Individual at Dovegate

Investigation into the circumstances surrounding the
death of a prisoner at HM Prison Dovegate on 23 January 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2005
CONTENTS
Summary
Investigation methodology
The prisoner
HMP Dovegate
Events prior to the prisoner’s death
Events after the prisoner’s death
Findings and conclusions
Recommendations
This is the report of an investigation into the death of a prisoner at HM Prison
Dovegate on 23 January 2005. The cause of death was cardiac failure.
One of my Investigators conducted this investigation. I also invited East
Staffordshire Primary Care Trust (PCT) to undertake a clinical review into the
care and treatment given to the prisoner. However, the PCT declined to
undertake such a review, primarily because Dovegate does not commission
its healthcare services from the National Health Service. The clinical review
was therefore undertaken by an appropriately qualified independent clinician
commissioned by my office.
I would like to extend my condolences to the prisoner’s family for their loss. I
would also like to thank the Director of HMP Dovegate, and his staff for their
help and co­operation during this investigation.
I make no recommendations in this report, although the authorities at
Dovegate will wish to check what offer was made in respect of funeral
expenses in line with my comments in paragraph 45.
Apart from some very minor amendments, and removal of those involved the
text of my report is as I submitted it in July 2005. I now refer to the prisoner
as the ‘man’.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2005
Summary
On 27 September 2002, the prisoner was sentenced to 4 years imprisonment
for a sexual offence. This was not his first period of imprisonment. On
sentencing, the man was initially held in HMP Parc. In June 2004, he
transferred to HMP Dovegate. He was a Category B prisoner until January
2005, when he achieved category C status. Following his re­categorisation,
the prisoner hoped to be transferred back to HMP Parc prior to his release, in
order to receive visits. He was due for release in March 2005. The prisoner
did not have any identified serious health concerns when he came into
custody.
On Sunday 23 January 2005, at 7.00pm, the prisoner died at Dovegate. He
was 55 years old when he died. He had been taken to the Health Care
Centre from his residential wing complaining of chest pains. Whilst in the
Health Care Centre, the prisoner suffered a cardiac arrest and lost
consciousness. Cardio­Pulminory Resuscitation (CPR) began immediately
and it was noted that the prisoner was breathing, although he remained
unconscious. The prisoner then suffered a further cardiac arrest and, despite
the continuous efforts of prison nursing staff and paramedics, he was
pronounced dead. The clinical review into his care and treatment whilst in
custody concludes that he received a good level of medical care, comparable
to that which is available in the wider community.
The Prison Service did not inform my office of his death until April 2005.
Meanwhile, the inquest had been held on 7 March 2005 at which it was
concluded that he had died of natural causes.
The investigation process
1. The investigation was opened at Dovegate on 13 April 2005 when Notices
were sent to staff and prisoners notifying them that my office was
conducting an investigation into the death of the man. The Director and
his staff produced his core record, his Medical Record and a number of
other documents for examination.
2. My investigator visited HMP Dovegate on 20 April, and spoke with
representatives from the prison including staff and a fellow inmate who
had known the prisoner at the time of his death.
3. One of my Family Liaison Officers contacted the prisoner’s partner and
offered the opportunity to meet with her and the investigator to discuss the
purpose of the investigation and to raise any concerns or questions that
she would like explored and addressed. The family have no issues in
respect of the care or treatment afforded to the prisoner whilst he was in
custody, but would like to see a copy of the draft report.
4. My investigator contacted Her Majesty’s Coroner to request a copy of the
Post Mortem report.
5. HMP Dovegate is a contracted prison that provides its own healthcare.
The East Staffordshire Primary Care Trust was given the opportunity to
conduct a review into the prisoner’s clinical care and management.
However, as they are not the commissioning body they have declined to
conduct a review. In light of this decision, my office independently
commissioned a clinical review.
6. Although Dovegate told the Prison Service Headquarters of the prisoner’s
death promptly, my office was not notified until April 2005.
The prisoner
7. The man was born in 1950. He was one of 11 children and was brought
up by his grandparents. He remained in contact with some of his siblings.
8. He left school with no qualifications. However, he later became a qualified
bricklayer and had been employed as a painter and decorator. He had
also undertaken some factory work as well as working as a Security
Guard. At the time of his conviction, he was unemployed.
