Individual at Dartmoor

Investigation into the circumstances surrounding the death of
a male prisoner at HMP Dartmoor,
who died in July 2005
Report by the Prisons and Probation Ombudsman for England and
Wales
May 2006
This is the report of an investigation into the circumstances of the death of a
man at HMP Dartmoor in July 2005. He had been suffering from ischaemic
heart disease and died of a heart attack.
I extend my sincere condolences to his family and friends for their loss.
I would like to thank the Governor of HMP Dartmoor, and the members of her
staff who assisted my investigator. I have found the prison’s contact with the
man’s family to have been both sensitive and respectful.
I am also grateful to those who, on behalf of South Hams and West Devon
Primary Care Trust, carried out a review of the man’s medical care whilst he
was at Dartmoor.
The man had a history of heart problems and was awaiting further tests at the
time of his death. The review of his clinical care by South Hams and West
Devon Primary Care Trust concludes that the treatment he received was
appropriate in the circumstances.
I make four recommendations alongside some other suggestions as to good
practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman May 2006
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Contents
Summary
The Investigation Process
HMP Dartmoor
The events leading up to the man’s death
Discussion of the issues
Findings and conclusions
List of recommendations
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Summary
1. The man was 45 years old when he arrived at Dartmoor on 7 June
2005. He was serving a sentence of two years and six months for
deception. He died on 24 July 2005 from a heart attack.
2. He had been at HMP Exeter since 9 May 2005. His health was initially
assessed on arrival at Exeter and he then had a further assessment
carried out by a doctor on 19 May. He was receiving drugs to relieve
pain in his leg from a previous injury and also took medication for a
heart condition. He was referred for an appointment at the local
cardiology department.
3. On 7 June, the man was transferred to Dartmoor. A brief health screen
was carried out for him but he did not see a doctor, signing a disclaimer
to say he would make an appointment if he needed one.
4. Due to his leg injury, he could not stand for long periods of time and
was located on the lowest landing of B wing. He spent much of his
time in education.
5. On 14 June, he attended an induction session at the gym where,
following his assessment, he was told that he needed to seek medical
advice before using the gym. There is no evidence that the man did
seek this advice but he did start attending sessions at the gym,
attending mostly on Sunday mornings.
6. On Sunday 24 July, the man attended a gym session and was working
on the mini-gym with a friend and fellow B wing prisoner. At 10:35am,
shortly after starting to exercise, he collapsed. The Physical Education
Officer (PEO), who was on duty in the gym, attended to him and an
officer, who was also on duty, telephoned for healthcare to attend.
Within a few minutes, a Healthcare Officer (HCO) arrived in the gym
and requested emergency equipment to be brought from healthcare
and for an ambulance to be called.
7. The HCO and Physical Education Officer began to carry out
cardiopulmonary resuscitation (CPR) on the man and a second HCO
then arrived with the emergency equipment. Resuscitation was
attempted until the paramedics arrived at 11:00am and took over.
Regrettably, the man did not respond to the resuscitation attempts and
was pronounced dead at 11:10am.
8. A clinical review was carried out on behalf of South Hams and West
Devon Primary Care Trust. The report concludes that the man’s
treatment was appropriate and the reaction to his collapse in line with
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good practice. However, the report does also highlight some areas
where improvements could be made.
9. The man’s family were informed of his death within an hour, the news
being broken to them in person by the Governor and a member of the
Chaplaincy. The prison’s liaison with the man’s family has been well
handled.
10. This report includes four recommendations and some other
suggestions that the Governor of Dartmoor may wish to consider.
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Investigation process
11. One of my investigators visited Dartmoor and met a member of the
Independent Monitoring Board and a representative of the Prison
Officers’ Association (POA). She also visited the wing where the man
had lived.
12. My investigator issued notices to staff and prisoners informing them of
the investigation and inviting comment.
13. Access to the man’s prison records, including his medical records, was
provided to the investigator. The Coroner kindly provided a copy of the
post mortem report. Devon and Cornwall Constabulary also shared
with the investigator the statements taken at the time of the man’s
death.
14. The investigator conducted formal and informal interviews with several
officers, members of healthcare staff and prisoners.
