Individual at Elmley

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING
THE DEATH OF A MAN IN SEPTEMBER 2005 AT
HMP ELMLEY
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2006
This is the report of an investigation into the circumstances of the death of
a man in September 2005 at HMP Elmley. He was 58 years of age when he
died, apparently from a heart attack, in his shared cell.
My colleagues and I would like to extend our condolences to his family and
friends for their loss. I would like to thank a Governor from Elmley who
ensured that all relevant information was available to my investigator.
One of my investigating officers conducted the investigation. A medical officer
carried out the clinical review on behalf of Swale Primary Care Trust. I am not
convinced that the clinical review covers all the pertinent issues, and it may be
that Prison Health will wish to commission a further investigation. It may also
be that the Coroner will want to call a representative of the PCT at the inquest
to answer questions about the healthcare the man received while in prison.
My report makes one recommendation relating to the clinical review. A further
recommendation relates to the efforts made by both staff and prisoners in
trying to resuscitate the man. My report also identifies one area of best
practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2006
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CONTENTS
Summary
Investigation Methodology
HMP Elmley
Events leading up to the man’s death
Events of 7 September 2005
Clinical Review
Findings and Conclusion
Recommendations and Best Practice
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Summary
1. The man died at the age of 58 years, while in custody at Elmley. In
June 2005, he had been sentenced to five years imprisonment for
sexual offences. He was described by his cellmates and staff as a
quiet and polite man who preferred to keep himself to himself.
2. Before arriving at Elmley, the man had been taking medication for
hypertension. At his reception health screen, he stated that he had no
concerns about his health but explained the medication he had been
taking. This medication was not re-prescribed, but there is no evidence
why this decision was taken. After the reception health screen, he was
referred to see a doctor. There is no evidence that he actually met with
the doctor.
3. On 3 September 2005, the man complained of chest pains and spent
the night in the prison’s Healthcare Centre. On the morning of
4 September, he was checked by the doctor before being allowed to
return at his own request to his cell on house block 4. Before returning
to his cell, he underwent a health review and a prescription for his
medication to control hypertension was issued.
4. He shared a cell with two other men. On the evening of 7 September,
he collapsed while cleaning his teeth. Despite the efforts of prisoners,
staff and the paramedics, he was unable to be resuscitated. The post
mortem suggests that he died as a result of a heart attack.
5. A clinical reviewer carried out a review of his healthcare needs on
behalf of the Swale Primary Care Trust. I am critical of the approach
taken in the clinical review.
6. My report makes two recommendations and draws attention to one
area of best practice.
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Investigation Methodology
7. All the initial indications were that this was a death from natural causes.
8. My investigator visited HMP Elmley and was given access to all of the
man’s prison records, including his medical records. My investigator
also met with the man’s cellmates. They confirmed that they had
nothing to add to the statement they had given to the Principal Officer
on 8 September 2005.
9. Notices to staff and prisoners were sent to the prison’s liaison officer to
be displayed around the prison. These announced the investigation
and invited staff and prisoners to submit to my investigator any
concerns or views they wished to express.
10. A clinical reviewer carried out a clinical review on behalf of the Swale
Primary Care Trust into the management of the man’s health needs
while in custody.
11. The man had no next of kin details in his prison record and he was
listed as having no fixed address. One of my family liaison officers has
written to the address found in his court records. However, there has
been no response from any family members. After his conviction, it
seems that he had no contact with his family.
12. Since issuing my final report one of my family liaison officers has had
contact with the man’s brother. He has asked me to pass on his
thanks to the prison and to his brother’s cellmates for all that they did to
help him. He was also very pleased to be informed of his brother’s
death in person so promptly and would like to pass on his appreciation
to the prison for this. I am happy to include his views here.
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HMP Elmley
13. Elmley is a purpose built prison serving all courts in the County of Kent.
The prison opened in 1992 and includes a Category C Unit of some
240 prisoners built in 1997 and a Vulnerable Prisoner Unit delivering
the Sex Offender Treatment Programme. Elmley is one of the six
‘Bullingdon’ design prisons, and is one of three adjacent jails forming a
cluster on the Isle of Sheppey.
