Individual at Coldingley

The death in custody of man
on 20 December 2005 at HMP Coldingley
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2006
This is the report of an investigation into the death on 20 December 2005 of a man whilst in the
custody of HMP Coldingley.
The man’s death was caused by 1) Viral Myocarditis (inflammation of heart muscle) 2)
Hypertensive heart disease. My colleagues and I would like to extend our condolences to his
family for their loss.
The Prisons and Probation Ombudsman investigates the death of all prisoners in custody
including those due to natural causes. In this case the investigation was carried out by one of
my investigators. The clinical review was carried out by a doctor from Woking Primary Care
Trust and a copy of his report is annexed.
I would like to thank the liaison staff for their assistance in sending the relevant paperwork and
facilitating my investigator’s visits to the prison.
Emma Bradley
Deputy Ombudsman August 2006
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Contents Page
Summary 4
Background 5
HMP Coldingley 6
The investigation process 7
Key Findings 8
Conclusion 12
Recommendations 13
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Summary
1. The man died aged 43 on 20 December 2005 whilst in custody at HMP Coldingley.
2. The man had suffered from abdominal pain for a large proportion of his sentence. He
had had an umbilical hernia repaired and then developed a ventral hernia. He was due
to have an operation to repair this in January 2006. Diabetes was diagnosed whilst he
was in prison. The man was given medication to stabilise this and was also given
dietary and exercise advice to control his weight. He was also taking part in remedial
gym sessions.
3. He developed a good rapport with staff and other prisoners and was well thought of. He
was involved in organising games and activities for prisoners. He also used his time
productively to gain educational qualifications.
4. The events of 20 December happened very suddenly. Staff and the colleagues he was
with had no indication that anything was wrong with the man, until he became ‘dizzy’ and
had to sit down.
5. Medical assistance and an ambulance were summoned and attended very quickly,
although all attempts to resuscitate him were sadly unsuccessful.
4
Background
6. Born in 1962, the man was 43 years old when he died. He lived in London.
7. His brother and sister visited and supported him whilst he was in prison. In 2001 his
mother passed away and he noted this as a time when he “went off the rails” and went
through a difficult period. The man had a son, although he had separated from his
partner. He wanted to further his skills whilst prison, so that he could provide for his son
on his release.
8. On reception into prison he was of no fixed abode and wanted to secure accommodation
for his release. He had referred himself to Langdon House in Poole, this is secondary
rehabilitation accommodation for ex-prisoners, this placement would have provided
accommodation and support for drug use on release.
9. The man ran his own retail business; it was problems relating to this that led to his
offence and subsequent imprisonment. During his time in custody, he undertook several
courses to develop his skills. As well as completing offending behaviour and life skills
courses, he successfully completed NVQ Level 2 engineering production/welding. He
was employed in the welding workshops at Coldingley before his job as canteen worker
and had received very positive reports.
10. Not only did he use his time in prison productively, by gaining qualifications, but he was
also involved in the Games Amenities Sports (GAS) group which ran a range of social
activities for other prisoners.
11. The man had a good rapport with staff and other prisoners. In reports and interviews he
was described as a hard worker, polite, gregarious, fun and very good at deescalating
potential arguments.
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HMP Coldingley
12. HMP Coldingley opened in 1969 on the site of a former Boys Home. It was then a
Category B Training prison and the country’s first ‘Industrial Prison’ aimed at providing a
regime designed around a 37 hour working week.
13. In 1993 the prison was re-designated as a Category C Training prison. There have
since been many changes and it is now focused on providing a range of purposeful
activity, employment and resettlement work.
14. Coldingley is made up of four residential wings and a small annex with the majority of
accommodation being single cell occupancy. It holds up to 392 prisoners serving all
sentence lengths, including life sentence prisoners.
15. There is no in-patient healthcare facility at Coldingley. Prisoners with increased
healthcare needs are transferred to nearby prisons with appropriate facilities. There is a
Healthcare centre which operates services parallel to a GP surgery, also offering a walk-
in clinic and treatment for minor injuries. This is located in the corridor between A wing
and D Wing, approximately 20 - 30 yards away from the association room where the
man was working at the time he became ill.
