Individual at Exeter

Investigation into the circumstances surrounding the
death of a prisoner at HM Prison Exeter on 13 February 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
May 2005
This is the report of an investigation into the death of a man on 13 February
2005. He was a prisoner at HM Prison Exeter. The cause of death was given
as cardiac failure.
One of my Senior Investigators and one of my Investigators conducted this
investigation. Torbay Primary Care Trust on behalf of the Exeter Primary
Care Trust provided a clinical review into the prisoner’s care and treatment.
I would like to extend my condolences to the prisoner’s family for their loss. I
would like to thank the Governor in charge of HMP Exeter, and his staff for
their help and co-operation during this investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman
May 2005
CONTENTS
Summary
Investigation methodology
The prisoner
The prisoner’s family
HMP Exeter
Events prior to the prisoner’s death
Events after the prisoner’s death
Findings and conclusions
Recommendations
Summary
At approximately 1.43pm on Sunday 13 February 2005, prison staff were
alerted by another prisoner to the fact that the prisoner was lying on the floor
of his cell. He was unconscious and not breathing. Assistance from other
staff was sought and efforts at resuscitation began immediately. Paramedics
were also in attendance and cardio-pulmonary resuscitation continued for
approximately one hour before the man was pronounced dead at a local
hospital. He had a history of heart problems and the post mortem indicates
that he died of a heart attack.
The clinical review indicates that the prisoner received appropriate care and
treatment whilst at HMP Exeter. Shortly before his death the prisoner was a
voluntary participant in a medical trial designed to reduce cholesterol. The
prisoner’s family have sought clarification as to whether stopping this
treatment was a contributory factor in his death. I hope the clinical review
reassures the family that this was not the case.
I have made four recommendations, which although not directly affecting the
circumstances of the prisoner’s death, could have a bearing on any future
incidents.
The Investigation process
1. The investigation was opened at HM Prison Exeter on 21 February 2005.
The Governor and his staff produced the prisoner’s core record and a
number of other documents for examination. Notices were issued to staff
and prisoners telling them of the investigation. My investigators were able
to speak to members of staff as well as prisoners who knew the deceased.
2. A Family Liaison Officer from my office contacted the prisoner’s family on
28 February 2005. She offered them the opportunity to meet with her and
the investigator to discuss the purpose of the investigation and to raise any
concerns or questions that they would like explored and addressed.
Whilst the family had no general concerns about the level of health care
afforded to the prisoner at Exeter, there was a concern that the decision to
stop him from participating in an ongoing medical trial may have had a
direct impact on his health.
3. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my 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 man’s death.
The Prisoner
4. The prisoner was born in January 1937 in London. He was 68 years old
when he died on 13 February 2005. He had been married for
approximately 28 years and had two daughters from the marriage. The
marriage ended a number of years ago.
5. The man had moved from London to Dorset with his immediate family a
number of years ago. He had been employed in London for 14 years. In
Dorset he worked in a number of factories. On retirement he moved to live
in Cornwall.
6. The prisoner was convicted of rape of a minor at Truro Crown Court in
October 2004. In December, he was sentenced to 8 years imprisonment.
He strongly denied the offence and wanted to appeal against the
conviction. He was subsequently denied leave to appeal and has been
described as being angry at this decision, although it was his intention
launch another appeal.
7. The prisoner had daughters. One of his daughters was his nominated
next of kin. He also had two sisters. Regular contact with his daughters
and sisters was maintained by telephone, letter and prison visits.
8. The prisoner’s daughters are devastated at the death of their father. They
have no particular concerns or questions about his death, acknowledging
that he had a history of heart problems. Indeed, one sister said that the
prison has been open and honest and that the prisoner received an
appropriate level of health care. The only issue of note is that he was part
of a medical trial to reduce cholesterol. His participation in this programme
was stopped just before his death. The family would like to know if this
was a contributory cause of their father’s death. The Primary Care Trust
were therefore asked to examine this point as part of their review.
9. The family are mindful and wary of the adverse publicity and impact that
the Coroner’s inquest might have on family members in the future.
HMP Exeter
10. Exeter is a Nineteenth Century prison that overlooks the city. It currently
has four accommodation units with a healthcare facility in support. It
accepts all adult and young offenders committed to prison by the courts
from Cornwall, Devon and West Somerset.
Events prior to the prisoner’s death
11. When the prisoner was convicted in October 2004, he was identified as at
risk of self-harm. However, he quickly settled into the routine at Exeter
and has been described by staff as a model prisoner with a mature outlook
on life, who did not present any management problems. He was a popular
man with other prisoners on the wing.
