Individual at Chelmsford

Investigation into the death of a man who died in a hospital on 25 February
2006, whilst a prisoner at HMP Chelmsford.
Report by the Prisons and Probation Ombudsman for England and Wales
October 2006
This is the report of an investigation into the circumstances of the death of a man
who died in hospital on 25 February 2006 whilst he was in the custody of HMP
Chelmsford. At the time of his death, he was aged 44 years.
A post mortem was carried out by a Home Office pathologist on 2 March 2006. He
found the cause of death to have been alcoholic liver disease.
My colleagues and I would like to extend our sincere condolences to the man’s family
and friends.
This investigation was conducted by one of my colleagues. A clinical review was
also commissioned to examine the medical care and treatment at Chelmsford prison.
This has been carried out by a clinical nurse from Essex Primary Care Trust, to
whom I am most grateful.
I would also like to take this opportunity to thank the Governor of Chelmsford and the
appointed liaison officer for their full and ready co-operation with this investigation.
This version of my report, published on my website, has been amended to remove
the names of the deceased and the names of staff and prisoners who were involved
in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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Contents
Introduction
Summary
Investigation Process
HMP Chelmsford
The man
Events leading to the man’s death.
Issues
Conclusions
Recommendations and Good Practice
Clinical Review
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Summary
This is the report of an investigation into the death of a man on 25 February 2006 at
a hospital to which he had been released on temporary licence from HMP
Chelmsford.
The man had been in custody since 27 January 2006. He had been sentenced to
three months imprisonment. The morning after his arrival in prison he was seen by a
prison doctor. After seeing the man, the doctor felt that he required hospital
treatment. He was taken to hospital under the escort of two officers.
On his arrival at the Accident and Emergency Department, he was assessed and
subsequently admitted for further care and clinical management.
The man’s medical condition continued to deteriorate despite medical intervention.
The officers were withdrawn on 21 February, when it was decided to release him on
temporary licence due to his ill health and poor prognosis.
My report examines the circumstances surrounding his death, the quality of the
written documentation provided, the effectiveness of the prison’s arrangements for
monitoring the well-being of prisoners temporarily located in a hospital within the
community, and communication between the hospital and the prison.
I also refer to the clinical review of his care whilst in prison. This review was carried
out at my request. The reviewer comments on the quality of record keeping and
concludes that it was of a high standard. The report also highlights good
communication between prison healthcare staff and the hospital where the man died.
The hospital contacted the man’s next of kin (his partner) to notify her of the death. A
letter of condolence was sent to her by the prison very soon afterwards. The deputy
governor contacted the next of kin to arrange a visit to the prison to collect the man’s
personal belongings and to offer any assistance that was required. Unfortunately,
the next of kin did not attend, and when a further date was arranged she again did
not arrive. I conclude that the deputy governor made every reasonable attempt to
meet with the family.
I make one recommendation in this report.
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Investigation Process
My practice in apparently natural deaths is to conduct an initial review to determine
the extent of the investigation required. My investigator arranged for all the
paperwork relating to this man to be sent to her. She was given access to all of his
records, including his medical record. Notices to staff and prisoners were sent to
HMP Chelmsford in order for them to be displayed around the prison. No member of
staff or prisoner expressed a wish to meet with my investigator. I suspect this is
because of the very short time that this man was actually in prison – just 16 hours
approximately.
A family liaison officer from my office contacted the man’s family. She explained the
purpose of the investigation, but the family wished to have no involvement.
A nurse from Essex Primary Care Trust carried out a clinical review of the
management of this man’s health needs whilst in HMP Chelmsford. She and my
investigator enquired as to whether this man was assessed properly on his arrival at
Chelmsford.
No formal taped interviews were conducted for this investigation.
Her Majesty’s Coroner for Essex and Thurrock was informed of the nature and scope
of my investigation. A copy of the post mortem report was also requested. This
report has been sent to the Coroner to assist with the inquest. The inquest was heard
on 12 December 2006 and concluded that the man died of natural causes.
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HMP Chelmsford
HMP Chelmsford was built in 1828 as a county gaol. Since 1987, it has been used
as a category B local prison and young offender institution.
Two new house blocks and a purpose built sports facility were opened in 1996 to
relieve overcrowding and provide extra activities. During 2000, Chelmsford
converted one of its residential units to house more young people.
A new healthcare centre was opened in July 2004. It has 12 beds, all single cell
occupancy. Healthcare provision is commissioned by Chelmsford Primary Care
Trust (PCT) with the Prison Service providing the nurses and the PCT providing the
medical officer. The healthcare centre provides care for both medical and psychiatric
admissions. Other specialisms available include alcohol and detoxification
counsellors and a dedicated mental health team.
Since April 2004, I have investigated two other natural cause deaths at Chelmsford
and one death that was apparently self inflicted.
An unannounced inspection of Chelmsford in 2004 by HM Chief Inspector of Prisons
records “an establishment continuing to make progress”.
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The man
He was separated from his partner and had three sons. He was 44 years old at the
time of his death.