15. One of my Family Liaison Officers contacted the man’s family to explain
the purpose of the Ombudsman's investigation and to discuss any
questions the family might have had. The family did not feel they had
any particular concerns about his time in Dartmoor and did not wish to
meet the Family Liaison Officer or investigator.
16. A draft of this report was sent to the family and to the Prison Service,
and where they have made comments on the draft these have been
reflected in the text.
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HMP Dartmoor
17. Dartmoor is a category C training prison. The prison was last inspected by
HM Chief Inspector of Prisons in February 2003. A relatively high percentage
of prisoners reported that they had never felt unsafe (63%). However, the
inspection team considered that there was little evidence of positive
engagement between staff and prisoners, with only 9% of prisoners reporting
that staff had checked on their well being in the last week.
18. Dartmoor works collaboratively with HMP Channings Wood and Exeter
as part of the Devon Prisons Health Partnership. The prison’s
healthcare has been the commissioning responsibility of South Hams
and West Devon Primary Care Trust (PCT) since April 2003. The
healthcare department has a doctor available every weekday.
Overnight and weekend cover is provided by Devon Doc, an out of
hours service commissioned by South Hams and West Devon PCT.
19. One other prisoner has died at Dartmoor since I became responsible
for the investigations into all deaths in prison custody in April 2004.
That death was self inflicted and occurred in August 2004.
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Events leading up to the man’s death
20. The man underwent reception screening on first reception at HMP
Exeter on 9 May 2005. This indicated that he had a history of pain in
his right leg following an injury sustained as a child in a road traffic
accident.
21. He was seen again by healthcare staff on 19 May, when he was given
a thorough health assessment at the request of Plymouth Crown Court.
His health assessment revealed a number of issues. He was found to
be overweight and suffering from high blood pressure. It was also
noted that he was registered disabled, was a smoker and was showing
signs of mild heart failure, possibly related to a leaking heart valve. It
was recorded that he was prescribed the following medication:
a. Gabapentin capsules 300mg, 4 capsules once daily for right
lower leg pain
b. Co-codomol, 2 tablets daily for pain relief
c. Lansoprazole 15 mg daily for prevention of stomach irritation
d. Naproxen 250mg
22. Following examination, 2.5mg daily of Bendroflumethiazide was added
to his prescription. It was noted that he was to be referred to the
cardiology department at the Royal Devon and Exeter Hospital for
further investigation. Notes were also made regarding the injuries to
his right leg. It was recorded that he had chronic pain, walked with
altered gait and suffered from immobility in his right ankle.
23. On 26 May, the man was seen by a doctor in his cell and was
prescribed Enalapril 2.5mg daily. He was to see the doctor again in 14
days. Also on 26 May, a letter of referral was sent to the Royal Devon
and Exeter cardiology department.
24. On 7 June, he was transferred to Dartmoor. A reception proforma was
completed for him, indicating his weight, height and that he received
medication. It was also recorded on the proforma that he had a history
of hypertension and physical disability, and had previously misused
drugs. The member of staff who completed the form placed a question
mark next to the question that asked about coronary heart disease.
The proforma also indicated that he should be located on a low landing
and should avoid standing for long periods. The member of staff who
completed the proforma with him did not fill in their own details on the
form.
25. The same day, the man completed a healthcare disclaimer, signing to
agree that he was happy not to see a doctor in reception and that he
was aware of the procedures to follow if he did want to see a doctor in
future. This disclaimer was endorsed by a Healthcare Officer (HCO).
A note was made by the HCO on his medical record that he had been
seen on reception and had stated that he was well.
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26. On 14 June, the man attended an induction session at the gym. When
a prisoner is inducted to the gym, they are required to complete a
physical readiness questionnaire and to sign an agreement confirming
that they will follow gym rules. The Physical Education Officer (PEO)
who conducted the man’s induction session advised the investigator
that approximately 10-15 prisoners are inducted to the gym each week.
On the questionnaire it was indicated that the man had a heart
condition and had been advised not to do physical exercise unless
recommended by a doctor. The PEO noted on the questionnaire that
the man had a heart murmur referral and was awaiting the results of
tests. Responses to the questions indicated that he should speak to a
doctor in person before starting to become more physically active. The
man signed the questionnaire and completed a compact agreeing to
comply with the gym rules. Following a conversation with this man, the
PEO noted the following information on his physical education record,
under ‘medical restrictions’:
“Cardio problems. To see doctor before using the gym. Right
leg short- must use raised personal footwear.”