12. On reception at Exeter, the Health Care staff interviewed the prisoner to
establish his past medical history and current health status. It was noted
that in 1987 he had suffered a heart attack and that in 1989 he underwent
a triple bi-pass operation. In 1997 he again suffered a heart attack and in
1998 was admitted to hospital suffering with severe breathing difficulties.
The prisoner also suffered from unstable angina. As a result of his heart
condition his blood pressure was monitored regularly and he was
prescribed the necessary medication.
13. The prisoner had also been taking SEARCH tablets, as part of the
research into their effectiveness in the reduction of cholesterol
homosistine, conducted by the British Heart Foundation. This was an
approved clinical trial. The prisoner was scheduled to finish his course of
SEARCH tablets in February 2005.
14. Upon receiving a sentence of 8 years from Crown Court, in December
2004, the prisoner apparently adjusted quickly to his new circumstances,
although he continued to assert his innocence. When his request for leave
for an appeal was rejected, it was his intention to launch another appeal.
15. In late December 2004 he was placed on the enhanced privileges regime.
On 17 January 2005, he was moved to D3 landing where he occupied a
single cell.
16. While at Exeter, the prisoner participated in education classes for
numeracy and literacy and was also attending offending behaviour
programmes. He had also previously taken part in the Thames Valley Sex
Offender Intervention Programme and was reported to have had a strong
commitment to this programme.
17. From the log of telephone calls made by the prisoner prior to his death, it
is evident that he was adapting to life at Exeter. He did not share or report
any issues or significant concerns in respect of his health or well being.
However, the prisoner did admit to having a slight cough to his sister. On
the morning of his death the prisoner telephoned one of his daughters, as
well as his sister. There was nothing in their conversation to indicate that
he was feeling unwell or out of sorts.
18. At 1.43pm on Sunday 13 February, an officer was alerted by a prisoner on
‘D’ wing that the man had been found collapsed in his cell and was not
breathing. A fellow prisoner on the wing had walked past his cell door that
had been left ajar and alerted an officer to the fact that he was lying on the
floor. The officer radioed for assistance stating that a prisoner had
stopped breathing. The prisoner’s cell bell was also activated, although it
is not known who activated the alarm.
19. At 1.45pm an ambulance was called. The prison doctor was also
requested to attend the wing. At the same time a request was made for
the Orderly Officer and the Duty Governor to attend the scene.
20. The Wing Officer was the first member of staff to reach the prisoner’s cell.
He ordered prisoners on the wing back into their cells, and this was duly
complied with. He then began Cardio Pulmonary Resuscitation (CPR) on
the prisoner. A Senior Officer assisted him. Both officers are trained in
first aid. The Orderly Officer and the Duty Governor quickly arrived at the
scene and they then took over resuscitation from the officers.
21. The Staff Nurse was in the Health Care Centre and also received a
request by radio to attend ‘D’ wing to attend a prisoner who had stopped
breathing. Before he could attend, arrangements had to be made for
another member of prison staff to relieve him. The Staff Nurse was the
only member of staff on duty at that time in the Health Care Centre. Local
policy requires that the Health Care Centre must be supervised at all
times. Fortunately, a member of staff was found immediately to supervise
the Health Care Centre.
22. Once the Staff Nurse was released from his supervisory duties, he made
his way to the prisoner’s cell. It should be noted that the Staff Nurse had
been informed that a prisoner was not breathing and so took the decision
to attend with only his personal resuscitation kit.
23. The defibrillator was not taken to the scene. It is, however, highly unlikely
that the use of such equipment would have affected the outcome in this
prisoner’s case. However, it did become apparent during the investigation
that the only defibrillator is located securely in the Health Care Centre and
can only be retrieved by a member of the nursing staff. The locally
available defibrillator has been described as ‘heavy and awkward to carry’,
depending on the individual’s physical ability. This could waste valuable
time in the effective deployment of the defibrillator elsewhere in the prison.
24. On entering the prisoner’s cell, the Staff Nurse took over the lung inflation
from one of the officers. However, the prisoner was not responding to
resuscitation and signs of cyanosis were detected on his lips.
25. At 1.55pm, the ambulance arrived and resuscitation attempts continued.
However, the ECG monitor showed no output. At 2.07pm, the Doctor
arrived. He advised that the ECG reading was ambivalent and that the
prisoner should be transferred immediately to hospital.
26. In the meantime the Deputy Governor tried to contact the prisoner’s
daughter to advise her of her father’s condition. A message was left on
her answer phone asking that she ring Exeter.
27. At 2.30pm, the prisoner was taken to hospital with two escorts as well as
the Staff Nurse in attendance. Mechanical restraints were not used on him
and the resuscitation attempts continued on the way to the hospital.
