Individual at Dovegate

Investigation into the circumstances surrounding the
death of a man
at HMP Dovegate in March 2008
Report by the Prisons and Probation Ombudsman for
England and Wales
October 2008
This is the report of an investigation into the death of a man who died on 3 March
2008. The man had been taken to hospital on the previous day after suffering a
spontaneous hypertensive intraparenchymal cerebral haemorrhage (brain
haemorrhage). An inquest was held in July 2008 and a jury came to a verdict of
natural causes death. He was a serving prisoner at HMP Dovegate when he died at
the age of 67 years.
The man had not given prison staff any contact details for his family, who lived in
Bolivia. Sadly, his family could not be informed about his health during the day
before he died. My colleagues and I would like to extend our condolences to his
family and friends.
The investigation was carried out on my behalf by my investigator. A review of
clinical care in prison was carried out by a team led by the Clinical Governance
Manager on behalf of Staffordshire Primary Care Trust (PCT). I am grateful for her
assistance in this case. I also thank the Director of HMP Dovegate for the co-
operation of his staff.
The clinical review has found that the man’s care was at least equivalent to that
which he would have received in the community. The review team has made seven
recommendations. I am pleased to be able to report that since the review was
drafted, the prison has taken steps to tackle the issues. In light of this, I only make
four recommendations.
Jane Webb
Deputy Prisons and Probation Ombudsman October 2008
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CONTENTS
Summary
The Investigation Process
HMP Dovegate
Key Findings
Issues Considered
Recommendations
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SUMMARY
The man was remanded into custody at HMP Wormwood Scrubs in December 2002.
His reception health screen showed no problems with his health except for high
blood pressure, for which he was prescribed medication.
On 29 March 2004, the man, who had by now been sentenced, transferred to HMP
Dovegate. Again, his reception health screen only reported problems with his blood
pressure and his medication was continued. However, in July that year he stopped
taking the medication. The reasons why are unknown, but it was recognised in
November 2004, and the medication was re-prescribed. He continued to have his
blood pressure monitored and was given appropriate medication.
In June 2006, he told healthcare staff that he had stopped taking his anti-
hypertension medication again, because he ‘felt cold’. There is no further
explanation but he was referred to see the doctor. In March the following year, the
man attended a ‘Well Man Clinic’ where his blood pressure was discussed as well as
the fact he was not taking medication. He was referred to the doctor and the
following day had an electrocardiogram (ECG). He told the doctor that he did not
want the medication for hypertension, but he did continue to receive a prescription
for aspirin, as an anti-clotting medication to reduce the risk of heart attack or stroke.
In April 2007, the man agreed to take the anti-hypertension medication again. He
continued to request and received repeat prescriptions for it until January 2008,
when he again chose not to take it. However he was prescribed medication for an
infection and a painkiller. In February 2008, he was prescribed a 28 day supply of
aspirin.
During the early hours of 2 March 2008, a nurse saw the man in his cell after he
complained of dizziness and a headache. He had taken one of the anti-hypertension
tablets which he still had in his possession. The nurse took his medical observations
and gave him paracetomol. He was advised to go to the medicine hatch in the
morning for another blood pressure check. When an officer went to check in the
morning he found that he was heavily asleep. A short while later another prisoner
told staff that he thought the man was breathing strangely. Staff attended and could
not get a response from him. Healthcare assistance was requested as well as an
ambulance. The response from healthcare was delayed as it was not clear to the
staff that the situation was an emergency. When the nurse and the ambulance
arrived, he was given oxygen and taken to hospital where he was put on a life
support machine.
Tests found that the man had suffered a brain haemorrhage and had little chance of
survival. The hospital staff switched off his life support machine and he was kept
comfortable with medication. The prison were informed that the man would not
regain consciousness and he was released on temporary licence, which meant that
he did not have to be escorted by prison officers or be cuffed. The following
morning, 3 March 2008 at 7.15am, the man passed away.
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Without any next of kin details, the prison was unable to contact the man’s family in
time to alert them to his condition before he died. The prison was later able to
contact the man’s family through the Bolivian Embassy.
My investigation found that the man received equivalent medical care in prison to
that which he would have received in the community. Several areas of policy and
procedures within the healthcare department are in need of review to ensure good
practice. However, the new healthcare management team are already taking action
in respect of these.
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INVESTIGATION PROCESS
1. My investigator requested all the relevant prison records including the man’s
medical and core prison records. My investigator visited the prison with the
clinical reviewer.
