’s family on the day she was sent to hospital and where she subsequently
died. My investigator also met the Home Office Controller, the chairperson of the
prison’s trades union and members of the Independent Monitoring Board (IMB).
My investigator informed those he met of the nature and scope of the
investigation. Notices were issued to staff and prisoners notifying them of the
investigation.
A trained nurse was appointed to carry out a clinical review of the woman’s care
and treatment. My investigator and the clinical reviewer visited Bronzefield and
carried out a number of formal interviews with staff and also spoke with a
prisoner. The clinical reviewer investigator subsequently carried out several
further interviews with staff by telephone.
One of my Family Liaison Officers contacted the woman’s mother to inform her of
the investigation.
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HMP BRONZEFIELD
HMP Bronzefield is a new prison in Ashford, Middlesex, which opened on 17
June 2004. It is a purpose built women's prison privately operated by United
Kingdom Detention Services (UKDS) and was the first women's prison in the UK
to be managed by the private sector. UKDS operates two other prisons, HMP
Peterborough and HMP Forest Bank in Salford. Bronzefield performs the role of
a local prison, taking prisoners directly from the courts. Additionally, sentenced
women may serve some of their sentence there. Bronzefield holds around 450
prisoners.
Accommodation at Bronzefield is provided in three houseblocks with mostly
single cells. Each houseblock is made up of four spurs of two landings each
containing 34 or 35 cells. There is also a unit for twelve mothers with babies.
The healthcare centre provides 18 in-patient beds. There is 24 hour nursing
cover. A doctor is available on site from 10am to 5pm, with an on-call service
operating outside of these times.
Bronzefield received an announced inspection by Her Majesty’s Chief Inspector
of Prisons (HMCIP) in June 2005. In her introduction, the Chief Inspector said
that over all it was a good report. The introductory paragraph to the healthcare
section of the report stated:
Prisoners at Bronzefield had a poor perception of the quality of healthcare
… Most complaints were about poor communication and delays in seeing
healthcare staff. Prisoners overwhelmingly raised this as a serious
concern. Staff acknowledged that healthcare services had been poor until
recently, but much had improved and was improving. A new head of
healthcare had been appointed and there was a stable staff group working
within a clear clinical management structure ... Despite the negative
perceptions, we observed very professional care from highly motivated
and caring staff to prisoners with very complex and challenging needs.
The woman’s death was the second death of a prisoner at Bronzefield since its
opening. The first death occurred four weeks before the woman’s death. In one
other case, a woman died in July 2004 within a few hours of being released from
Bronzefield. Both cases were investigated by the Ombudsman.
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THE WOMAN
The woman was born on 4 January 1975 and grew up in Sussex. She had one
sister and one brother. When she was eight, her father died of a heart attack at a
young age. The woman left school with a number of qualifications, including
mathematics and English. After leaving school, the woman did shop work and later
became a restaurant manager.
The woman’s first criminal conviction was in relation to offences of theft, deception
and handling stolen goods, occurring in late 1999. She was placed on a probation
order for two years. Following that first conviction, the woman was convicted for
many similar offences over the following years. She was sentenced to a number of
separate terms of imprisonment for periods ranging from one to four months.
The woman informed a probation officer that all her offences were linked to heroin
and cocaine addiction.
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THE EVENTS OF 27 SEPTEMBER TO 19 OCTOBER
On 27 September 2005, the woman was convicted at Magistrates’ Court for breach
of a community order. While awaiting sentencing, she was remanded into HMP
Bronzefield and she arrived there later that same day.
Upon arrival in Bronzefield, the woman received a First Reception Health Screen
assessment with a prison nurse. During this assessment, the woman supplied the
name and address of her doctor and reported that in the previous few months she
had consulted her doctor about symptoms of a severe headache and a groin
abscess. In answer to a question about whether she had any concerns about her
health, the woman replied that she was concerned about her headaches. She
declared that she was a user of illegal drugs and a urine test proved positive for
heroin, methadone and cocaine/crack. The woman signed a form giving her
consent for her doctor to release information about her medical history. She was
allocated a single cell in C spur of houseblock 1. (Houseblock 1 is the induction and
detoxification unit. The majority of cells in Bronzefield are single cells.)