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The investigation process
16. My investigator requested all the relevant prison records relating to the man. These
included his medical record and core prison record. She also visited the prison.
17. A clinical review was undertaken on behalf of the Surrey Heath and Woking Primary
Care Trust and his report is annexed.
18. HM Coroner for Surrey was informed of the Prisons and Probation Ombudsmans’
investigation. He provided my investigator with the Post Mortem. The Coroner will
receive a copy of this report upon its completion.
19. The man’s sister was identified as the next of kin. It was his brother however, who
requested contact with my office. The man’s brother had visited him three weeks
previously and said he had not mentioned any particular concerns. He was aware that
his brother was still having trouble with a hernia, but that was the only matter raised.
20. There was a considerable delay in receiving toxicology results and the family did not
want to bury the man until the cause of death was confirmed. This has caused
understandable distress to the family.
21. All the notices to staff and prisoners were supplied to, and displayed by the prison, to
allow anybody with information to be able to talk to my investigator. One prisoner asked
to speak to my investigator and was concerned that the man was initially only asked to
sit down and have a glass of water, before the ambulance was called and that he had
had hospital appointments cancelled. My investigator interviewed three other friends
and colleagues of the man’s, who were present and helped him to sit down. Their
actions are detailed later in the report, and my investigator is satisfied that the response
to the situation was swift and appropriate.
22. A draft copy of this report was issued to the man’s family and Coldingley for them to
make any comment. The man’s family have not made any comments. Coldingley have
found some factual inaccuracies which have been amended and their response to the
recommendations made is included in the recommendation section.
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Key findings
23. The man was remanded in custody at HMP Wandsworth on 13 July 2002. He was
sentenced at Harrow Crown Court on 3 December 2002 and received a seven year
sentence.
24. On 20 May 2003, he was transferred to HMP Coldingley which is a lower category
training prison.
25. During his sentence the man used his time productively. He attended and, successfully
completed programmes to address his offending behaviour. He also enrolled in many
courses and jobs to further his education and skills, he subsequently achieved several
certificates including an NVQ level 2 in engineering.
26. The man had referred himself to the substance misuse team (CARATs) for his use of
cannabis and occasional use of cocaine. Substance misuse did not appear to be a
problem for him in prison. He had no positive voluntary drug tests (VDT) and only one
positive mandatory drug test (MDT) is recorded, which was in December 2005 for
cannabis. He had however, referred himself to a hostel in Poole, a secondary
rehabilitation accommodation which specializes in supporting substance misusers.
27. There are very few medical notes during the first year of his custody and these
documented entries state that he was well and had no particular problems. On 15 July
2003, he received treatment for a cyst on his back. The next entry is on 5 September
2003 when he requested remedial gym sessions to help him lose weight. He weighed
140kg at the time and also had high blood pressure. He was advised about diet and
exercise. From this date on, there are a number of occasions when the man had
attended healthcare appointments and, as there is no evidence to the contrary, I assume
that he requested these himself.
28. On 23 December 2003, a referral was sent to the consultant surgeon at St Peter’s
Hospital requesting him to see the man, after the prison doctor had examined him the
previous day and suspected an umbilical hernia. He had expressed discomfort after
straining. An appointment was made for 29 January 2004, and a reducible umbilical
hernia was diagnosed. The man was put on a waiting list to have it repaired.
29. Apart from some sinus problems there is little in the records from then until 18 May
2004. St Peter’s Hospital had telephoned regarding his pre-assessment for dental
extractions due on 1 June 2004. Glucose had been found in his urine and diabetes was
suspected. It is important for patients with diabetes, that it is stabilised before they
undergo any operations. The dental extraction was postponed until diabetes was
formally diagnosed and stabilised. The appointment was rescheduled and attended on
14 September 2004.
30. The man was given literature about diabetes on 5 June 2004 and kitchen staff were
informed regards the impact on his diet. On 8 June 2004 the diabetes was formally
diagnosed. Healthcare staff have noted that it was unlikely it could be controlled on diet
alone and medication (Metformin) was prescribed. The man was again given dietary
advice.
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31. Healthcare staff arranged for the man to receive salads twice a day as part his dietary
requirements. He was also referred to the physical education department so he could
take part in remedial gym again. These arrangements were in place to try and aid the
man in looking after his health and his desire to lose weight. At this point his weight was
documented as 117kg.