27. The PEO told the investigator that, following this induction session, the
man’s records would have been filed in the gym. He also said that he
would have mentioned to other members of gym staff that he had
carried out an induction session for a prisoner with medical problems.
The PEO felt that, as a close-knit team with only six members of staff,
information was easily shared in this way.
28. A further note was made on the man’s medical records on 17 June to
confirm that he was fit for education. As part of the review of his
medical care, the clinical reviewer established that he was seen by a
doctor that day, and that he sought advice on his fitness to attend
education but not about his fitness to attend the gym.
29. There are two further entries in the man’s medical record on 20 June.
The first of these confirms his appointment with the cardiology
department at the Royal Devon and Exeter Hospital. The second entry
refers to a conversation between healthcare staff and wing staff
regarding moving him to a higher landing on the wing. The note states
that he was only able to walk up one flight of stairs at the most, was
awaiting a cardiology appointment and was to remain on the lower
landing.
30. A fellow B wing prisoner, who was a friend of the man’s, told the
investigator that he and the man attended the gym together on several
occasions. The gym attendance records indicate that the man
attended on Sundays 3, 10 and 17 July. His friend said that he was
aware that the man had not been to the gym for some years as he had
problems with his leg. He knew that he had been keen to get fit and he
had never seen him struggling on any of the other occasions they had
been to the gym together.
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24 July
31. At 10:15am on 24 July, the duty PEO arrived at B wing to collect 20
prisoners to attend a session at the gym. The PEO made a list of the
names of the prisoners and, together with a second officer, escorted
the group to the gym. The man and his friend were amongst the group
of prisoners. They arrived at the gym and each prisoner was ticked off
the list, admitted to the gym and went to get changed. The gym
session started at about 10:25am.
32. The man and his friend began using the multigym with the man pulling
weights, whilst his friend counted the repetitions for him. The man had
been exercising for only a few minutes when he appeared to give a
loud sigh and fall towards the floor. The friend guided him on to the
floor. The PEO was standing a few metres away from where the man
had collapsed and immediately went over to assist. This PEO ensured
that the man’s airway was clear and asked the second officer to contact
healthcare. The officer made a call to healthcare, informing a
Healthcare Officer (HCO) that a prisoner had collapsed and they
needed assistance. The PEO put a call out over the radio to say that
there was a medical emergency. The incident log records that this
happened at 10:40am.
33. The officer that had made the call told the investigator that, when he
got through to healthcare, he was asked for the name and number of
the prisoner who had collapsed and what was wrong with him. The
prisoner’s friend told the investigator that he was confused by the
request as he felt that it was irrelevant and delayed the response of
assistance from healthcare.
34. The gym is approximately 200 metres from the healthcare centre. The
HCO arrived just before 10:40am and immediately carried out a quick
assessment of the man’s condition. He then asked for the emergency
bag, oxygen and a defibrillator to be brought from healthcare, and for
an ambulance to be requested. It is not clear whether he telephoned
through to healthcare himself or whether this was done by the PEO or
officer. The internal telephone log showed that a call was made from
the gym to healthcare at 10:39:19 and a call was then made to the
emergency number “222” at 10:39:45. The second officer remembers
making this call to the emergency number to ask for an ambulance.
The incident log notes that it was received at 10:42am.
35. The HCO and the PEO started to carry out cardiopulmonary
resuscitation on the man, with the PEO carrying out compressions and
the HCO performing mouth to mouth resuscitation. The second officer
asked other prisoners to move towards the back of the gym, away from
the area where the man was being attended to.
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36. One of Dartmoor’s governors told the investigator that she was duty governor
on 24 July and, at 10:40am, heard a call over the radio that there had “been a
collapse” in the gym. She made her way to the gym and, on arriving, saw the
HCO and the PEO carrying out CPR on the man. She and the PEO began to
move the prisoners out of the gym, escorting them from the entrance furthest
from where the man had collapsed.