On 28 September, the woman was seen by a GP, one of the prison doctors. The
GP’s note of his consultation with her mentioned her groin abscess, which he noted
as ‘improving’ and for which he prescribed two antibiotics and an anti-inflammatory
drug. However, the GP made no reference to headaches. At interview with the
investigators the GP said that he would have seen the First Reception Health
Screen form that included the references to headache. His practice, however, was
to ask open ended questions and when he asked the woman whether she had any
concerns or worries, she made no reference to headaches and so he did not ask
her any direct questions about that condition. He added that she did not ask for
stronger painkillers than the paracetamol that he prescribed for symptoms of drug
withdrawal. There is no documentary evidence of the woman mentioning
headaches in four subsequent consultations with other health professionals. Given
her declared use of opiates and cocaine and the positive urine test result, the GP
prescribed Lofexidine for the symptoms of opiate withdrawal and diazepam for
withdrawal from Benzodiazepine.
On 29 September, the woman attended gym induction (part of the prison induction
programme). During gym induction, prisoners receive some basic health and
fitness checks and are shown how each piece of equipment works. The woman
fainted while receiving induction and a nurse was called to examine her. The nurse
told the investigators that, when she got to the gym, the woman was lying on the
floor. She was alert and wanting to get up, but staff had told her to stay on the floor.
The woman said that she had not been well since being on Lofexidine. The nurse
took the woman’s blood pressure and pulse. After this, the woman was taken to an
office in the gym and was given a cup of tea. At interview, the nurse said that, as
Lofexidine sometimes lowers the blood pressure, she thought that that might have
been why the woman fainted. When the nurse took the woman’s blood pressure,
however, she found it to be 141/ (a slightly elevated reading).
90
Although the GP had prescribed antibiotics and an anti-inflammatory drug on 28
September, these drugs were not issued to the woman until 3 October. It seems
that there was a delay in this medication being supplied by the prison pharmacy, but
9
precisely why there should have been such a delay, or even any delay, is unclear.
Once these drugs were supplied, the woman was issued a seven day supply for her
to hold in her own possession.
On 4 October, the woman reported that she had overdosed by taking 14 of her in-
possession antibiotic tablets. The remainder of her in-possession medication was
taken away from her, although nothing was documented about precisely how many
tablets were taken from her. No note was made about whether she was spoken to
about her reasons for taking the overdose. However, an entry was made in the
woman’s medical records that in future, she was not to be issued with in-possession
medication.
Entries were made in the woman’s prescription chart showing that she was issued
medication in single doses for the remainder of 4 October, and throughout 5
October. However, it is unclear from these entries whether she was issued all of
the drugs that had been prescribed for her.
Despite the fact that a note had been made in the woman’s medical records that
she should not be re-issued with in-possession medication, three days’ worth of in-
possession medication was in fact issued to her on 6 October.
On 8 October, the woman moved to a single cell in D spur of houseblock 3.
The investigators spoke to a friend of the woman, a prisoner at Bronzefield who
knew her. The friend said that the woman had been suffering from ‘drop fits’ while
in Bronzefield and had told the officers that she was suffering from headaches. The
friend also said that the woman had not been eating or drinking in the last week of
her life.
Although it was recorded that the woman fainted in the gym of 29 September, her
records contain no other reference either to headaches or fits apart from her first
and last days at Bronzefield. Nor do the woman’s records contain any entries to
suggest she was failing to eat.
One of the officers told the investigators that the woman had complained about
headaches in the last two days of her life and he had advised her to ask for some
painkillers at medication rounds. In these final days, one of the PCO’s thought that
the woman was looking very tired and that, when coming down the stairs at meal
times she would walk slowly while holding on to the banisters. Also at around this
time there was an occasion when the PCO saw the woman having a fit. He
believed that a nurse was called from healthcare to deal with that problem.
On 19 October, the woman wrote a letter to her partner (which was never sent). In
her letter she wrote: ‘I haven’t gone to work at all today, I’m suffering severe
migraines, so I’ve been told …’
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THE NIGHT OF 19 OCTOBER AND THE DAY OF 20 OCTOBER
In a telephone interview, the night PCO told the clinical reviewer that at around
10pm on 19 October, the woman pressed her cell call bell. She said that she had a
bad headache and needed painkillers. As the night PCO had not previously worked
at night time, she did not know the procedures for dealing with an event such as this
and sought guidance from another officer. The night PCO was told that healthcare
nurses did not usually come out to prisoners at night for complaints of a headache.
The night PCO passed this information to the woman, who accepted what she was
told.
At about 5am on 20 October, the woman pressed her call bell again. She told the
night PCO that her headache was more severe and the pain was now running down
the right hand side of her body. The night PCO said that she telephoned a nurse in
healthcare who said that nurses did not visit prisoners after a certain time in the
morning – the night PCO thought the nurse said after 4am – and that the woman
would have to wait until the morning medication round. The night PCO went to the
woman’s cell to inform her of this, but she was underneath her bedclothes and
seemed to be sleeping. The night PCO therefore left without speaking to her.