9. He had been married and has one grown­up son. However, the marriage
broke down some time ago and there is no indication that contact was
maintained between the prisoner, his ex­wife or his son.
10.He lived with his partner, who was his identified next of kin. She remained
supportive of him throughout his sentence. Contact was maintained
through frequent telephone calls and letters. However, due to the
distance and expense involved, the prisoner did not receive any visits
from his partner whilst at Dovegate.
11.He had a history of offending dating back to 1964. The offences were
varied and included previous sexual offences. Consequently, he had
experienced prison on a number of occasions. Throughout his custodial
history, the prisoner did not participate in any programmes, for example
the Sex Offender Treatment Programme (SOTP), to address his offending
behaviour.
12.From September 2002 until 10 June 2004, he was held in HMP Parc. In
June 2004, he was transferred to Dovegate.
13.In late November 2002, the prisoner complained of pain and discomfort in
his groin and was admitted to the Health Care Centre at Parc for
assessment. He was then referred to an outside hospital for tests, as
there was a suspicion that he was suffering from kidney stones. The
prisoner was advised to take regular analgesics for the pain and to drink
plenty of fluids. However, a subsequent test on his urine sample detected
the presence of abnormal cells for which he was referred for further
investigations including a cystoscopy and biopsy.
14.From 3 to 5 June 2004, he was treated as an inpatient at hospital. The
investigations undertaken did not detect anything sinister or untoward.
15.He was transferred to HMP Dovegate on 11 June 2004. On arrival at
Dovegate, the Health Care staff reviewed him. The prisoner’s reception
screening indicates that he had suffered from a torn muscle in his left leg.
He also stated that he had a hernia. The prisoner indicated that there was
a family history of heart problems in that his mother had died of a massive
heart attack, but denied that he had a heart condition.
16.On 29 June 2004, the prisoner made a formal complaint to the prison
about the lack of treatment for his hernia, stating that whilst he was at
Parc he had been advised that he would require an operation. He had
been complaining for some months of a pain in his groin. The Health
Care Centre advised himthat a previous investigation had not detected
anything untoward. However, on 13 September, the prison arranged for
himto attend another hospital, as an outpatient. Investigations
determined that there was no convincing evidence of a hernia and the
prisoner was duly informed of this.
17.The only other contact the prisoner had with the Health Care Centre at
Dovegate was on 5 August, when he, along with a number of other
prisoners, was a victim of assault on ‘G’ wing. He received a cut above
his right eye from a punch that required some sutures. The sutures were
removed on 10 August. As a result of this incident, he and other
prisoners made applications for compensation to the Criminal Injuries
Compensation Board (CCCB). At the time of his death, the prisoner was
still awaiting the outcome of his claim for compensation.
18.On 11 January 2005, the prisoner was told that he had been successful in
achieving category C status. It was his intention to seek a transfer back to
Parc, in order to receive visits from his partner prior to his release on 31
March 2005. According to his personal officer, the prisoner was a quiet
man who did not present any problems to staff. He would spend a lot of
his time watching television in his cell. He shared a cell and it was
reported that he got on well with his cellmate. Whilst at Dovegate, the
prisoner did not take part in any educational programmes and was not
employed. He did not engage in any offending behaviour programmes.
19.There is no indication from speaking to the prisoner’s personal officer or
his cellmate that he was unduly worried about his health. There is nothing
to indicate that, in the time preceding his death, the prisoner was suffering
from any chest pains, although he had taken to wearing a pressure
bandage on his left arm. The prisoner complained on occasion of
indigestion and was in the habit of drinking milk in order to reduce the
discomfort.
20.Before his sentence, the prisoner lived with his partner. Following his
death, his ex­ wife and someone representing his son telephoned the
prison claiming to be the rightful next of kin. The prison, quite rightly,
sought advice from the Coroner who advised that his current partner
should be considered the next of kin.
.
21.Following the prisoner’s death, a member of the prison chaplaincy acted
as family liaison officer. This role has included arranging for his partner to
view the body in the Chapel of Rest, as well as visiting Dovegate in order
to meet staff and prisoners who knew him.
HMP Dovegate
22.Dovegate opened in July 2001 and is a male category B training prison. It
is operated by Premier Custodial Services, now part of the SERCO Group.