On 3 October 2005, this man appeared at Southend Magistrates’ Court where he
was bailed to appear again on 27 January 2006. He returned to court on 27 January
and was sentenced to three months imprisonment for possession of an offensive
weapon. He was taken from Southend Magistrates’ Court to HMP Chelmsford by the
escort service, Premier Prison Services.
His family have been contacted by my family liaison officer. She told them how I
would be approaching the investigation and what it might include. She also offered
them the opportunity to meet and discuss any concerns they might wish to raise.
The family declined the offer of a meeting, and do not wish to have any further
involvement with this investigation.
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Events leading to the man’s death
Following his sentencing, this man arrived at HMP Chelmsford at 5.30pm on 27
January 2006.
On his arrival, he was medically assessed in reception. (Reception is an area within
the prison where prisoners are seen by a nurse and asked a variety of screening
questions pertaining to their health and medical history.) This assessment was
carried out by a nurse. The man disclosed that he had an enlarged liver due to an
excessive alcohol intake. He also said that he suffered with hypertension and was
on regular medication, although he was not sure what the medication was. The nurse
recorded her own observation from his physical appearance. She noted that he was
shaking, yellow in appearance, had shortness of breath and a dry mouth. The man
denied any use of illegal drugs, and said that he had no mental health problems. The
nurse concluded the first reception health screen by referring him to the doctor.
Within his medical record, the nurse wrote: “Admit to HCC (Healthcare Centre)
SOB++ (shortness of breath) Enlarged liver, excessive alcohol, waiting for ultra
sound appointment.”
Along with the clinical reviewer, I judge that the initial health screening was detailed
and that this man was appropriately admitted to the healthcare centre.
He was located in cell 001 in the healthcare centre. The centre can hold 12 patients.
All cells are single occupancy - ten are known as safer cells (to reduce the risk of
deliberate self-harm by patients) and the other two have special beds in them to
accommodate patients with any physical disability.
There are usually two/three officers working in the healthcare centre along with
three/four nurses. The nurses are both RGN (registered general nurses) and RMN
(registered mental nurses).
The next day, 28 January, the prison doctor saw this man at 11.35am. This
consultation took place in the healthcare centre.
The doctor wrote the following entry in the medical record:
“Not feeling well, loss of appetite. PMH (previous medical history)
1 - Hypertension not on medication.
2 - Liver Cirrhosis alcohol induced. Has had blood tests and was supposed to
go for abdominal ultrasound.
O/E (on examination)
Adb(abdominal) Distension++, Dilated abdominal veins++ Abdominal
ascites++ Liver palpable smooth tender. Oral mucosa/tongue dry.
Impression - 1 - Dehydration,
2 - Abdominal Ascities ?liver Cirrhosis,
3 - ?Portal Hypertension.
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Plan - Admit to hospital.”
Following this consultation, the man was taken to the Accident and Emergency
Department of a nearby hospital by prison escort.
When circumstances permit, a risk assessment has to be carried out when a prisoner
leaves an establishment. This assessment is to assess the level of security required.
At 12 noon on 28 January, the risk assessment for him was carried out and recorded
on a form. It was signed by a member of healthcare, security, Governor and I/C (in
charge) escort.
Sections that were completed in this form and are relevant;
1.1 Reason for appointment (ie broken arm, eye injury etc)
Ans Liver failure.
1.4 Is the condition life threatening?
Ans Potentially
1.6 Will the use of restraints impede the consultation and /or treatment? If
Yes explain how.
Ans Please be advised by hospital staff, at times a closeting chain may be
preferred.
1.7 Does the prisoner have a history of feigning illness or self-harm to
obtain an outside visit to hospital?
Ans Has just arrived some 16 hrs ago so no history.
1.8 Given his condition is the prisoner able to escape unaided?
Ans With difficulty.
The form concluded with the instruction that this man was to remain on his escort
chain at all times and that he would be supervised by two officers.
The form also covers visiting restrictions should the prisoner become an inpatient at
hospital. All visitors to the patient had to be booked with the security department.
Visitors would receive a rub down search using a hand held metal detector and a
thorough manual search of in possession belongings before a visit commenced. The
visits would coincide with hospital visiting hours.
He arrived at the hospital at approximately 12.40pm. The PER (prisoner escort
record) for this journey shows that he was double cuffed on leaving the prison at
12.15pm, this would be reduced to a single cuff for a doctor’s examination.
On arrival, he was seen and assessed in the Accident and Emergency Department.
He underwent a series of tests before being admitted.
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At 1.10pm, a request was made to Oscar 1 (the senior operational officer in charge of
the prison) to put the patient on a closet chain whilst he was being assessed in the
hospital. This request was granted. At 2pm, the prison was notified by an officer that
the man was going to be admitted to the hospital.
On his admission, a bedwatch log had to be arranged. The purpose of the log is to
provide escort staff with a picture of events surrounding the admission. It records
changes in medication, treatment, location, behaviour and level of restraint. The log
is also to show that staff have made regular security checks on restraints and
equipment at least hourly and on staff handover, as instructed in Chelmsford’s local
security policy.