Also in a telephone interview, the night nurse told the clinical reviewer that she was
on duty during the night of 19/20 October and received a telephone call from the
night PCO at around 5am. The night PCO said that a prisoner was complaining
about a headache/migraine and had tingling in the side of her face. The night nurse
asked the night PCO whether the prisoner had any other symptoms, such as
vomiting, but there were no other symptoms. There was nothing to indicate to the
night nurse that this was an emergency situation, so she told the night PCO that the
woman could not be given any medication at that time as it would interfere with her
morning medication. The night nurse told the night PCO to telephone again if there
were any further problems.
In her discussion with the clinical reviewer, the night nurse went on to explain that
Bronzefield’s policy, in general, was only to issue medication at night time if it was
absolutely necessary. She said that she had written a procedure on medication and
this had been distributed to the house blocks. The night nurse said that at night
time there were usually just two nurses on duty; personally, she did not think this to
be sufficient.
A Senior Prison Custody Officer (SPCO) said that, when he came on duty on 20
October, he read the occurrence book and saw an entry timed 5am that the woman
had been complaining all night about a bad migraine. At about 7.35am, the woman
rang her cell call bell again and once more reported that she had a severe
headache. Prisoners were due to be unlocked for medication at 7.45am and the
SPCO asked a PCO to ensure that the woman was first in the medication queue. A
Residential Manager was also present at this time and confirmed the instructions
given to staff. From a Residential Manager’s point of view he was satisfied that
everything was being done to help the woman. The SPCO said that when he saw
the woman walking after leaving her room, he could see that her problem was more
than a headache – she was unsteady on her feet and was very pale. The SPCO
got a chair for her to sit on and he told the medication nurse about the woman’s
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complaints of a headache. The SPCO said that the medication nurse did not come
out of the medication room. Instead, she spoke to the woman through the
medication hatch; this surprised him (the residential manager’s evidence, however,
was that the medication nurse did come out of the medication room).
The PCO confirmed what the SPCO said about ensuring that the woman should be
first in the medication queue and that she was unsteady on her feet.
The medication nurse said that she only worked part time at Bronzefield – working
as and when shifts were offered to her. On 20 October, she was due to deal with
the morning medication round. The medication nurse explained at interview that
this is a busy duty due to the number of women receiving medication, several of
whom receive vitally important medication such as insulin. The medication nurse
said that the SPCO told her that one of the prisoners had been complaining about a
headache all night and he asked that something be given for that symptom. The
medication nurse had not previously met the woman. The woman was being
supported by an officer and she was then given a chair to sit on. The medication
nurse said that she knelt in front of the woman and asked her how she was feeling.
She looked drowsy and did not respond to the question. The medication nurse told
the woman that she understood she had a headache and the woman muttered
something in reply. The medication nurse asked the woman whether she had taken
any medication and she shrugged her shoulders. The medication nurse then asked
the woman whether she would be able to swallow two paracetamol tablets and the
woman nodded. While the woman was swallowing the paracetamol with water, the
medication nurse asked an officer why the woman was not talking. The officer
replied that he did not know. The officer then said that he would take the woman
back to her cell and then bring the other prisoners waiting for morning medication.
The medication nurse told the investigators that she did not think that the woman’s
condition needed urgent attention – the SPCO had said that the night nurse had not
thought her condition serious enough for her to be seen during the night. The
medication nurse added that, at that time in the morning, the only nursing support
available is the ‘response nurse’ who deals with emergency situations. This meant
that there was no nurse on duty at that time to which the medication nurse could
have referred the woman for a full, non-emergency, examination. The medication
nurse said that procedures have changed since the time of the woman’s death. The
procedure now is that there is a nurse triage system in place that allows time for
those prisoners with health issues to be seen by the nurse after the medication
rounds are completed.
The PCO said that, after the woman had been seen by the medication nurse he
took her to a cell on the ground floor and he asked another prisoner, the woman’s
friend, to keep a watch on her. The cell used was not the woman’s own cell – her
cell was on the first floor and the PCO thought it safer to keep her on the ground
floor as she was unsteady on her feet. The PCO said that over the next few hours
he kept popping into the cell to check on the woman. During this time she was
sometimes awake and sometimes asleep. The PCO did not perceive any real
change in the woman’s condition through the morning and, as far as he could recall,
she made no complaints to him about being in pain.
