Individual at Eastwood Park

INVESTIGATION INTO THE CIRCUMSTANCES
OF A WOMAN
AT HMP EASTWOOD PARK
PRISONS AND PROBATION OMBUDSMAN
FOR ENGLAND AND WALES
APRIL 2005
This woman died on in June 2004. She had been recalled to prison on 3 June for
breach of home detention curfew and was housed on the detoxification wing at HM
Prison Eastwood Park where she was receiving medication. The post mortem report
indicates that the cause of death was a pulmonary thromboembolism.
We extend our condolences to this woman’s family.
Under my terms of reference from the Home Secretary, I am required to investigate
all deaths of prisoners no matter what the cause, to establish what happened, and to
see whether there are any lessons to be drawn. The investigation looked carefully at
the detoxification care this woman received.
The Prison Health Development Manager for the South West, has conducted the
investigation on my behalf working in collaboration with one of my Assistant
Ombudsmen. Clinical advice has been provided by two highly experience doctors of
the South Gloucester Primary Care Trust and a Consultant Psychiatrist in Substance
Misuse.
I am grateful to all those who have contributed to the investigation.
This version of my report, published on my website, has been amended to remove
the name of the deceased and the names of staff and prisoners who were involved
in my investigation.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN
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CONTENTS
SUMMARY
HMP EASTWOOD PARK
THE SEQUENCE OF EVENTS
MONDAY MORNING 7 JUNE 2004
RECOMMENDATIONS OF THE CLINICAL ADVISERS
CONCLUSIONS AND RECOMMENDATIONS
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SUMMARY
This woman was recalled to prison from Home Detention Curfew. At the time she
was taking various prescribed medication including Dihydrocodeine. At Eastwood
Park, she was placed on a methadone detoxification regime and other medication.
She was admitted to prison on a Thursday. On Friday, the woman said she felt light-
headed and had fallen in her cell. On Sunday, she exhibited symptoms that can
indicate opiate overdose. The woman said it was an adverse reaction to methadone
that she had experienced before. She was observed by nursing staff, and her
condition improved. On Monday morning, the woman was found collapsed in bed in
her cell. Staff attempted resuscitation but she died in hospital later that morning.
The post mortem report indicates pulmonary thromboembolism as cause of death.
The pathologist’s report indicates that the detoxification treatment had no connection
with her death. The subsequent coroner's inquest held on 24th February 2005,
returned a verdict of:
'Natural causes as a result of pulmonary thromboembolism'.
The Ombudsman concludes the report with five recommendations. In addition,
specialist clinical advisers have examined the circumstances and made
recommendations about healthcare, medical record-keeping and the care and
treatment of women withdrawing from substance misuse.
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HMP EASTWOOD PARK
Eastwood Park is a women’s local prison which holds remand and short term
sentenced prisoners. It has an operational capacity of 346.
The accommodation is a mix of refurbished 1960s accommodation and some new
buildings.
B wing is a small, refurbished self-contained area which is part of the original older
construction. It has 43 spaces for women undergoing detoxification from substance
misuse, mainly in double cells. It was opened in the spring of 2004.
Over the last two years the population pressures have meant Eastwood Park has
become almost entirely a remand prison and turnover of prisoner population has
increased dramatically. The prison serves courts throughout the whole of the
southwest, the south Midlands and as far as the edge of the London catchment area.
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THE SEQUENCE OF EVENTS
This woman was arrested at Congresbury on Wednesday 2 June at 12:30 and taken
to Bridgwater Police Custody Unit .
In police custody, she was seen by the police surgeon. At 20:00 she was given
Zyprexa (Olanzepine) 10mg, Dihydrocodeine 30mg and Diazepam 10 mg. At 23:00
she was given Diazepam 20 mg and Temazepam 20mg (a short-acting
benzodiazepene with a sedative effect). Next morning at 08:56, the police gave her
Cipralex (an SSRI anti-depressant) 5mg, Dihydrocodeine 30mg and Diazepam
10mg.
The woman was then taken to HMP Eastwood Park, where she arrived at 10:20.
One of the senior nurses was called by reception to say the woman had arrived and
someone was needed to go through the healthcare admission screening with her.
As there was no one else available, the senior nurse volunteered to go and see her
rather than her having to wait perhaps several hours in reception, as they usually
received prisoners direct from the courts in the afternoon. He completed the first
part of the reception screening form and made notes in the continuous medical
record sheet.
The notes are full and informative, including contact details for the woman’s GP and
a list of her medication with dosages. The woman told the nurse she was drinking
one bottle of vodka a day but said she was not taking illicit drugs. Her urine tested
positive for benzodiazepine and opiates which was not inconsistent with her
prescribed medications. On the screening form the nurse has noted concerns about
mental health and alcohol withdrawal.