37. A second HCO arrived from healthcare with the additional equipment.
He attached the defibrillator to the man whilst the first HCO inserted an
airway. CPR was stopped twice to enable the defibrillator to be used.
Neither of these attempts to start the man’s heart was successful and
CPR continued until the paramedics arrived to take over the
resuscitation.
38. The prison control room was originally told that an air ambulance had
been dispatched and the police were informed that a helicopter would
be landing in the grounds of the prison. However, at approximately
10.50am, an ambulance vehicle arrived at the gate and was escorted
to the gym, arriving at 11:00am. The paramedics took over resusitating
the man but were unable to get any response. He was pronounced
dead at 11:10am.
39. The incident log shows that the police were called at 11:10am. They arrived at
the prison at 12:15pm.
40. The governor who had been duty governor on the day, told the investigator
that she and the prison’s Roman Catholic priest went to break the news of the
prisoner’s death to his family. The man’s records contained addresses for two
next of kin, one for his mother and one for his son. The decision was made to
visit his mother’s address as his son’s age was not known. The Governor and
the Roman Catholic priest left the prison at 11:40am. The man’s family were
advised that the prison would help towards the cost of the funeral and were
offered the opportunity to visit the prison if they wanted to.
41. A hot debrief was held for staff on the day following the man’s death. This was
chaired by the deputy governor.
42. The Governor wrote a letter of condolence to the man’s mother on 26 July,
reiterating the prison’s willingness to help with the funeral costs. Appropriate
arrangements were made to return his possessions and personal cash to his
family.
43. The man’s funeral was held on 8 October. While several prisoners expressed
a wish to attend the funeral, this was something which the prison was unable
to authorise. Prisoners were, however, given the opportunity to contribute
towards a wreath for the funeral.
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Discussion of the issues
The appropriateness of the man’s medical care
44. The clinical review by the PCT concludes that the man’s family history
and lifestyle resulted in a high risk of coronary heart disease. The
results of the post mortem showed that he suffered from severe heart
disease that was very advanced for someone of his age. The
assessment made by the doctor at Exeter included a detailed medical
history, but did not make reference to the man’s family history of heart
disease.
45. The clinical review considers that aggressive management of the man’s
condition with drugs and cardiological intervention might have reduced
the likelihood of an acute event. However, the combination of genetic
and environmental factors made it impossible to say whether his death
could have been prevented.
46. The clinical review notes that, while the man’s assessment at HMP
Exeter was thorough, no blood tests were requested.
47. When he arrived at Dartmoor on 7 June, the man was not seen by a
doctor and so his planned 14 day follow up after his appointment in
Exeter on 26 May was not taken forward. It appears that this would
have been a good opportunity to review his treatment. It is noted,
however, that the man was given the opportunity to make an
appointment with the doctor and signed a disclaimer to say that he did
not wish to do so.
48. I make recommendations concerning medical reviews of prisoners with
pre-existing medical conditions, and also regarding the appropriateness
of medical disclaimers for these prisoners. In addition, the clinical
reviewer raised some housekeeping points in terms of record keeping.
The man’s use of the gym
49. The clinical review of the man’s care considers that exercise in the gym
could have precipitated his collapse, but that he was at a high risk of
such an event at any time.
50. Discussions with gym staff revealed different approaches to managing
prisoners wishing to use the gym who should seek medical advice first.
The man does not appear to have sought advice between the gym
induction on 14 June and the first session on 3 July, and there was no
system in place to prevent him using the gym. The gym staff may wish
to consider, in conjunction with healthcare staff, ways to introduce
remedial or graded exercise for prisoners with known pre-existing
medical problems.
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The speed of response by healthcare staff
51. The man’s friend told the investigator that he felt frustrated that
healthcare staff had not arrived quicker, and he felt time was wasted
asking questions such as the prisoner’s name and prison number.
52. Unfortunately, it has not been possible to interview the HCO who
arrived first to attend to the man and so it remains unclear whether he
did ask for the information and, if so, what his reasons were. However,
both the second officer and the PEO told the investigator that their
initial reaction to the man’s collapse was that he was having some sort
of seizure. If this information was relayed to the first HCO then he may,
quite rightly, have been trying to establish what medication might be
needed to treat the prisoner or to pass the details on to another
healthcare officer to look at the prisoner’s records whilst he went to
give assistance. The clinical reviewer told the investigator that he
believed this to be entirely appropriate in the circumstances. Routinely
asking for a prisoner’s name and number if they have collapsed should
not be necessary, and certainly not if urgent assistance is being
requested. However, given the information that the first HCO may
have received, his questions were entirely reasonable.