Other significant entries may include visits to the prisoner, whether family, friends or
legal visits. It will also include any telephone calls made by the prisoner and any
correspondence received.
A bedwatch log commenced at 5pm on 28 January.
Escort staff also had responsibility to ensure that the prison was contacted at regular
intervals (no more than four hours) to update them on the current situation. The
instruction given is that the quality and standard of the log should be checked at the
end of shift by the in charge escort. The log continues with several entries made per
day until the man was released on temporary licence on 21 February.
`
My investigator examined the bedwatch logs for this man beginning 28 January and
ending 21 February. She checked that the contents were factual, consistent and
accurate.
Continuous entries in the man’s prison medical record after his admission to hospital
show regular liaison with the hospital in the community regarding his condition,
treatment and prognosis.
It is noted from the documentation that on 21 February the man received the last rites
from the hospital chaplain, as he was very poorly. This was also the day that he was
released on temporary licence. The application for this release was completed on
behalf of the man by the prison’s probation department. The licence was applicable
until the end of his treatment (it was a daily licence, meaning that the situation would
be reviewed on a daily basis). It also stated that daily visits from an Orderly Officer
should take place. The release on temporary licence was granted and signed by the
deputy governor. A follow up contact and monitoring log shows that the daily visits
did take place following the temporary release.
On 23 February, his condition was reported as deteriorating slowly and his family
were by his bedside. The following day, he was placed on a morphine pump. At
7pm on 25 February, he passed away. The prison sent a letter of condolence to his
family.
.
The deputy governor made two attempts to meet with the family, but each time they
failed to attend. For this reason, discussions regarding financial help for the funeral
and a representative attending from the prison never arose.
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Issues
Should this man have been admitted to the healthcare centre on his first night
or should he have gone straight to hospital? Did this have an impact on his
chances of survival?
My view, and that of the clinical reviewer, is that the initial healthcare screening was
detailed and that the man was appropriately placed in healthcare. Although the
nurse was concerned he was jaundiced, his GP was aware of his symptoms and he
was awaiting further investigations. There was no evidence of this man requiring
immediate or emergency medical attention.
Could he have been released on temporary licence sooner, and would this
have benefited him?
The clinical review recognises the need to balance the risks associated with issuing a
licence and the welfare of the prisoner. The reviewer adds that the involvement of
the healthcare staff in specific instances could enable licences to be issued
judiciously.
Was the level of security adequate or too high and did this impede the man’s
medical treatment?
There is no evidence to suggest that the level of security impeded the man’s medical
treatment. Although he was cuffed until 20 February, the day before he was released
on temporary licence, and was very ill with liver failure, he remained mobile and alert.
Having reviewed the circumstances, I believe that the decisions made in respect of
security were appropriate.
Were sufficient observations made and recorded?
In addition to the bedwatch log, management checks were carried out and recorded.
I judge that HMP Chelmsford met all due requirements.
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Conclusions
This man was seen and assessed appropriately at the prison. He was located in the
healthcare centre and seen by a medical officer within 16 hours of his arrival. The
healthcare staff maintained a high level of communication with the local hospital
following his admission. The healthcare records were of a high standard, all entries
were dated, timed and legible. The writers’ signatures also appeared in print.
Bedwatch Entries
The entries within the bedwatch logs were examined to ensure that they were factual
and sensitive records. They show the patient’s treatment, progress and any change
in behaviour and demonstrate that the prison was updated on his condition
throughout his stay at the hospital. The entries were fully consistent with what was
required.
Release on Temporary Licence
He was released on temporary licence on compassionate grounds on 21 February.
He died six days later. The clinical review notes that whilst the balance of risk has to
be recognised, so does the welfare of the prisoner. This must be right. I agree with
the clinical reviewer that it would be beneficial to have regular multi-disciplinary
meetings between all involved in health related matters (ie healthcare staff, bed
watch officers etc). This would ensure a complete picture is provided, enabling the
right decision to be made at the most appropriate time. In fact, I understand the
issue of this man being released on temporary licence was raised by the prison’s
probation department and agreed the same day.
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Recommendations and Good Practice
In view of the findings in the clinical review, I make one recommendation to the
Governor of Chelmsford:
There should be regular multi-disciplinary meetings once a prisoner has been
an in patient at a hospital in the community for more than a week, so that
decisions made about him are appropriate, timely and well informed.
The Prison Service accepted this recommendation and has reported that the Head of
Healthcare will organise weekly review meetings to include a representative from the
Security department and an Operational Manger. The notes will be published in the
prison’s daily briefing sheet.
Good Practice
• Record Keeping - This was of a high standard with entries timed, dated and
legible. Having said that, it is becoming common practice for medical records
to be computerised: this may be something the Governor can consider in
conjunction with the PCT.
• Communication - Prison healthcare staff made regular contact with the
hospital regarding this man and his prognosis. This was recorded in his
medical record and showed an on going concern for him and his welfare.
Where appropriate, the information was relayed to governors.
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