32. On 2 July 2004, he was admitted to St Peter’s Hospital to undergo the operation to
repair his umbilical hernia. A visit to healthcare shows that on 22 September 2004 there
was still swelling in his abdomen and a small ventral hernia was suspected.
33. Another visit to healthcare on 21 December 2004 shows that he was still experiencing
swelling and the small epigastric hernia was thought to be the cause. He was advised to
only partake in light duties and to have a further review if he experienced pain.
34. On 18 January 2005 the man attended healthcare again, he was experiencing
discomfort in his abdomen again, especially after straining. The next day the doctor
referred him to consultant surgeon at St Peter’s Hospital, who had repaired his umbilical
hernia, explaining that he suspected a ventral hernia and requesting that the consultant
see the man.
35. He attended St Peter’s hospital on 3 March 2005, to see the consultant. It was
confirmed that he had a ventral hernia, which he wanted repaired and that his name had
been added to the waiting list.
36. The man commenced employment as a canteen orderly on 7 November 2005, previous
to that he was working as a welder in the Engineering workshop. The change of
employment was at his request. My investigator was informed that he would have had
training for safe lifting and handling of equipment as part of the induction for the job.
37. A pre-operative for his hernia operation was scheduled for 20 December 2005 at St
Peter’s, but was postponed and rescheduled to be carried out at the prison, rather than
the hospital on 5 January 2006. The operation was scheduled for 20 January 2006.
20 December 2005
38. On 20 December 2005, the man attended work in the canteen. The work involved
preparing the canteen packs and delivering them around the prison, wing by wing. The
canteen manager, a civilian member of staff employed by Aramark contractors, stated
that he knew the man had had a hernia operation and would sometimes tell him not to
undertake certain duties because of it. That day, the man started work at approximately
8:15am. The canteen was being delivered a day earlier than usual due to it being
Christmas week, it was also busier.
39. The team arrived at A wing at approximately 4:00pm and began sorting the packs out in
time for ‘freeflow’, which is the term given for the free movement of prisoners returning
from work and moving around the prison.
40. Between 4:30pm and 5:30pm there is a lot of movement through the prison, with people
returning from work, others requesting information from officers in the offices, dispensing
9
of medication and the start of flow to the dining hall for supper. Once a week the
canteen delivery adds to this already busy routine.
41. At approximately 5:10pm one of the other canteen orderlies thought that the man started
to look “like jelly”, and told him to sit down while he continued with their duties. A
prisoner who was a friend of the man’s, was at the front of the queue for his canteen and
thought that he started to look “sweaty”. At first he thought the man was joking with his
work friends, as was his nature, but then he started having trouble breathing. The
prisoner immediately ran to get the attention of the officer in the office opposite. The
office was busy, so he ran straight to the healthcare, about 40 metres away and told the
nurse and the Healthcare Officer (HCO) that he thought the man was hyperventilating.
The HCO is a psychiatric nurse, not a general nurse, so it was general nurse who
responded to the prisoner’s request. Medical notes refer to the time being approximately
4:55pm, however the statements of other staff and prisoners present put the time at
5:10pm. I am satisfied from the number of statements and interviews, including
healthcare staff that 5:10pm was closer to the right time.
42. In the meantime the man had stumbled against the canteen manager. He and the
orderlies helped the man to sit down and the manager also went for help. Another of the
man’s colleagues stated that his head was going back and he was making a gurgling
sound, so he tried to hold his head forward to avoid him swallowing his tongue.
43. It is important to note that this was all happening simultaneously and quickly. The officer
responded immediately to the canteen manager’s request and as soon as he entered
the association room he radioed the communication room to get medical assistance and
an ambulance. He was not aware at this point that Healthcare had already been called.
The officer’s first instinct was that he would need to give the man the ‘kiss of life’. At this
point however, the nurse entered the room. She, with the assistance of those present,
put the man into the recovery position and she instructed the prisoner to go back to the
treatment hatch and get the HCO to bring the emergency bag. She had not initially
taken it with her, as she believed she was attending someone who was hyperventilating,
which she suspected was a panic attack. She immediately requested an ambulance and
was informed that one had already been called. The communication room log shows
that the ambulance was called at 5:14pm. The man’s friends tried to ensure he was
comfortable by placing a jumper under his head, and a jacket over his body to keep him
warm.