12
The woman’s friend said that officers asked her to look after her friend once she
had been seen by the medication nurse. The woman came into her friend’s cell and
sat on her bed. The woman’s friend told my two colleagues that the woman’s arm
and hand were going numb and she was losing consciousness. The friend said that
the woman wet the bed, but we have not been able to substantiate this (it was not
until after her admission to healthcare that any incontinence was apparent to staff).
The friend said that she spoke to the PCO and he said that he was waiting for
healthcare to arrive.
At about 10.30am, a scheduled fire drill took place. This required all the prisoners
from D spur (where the woman was based) to move to a small courtyard adjacent to
the spur. The PCO said that the woman walked to the courtyard, but two prisoners
supported her as she was walking. When they got to the yard the woman sat down
on a low concrete plinth that prisoners use as seating. Two prisoners sat down
either side of her. After about 10 or 15 minutes, the PCO asked a prisoner to call
the SPCO for him to check on the woman. At interview, the PCO said that he could
not recall what triggered him to ask for the SPCO’s opinion at that particular
moment. The woman was still conscious at this stage.
The SPCO said that when he saw the woman in the courtyard she looked pale and
her eyes were closed. The SPCO ran to healthcare and asked a nurse to see the
woman.
The healthcare nurse said that, when she went to see the woman, she asked her
how she was feeling. She replied that she had had a headache for the past month
or so. The woman was alert and was able to answer other questions that the
healthcare nurse asked her, for instance whether she had had breakfast. She was
displaying no obvious signs of distress. The healthcare nurse decided to take the
woman to healthcare in order to take clinical observations. The healthcare nurse
collected a wheelchair and took the woman to healthcare. It did not seem to the
healthcare nurse that the situation was serious at that stage. When they got to
healthcare, the healthcare nurse took the woman to one of the empty cells. With
minimal assistance, the woman was able to transfer from the wheelchair to the cell
bed. The healthcare nurse took clinical observations of the woman’s pulse and
blood pressure and also checked her pupils. These checks did not indicate any
abnormalities. The healthcare nurse told the woman to lie down and rest and that
she would return to check her later on. It was by then approaching lunch time and
the healthcare nurse had a few tasks to carry out, including helping at the doctor’s
morning clinic. When the healthcare nurse returned to the woman’s cell, the woman
was sitting on the floor. She had been incontinent of urine. The healthcare nurse
asked her how she was feeling and asked her why she was on the floor. The
woman’s reply was incoherent. The healthcare nurse asked her to sit on her bed,
and she was able to do that. The healthcare nurse examined the woman and noted
that her right pupil was dilated and was sluggish in reacting to light. She said she
had a headache. The healthcare nurse then went to ask for the doctor’s assistance.
The healthcare nurse’s entry in the medical records is timed at 12.05pm.
The GP confirmed that at about 12.10pm he was asked by the healthcare nurse to
see a prisoner about whom she was concerned. The GP examined the woman and
found that her right eye was dilated and sluggish. The healthcare nurse told him
13
that the woman had been having headaches for several days, but when he tried to
question the woman about her symptoms she was largely unresponsive. The GP
said that, having observed those neurological symptoms, he decided that she
needed to be transferred to outside hospital for urgent assessment.
Records made at Bronzefield show that ambulance paramedics reached the woman
at 12.35pm and she was subsequently transferred to a general hospital about 10
miles from Bronzefield. Despite treatment at the hospital, the woman died that
evening.
THE WOMAN’S CAUSE OF DEATH
At post mortem, the woman’s cause of death was recorded as cerebral
compression caused by a brain abscess. In her case, the abscess had formed in
the right frontal lobe of her brain. The following information about brain abscesses
can be found on the NHS Direct website:
Brain abscess is a serious disorder that occurs when micro-organisms such as
bacteria or fungi get into the brain, causing inflammation. The bacteria or
fungi, along with infected brain cells and pus, mass together in one area of the
brain. They are joined by white blood cells that have been trying to fight the
infection. The body’s immune system responds by creating a membrane
around this infected portion of the brain.
The swelling inside the brain can put pressure on delicate brain tissue and the
mass of pus itself can block blood vessels that are supplying essential blood to
parts of the brain. If prolonged, this can cause brain damage, because the
oxygen supply to these tissues has been disrupted. It is therefore important to
treat abscesses as early as possible. Medication is the first line of treatment.
Most brain abscesses occur when infection spreads to the brain from
elsewhere in the body, mostly from nearby areas such as the ears. They can
also be carried in the blood from further away areas of the body. Sometimes
they are caused by head injuries or surgery.
Brain abscesses are very rare, but as long as they are treated before the
person goes into a coma, nine out of ten people will survive.