53. In his incident report, the first HCO estimated that he arrived at the gym
some five minutes after receiving the call from the other officer. The
internal telephone log shows that two calls were made from the gym to
healthcare in very quick succession, one at 10:35:21 and one at
10:35:30. It would appear that one of the calls requested assistance
from healthcare, although it has not been possible to establish why two
calls were made. The internal telephone log also shows a call being
made from healthcare to the gym at 10:38:28. It has not been possible
to establish who made this call. However, at 10:39:19 a call was made
from the gym to healthcare, and 26 seconds later a call was made to
the control room. It seems very likely that the last two calls were the
result of the first HCO’s assessment of the man. It therefore seems
likely that the first HCO was already en route to the gym when the call
was made from someone there at 10:38:28.
54. The officer and the PEO both told the investigator that the first HCO
arrived quickly and made an immediate assessment of the prisoner’s
condition. An ambulance was requested immediately and efforts were
made to resuscitate the man. Both the PEO and the first HCO had up
to date CPR training, and the review carried out by the PCT concludes
that their efforts to revive the man were in keeping with best practice.
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The use of ‘codes’ when an emergency call is put out
55. At the time of the man’s death, there was no system in place to alert
healthcare staff to the type of emergency. The clinical reviewer
explained to the investigator that the prison would now be
implementing a radio procedure where the nature of the emergency
would be conveyed. This would enable staff to take appropriate
equipment with them.
Use of emergency services
56. The clinical reviewer also told the investigator that consideration had been
given by West Country Ambulance Service to send an air ambulance. The
road ambulance arrived in good time and so the air ambulance did not prove
necessary. However, the experience highlighted that there was no prior
agreement in the prison about where a helicopter would land if necessary.
The clinical review recommends that a protocol is established to deal with
similar events in future.
Delivering the news of the man’s death to his family
57. The duty governor on the day told the investigator that she decided that
she needed to act very quickly to inform the man’s family of his death.
The man was well known in the local area, his collapse had been
witnessed by many prisoners and a call had already been received at
the prison from someone enquiring whether it was true that he had
died. The prison’s death in custody contingency plans include a note
that advice from probation and police may be valuable in deciding on
the best way to inform a family of a prisoner’s death. The Governor
believed that she needed to make a decision based on individual
circumstances, and her swift action probably prevented the man’s
family from hearing the news from another source. The governor
explained that she asked the Roman Catholic priest to attend with her
for two reasons. First, she knew from the man’s records that he was a
Roman Catholic. Secondly, she had not undertaken family liaison
training herself and therefore was appreciative of the priest’s
experience.
58. Prison Service Order (PSO) 2710, which came into force in January
2006, provides comprehensive advice about important considerations
when delivering the news of a prisoner’s death. The PSO advises that
as much information as possible should be sought about a prisoner’s
family before making the initial visit to break the news of a death. As
far as is possible, staff should endeavour to gather as much information
as they need to be sure that they are not entering an unsafe
environment. The governor had not undertaken FLO training, nor was
PSO 2710 in existence at the time of the man’s death. Whilst steps
should be taken to ensure the safety of staff whenever possible, the
governor’s quick action and consideration for the family is
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commendable. I judge her actions in dealing with the man’s family to
have been prompt, sensitive and well handled.
Attendance of prisoners at the man’s funeral
59. The man was a popular prisoner and a number of prisoners wanted to
attend his funeral. The duty governor on the day of the man’s death
told the investigator that the decision was taken by senior management
that this would not be possible for security reasons. This information
was not relayed back to those prisoners who had asked to attend the
funeral, leaving them feeling frustrated. The governor explained that in
future the prison would be aware of the need to keep prisoners
informed whether they were allowed to attend the funeral of a friend
and that, in the event they were not, the reasons would be clearly
explained. The investigator was told that prisoners who knew the man
had made a collection for his family. The governor explained that the
prison planned to hold a memorial service on 16 October. The
investigator was subsequently told that this had not gone ahead as only
three or four prisoners expressed an interest in attending.