From reception the woman was located on B wing, the detox unit. That afternoon,
she saw the Medical Officer. He examined her on B wing. In addition, one of the
nursing staff gave him a bag of medication that the woman had brought with her.
The woman gave a history of mental illness, drinking alcohol in excess amount and
receiving Dihydrocodeine 30mg four times a day from her doctor for opiate abuse.
The medical officer said that when he explained that it was not the current policy to
prescribe Dihydrocodeine but to use methadone, the woman told him that she had
been smoking heroin and had taken methadone in the past so preferred that as a
detox. She also gave a history of Diazepam 60mg a day and Temazepam 20 mg at
night from her doctor; and in addition Olanzepine 15 mg once a day and Cipralex
5mg once a day for psychiatric problems.
The Medical Officer said he decided to place the woman on the standard two-week
methadone detoxification programme. In accordance with the doctor’s prescription,
the woman received 10mg in the afternoon of Thursday 3 October; on Friday she
received 10 mg in the morning and 15 mg in the afternoon; and on Saturday 15 mg
in the morning and 15 mg in the afternoon. On Sunday she received a single dose
of 30 mg in the morning.
The other medications that she received were Diazepam 20mg in the afternoon of
her admission to prison, then subsequently 20 mg in the morning and again in the
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afternoon, Olanzepine 15mg once a day in the afternoon and Cipralex 5 mg once a
day in the morning. All these medications were administered under supervision of
nursing staff. She was also prescribed two inhalers for asthma, Beclomethazone
and Salbutamol, which were given to her to keep in her cell.
The Medical Officer made the decision not to use a front-line alcohol detoxification
because he considered the relatively large dose of Diazepam to be sufficient to deal
with any withdrawals. The Medical Officer expressed some concern that he felt the
protocol to use only methadone as the withdrawal medication from opiates had
become uniform in women’s prisons. He said that methadone was generally a
superior treatment to Dihydrocodeine but there should be some facility to use
Dihydrocodeine if the clinician judged it more appropriate for a particular individual.
Dihydrocodeine is not licensed for detoxification but can be used for symptomatic
relief if a clinician considers it appropriate.
The next entry in the continuous medical record is dated 4 October (Friday). No time
is given. A Healthcare Assistant has recorded that the woman said she fell in her
cell and was complaining of feeling light headed. Her blood pressure was taken and
registered 154/98 (slightly elevated) and pulse was 76. The note says that she was
to be observed for any further attacks. It is not known how this was communicated
to other staff. The Healthcare Assistant was a member of agency staff and has not
been interviewed. There is no record of any further observations following the
incident.
There are no records of any further incidents on Friday or Saturday but it is recorded
that the woman collected her medication as prescribed morning and afternoon.
There are two entries in the medical record for Sunday afternoon 6 June, made by
an agency RMN. She states that at 14:45 the woman was very drowsy, her speech
slurred, unable to sit up, dribbling, and with pinpoint pupils. Initially she was unable
to understand what the woman was saying. Her blood pressure was 133/76 and her
pulse 116. The woman denied taking any drugs in prison other than those
prescribed for her. The note says the woman then told the RMN that methadone
always had that effect on her but she had not liked to say anything when it was
prescribed for her. The RMN recorded that the woman was not to have any further
does of methadone, she must be closely observed and must be seen by the medical
officer next morning.
At 16:20 the RMN tested the woman’s urine which was positive for benzodiazepine
and methadone, both of which were prescribed. The RMN noted that the woman
was looking and feeling better than earlier.
The protocol for the standard detoxification regime at Eastwood Park contains
instructions and guidance to the clinicians administering the treatment. The protocol
states that the nursing staff dispensing methadone must withhold the treatment if the
patient shows signs of intoxication, such as drowsiness, confusion, slurred speech
and small pupils. The protocol also contains guidance on the management of opiate
overdose. It states that signs of opiate overdose are drowsiness, collapse, slow
shallow breathing leading to respiratory arrest and pinpoint pupils. Action to be
taken in the event of overdose is to call for an emergency ambulance, start basic life
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support and administer Naxolone (an opiate blocker) repeatedly until the ambulance
arrives.
The RMN was asked whether she had considered giving the woman Naloxone in
view of the symptoms she was exhibiting. The RMN said that she made an
assessment of the woman’s condition. She also consulted a fellow-nurse and made
the decision that the woman’s condition warranted close monitoring and did not
require the full range of actions described in the overdose protocol being delivered at
that time. The RMN stated that the woman was kept under close observation
throughout the afternoon and evening and that she handed over the information to
the night staff. Those observations are not recorded.