44. The healthcare staff administered oxygen and checked the man’s blood pressure. They
knew of his health problems and thought that it might be a diabetic emergency. The
nurse went to collect the blood glucose monitoring equipment. The man’s glucose levels
were noted to be low but not dangerously so. The HCO then left the nurse to continue
attending to the man, and went to collect a glucogen injection in case the need for it
arose. The nurse continued to check the man’s vital signs and as the HCO returned, felt
the pulse deteriorate. She asked the HCO to continue checking it and she began to
carry out Cardiopulmonary Resuscitation (CPR).
45. The ambulance arrived at the prison gates at 5:24pm and was taken straight to A wing.
The man was wired up to their defibrillator, which recorded that it would not be
necessary to give him a shock. Healthcare also have a defibrillator, which was not used
nor was it with the emergency bag. The clinical reviewer confirmed that the defibrillator
was not necessary whilst attending to the man, however it is good practice that it is now
10
kept in the emergency bag. With the help of staff, CPR was continued and the man was
put on the stretcher and taken into the ambulance. The time was logged at 5:47pm
when the ambulance left for Frimley Park Hospital. Two officers were assigned to the
escort for security purposes but, given the man’s clinical condition, no handcuffs were
applied. A second officer, a new officer who had received first aid training on his prison
officer course, assisted the ambulance crew to continue the CPR all the way to the
hospital. This officer should be commended for his efforts and support of the paramedic
team. They arrived at the hospital at approximately 5:55pm and went straight to the
Resuscitation Unit.
46. Medical staff continued with CPR and administering medication to try and resuscitate the
man. The attempts however, were not successful and the man was pronounced dead at
6:08pm.
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Conclusion
47. The man spent a productive time in custody. He attended many courses and gained
several qualifications which he planned to use for employment on his release. He was
well thought of by his peers and staff and involved himself in the activities group on the
wing.
48. He appeared to suffer from abdominal pain through most of his sentence and was twice
referred for treatment of a hernia. He had one operation to repair an umbilical hernia
and was due to have an operation for a ventral hernia. Apart from this, diabetes was the
other main medical concern. The man was a smoker and overweight. To manage his
diabetes, diet and exercise were recommended along with medication.
49. On 20 December the man was suddenly taken ill. I am satisfied that the care and
treatment provided by the prison service and the man’s friends was swift and
appropriate. As a result of the quick actions of the first prisoner and the response from
healthcare staff, I am also satisfied that the man would not have received quicker
treatment were he living in the community. My only concern is the suitability of the
man’s job as canteen orderly, which involves lifting heavy bags and boxes. Whilst he
had a hernia and was experiencing discomfort on straining, a job that was less physically
demanding might have been more appropriate. The choice of job however, was his own
and he would have had an induction in lifting techniques for the role. Although my
investigator has not seen any related paperwork, the prison have commented that there
is evidence to support this.
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Recommendations
1. The Governor and Primary Care Trust should commend the actions of the second
officer in his efforts to support the paramedics in the resuscitation of the man on
the way to hospital.
Coldingley have accepted this recommendation and the officer will receive performance
recognition at the next full staff meeting.
2. Whilst not a formal recommendation, I would like to draw the Governor’s attention
to the comments made about the suitability of employment in terms of prisoners’
health.
Coldingley have taken action regarding the above by introducing a system whereby a
healthcare representative attends activity allocation boards to ensure employment of
offenders is appropriate to and takes account of their health and fitness. This is due be
in place by the end of July 2006
The following are additional actions added by Coldingley in response to the draft report.
1. All staff and offenders involved in responding to the man to be recognised. This will also
be via the next full staff meeting and offender committees.
2. The defibrillator to be kept with the emergency bag. Healthcare are to ensure this
happens.
3. Alarm response codes to be introduced so that healthcare staff know when there is a
medical emergency and what type so respond and be equipped appropriately. The
Healthy Living PO will consult, agree and implement alarm response codes and
healthcare systems and equipment for responding.
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