Individual at Dovegate

Investigation into the death of a man
at HMP Dovegate on 10 December 2004
Report by the Prisons and probation Ombudsman for
England and Wales
May 2005
This is the report of an investigation into the circumstances leading to the
death of a man, who died on 10 December 2004 at HMP Dovegate.
I offer my sincere sympathy and condolences to the man's family for their
loss.
I wish to extend my thanks to the Director, and his staff at Dovegate for their
help and co­operation during the investigation.
There are no recommendations arising from this investigation. There were
however two actions which I feel deserve commendation as good practice.
The style and tone of the Director of Therapy's information sheet for prisoners
about the man’s sudden death is notable for its humanity. It was also
commendable that, on 12 December, the man's mother, and other family
members were brought to the unit where he had resided not only to see it but
also to sit and meet with other residents to remember the man.
This version of my report, published on my website, has been amended to
remove the names of the woman who died and those of staff and prisoners
involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman
CONTENTS
Summary
Investigation methodology
About the man who is the subject of this report
HMP Dovegate
Events leading to the man’s death
Clinical Review
Findings and conclusions
Recommendations
Summary
1. The man who was serving a life sentence for murder was 54 years of age
when he died on 10 December 2004 at HMP Dovegate.
2. He had served almost 19 years in prison despite the sentencing court
recommending a 15 year tariff. He had a parole review report in February
2004 in which he was not approved for life licence. He was due to be
reviewed again between February and August 2005. During his sentence he
had been held in a variety of prisons designated to hold life sentence
prisoners. He transferred to Dovegate on 3 March 2003 to undertake the High
Intensity Programme (HIP) to address his offending behaviour.
3. The man was being treated for longstanding heart disease complicated by
severe obesity. His weight was around 35 stone and his health and mobility
were severely impaired by this.
4. The man was found dead in his cell in the HIP community at teatime on 10
December 2004. Paramedics attended and estimated that he had been dead
for about three hours.
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Investigation methodology
5. My Investigator, opened the investigation at HMP Dovegate on 21
December 2004. The Director and his staff produced the man's Core Record
and a number of other documents for examination. Notices were issued to
staff and prisoners informing them of the investigation.
6. My investigator visited the High Intensity Programme (HIP) Community
and spoke informally with staff about the man. Subsequently he returned to
speak with a prisoner who requested to speak with him regarding the man's
death.
7. One of my Family Liaison Officers, contacted the man's next of kin. She
was told that the family had no concerns or unanswered questions about his
care or death.
8. A clinical review of the healthcare the man received whilst at Dovegate
was commisioned.
9. My Investigator contacted Her Majesty's Coroner to inform him of the
nature and scope of the investigation and to request a copy of the Post
mortem report. Upon completion, this report will be sent to the Coroner to
assist him in his enquiries into the death.
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About the man who is the subject of this report
10.The man was born in Glamorgan in 1950, the eldest of three children. His
parents were self­employed local business people. After passing the 11+ he
failed to achieve any educational qualifications. He left school just before his
17 th birthday and went into the family business in their 'mobile shop'.
Interestingly, while serving his sentence, the man achieved an M. Phil at
University.
11.The man was sentenced to life imprisonment in 1986 for the murder of a
shopkeeeper in the course of a theft. He was set a tariff of 15 years, which at
the time of his death had expired without approval for a life licence. His next
Parole Board Review was due to commence in February 2005. the man had
no history of criminality before the offence for which he was sentenced to life
imprisonment.
12.During his sentence the man moved to a number of different lifer units,
progressing through his life sentence plan. His behaviour was always
reported positively, with no breaches of prison discipline. Having been found
unsuitable for the therapeutic community at Grendon, he was accepted for the
high intensity programme (HIP) at Dovegate and transferred in March 2003.
13.The man made use of the Prison Service Complaints system, making 17
complaints at Dovegate in 2003 and 21 in 2004. As an articulate man, this
system may have been one avenue whereby he could vent his frustration with
the custodial environment. His main issues of complaint related to food,
healthcare and privileges. Latterly, he was frustrated by the healthcare
management's refusal to make him a special case with regard to attending the
healthcare centre to see the doctor.
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HMP Dovegate
14.Dovegate is a male Category B training prison. It was opened in July 2001
and is operated by Premier Prison Services, which is part of the SERCO
group. They have the contract to run both sections of the prison for 25 years.
15.Dovegate was built on a former MOD brownfield site and consists of two
prisons, the main prison and a Therapeutic Community. This is a discrete
facility located on the same site as Dovegate main prison and sharing some of
the main prison services, healthcare, gymnasium and visitors centre.
16.The report of the announced inspection by HM Chief Inspector of Prisons
in April 2004 is generally positive, stating, 'there is much to commend both in
the therapeutic model and in the way it has been implemented in the
Dovegate TC'
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Events leading to the man’s death
17.The man arrived at Dovegate from Bristol on 4 March 2003. The initial
assessment described him as obese, having arthritis and taking a number of
medications for his heart. The nurse was unable to weigh himor take his
blood pressure due to lack of suitable equipment. Unfortunately the doctor's
examination report was almost totally illegible apart from a history of raised
blood pressure since 1983.