Throughout the weekend the woman’s cellmate was being closely monitored
because she was thought to be at risk of self-harm. Observations were being made
three times an hour and are recorded in the cellmate’s file. This would have meant
looking in to the cell where both the woman and her cellmate were located
throughout the periods when prisoners were locked in their cells. An entry for 06:40
on 7 June notes that the cellmate was helping the woman to go to the toilet.
On Sunday 6 June it appears that the woman started to write a letter and made an
entry in her diary about how she was feeling. The note in her diary says she had
“overdone it on their detox” and was feeling ill. She expected to be “put on codeine
now”. In the letter she says:
“Because of the codeine that was in my system they put me on 30 mg meth. a day.
Today I think they’ll stop it. My legs are swelling up and I’m not that coherent. It’s
only 2 days from the day you spend on this wing. My legs are really, really swollen.
I told them I wasn’t on it. I feel ill and it’s all down to that.”
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MONDAY MORNING 7 JUNE 2004
On Monday morning at about 08:15 an officer entered the woman’s cell, B1-5, to ask
both prisoners if they wanted exercise. The cellmate left the cell and, as she did so,
asked the officer to keep an eye on the woman as she had been unwell in the night.
The officer recalled in her statement that she entered the cell and asked the woman
once more if she wanted exercise. The woman opened her eyes and shook her
head. The officer went back to the cell about 30 minutes later and shook the woman
and asked her if she was OK. She ‘grunted’ in response. Further to this the officer
went to the cell at 09:30 to return the cellmate from exercise and at that time
observed the woman breathing.
Another officer entered cell B1-5 at about 09:50 and was concerned with how the
woman was lying and breathing. He records that he could not get a response by
talking to her or shaking her so he asked an officer to send a nurse to the cell.
The unit manager and senior nurse, was present on the wing and attended within
seconds. She found the woman to have no pulse and not to be breathing. She
asked an officer to call a Code Blue (emergency call) over the radio to summon
urgent assistance. When this was done she asked the officer to call for the Senior
Nurse to assist. The senior nurse was also on the unit at the time. Cardio-
pulmonary resuscitation was carried out using emergency equipment (an ambu-bag
for artificial respiration) brought from the unit office. Resuscitation continued and
another nurse arrived within minutes from the outpatient area, some 200-300 yards
away, with the automatic defibrillator. She applied the defibrillator pads, did a full
check of vital signs and found a pulse but the woman was still not breathing. She
recommenced artificial respiration following the defibrillator’s guidance. After
approximately nine minutes the woman was breathing. She was placed in the
recovery position still on the bed and the nurses continued to monitor her condition
by close continual observation and with the aid of the defibrillator. Eight to twelve
minutes later, it was observed that the woman was no longer breathing and had no
pulse. She was placed on the floor and full CPR was recommenced. At no time did
the defibrillator detect a cardiac rhythm that was amenable to electric shock. CPR
continued until the paramedics arrived and took charge. The ambulance arrived at
10:30, having been delayed by a major accident which partially closed the M5
motorway. They left the prison at 10:55. The woman was taken to a nearby hospital.
She was pronounced dead at 11:28.
I understand that a doctor was in the prison during these events and would have
been aware of the emergency but was not called to assist.
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RECOMMENDATIONS OF THE CLINICAL ADVISERS
In conducting this investigation I have had the benefit of clinical advice from three
experts.
Two examined the woman’s care from the point of view of primary care. The
consultant psychiatrist in substance abuse was asked to advise in particular about
the detoxification treatment.
They reports produced contain much valuable expertise and I commend them to the
Prison Service and all those who have the care of prisoners suffering the effects of
substance abuse.
I set out below the principal conclusions and recommendations from the clinical
reviews.
Primary Care
CR1 All staff involved in trying to resuscitate the woman should be
commended. They had all had training in basic cardio-pulmonary
resuscitation, which should be regularly updated. Defibrillator training
should be kept current for healthcare staff.
CR2 Observation of the woman should have been carried on in to the
evening of 6 June, with a hand over at change of staff time. Depending
on the results of these observations consideration should have been
given to carrying them through the night. The afternoon dose of
diazepam should have been withheld given the history of marked
drowsiness earlier in the afternoon.
CR3 The medical officer should write full notes. From the records there was
no indication for prescribing methadone.
CR4 Ambulance access must be looked into. Pathways of getting stretchers
from cells to the ambulance should be as unobstructed as possible.
CR5 Critical Event Analysis should be carried out following events such as
this, in order to learn from the incident, commend good practice and as
a form of support for those involved.
