Individual at Ford

INVESTIGATION INTO THE CIRCUMSTANCES
SURROUNDING THE DEATH OF A MAN AT HMP FORD IN
SEPTEMBER 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2007
This report considers the circumstances surrounding the death of a man in
September 2006 at HMP Ford. He was found dead in his room during the late
morning roll check. The post mortem concluded that he had died as a result of fatal
toxicity. The man was 31 years of age.
I extend my personal condolences to the man’s family and to all those touched by his
death.
My colleague undertook the investigation with the assistance of a second
investigator. I would like to thank the Governor of Ford and her staff for their
cooperation during this investigation. I am also grateful to Western Sussex Primary
Care Trust for carrying out a thorough clinical review of the care the man received
during his time in custody.
The man had misused drugs and alcohol, and had a complicated history of mental
health problems, which were diagnosed shortly before he entered custody. As his
mental health appeared to have stabilised by the time he went to HMP Wandsworth
he did not receive his prescribed medication but was seen regularly by the mental
health team. When he transferred to HMP Ford, the man’s mental health was
beginning to show signs of deterioration. However, this was quickly addressed by
the prison’s GP and primary mental healthcare nurse.
It has not been possible to ascertain whether these mental health problems
contributed to his death or whether it was accidental. His mental health aside, the
man was a generally fit and healthy young man. The police investigation has ruled
out any suspicious circumstances. The man’s death was a great shock to everyone
at HMP Ford and no one has come forward with specific evidence that his death
might have been intentional.
Based on the clinical review, I make five recommendations (two of which relate to
the man’s care at HMP Wandsworth).
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2007
2
CONTENTS
Summary
The Investigation Process
HMP Ford
Key Findings
Chronology
Clinical findings
Findings relating to policy and procedure
Conclusion
Recommendations including Prison Service response
3
SUMMARY
The man was arrested in December 2005, but was not remanded into custody until
March 2006 after a period as an in-patient at a private clinic in London, The Priory.
Prior to custody, the man had a history of drug and alcohol abuse, gambling and
suicidal ideation. He also suffered with anxiety and bipolar disorder, and had other
mental health problems. These were diagnosed whilst he was at the private clinic
and he was prescribed methylphenidate (for hyperactivity), semi-sodium valproate
(for bipolar disorder) and venlafaxine (an antidepressant). He discharged himself
and then occasionally attended as an outpatient.
During early March, the man was remanded to HMP Wandsworth and began a three
week detoxification process for alcohol abuse. His mental health appeared to have
stabilised following his treatment. Healthcare staff, including the dual diagnosis
team, decided that he did not present as needing his prescribed medications.
However, he continued to receive regular monitoring and counselling from the dual
diagnosis team for the next five months. The man remained largely stable with short
periods of feeling low in mood. During this time, his consultant psychiatrist at the
private clinic sent two letters expressing concern that his patient was not receiving
his prescribed medications. The dual diagnosis team remained firm in their
judgement that he did not require them.
In June 2006, the man was sentenced to three years and eight months
imprisonment. He moved from Wandsworth to HMP Ford as a category D prisoner
on 24 July. On reception, the man referred to his mental health history and said he
would refer himself to the Counselling Assessment Referral Advice Throughcare
team (CARATS) for substance misuse support. Two appointments were made, one
for the next day with the doctor, and a second with the mental health nurse the
following week. On assessing the man, the doctor referred him to the psychiatric
practice in Bognor Regis, The Bedale Centre, for a second opinion on the diagnoses
made by The Priory.
Unfortunately, the mental health nurse was on leave until the end of August, but the
man continued to have contact with healthcare during this period for complaints
about ear and jaw ache. He did not present with any concerns regarding his mental
health until 21 August when he saw a nurse and told her that he felt low in mood. He
again explained that he had not received the medications prescribed by the private
clinic in London since early March. An appointment was scheduled for the man to
see the doctor the following day, but it is not clear if this took place.