18.On 20 March 2003 the doctor recorded that the man weighed 151 kg. This
equates to 23.7 stones. By 25 September 2004 he was reported to weigh 35
stones. Given the reported major problems with transporting the man to
hospital on later occasions and the reported need for a special bed to
accommodate him in hospital, it is likely that his weight was much closer to 35
stones than 23 stones. Once an appropriate sized cuff was obtained his
blood pressure was regularly monitored and was usually around 150/90.
19.Apart from a fairly lengthy schedule of medication for his heart condition,
the man had few interactions with healthcare until January 2004. However he
was prescribed risperidone 4mg daily by a forensic psychiatrist, on 31 August
2003. Records do not indicate why the psychiatrist prescribed risperidone but
she stopped it on 30 January 2004 because she noted that the potential
benefits were no longer outweighing the possible detrimental effects. This
followed the man’s' transfer to Accident and Emergency at the local hospital,
on 23 January 2004. He was sent there because he was presenting with a
rapid pulse and breathlessness. The electrocardiogram (ECG) done by the
prison healthcare team indicated he might be in atrial fibrillation. He was
discharged later that night on increased dose of atenolol and a course of
antibiotics with no follow up appointment. The hand­written discharge letter
from the Senior House Officer (SHO) confirmed atrial fibrillation
recommending the prison doctor to consider anticoagulants if it persisted.
The SHO also diagnosed a chest infection for which the antibiotics had been
prescribed.
20.On 2 February 2004 the man told the doctor he had been told in the
hospital that he had a chest infection but the doctor found no signs of cough,
sputum or raised temperature. The prison doctor wrote that he disagreed with
the SHO's diagnosis. He also noted that anticoagulation should be done in
hospital not in the community. On 13 February the doctor recorded chest
clear and the heart in sinus (ie normal) rhythm.
21.The man next saw a doctor on 26 April 2004 when he was presenting with
giddiness. The examining doctor (probably a locum) thought his atrial
fibrillation had returned and was causing the giddiness. He advised a need
for warfarin but did not prescribe it. He also mentioned starting on the
appetite suppressant reductil, but no evidence that it was prescribed was
found in the notes.
22.In June 2004 his arthritis flared up and he was prescribed the anti­
inflammatory drug, voltarol.
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23.On 2 July 2004 the man refused to attend healthcare on the grounds of his
breathlessness on exertion. A nurse asked a doctor to visit him on the unit
but the doctor was unable to do so because of the demands of his fully
booked clinic. This led to himhaving to sign a disclaimer for refusing to attend
the healthcare centre, which prompted a complaint from the man. On 5 July a
nurse offered to admit the man to the healthcare centre for assessment and
observation. He declined.
24.The offer was repeated and again declined, on 18 July but on 20 July he
was admitted to the healthcare centre. He was prescribed a strict diet
consisting of Green vegetables and fruit, skimmed milk, tea/coffee without
sugar, no carbohydrate or fat and meat with fat removed. He complained of
chest pain on 21 July but after a full medical examination he was advised to
continue on his regular analgesia and take an antacid for indigestion. He was
discharged back to the HIP unit.
25.In August 2004 the man developed infections in both his legs. This led to
skin breakdown and the need for regular dressings and a course of antibiotics.
26.On 19 September 2004 the man had another episode of chest pain which
was assessed and treated as indigestion related.
27.On 20 September the man suffered a fall with no apparent injuries
sustained. The next day he began to complain of a painful and swollen
scrotum and was admitted to the healthcare centre as an in­patient. On 24
September, a doctor assessed the man and diagnosed infection in the
scrotum and abdominal skin folds. He referred the man to the NHS
expressing concern that there was potential for septicaemia which could be
fatal.
28.At hospital he was diagnosed as having a hydrocele, a swelling on the
testes, which needed draining surgically. However there was no equipment or
bed large enough to accommodate him and the NHS would need time to plan
how to manage him.
29.The man returned to the prison but was transferred back to hospital on 27
September where he remained until 18 October 2004. The discharge reports
show that he was suffering from iron­deficiency anaemia for which he was
transfused two units of blood. He was also diagnosed as suffering congestive
cardiac failure. His drug treatment was a continuation of his previous regime
comprising the following:
30.Diclofenac ­ non­steroid anti inflammatory
31.Gaviscon liquid ­ antacid
32.Aspirin ­ prophylactic anti­platelet
33.Cetirizine ­ antihistamine (for allergies)
34.Orlistat ­ anti­obesity drug acting on the gastro­intestinal tract
35.Multivitamins
36.Atenolol ­ A beta­adrenoceptor drug used in hypertension, angina and
arrhythmia
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37.Omeprazole ­ proton pump inhibitor used in gastro­intestinal ulceration
38.Frusemide ­ diuretic
39.Enalapril ­ drug used in hypertension and heart failure
40.The man continued on the above medication without incident until the day
of his death.