2. Notices to staff and prisoners were sent to the prison to be displayed. These
invited anybody with information to talk to my investigator. In this instance,
no-one raised any matters relevant to the investigation.
3. A clinical review into his clinical care in prison was commissioned and carried
out by a panel led by the Clinical Governance Manager on behalf of
Staffordshire PCT. The review was received by my office on 30 June 2008.
4. HM Coroner for Staffordshire was informed of my investigation. The Coroner
has kindly shared the post mortem with my investigator. He will receive a
copy of this report. An inquest was held in July 2008 and a jury reached a
verdict of natural causes.
5. After his death, the prison service traced the man’s family through the Bolivian
Embassy. One of my Family Liaison Officers has been in contact with the
man’s son to offer him and his family the opportunity to be involved in this
investigation. His son asked if his father’s life could have been saved if he
had been taken to hospital sooner. I will attempt to address this question in
my report.
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HMP DOVEGATE
6. Opened in 2001, Dovegate is a category B private sector prison for adult male
prisoners sentenced to over four years. It is managed by Serco under
contract to the National Offender Management Service (NOMS). It currently
holds up to 860 prisoners. This is made up of 660 in the main prison and 200
in the therapeutic community.
7. Healthcare services in Dovegate are provided by Serco Health. The
healthcare management team had changed prior to the man’s death. The
healthcare manager had been appointed at the end of 2007 and the deputy in
the beginning of 2008. The new managers are currently reviewing and
improving the existing policies and procedures within the healthcare
department.
8. The last inspection by Her Majesty’s Chief Inspector of Prisons (HMCIP), prior
to his death was in September 2006. The Chief Inspector found that safety
and control were a concern. The provisions for foreign national prisoners
were significantly under-developed. The report did find however, that staff
were polite and supportive to prisoners but some staff appeared to lack
confidence in challenging poor behaviour. Prisoners had plenty of time out of
cell and most were able to participate in purposeful activity.
9. My office is currently investigating a self inflicted death at Dovegate. Several
of the clinical issues highlighted in the man’s case are similar to the recent
death. I am pleased to note however, that Dovegate are already taking steps
to address these.
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KEY FINDINGS
10. The man was remanded into custody in December 2002. He was initially held
at HMP Wormwood Scrubs in London. Upon his arrival he underwent a
reception health screen. This noted that he did not smoke, take drugs or
alcohol and had no allergies. The assessment also noted that he was not
taking any medication. His blood pressure was noted to be a concern which
required treatment and monitoring by healthcare staff.
11. Over the next year, the man’s blood pressure was monitored approximately
every two to four weeks. He was prescribed medication (Bendrofluazide and
Atenolol) to manage his condition.
12. The prison records give little information about the man other than his positive
conduct on the wings. He regularly attended education classes where he
helped teach Spanish. He also attended the chapel.
13. On 29 March 2004, the man transferred to HMP Dovegate. Here he had
another reception health screen by a nurse. A doctor saw him the following
day and noted no health problems other than his blood pressure. Although he
signed an ‘in-possession’ medication compact (to be allowed to keep his
medication in his cell) there was no risk assessment carried out to verify his
suitability for this. On 15 April, he was given extra medication (Ramipril) for a
kidney problem. It was due to be reviewed after a month, but there is no log
of this in his medical record or of the medication being re-prescribed.
14. The man’s medical record does not show any further healthcare contact until
November 2004, when he saw a doctor. The record shows that he had been
experiencing occasional headaches and had stopped taking his anti-
hypertension (blood pressure) medication five months previously. The doctor
took his blood pressure which was found to be high (200/100). He was re-
prescribed medication (Bendrofluaxide, Atenolol, aspirin). He continued to be
prescribed this medication through 2005.
15. In September 2005, the man complained of back pain and said that he was
worried about his blood pressure. The doctor requested that his blood
pressure be regularly reviewed and increased his Atenolol medication. Two
months later, in November, the doctor asked for his blood pressure to be
checked daily, but these checks are not logged in the records and I am unable
to confirm whether they happened. At the end of November, he complained of
excess phlegm and was given medication to treat this. He continued to be
prescribed anti-hypertension medication for the rest of the year and first five
months of 2006.
16. On 9 June 2006, the told healthcare staff that he did not want to take
medication because he was feeling cold (this is not explained further in the
records). An appointment was made for him to see the doctor. The man was
advised to continue taking the medication until it could be reviewed. An
unsigned entry on 14 June, which may have been by the doctor, again notes
that he had stopped taking his medication.