The two doctors conclude their report by noting that the post mortem result reports
death by natural causes, multiple pulmonary emboli. There was no sign of a deep
vein thrombosis and so there was nothing that could have been done to avoid this.
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Consultant Psychiatrist
CR6 It may be that difficulties in staffing contributed to a lack of observations
and further assessment and treatment. If vital signs are found to be
abnormal, they should be monitored until they return to normal.
CR7 Records of observations of patients who are clinically of concern should
be kept. It is likely that the woman was observed considerably more
than her records imply. Observations through the door or viewing port
are unlikely to be sufficient in cases of clinical concern, meaning that
the cell door will need to be opened to make a proper examination and
ensure proactive management.
CR8 Symptoms of drug overdose should activate an agreed local procedure,
or mean that a doctor should be called. This would include withholding
of non-essential and sedative medications and monitoring of respiratory
rate and conscious level as well as consideration of appropriate
treatment.
CR9 Medication doses reported by a prisoner should be confirmed with the
GP where such medications are abusable and there are inconsistencies
in the dose specified.
CR10 A detox regime should not automatically be given to patients purely
because they have a past history of misuse of certain drugs and test
positive for them, as seems to have happened in this case where
methadone was probably completely clinically unnecessary. A good
standard of clinical care requires good assessment and individualised
care.
CR11 Clinical evidence of physical dependence on opiates or benzodiazepines
should be elicited prior to starting a detox regime for these drugs. In
situations where uncertainty exists over the presence of a physical
dependence, the prisoner should be observed, and treatment
commenced if objective withdrawal symptoms develop, While such
observations are difficult to achieve in a prison environment, they are
essential in order to provide a reasonable standard of clinical care.
CR12 In this particular case the urine screening test which was found to be
opiate positive, did not distinguish between the presence of morphine
(which could be related to heroin) and the presence of Dihydrocodeine.
It may be a training issue that immunological screening tests do not
detect morphine only and that Dihydrocodeine comes up positive on
opiate screens, even though it is only metabolised to morphine, A
confirmatory urine screen would have distinguished Dihydrocodeine
from morphine, but such tests often require a wait for the result which
may mean they are not particularly suited to a prison context.
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Relying on the pathologist’s report, the consultant psychiatrist concludes, in
summary, that it appears that, although the woman did not receive the quality of
treatment that would have been expected in the community, her death does not
appear to be directly related to these factors and it is unlikely that her death would
have been prevented if she had received such treatment.
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CONCLUSIONS AND RECOMMENDATIONS
The purpose of my investigation is to establish the circumstances surrounding the
death, in part to see whether there are any lessons that the Prison Service can draw
about the care and treatment of prisoners. The investigation therefore examined in
detail the care extended to this woman in the few days she spent at Eastwood Park
immediately before her death. She had a history of drug and alcohol misuse and
was taking a variety of prescribed medication before her recall to prison. She was
located in the detoxification unit and received prescribed medication including
methadone.
The post mortem conducted for the Coroner has found that the cause of death was a
pulmonary thromboembolism. The pathologist has indicated that she sees no
connection between her detoxification regime in prison and her sudden death.
When my investigation began I did not have the benefit of the pathologist’s findings.
The investigators necessarily examined all the circumstances with an open mind.
The investigation has identified some areas of good practice and some areas of
concern which I consider should be shared with the Prison Service and those
responsible for prisoners’ health even though not all are directly related to this death.
Accordingly, I make the following recommendations:
R1 The efforts that the staff made to resuscitate this woman are to be
wholly commended. They demonstrated good skills and the use of the
defibrillator was good practice. The staff showed both persistence and
a high level of care in their attempts at resuscitation. The Governor
should draw these comments to the attention of the staff concerned.
R2 The outcome would not have been altered in this instance, but the
Governor should ensure that response protocols in the prison include
the attendance of a doctor at serious incidents such as this if a doctor is
present in the prison.
R3 On admission to prison, she was apparently stabilised on
Dihydrocodeine prescribed by her doctor. I recommend that prisons
should be advised that the detoxification regime should not
automatically be given to patients purely because they have a past
history of the misuse of certain drugs or test positive for them. A good
standard of clinical care requires individualised assessment and care.
R4 There are clear gaps in the patient records which fail to demonstrate the
care properly afforded to the woman. Records must be maintained to
the standards for professional practice laid down by the General Medical
Council and the Nursing and Midwifery Council. The records must
provide clear evidence of the care and treatment planned, the decisions
made, the care and treatment delivered, and what information has been
communicated to others. I recommend that my comments be drawn to
the attention of all medical staff at Eastwood Park.
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R5 The Governor should arrange a review of the protocols for treatment of
suspected opiate overdose in view of the comments made by the clinical
advisers.
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