41.On 10 December 2004 about 4 pm an officer looked into the man’s cell
and told him that he had mail. He got no response, but thinking that he was
asleep, as he often was, did not disturb him. At approximately 5.15 pm,
nursing staff were called to make an emergency response to the High
Intensity Programme unit after another officer, could not rouse the man when
he failed to appear to collect his tea meal. An ambulance was called. At 5.18
pm a Nurse found no signs of life ­ no pulses, no breath sounds, pupils fixed
and dilated, skin mottled to both legs, stomach and arms, nails blue. The man
was on his side and due to his weight the nurses could not turn him on to his
back to commence Cardio­pulmonary resuscitation (CPR). Paramedics
attended at 5.39 pm and declared that the man had been dead for some time
­ later estimated to be three hours. The Paramedic pronounced life extinct at
5.43 pm.
42.Post mortem findings were that death was due to ischaemic heart disease
and hypertensive heart disease with severe obesity as a contributory factor.
43.My investigator was contacted by one of the man’s fellow prisoners, who
had seen the notice of the investigation displayed around the prison. He had
concerns about the medication that the man had received. Apparently the
man had told him that Healthcare was not issuing him medication which he
believed the doctor had prescribed. This allegation was examined by the
clinical reviewer.
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Clinical Review
44.My investigator requested that the person who carried out the clinical
review, investigate the concern raised by the prisoner about the man not
receiving the medication that he believed the doctor had prescribed.
45.The man was prescribed risperidone 4mg daily on 31 August 2003. The
doctor stopped this on 30 January 2004 because she noted that the potential
benefits were no longer outweighing the possible detrimental effects. The
clinical reviewer says that perhaps the man did not fully appreciate why the
risperidone was stopped from which, in his view, he probably derived some
benefit.
46.On 23 January 2004, the man went to Accident and Emergency on 23
January 2004. He was discharged later that night on an increased dose of
atenolol and a course of antibiotics with no follow up appointment. The hand­
written discharge letter from the Senior House Officer confirmed atrial
fibrillation recommending the prison doctor to consider anticoagulants if it
persisted. The SHO also diagnosed a chest infection for which the antibiotics
had been prescribed.
47.On 2 February, the prison doctor found no signs of cough, sputum or
raised temperature. The prison doctor wrote that he disagreed with the SHO's
diagnosis. He also noted that anticoagulation should be done in hospital not
in the community. On 13 February the doctor recorded chest clear and the
heart in sinus (ie normal) rhythm. The reviewer says it is possible that the
man had expected a further course of antibiotics and mentioned this to his
fellow prisoner as a complaint. It is also possible he believed the prison
doctors were refusing him medication prescribed by the hospital doctor,
namely anticoagulants, as well as antibiotics.
48.On 26 April, the man complained of giddiness. During the course of the
examination, the doctor mentioned starting on the appetite suppressant
reductil but no evidence that it was prescribed was found in the notes. The
review comments that the complaint mentioned by the prisoner may have
related to the reductil. Perhaps the man thought he had been prescribed it
whereas the doctor’s entry was more in the way of a possibility for
consideration. If he articulated his thought to the man, it could have sounded
like an actual prescription was being made.
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Findings and conclusions
49.The care the man received in Dovegate was similar to that which he would
have received had he been in his own home under the care of community
health services. He was referred for secondary care in a timely and
appropriate way. The reports from Queens Hospital indicated that he had
been treated according to his clinical needs and informative discharge reports
were sent after each admission.
50.The man entered the prison system with chronic conditions of high blood
pressure and asthma both of which were attributed to or at least complicated
by, his severe obesity. He was prescribed medication appropriate to his
chronic diseases and also to help him manage his weight. From the
evidence, diet was a major concern to the man and the staff. It may be that
there was a misunderstanding whereby his diet was so restricted that it was
lacking in protein and iron. It is possible that this contributed to his iron
deficiency anaemia for which he was treated with a blood transfusion.
51.It was unfortunate that the man was not found until he had been dead for
some time, thereby eliminating any possibility of resuscitation. However his
obesity would have made cardio­pulmonary resuscitation very difficult.
52.The prison staff responded appropriately at every level once the incident
had occurred. The family were contacted and the man’s mother, sister and
brother­in­law visited the High Intensity Programme Unit on 12 December.
53.Another prisoner said that the man thought he was not being issued with
all the medication that he had been prescribed. Although there is nothing in
the clinical review that can be regarded as conclusive, I think there are three
occasions on which the man may have been disappointed enough to mention
to his fellow prisoner that medication, apparently promised or prescribed, had
failed to materialise.
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RECOMMENDATIONS
54.I have no recommendations to make following this investigation.
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