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17. At a ‘well man clinic’ on 21 March 2007, the man told healthcare staff that he
had occasional front and back chest pain. The clinic note also records that
apart from aspirin, he was not taking any medication for hypertension. An
appointment was made for him to see the doctor. This appointment appears
to have taken place on 22 March. The note in the medical record comments
that he was still declining prescription tablets with the exception of aspirin. He
was however prescribed medication for the treatment of excess phlegm.
18. Just over two weeks later, the man was re-prescribed the medication for his
hypertension, although the records do not show the reasoning for this, or why
he may have changed his mind about taking it. He continued to request
repeat prescriptions until 18 January 2008, when the medical record notes
(entry unsigned) that he had stopped taking the medication. He was advised
of the risks and was prescribed a painkiller for what appears to have been
neck pain and medication to treat a cough.
19. A month later, on 27 February, there is another entry in the medical record
referring to the man not taking anti-hypertension medication. The record also
shows that he had a painful neck, for which he was given more painkillers.
20. At approximately 3.00am on Sunday 2 March, wing staff called the night
healthcare staff to see the man in his cell. He was complaining of dizziness
and a headache. A nurse went to see him and asked about his anti-
hypertension medication, which he said he had not been taking. The man
told the nurse however, that he had taken an Atenolol tablet earlier that
morning (it appears to have been left over from his previous prescription).
The nurse took his medical observations (his blood pressure was high at
180/105) and gave him some paracetomol. He was advised to go to the
medical hatch in the morning to have his blood pressure checked again.
21. At approximately 8.30am, one of the wing prison custody officers (PCO), went
to the man’s cell because he had received information in a handover book that
the man needed to collect his medication. The PCO found the man sleeping
and breathing heavily. The PCO said he had previous knowledge of the man
being a heavy sleeper and, after unsuccessfully attempting to wake him, he
left the cell.
22. The PCO did however contact a nurse regarding his medication. A nurse
assured him that it would be alright for the man to take his medication later
when he woke.
23. An hour later, at approximately 9.40am, another prisoner went to tell the PCO
that he did not think the man was well, because his breathing was erratic. The
PCO went to check and tried to wake him again. He remained unresponsive
so the PCO requested nurse assistance via the control room radio system.
The request is timed at 9.45am on the communication log. At 9.51am an
ambulance was called by the orderly officer who had responded to the call for
assistance. At the same time, the PCO contacted the control room again to
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ask where the nurse was. Another call was made for medical assistance, this
time as an emergency.
24. A nurse arrived at the cell shortly before the first paramedic response at
10.05am. The ambulance arrived at 10.07am. The man remained
unresponsive; he was given oxygen and taken to the local hospital.
25. The man was admitted to a Hospital at Burton upon Trent at 10.55am. At
11.30am he had a computed tomography (CT) scan, the results of which
showed that he had suffered a brain haemorrhage and had little chance of
survival. The man was on a life support machine until 1.45pm when a hospital
doctor authorised it to be switched off. He was given medication to keep him
as comfortable as possible.
26. A senior hospital nurse told prison staff that the man would not regain
consciousness. Early that evening, 2 March, the prison arranged for the man
to be released on temporary licence for compassionate reasons. This meant
that he was neither handcuffed nor escorted by prison staff. The staff who
had initially gone out as escorts returned to the prison at 7.00pm.
27. The following morning, 3 March 2008 at 7.15am, the hospital doctor
pronounced the man’s death.
Events after the man’s death
28. During the clearance of his cell a box of medication was found and returned to
healthcare. It contained several unused boxes of his prescribed medication,
including some which he had not been prescribed since January 2008.
29. The prison traced the family of the man through his Embassy. In consultation
with the family, the man was cremated and preparations have been made for
his ashes to be returned to his family.
30. Other prisoners had a collection and this money, together with the money the
man had in his prison spending account, will be sent to his family.
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ISSUES CONSIDERED
Recordkeeping
31. The man needed regular blood pressure checks. When he was initially
imprisoned at HMP Wormwood Scrubs, there was a useful form in which all
checks could be recorded in date order. The form also showed the days when
the man did not attend for his checks.
32. Whilst at Dovegate the doctor recommended that his blood pressure continue
to be checked and recorded. This was requested several times during his
imprisonment and the results were logged reasonably frequently with the
exception of the period between May 2007 and January 2008.