Information obtained by the investigation team from the woman’s own doctor shows
that she last consulted him on 23 September. She complained that day about
symptoms of headache and groin abscess. The doctor prescribed antibiotics and
noted that the woman had said that her symptoms of headache had previously
improved when taking antibiotics.
The woman’s weight on arrival at Bronzefield was recorded as 67kg. At post
mortem, her weight was recorded as 55kg. This suggests a very significant loss in
weight of 12kg (26lbs). In its response to the draft version of this report, Bronzefield
presented a number of persuasive arguments that suggest it likely that the woman’s
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weight on admission to Bronzefield was not 67kg, but was more probably 57kg. In
accepting this explanation, criticism must be made about standards of clinical
record keeping which is subject to separate criticism elsewhere in this report.
CONTACT WITH THE WOMAN’S FAMILY
The security manager at Bronzefield was informed that there was a medical
emergency at about 12.30pm and he was given further information, including the
identity of the prisoner, before the woman left for hospital. One of Bronzefield’s
nurses was at the hospital seeing another prisoner so the security manager asked
her to keep him informed about the woman’s condition. At 2.30pm, the security
manager was told that the woman’s condition was extremely serious and the
hospital was requesting the attendance of her next-of-kin. The security manager
was able to make telephone contact with the woman’s partner and her sister, both
of whom live in Sussex. They said that they would come to the hospital. After this,
the security manager was also able to make contact with the woman’s mother. At
6.30pm, the security manager was informed that the woman would not recover and
that the hospital was awaiting the arrival of her family. The security manager then
went to the hospital. When he arrived, he was told that the doctors wished to
withdraw life support. After the security manager spoke to a nurse, the hospital
agreed to delay the withdrawal of life support until the arrival of the woman’s family.
The woman’s partner and sister arrived at 7.40pm and they were with her when she
died at around 9.30pm.
The security manager paid for a taxi to take the woman’s partner and sister back to
Sussex. Bronzefield arranged a memorial service at the prison, which a number of
the woman’s family attended. The prison mini-bus collected her family from
Sussex and took them back there after the service.
Bronzefield paid for the woman’s funeral. The security manager represented the
prison at the funeral service and organised the transfer of her property to her
family.
15
FINDINGS AND CONCLUSIONS
When the woman was received into Bronzefield on 27 September 2006 she saw a
nurse for the purpose of a first reception health screen. At this consultation the
nurse recorded that in the recent past the woman had seen her doctor about two
conditions – severe headache and an abscess in her groin. In answer to a
separate question further on in the health screening form about physical health
concerns, she said that she was concerned about her headaches. The woman
supplied the name and address of her doctor.
On 28 September, a prison doctor, the GP, saw the woman. The GP recorded
that the woman had a groin abscess, but his records contain no reference to
headaches. At interview, the GP said that he had read the woman’s first
reception health screen form, but his practice was to ask open questions and the
woman made no mention of headaches. While I acknowledge the value of open
questions as a way of eliciting information, closed questions also have a value. I
consider that the GP should have followed up his open questions by asking the
woman specifically about her headaches. It may well be that she made no
mention to the GP of that symptom, but her first reception heath screen form
contained two separate references to it.
During the consultation, the GP prescribed the woman medication for
detoxification from opiates. The GP also prescribed antibiotics and an anti-
inflammatory for the woman’s groin abscess. There was no delay in the
commencement of the woman’s detoxification medicines, however six days
passed before she began to receive her antibiotics.
Although the woman gave her consent for her doctor to release to Bronzefield
information from her medical records, it would not seem that the doctor was
contacted. Several other matters of concern were identified in the two clinical
reviews obtained to consider this case. One matter was the recording of clinical
observations. It is a Prison Service requirement that clinical observations should
be recorded for at least the first 72 hours for those going through detoxification.
Where there are complications, such as an abscess or headaches, these
recordings should continue until the physical symptoms have resolved
satisfactorily. In the woman’s case, a few recordings were made of her blood
pressure and pulse, but no recordings at all were made of her temperature. A
high temperature (pyrexia) is a classic warning sign of infection, enabling
clinicians to deliver appropriate care and treatment.
In her review of the woman’s detoxification plan, the clinical reviewer has criticised
aspects of the regime used and has also criticised the later addition to the regime
of a night time sedative. The clinical reviewer is also critical of the standard of
record keeping, referring to the lack of a care plan and the lack of
contemporaneous nursing records.
Another matter identified in the clinical reviews relates to the overdose of
antibiotics that the woman took on 4 October. The clinical reviewer points out in
her report that only a very limited range of medicines, for instance asthma
inhalers, should be issued in-possession during the detoxification period. Having
16
taken the overdose, an entry was made in the woman’s records that she should
not be reissued with in-possession medication. It is not clear if the woman was
issued all of her medication during the following 36 hours or so. However, on 6
October, she was reissued with in-possession medication contrary to the explicit
instruction recorded two days earlier.