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Findings and Conclusions
60. The man had a history of heart problems, was on medication and was awaiting
an appointment with a specialist. His heart condition was severe and an acute
episode might have occurred at any time.
61. The clinical review of the man’s care considers that, while his assessment and
care appear to have been appropriate, his arrival at Dartmoor was an
opportunity which was missed for his care plan to be reviewed. Therefore,
based upon the view of the clinical reviewers:
I recommend that all patients with a current healthcare
management plan for a medical condition should be reviewed by a
doctor within five days of arrival at Dartmoor.
This recommendation has been accepted by the Prison Service. The
service gave the following response:
“The existing protocol is to be modified to include medical conditions.”
62. On his arrival at Dartmoor, the man completed a reception disclaimer
form indicating that he was happy not to see a doctor. He was taking
medication and was awaiting an appointment at a cardiac department.
I consider that an individual presenting with the man’s condition should
have been seen and assessed by a doctor without being given the
option to sign a disclaimer. Therefore, in addition to the above
recommendation:
I recommend that the practice of prisoners signing reception
disclaimers is reviewed. Prisoners who are prescribed medication
and present with medical problems should not be given the option
to complete such a disclaimer and should be seen by a doctor
within five days of arrival at Dartmoor.
The Prison Service has partially accepted this recommendation and
has issued the following response:
“Doctors are only available at Dartmoor four days per week. The doctor
will see all such prisoners within seven days from the date of arrival.”
63. The man was advised to seek medical advice before attending the
gym, but appears not to have done so. He attended the gym on
several occasions and did not experience any difficulties. It is not
possible to know whether his collapse was caused by sudden exercise.
64. The man was able to use the gym, unchallenged, despite his induction
session revealing that he needed to seek medical advice. There
appears to be no system for monitoring what happens to the
information that is recorded when a prisoner is inducted to the gym.
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I recommend that a system is put in place to minimise the risk of a
prisoner using the gym unless he can demonstrate that he has
sought appropriate advice. Consideration should be given to
introducing remedial or graded exercise for prisoners with known
medical problems.
The Prison Service has accepted this recommendation and made the
following comment:
“PERQ (Physical Education Readiness Questionnaire) are filled in for
each prisoner and any issues are referred to Healthcare Centre
immediately for examination and a report is done with
recommendations, which are acted upon.”
65. The response to the man’s collapse was swift and appropriately handled.
Both the PEO and the first HCO had up to date CPR training and their care of
the man is described as in keeping with best practice. The clinical reviewer
told the investigator that a system was being put in place to ensure that
“codes” were used to alert healthcare staff to the type of emergency they were
being called to. Systems such as this are common practice across much of
the prison estate.
I recommend that the Governor ensures that staff are aware of,
and are adhering to, the use of emergency “codes”. All staff
should be advised of the meaning of the codes and in what
circumstances to use them.
The Prison Service gave the following response to this
recommendation:
“In the event of a medical emergency, the first on scene will summon
help via the control room to alert Healthcare Centre response staff. The
first on scene will also use code ‘RED’ for blood and ‘BLUE’ for
oxygen.”
66. The governor who was duty governor on the day of the man’s death had not
attended FLO training and worked closely with the Roman Catholic priest to
deliver the news of the man’s death to his family. Her liaison with the family
has been compassionate and timely.
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List of Recommendations
1. I recommend that all patients with a current healthcare
management plan for a medical condition should be reviewed by a
doctor within five days of arrival at Dartmoor.
2. I recommend that the practice of prisoners signing reception
disclaimers is reviewed. Prisoners who are on medication and
presenting with medical problems should not be given the option
to complete such a disclaimer and should be seen by a doctor
within five days of arrival at Dartmoor.
3. I recommend that a system is put in place to minimise the risk of a
prisoner using the gym unless he can demonstrate that he has
sought the appropriate advice. Consideration should be given to
introducing remedial or graded exercise for prisoners with known
medical problems.
4. I recommend that the Governor ensures that staff are aware of,
and are adhering to, the use of emergency “codes”. All staff
should be advised of the meaning of the codes and in what
circumstances to use them.
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