Dovegate consists of two prisons, the main prison and a Therapeutic
Community (TC). The establishment has capacity for 1,060 prisoners of
whom600 can be housed in the main prison and 200 in the TC
23.The prison is not well served by public transport and is well away from the
home areas of most prisoners. The prison offers a wide variety of
education programmes as well as industrial work including light
engineering, packing and other manual activity. There is a large
gymnasium, with a well equipped weights room as well as a football pitch
and running track.
24.Dovegate runs a 24 hour primary healthcare facility, which has a full time
medical officer. There are regular clinics by a dentist, chiropodist, optician
and psychiatrist. The prison contracts staff working within the Health Care
Centre although agency staff are used to meet shortfalls in staffing levels.
25.In the past, Dovegate has suffered from a high turnover of staff that has
led to the dilution of experience within the prison. According to a member
of the Independent Monitoring Board (IMB) to whom my investigator
spoke, staff retention rates are now becoming more stable.
Events leading to the prisoner’s death
26.On Sunday 23 January, at approximately 5.30pm, the evening meal was
being served on ‘G’ wing. The prisoner had been served his main meal,
although he was unable to eat it. However, he did take some ice cream in
order to aid his digestion. According to staff who had seen him that day,
he did not complain of any pain or discomfort.
27.At 5.30pm, the prisoner approached two members of prison staff, one of
whom was his personal officer who were working on the servery and
asked if he could speak to one of them. He complained of pains in his
right arm and his chest and was holding his hands across his chest. The
prisoner felt that he had indigestion. He looked pale.
28.The prisoner was told to lie down in his cell, although he commented that
this made the pain worse. He was therefore advised to sit down instead.
Because of his pain he was accompanied by an officer, whilst another
officer contacted healthcare by telephone, detailing his symptoms.
29.Initially, staff from healthcare stated that they would attend ‘G’ wing to
assess the prisoner. However, it was quickly decided that because of his
symptoms, the prisoner should be taken immediately to the Health Care
Centre. There he could be assessed and monitored more effectively with
the specialised equipment that was to hand. Staff in healthcare strongly
advised the custody officers that the prisoner should be transported from
‘G’ wing to the Healthcare Centre, a distance of some 200 yards, by
wheelchair. A wheelchair was available for use on the wing.
30.When staff returned to the prisoner’s cell with a wheelchair, he appeared
to be a little more relaxed sitting on a chair. He continued to complain of
pains in his chest as well as a horrible taste in his throat.
31.At first, the prisoner was reluctant to leave the wing in a wheelchair and
walked with the aid of two officers to the wing exit. He then agreed to be
pushed to the Health Care Centre. On leaving his cell he asked his
cellmate to look after his possessions as he was going to hospital. Whilst
he was being conveyed to the Health Care Centre by the two custody
officers, the prisoner was quite chatty, talking about his home and his
family.
32.At 5.45pm, the prisoner arrived with his escorts at the Health Care Centre.
He was taken to the triage room where he was asked to sit on a bed. He
was attached to a heart­monitoring machine. Whilst this procedure was
being carried out, he was asked by the nurse if there was any family
history of heart problems. The prisoner confirmed that his mother had
died of heart failure and joked that he had some time to go yet. His pulse
and blood pressure were taken. The pulse was weak and his blood
pressure slightly elevated. The ECG test confirmed that some myocardial
damage had occurred that indicated a problem with his heart.
33.In view of the ECG reading, the prisoner was immediately given 300mg of
aspirin that he swallowed in the nurse’s presence. The nurse had also
ensured that an ambulance was called and the Duty Operations Manager
informed. An oxygen cylinder and mask was prepared for his immediate
use.
34.On returning to the triage room, the prisoner was informed by a nurse that
he was being taken to hospital. Whilst sitting on the bed, it was noted that
his complexion paled and his eyes rolled to the back of his head. He
became unconscious and slumped on the bed. The time was
approximately 6.00pm.
35.In response to his collapse, another member of the nursing staff was
summoned to the triage room and cardio–pulmonary resuscitation (CPR)
began. After approximately two minutes of CPR, it was noted that he
could breathe unaided. However, his pulse was faint and he remained
unconscious.
36.Healthcare staff had been advised to contact the paramedic team if the
prisoner’s condition deteriorated. Whilst a member of the nursing staff
was speaking to the paramedic team, he suffered another cardiac arrest.
The time was 6.05pm. The information was relayed to the paramedics by
one of the custody officers who had escorted the prisoner to the Health
Care Centre, thus allowing the nurse to attend the triage room and assist
her colleagues with CPR.