The woman’s friend said that the woman had been suffering with headaches
and had told the officers about that. She had also been having ‘drop fits’. One
of the PCOs acknowledged that the woman had complained to him about
headaches in the last two days of her life and he advised her to ask the nurses
for painkillers. He had also witnessed her having a fit at this time and he
thought that a nurse had come from healthcare. There is nothing in the
woman’s records to indicate that staff noticed any problems with her health.
The sequence of events as they unfolded through the night of 19 October, and as
they continued through to midday on 20 October, make for disturbing reading. At
about 10pm on 19 October, the woman rang her cell bell and told the night PCO
that she had a bad headache and needed painkillers. The night PCO had never
previously worked a night shift, so she asked another officer for advice on
procedures and was told that nurses do not usually visit the wings at night for
headaches. The night PCO passed this information to the woman. At around
5am on 20 October, she rang her cell bell again and told the night PCO that her
head was really painful and the pain was also now running down the side of her
body. The night PCO contacted healthcare and was told by the night nurse that
the woman could not be given any medication at that time, as it would interfere
with her morning medication.
When the SPCO came on duty in the morning he checked the wing observation
book and saw an entry stating that the woman had been complaining all night
about a bad migraine. The SPCO made arrangements to ensure that the woman
was the first to be seen at the morning medication round. I commend the SPCO
actions. While waiting to be seen, the woman was noted to be unsteady on her
feet and was given a chair to sit on. The SPCO said that the medication nurse
remained inside the medication room and she spoke to the woman through the
medication hatch. This had surprised him.
There is a disparity between the evidence given by the SPCO and that given by
the medication nurse. The medication nurse said that she did come out of the
medication room and that she knelt in front of the woman to speak to her.
Whether or not the medication nurse came out of the medication room, we do
know that the medication nurse had difficulty in obtaining information from the
woman and she asked the officer why she was not talking. The medication nurse
gave two paracetamol tablets after the woman nodded her head to indicate that
she would be able to swallow the tablets. The medication nurse explained to the
interviewers that the only nursing support available to her at that time of the day
was the ‘response’ nurse who has responsibility for dealing with emergency
situations. The clinical reviewer considered that the woman’s condition at this
time was such that she should have been admitted to healthcare for observation.
17
After she had been seen by the medication nurse at around 8am, the woman went
to her friend’s cell and this friend was asked to keep a check on the woman. The
woman’s friend said that the woman was incontinent, her right arm was going
numb and she was lapsing in and out of consciousness. She said that she spoke
to the PCO and he said they were waiting for healthcare to come. The PCO told
the investigation team that throughout the next few hours he kept going back and
forth to the woman friend’s cell to check on the woman (this is confirmed from the
CCTV footage). He said that, although the woman was very drowsy, there was
nothing about her condition to give him cause for concern. Nor did the woman’s
friend say to him that she was concerned.
At about 10.30am, a pre-arranged fire drill took place and prisoners were taken to
a small courtyard. The woman was unsteady on her feet and was escorted to the
yard by two of the prisoners. When they reached the yard, she sat down on a low
concrete plinth. Staff and prisoners became concerned about her condition, so
healthcare were contacted. The healthcare nurse came to see the woman and
decided she should take her to the healthcare unit. The healthcare nurse did not
consider that the situation was serious at that time. When they arrived in
healthcare, the healthcare nurse recorded the woman’s pulse and blood pressure
and checked her eyes. The healthcare nurse told the woman to rest and said she
would return later to check on her. The healthcare nurse was still not concerned
at that stage. It was when the healthcare nurse returned to see the woman at
around midday that she realised that the situation might be serious and she called
the GP. With very little further delay, an ambulance was called and the woman
was rushed to hospital. When she reached hospital, it seems to have become
clear fairly quickly that she would not survive.
The woman died from cerebral compression caused by a brain abscess. The
clinical reviewer points out in her report that, although a rare condition, brain
abscess is a known complication that can arise from injecting drug use. In the
woman’s case, opportunities were missed that might have had an impact upon the
ultimate outcome:
• When she first arrived in Bronzefield the woman reported that she had
recently consulted her doctor about a groin abscess and about headaches.
Despite this recent clinical history, the woman’s doctor was not contacted and her
medical records were not obtained. PSO 3050, issued in February 2006, advises
that efforts should be made to obtain the records from doctors or other relevant
services with whom the prisoner has been in recent contact.