14. Her Majesty’s Chief Inspector of Prisons carried out a full inspection in
2001. Her report described a prison that had lost direction and was
stalling. The latest follow up inspection in May 2003 showed that
senior managers had identified the problems and taken effective action
to stop, and reverse, the drift. Given the pressures that they were
under, and in particular the fact that a third of the prison’s population
were now remand prisoners, this was considered no mean feat.
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Events leading up to the man’s death
15. The man was sentenced to five years imprisonment in June 2005.
Following sentencing he was taken from the Crown Court to HMP
Elmley.
16. The man was given a reception health screen on his arrival where he
was asked about his current health needs. He indicated during the
reception screen that he had no concerns about his health. However,
he explained that he had been taking medication (enalapril tablets for
hypertension) before arriving at Elmley. This medication was not re-
prescribed.
17. He was referred to see the doctor. There is no evidence in his medical
records to say that he met with the doctor.
18. The man was considered fit enough for any normal location, work and
cell occupancy. He asked to be placed on prison rule 45 (this is a
protected regime for vulnerable prisoners) for his own protection due to
the nature of his offences. He was then located to house block 4. He
attended work in the prison laundry and settled into the prison regime
quite quickly, choosing to keep himself busy.
19. At 5.35pm on 3 September, the man complained of chest pains and
was seen in his cell on house block 4 by the nurse. The man explained
that he had suffered from hypertension in the past and had been taking
medication before arriving at Elmley. An appointment was made for a
detailed assessment and investigation into his medical needs.
20. The nurse was called back to house block 4 to see him at 6.00pm
because his chest pains had returned. He was moved to the
Healthcare Centre. On arrival, he was described as having good
colour and no shortness of breath. He was settled onto the bed and
given 300mg of aspirin, then asked to rest. At 7.00pm, it was decided
that he would remain in the Healthcare Centre overnight for
observation. He was asleep when he was next checked at 7.40pm.
21. The man was seen by the prison doctor on 4 September. His condition
had improved - even though he had been sick in the night - and he
reported feeling better with no chest pains. He was asking to return to
his cell on house block 4. The doctor recorded no diagnosis in his
medical record, but did issue him a prescription for enalapril and
allowed him to return to the house block.
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Events of 7 September
22. There were two prisoners who shared B1/13 on house block 4 with
him. The cell is on the ground floor of the block. In the early evening
of 7 September, he was cleaning his teeth at the sink, and all three
men were laughing and joking. He suddenly collapsed onto the floor,
hitting a chair as he fell. The two cellmates thought he was having an
epileptic fit and placed him in the recovery position. They then noticed
that he had gone blue and was not breathing. One of them began to
press on his chest while the other rang the cell bell and kicked the door
to attract the attention of the staff.
23. At approximately 7.10pm, an officer was on the second floor landing
area of house block 4 when he was called by another prisoner, who
said that there was an inmate who had collapsed in cell B1/13. The
officer went straight to the cell and, on entering, saw the man on the
floor lying in the recovery position where he had been placed by his
cellmates. Thanks to the efforts of his cellmates, the man was still
breathing although his skin was blue in colour. The prison officer
called to a wing officer to radio for medical help which he did, using the
term code blue to alert healthcare staff that someone had collapsed.
The wing officer then entered the cell. The prison officer then left,
taking the cellmates with him, to make room in the cell for the
healthcare staff. Both prisoners were strip searched and their clothes
were placed in sealed bags to preserve any evidence for the police.
24. At this point, the wing officer says that the prisoner was shallow
breathing and gurgling. After about three minutes, he noticed that he
was turning blue and not breathing. He checked his response to
pinching, his breathing and pulse but found nothing. He alerted a
senior officer, who was in charge of the wing and standing outside the
cell. At this point, healthcare staff arrived. The senior officer was then
told by the orderly officer to lock up the remaining prisoners on the
wing.
25. At 7.15pm, a healthcare officer and a nurse arrived at the cell and the
nurse started cardio pulmonary resuscitation (CPR). The wing officer
took out a resusiade (this is a small device to stop any transfer of
bodily fluids during mouth to mouth resuscitation) from the pouch on
his belt, and began to assist in CPR.