33. Additionally, there are instances, for example the medication for kidney
problems, when no follow ups, repeat prescriptions or explanations are logged
in the medical record. Many of the records are unsigned or have illegible
signatures. There are specific guidelines for doctors and nurses to complete
medical records. It is essential that all contact is recorded accurately and
chronologically to ensure there is an accurate and continuous history of a
prisoner’s needs and treatments. Since his death, the healthcare team
implemented a list of sample signatures to help identify records with illegible
entries.
The Head of Healthcare should remind all healthcare staff of the
guidelines for recordkeeping and audit the records to ensure the
standards are adhered to.
The Head of Healthcare, in conjunction with the doctors, should ensure that
when a doctor suggests or requests interventions, they are duly undertaken
and recorded in the medical record.
Medication management
34. Upon his arrival at Dovegate, the man signed an ‘in-possession’ medication
compact. However, there was no risk assessment carried out to determine his
suitability for this. In retrospect, he would have initially been assessed as
suitable, but he was not taking his medication as instructed and his excess
medication was not returned to the pharmacy. It would also have been
possible that his suitability to hold certain medication in-possession could
have been reviewed to ensure better monitoring. The man was entitled to
choose whether he took his medication however; there is no indication that
any action was taken to monitor it, other than to warn him about the risks of
not taking his anti-hypertension medication. The man’s non-compliance with
his blood pressure medication is directly linked to his cerebral haemorrhage.
35. If wing staff had been aware that he was not taking his medication as
prescribed, the information could have been used when searching his cell.
The man had been subject to a routine cell search a few days before he was
taken to hospital, but the officers did not check his medication or examine the
quantity he had in-possession. It is not unknown for prisoners to use
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medication as ‘currency’ or have it stolen. Additionally, some medications
should not be taken together as they pose health risks. I appreciate that this
was not an issue in his case, but nonetheless he should not have had this
quantity of unused medication in his cell.
36. The healthcare management team are aware that the policy for medicines and
in-possession medication is overdue for review. A newly convened medicines
management meeting was scheduled to commence in June 2008. At the time
of issuing this report two meetings had taken place. I am pleased to report
that the prison now has a risk assessment system in place.
37. In addition, new pharmacy arrangements are soon to be implemented with a
pharmacist taking up post on 4 August. The medicines management policy
remains under review and the return of unused medication will be discussed.
The Director and Head of Healthcare should ensure that the in-
possession medication policy is reviewed at an early date and
operational staff are aware of its contents especially regarding cell
searches.
38. The new healthcare team at Dovegate has started to introduce clinical
governance arrangements. A first meeting was planned for June 2008, but
was cancelled and rearranged for 24 July. The clinical governance
arrangements will include incidents, complaints, policies, prison risk register,
clinical audit, health and safety and clinical supervision.
Emergency codes
39. When the PCO called for medical assistance on 2 March, there was a delay in
the healthcare staff response because it was apparently not clear to them that
it was an emergency.
40. In Dovegate’s death in custody contingency plans there is a code system for
emergency medical responses. Regrettably, healthcare and operational staff
are not familiar with the instructions. By identifying a call with a code,
healthcare staff have more information about what equipment to bring with
them for example oxygen and/ or a defibrillator.
41. The response time of the ambulance was reviewed by the clinical review
team. They found no delays in an ambulance being dispatched to the prison
or between the time the ambulance arrived at the prison to the time the
paramedics reached the man. Once he was admitted to hospital, he received
the care and treatment appropriate to patients presenting with his symptoms.
It is the view of the clinical review panel that there were no delays in providing
the man with appropriate clinical assistance.
The Director and Head of Healthcare should ensure all staff are familiar
with the emergency response guidance and implement it as appropriate.
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RECOMMENDATIONS
1. The Head of Healthcare should remind all healthcare staff of the guidelines for
recordkeeping and audit the records to ensure the standards are adhered to.
HMP Dovegate has accepted this recommendation. An audit is due to take
place this month.
2. The Head of Healthcare, in conjunction with the doctors should ensure that
when a doctor suggests or requests interventions, they are duly undertaken
and recorded in the medical record.
HMP Dovegate has accepted this recommendation. Interventions are now
recorded on a notice board in the nurse’s office.
3. The Director and Head of Healthcare should ensure that the in-possession
medication policy is reviewed at an early date and operational staff are aware
of its contents.
HMP Dovegate has accepted this recommendation. This was pending and
should be resolved this month.
4. The Director and Head of Healthcare should ensure all staff are familiar with
the emergency response guidance and implement it as appropriate.
HMP Dovegate has accepted this recommendation. Posters are displayed on
residential areas describing the current emergency response procedure. A
new emergency response procedure is currently under development.
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