• The woman also reported on that first day that she was concerned about
headaches, but this report was not explored.
• The woman was prescribed antibiotics for her groin abscess on 28
September, but six days passed before the antibiotics were issued by the prison
pharmacy.
• The woman’s clinical observations should have been recorded for at least
the first 72 hours, but her temperature was never recorded and so this possible
warning sign of an infection was missed.
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• Finally, the woman began complaining of a severe headache from around
10pm on 19 October. She complained again at around 5am the following morning
and at around 8am she was observed to be unsteady on her feet so a chair was
brought for her to sit on. When the medication nurse tried to speak to the woman,
she was minimally responsive. Despite these obvious signs that morning that the
woman was unwell, three hours had passed before she was taken to healthcare
and it was a further hour before an ambulance was called to take her to outside
hospital.
19
RECOMMENDATIONS
I make the following recommendations which are based upon the clinical
reviews obtained in this case.
In response to early disclosure of an interim draft of this report, UKDS
responded with comments on existing practices or action since taken in relation
to specific recommendations. Comments from UKDS appear below the relevant
recommendation.
HEALTHCARE AT BRONZEFIELD
1. The PCT, in partnership with the Director, must undertake a health
needs assessment of the local primary and secondary care services for
female prisoners at Bronzefield. This must include considering the next
steps to address the identified learning from this investigation and an
action plan to meet them.
Recommendation accepted.
The PCT have confirmed that a Health Need Assessment will be carried
out at the prison starting July 2006.
HEALTH SCREENING
2. Where a prisoner presents with any previous medical history or
reports that they are receiving prescribed medication, information
regarding medical history and current prescribing must be obtained
from the GP or hospital.
2.1. Where a medical history is requested but does not arrive, this must
be pursued until the information is obtained.
2.2. Where there have been previous admissions to prison, the medical
record for the past periods in custody must be obtained.
Recommendation accepted.
Response from UKDS: It is now the practice of the nurses in the out
patients service to contact the prisoner’s GP within 24 hours of arriving at
the prison for those whom this is deemed necessary.
It is already the practice of the nurses in the outpatient’s service to
contact the prisoner’s GP within 24 hours of arriving at the prison for
those for whom this is deemed necessary. A monitoring system is now in
place which includes regular chasing of non received information. This is
not to say, however, that every set of notes should be obtained. The
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need for clinical records is a decision that should remain with the lead
clinician.
Archived medical records are now kept with the core records and are
retrieved each time a prisoner returns to the prison. The medical in
confidence guidelines are still maintained, however this does ensure that
previous medical records are available to healthcare staff as soon as
possible.
3. The First Health Reception Screen form should be used to inform
subsequent clinical consultations. All physical, psychological and drug
related health issues declared on the form must be discussed with the
prisoner and further clinical information obtained to enable an appropriate
management plan, including clinical tests and treatment to be developed.
Recommendation accepted.
4. A pregnancy test must be undertaken for all women of child bearing
age with the result being entered in the medical records.
Recommendation partially accepted locally.
Whilst this cannot be enforced, a pregnancy test is offered to all on
reception with decisions to refuse recorded.
CLINICAL SUBSTANCE MISUSE
5. HMP Bronzefield must fully review their drug service provision in line
with the Drug Treatment Services Guide and the identified learning from
this investigation, including the two specialist reports, and develop an
action plan to address the identified issues.
Recommendation accepted.
UKDS have recently met with a specialist and the Head of Health and
Offender Partnerships to explore a service which links more closely to the
Drugs Treatment Service Guide. As a result of this meeting the specialist
will be assisting all UKDS prisons with a review of the current drug
service provision and will work in partnership with the UKDS Healthcare
Advisor to agree changes to promote a closer working relationship.
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MEDICATION
6. Other than in the case of exceptional circumstances, medication must
be issued and dispensed on the day it is prescribed. The Director might
wish to investigate the reasons for the six day delay in the woman being
issued her prescribed antibiotics.
Recommendation accepted.
We are investigating the circumstances which led to the delay, and will
act on any outcomes.
7. Medication (other than asthma inhalers and topical creams) should not
be given in-possession during the withdrawal phase.
Recommendation accepted.
This will be incorporated into the review referred to under
recommendation 5.
8. An overdose in custody can be a contra-indication for issue of in-
possession medication. Where a prisoner has taken an overdose, an
appropriate risk assessment should be carried out with that individual
before issuing further in-possession medication.
Recommendation accepted.
Response from UKDS: This is current practice.
9. The use of Tricyclic anti-depressants for sedative effect at night must
be reviewed.