37.CPR continued by three members of the health care nursing staff without
interruption. A spinal board was placed under the mattress of the bed to
reduce the bounce effect and to allow for more effective treatment.
However, there was no evidence of a pulse or respiratory effort from the
prisoner. Nursing staff attempted to insert a geudal airway in order to
assist with his breathing, but they were unable to do this as his jaw had
locked in a closed position. An ambubag was connected to the oxygen
mask already on his face. There was still no cardiac output.
38.At 6.30pm, the ambulance arrived and the paramedics were promptly
escorted to the triage room. The paramedics attached their own cardiac
monitor to the prisoner’s chest and continued with CPR. Electric shocks
were also delivered via the defibrillator, but there was still no response.
39.After approximately five minutes of CPR in the triage room, the
paramedics decided to move the prisoner to the ambulance by stretcher.
An intubation tube was inserted into his throat to oxygenate his lungs. An
intravenous canula was inserted into the forearm so that advanced life
support medication could be administered. Heart massage and shock
treatment continued for a further 30 minutes. Throughout this procedure
there was no response from the prisoner.
40.At 7.00pm, the prisoner was pronounced dead by the paramedics. He was
moved back to the triage room in the Health Care centre to await the
arrival of the police and the Coroner’s officer. Police arrived at Dovegate
at 7.40pm to begin their investigation. They have confirmed that they do
not suspect any foul play. The Assistant Director of Healthcare was also
notified of the death. The prison contingency plan in the event of a death
in custody was implemented and followed correctly.
Events after the prisoner’s death
41.After the prisoner was pronounced dead, his cell was sealed until the
arrival of police. The prisoner’s cellmate was informed of his death and
was moved to another cell until the police had completed their enquiries.
Other inmates on the wing were confined to their cells for the rest of
Sunday evening.
42.A senior member from the prison contacted the Police station near to
where the prisoner’s partner resides. Police visited her and conveyed
news of his death. In other circumstances, the Director or a prison
representative would normally have visited in order to break the news, but
in view of the distance involved this was not possible.
43.On Monday 24 January, a member of the prison chaplaincy staff made
contact with the prisoner’s partner by telephone. Arrangements were
made for her to travel from her home to view the body in the Chapel of
Rest and to visit Dovegate. She was also given the opportunities to meet
staff and prisoners who knew her partner, and express their condolences.
44.Prisoners were formally informed of their fellow inmate’s death on 24
January. The prisoner was a popular man and prisoners, as well as staff
who knew him, were shocked and saddened at the news. A memorial
service was held on ‘G’ wing shortly after the prisoner’s death and was
well attended.
45.On 3 February, the funeral of the prisoner took place. The prison
contributed to the funeral costs by paying for a member of the family who
lived a long way away. The prisoner’s partner and other members of his
family attended. A representative from Dovegate also attended the
funeral. Although I make no formal recommendation, the prison will wish
to check that it offered to meet all reasonable funeral expenses. If it did
not do so, a renewed offer should now be made.
46.The Inquest into the prisoner’s death was held on 7 March 2005. The
inquest concluded that he died of natural causes.
47.The clinical review concludes that the prisoner received timely, efficient,
and appropriate treatment whilst in custody. The review also concludes
that in the time leading to his death, he received prompt attention from
prison and healthcare staff.
48.The review confirms that the treatment afforded to the prisoner was at
least comparable to that found in the wider community.
Findings and conclusions
49. The prisoner had no known previous history of heart problems, and to all
intents and purposes, was considered to be a fit and healthy man up until
his death. He had relatively few dealings with healthcare whilst in prison,
and did not appear to have any significant issues that would affect his
health. The prisoner’s family have raised no issues in respect of the care
or treatment he received whilst he was at Dovegate.
50.The clinical review confirms that the prisoner enjoyed reasonably good
health and that he received timely and appropriate medical and nursing
treatment. This treatment was equivalent to that found in the wider
community.
51.The action taken by the custody officers and nursing staff on 23 January
appears to have been appropriate and timely. The prisoner suffered
spontaneous cardiac arrests and, despite the continuous efforts by health
care staff and paramedics, they were unable to save him.
Recommendations
52.I make no recommendations in respect of the prisoner’s death but
attention is drawn to my comments in paragraph 45.