Despite continuing attempts at resuscitation, at 2.44pm a Doctor at the
hospital pronounced the prisoner dead. A hospital chaplain administered
the appropriate last rites to him.
28. Once the prisoner had been pronounced dead, his cell was sealed and all
contingency plans were activated and correctly followed. All relevant
documentation was provided to the investigators by the prison. This was
completed to a high standard, enabling the investigation team to establish
a clear picture of the events of that afternoon.
Events after the prisoner’s death
29. When the prisoner had been pronounced dead, the Duty Governor sought
help from the Duty Governor at HM Prison Weare to visit the prisoner’s
daughter’s home address in Dorset and tell her of the death of her father.
While these arrangements were being made, the prisoner’s daughter
telephoned Exeter in response to the message left on her answer phone.
The Duty Governor relayed the sad news of her father’s death.
30. At approximately 3.05pm, a ‘Hot Debrief’ was carried out with all staff who
were involved in the incident. Staff informed prisoners on the wing of the
death of their fellow inmate. Appropriate support and counselling was
offered to the prisoners.
31. The prisoner’s daughter contacted Exeter again on the morning of 14
February and spoke to the Acting Deputy Governor. Following this
telephone call, the Governor sent a letter offering condolences. The letter
also mentioned that arrangements could be made for the family to visit
Exeter and that assistance could be given with funeral expenses if they
wished. On 16 February, staff from Exeter visited the prisoner’s daughter
at home. She was told that the Prisons and Probation Ombudsman would
undertake a full investigation of the circumstances surrounding the
prisoner’s death, and that the Exeter Coroner would be conducting out an
inquest.
32. On 24 February, the prisoner’s funeral took place. His family were
determined that this should be a quiet affair.
33. On 28 February, the prisoner’s daughter was contacted by one of our
family liaison officers. She had no general concerns in respect of the care
and treatment of her father whilst he had been at Exeter.
Clinical Review
34. The clinical review undertaken on behalf of the Exeter Primary Care Trust
confirms that the prisoner’s death was not related to the quality of care that
he received whilst in prison but was from apparent natural causes.
35. In respect of the decision to stop the prisoner’s participation in the
SEARCH programme, shortly before his death, the review concludes that
the programme was designed to reduce cholesterol over a long period of
time and that withdrawal from medication would not have been a
contributory factor in his death.
Post Mortem report
36. The post mortem report indicates that the prisoner died from cardiac
failure. The toxicology report also indicates that there were no illicit
substances detected in the blood. The pathologist also identified that
there were no suspicious findings.
Findings and conclusions
37. Up until shortly before his death, the prisoner was taking part in an
approved medical trial sponsored by the British Heart Foundation called
SEARCH. The trial is designed to reduce cholesterol in people who have
suffered with a heart condition. The prisoner’s family expressed concern
that taking him off this programme shortly before his death might have
contributed to his death. The clinical review on the prisoner concludes
authoritatively that this could not have been the case.
38. It became apparent during this investigation that there could have been a
delay in medical staff attending to the prisoner in that, at the time
assistance was required from the Health Care Centre, there was only one
member of staff on duty. The Health Care Centre needs to be supervised
at all times and an appropriate member of prison staff would need to be
found to undertake supervisory duties. In this particular case, cover was
found immediately. However, without adequate local arrangements there
might be occasions when appropriate cover cannot be found so quickly,
delaying medical staff from attending an emergency situation.
39. The location of defibrillators was also noted to be an issue, although the
use of this equipment did not have a bearing on the outcome in this
prisoner’s case. Currently, the only defibrillator is located securely within
the Health Care Centre and can only be retrieved by a member of the
Health Care team who has the necessary keys. The equipment has been
described as ‘bulky and awkward’ and has to be taken by a member of
staff to where it is required. It may be more prudent to locate and secure
such equipment in other parts of the establishment.
Recommendations
Establishment
The Governor of Exeter should satisfy himself that adequate arrangements
are in place to provide prompt cover to the Health Care Centre when staff are
required to attend an emergency in the prison.
The Governor should consider the introduction of a coded radio call system to
ensure that Health Care staff attending an emergency are able to take the
necessary equipment to the incident and to manage it effectively.
Primary Care Trust
The Primary Care Trust should give consideration to placing appropriate
portable Automated External Defibrillators strategically in other parts of the
prison with easy access in the event of an emergency.
The Primary Care Trust should give consideration to the introduction and use
of emergency bags that can easily be moved from health care to the scene of
an incident and contain the necessary equipment to manage incidents until
the arrival of paramedic support.