26. The healthcare officer prepared an airway and secured it to an airbag.
The nurse and the wing officer then continued the CPR. After a short
while, the airbag broke and the wing officer went back to using his
resusiade. At one point, the man’s chest did not rise, so the healthcare
officer checked and cleared his airway with a suction pump and then
resuscitation continued.
27. At 7.20pm, the log keeper in the prison control room telephoned the
paramedics. At 7.30pm, the paramedics arrived at the cell and took
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over the chest compressions from the nurse. They also supplied a new
airbag and the wing officer continued to assist in CPR.
28. Despite all their efforts, at 7.45pm the paramedics pronounced the
man’s death. At this point, the wing officer left the cell, leaving any
equipment behind. The paramedics left the cell and it was sealed at
7.55pm by the senior officer.
29. The Coroner was informed of the prisoner’s death at 8.02pm. A
Detective Inspector, a Detective Sergeant and a Detective Constable
arrived at the cell at 9.21pm, and left shortly after. The undertakers
arrived at the cell at 11.45pm to remove the man from the prison.
30. The post mortem report concluded that the prisoner died as a result of
a heart attack.
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Clinical Review
31. The clinical reviewer completed a clinical review into the care the man
received at Elmley. He concluded that the nursing interventions were
of an adequate standard. He added that the evaluation of the anginal
episode on 3 September was to a good clinical standard as was the
record keeping.
32. The reviewer makes two recommendations in his review:
(cid:131) There is a need for clinical leadership at HMP Elmley or at the
Sheppey cluster of prisons.
(cid:131) There is also a need for a clinical governance committee, where
untoward incidents can be investigated in a non judgmental
blame free atmosphere, and where key findings are translated to
time-tabled action with post-incident reviews. This committee
should be chaired by a senior manager or governor grade
directly reporting to the governing Governor or the senior
management team. Clinical governance should be a standing
item on the senior management agenda. The CGC should take
reports from sub committees concerned with suicide prevention,
serious untoward incidents, risk management, medical
cover/complaints, request/complaints from patients, IMB health
concerns and Drugs and Therapeutics. This is the structure in
most NHS Trusts, where, virtually complaints of this nature are
replied by the governing Governor (sic).
33. I have some concerns about the quality of the clinical review.
(cid:131) First, it does not explore why the man did not continue to receive
medication for hypertension in June 2005, when he was first
received into Elmley, or the impact this may have had on his
condition.
(cid:131) Second, it does not explore why the man appears not to have seen
a doctor when he arrived at Elmley, despite the fact that a referral
was made.
(cid:131) Third, it is not clear how the recommendations follow from the
findings of the review.
34. Prison Health may wish to commission a further investigation into these
matters. They may also wish to advise Swale PCT as to their
expectations as to the level of detail that should be found in a clinical
review.
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Findings and Conclusion
35. The post mortem report concluded that the man died of natural causes
as a result of a ruptured myocardial infarction (Heart Attack).
36. Prison Service Order 2710 sets out what action must be taken
following a death in custody. Elmley fully complied with this order.
37. All necessary information was collated for the purposes of this
investigation.
38. The clinical reviewer considers that the care the man received was of
an acceptable standard. However, the review failed to address two key
questions about the way his health needs were dealt with when he
arrived at Elmley – the apparent failure to review his medication and
the apparent failure to ensure he was seen by a doctor.
39. A comprehensive review of clinical matters is essential to most of my
fatal incident investigations, but especially those where death was from
natural causes. With colleagues in Prison Health, I shall continue to
keep a close eye on both the timeliness and quality of the clinical
reviews that PCTs commission on my behalf.
Recommendations and Best Practice
40. I recommend that Prison Health considers whether it should
commission a further investigation into the healthcare the prisoner
received while in prison.
41. I commend staff and prisoners at Elmley for the efforts made in trying
to resuscitate the man and recommend that the Governor writes
accordingly to those concerned.
42. The use of the term Code Blue to summon help to medical
emergencies is good practice. It alerts everyone carrying a prison
radio and those within hearing distance that urgent medical assistance
is required.
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