Recommendation accepted.
Response from UKDS: The Head of Healthcare and the UKDS Medical
Adviser will undertake a review of the use of Tricyclic anti-depressants for
sedative effect at night.
RECORDS/RECORD-KEEPING/COMMUNICATION
10. Baseline clinical observations of temperature, pulse and blood
pressure must be undertaken on every new admission requiring clinical
substance misuse management for at least the first 72 hours as indicated
in PSO 3550. Any abnormalities in temperature or blood pressure
recordings should be monitored until stable for a period of several days
and the patient reviewed by a doctor.
Recommendation accepted.
22
This will be incorporated into the review referred to under
recommendation 5.
11. Where there is any concurrent infection in a patient, or other
symptoms such as headache or fainting, clinical observations must be
monitored until the physical symptoms resolve.
Recommendation accepted.
Response from UKDS: All healthcare staff will be reminded of the need
to monitor prisoners with the described symptoms. This will also be
reinforced in the nurses/healthcare assistants training programme.
12. Any persistent complaint of a headache should be viewed as
potentially serious and monitored and/or assessed. If there are other
presenting symptoms, or the headache is unusually severe, or persists
over a protracted period, assessment in outside hospital must be
arranged.
Recommendation accepted.
Response from UKDS: This will be put on the agenda of the next Clinical
Governance meeting to be discussed with the lead GP.
13. An audit of record keeping practices at Bronzefield against Nursing
and Midwifery Council (NMC) and General Medical Council (GMC)
standards should be undertaken. It should include the use of
contemporaneous nursing records and care plans for the acute period of
stabilisation and for a prolonged period where concurrent physical
symptoms persist. Language used in medical and nursing records should
be respectful and demonstrate empathy.
Recommendation accepted.
Response from UKDS: This has already been planned.
14. Communication between the members of the healthcare team should
be encouraged. Multidisciplinary team meetings and discussions should
be considered as this would improve continuity of care. Communication
between multidisciplinary staff needs to be addressed as a matter of
urgency and should abide by the principles set out in the Nursing and
Midwifery Council’s code of professional conduct.
Recommendation accepted.
Response from UKDS: The healthcare department holds weekly care
plan meetings. Action can be taken by healthcare staff in the interim
periods as required after assessment.
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SELF-HARM
15. The Director must arrange introduction of a policy for caring for, and
for the clinical monitoring of, patients who have taken an overdose. The
policy must include both the physical assessment and psychological
support aspects of care and should reflect the local suicide and self-
harm policy and must be communicated to all healthcare staff.
Recommendation accepted.
Response from UKDS: The healthcare department has an in-possession
risk assessment currently in place. A protocol for the treatment of a
prisoner who takes an overdose has now been completed.
CONTINUOUS PROFESSIONAL DEVELOPMENT
16. The Director must ensure that a policies and procedures manual is
available in a hard copy and electronic format for all staff. Healthcare staff
must be reminded to follow policy at all times and should ensure that they
remain up-to-date in accordance with the NMC code of professional
conduct.
Recommendation accepted.
Response from UKDS: Each member of the healthcare team will be
issued with a personal copy of the policies and procedures relating to
healthcare, with a copy to be held centrally. Policy reviews will be
considered at Clinical Governance meetings with revised policies
disseminated for individual update. Training on policies will also form part
of the healthcare training programme.
17. A professional training and development needs analysis must be
carried out to identify the training needs of all staff working in healthcare.
Recommendation accepted.
Response from UKDS: This has already been started and will be
completed shortly.
18. Staff on professional registers must be reminded that they have a
personal responsibility to maintain their continued professional
development.
We recall this was discussed with the Deputy Ombudsman at the time
of her visit. The Deputy Ombudsman advised that this was indeed a
general comment, which refers to the actions or a few individual nurses
and was not referring to the entire healthcare staff. It was meant to
suggest that it is always useful to have reminders to any nursing group.
24
The Head of Healthcare already has this as part of her ongoing clinical
supervision of the department.
19. Staff on professional registers must be reminded that they have a
personal responsibility to adhere to the standards set out by their
professional bodies in relation to patient care. For instance the
requirement that staff should understand and work within the limits of
their competency.
(See response to recommendation 18)
20. Prison Custody Officers should receive an induction on night time
procedures before carrying out a night shift.
Recommendation accepted.
Response from UKDS: The Head of Healthcare already has this as part
of her ongoing clinical supervision of the department.
A review of the Local Operating Policy covering night procedures has
already taken place and has been distributed to all staff. The night
orderly officer will additionally brief any new member of night staff.
25