Towards the end of August, he had his first appointment with the mental health
nurse. The man told her that he was “not feeling right” and explained his mental
health history. She suggested restarting his medications and agreed to discuss this
with the doctor. His medications were resumed that day. The referral to the Bedale
Centre was confirmed and an appointment was set for a date in September.
The man saw the mental health nurse again in September. During this consultation,
he told her that he had stopped taking his venlafaxine as it was giving him
headaches. He was also feeling tired and lethargic. The nurse noted that the
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psychiatrist would review the medications. She also scheduled a follow up session
for two weeks later.
A few days later, the man withdrew from CARATs. He had completed the courses
relevant to him and continued to test negative for illicit substance use. The man and
his counsellor agreed that he could continue without their support.
In September, the man was seen in healthcare regarding his continuing ear and jaw
ache. He was prescribed seven days of painkillers.
During his appointment with the mental health nurse in September, he appeared
stable, but referred to feeling emotionally cold. He complained once more about his
ear and jaw ache, so she made a referral to a dentist for an x-ray. This took place
the following morning.
The man attended his appointment with the psychiatrist at the Bedale Centre. He
went unescorted. The psychiatrist referred to the man’s documented mental health
history and assessed his current presentation. He concluded that the man was not a
concern and showed no self harm or suicidal ideation.
On his return to the prison, the man spent the remainder of the day associating with
fellow prisoners. Both staff and prisoners who recall seeing him note that he was his
usual self and did not give cause for concern. No one saw him with any contraband.
The next morning, the man was found dead during the 11.30am roll check. Although
staff and prisoners had looked in on several occasions earlier in the morning, he had
appeared to be sleeping. At weekends, prisoners at Ford are allowed to have a lie in
and it is not unusual for some people to remain asleep until the roll check. When he
was found, it was clear that he had been dead for some time and was beyond
resuscitation.
A police investigation was undertaken. On searching the man’s room they found a
bottle of vodka (unopened), a wrap of brown powder, a small amount of cannabis
resin, a mobile phone and his prescription medications. All items apart from the
vodka were taken away for examination. The powder was found to be heroin based
(diamorphine). There was no SIM card in the mobile phone so it was not possible to
trace any calls made. In addition to a post mortem, a toxicology report was
requested. The results showed high levels of morphine and ethanol, consistent with
fatal toxicity. There was no evidence of him having used injecting equipment. It is
not apparent whether the man’s death was accidental or intentional. The police
investigation has ruled out any suspicious circumstances.
5
THE INVESTIGATION PROCESS
1. During the opening of the investigation, my investigator discussed with Ford’s
Governor the circumstances surrounding the man’s death. The Governor
asked for the circumstances to remain confidential at that stage to reduce the
possibility of negative media attention, which could have been insensitive to the
man’s family. My investigator agreed the need for sensitive handling.
2. My investigator asked Western Sussex Primary Care Trust (PCT) to conduct a
clinical review of the healthcare the man received in custody. My investigator
and the clinical reviewer agreed to hold joint interviews with the main
healthcare staff at Ford who had provided care for the man. My investigator
conducted all other interviews at the prison with a colleague. These took place
on 16 January 2007, with the clinical interviews the following day. On
concluding the interviews, my investigator provided verbal feedback to the
Governor on her findings. In addition to the interviews held at HMP Ford, the
clinical reviewer also spoke with healthcare staff at HMP Wandsworth, the
man’s consultant psychiatrist at The Priory, and with the consultant psychiatrist
from the Bedale Centre.
3. The man’s family was contacted by one of my family liaison officers to explain
the purpose of the investigation and to allow them the opportunity to raise any
concerns they would like explored and addressed. The man’s family have
remained in contact with my office and have raised a number of issues:
• How were his mental health needs monitored?
• What medications were prescribed and how were these monitored?
• The family were aware that he had visited the consultant psychiatrist
the Bedale Centre. They were under the impression that he might
have been prescribed medication twice the strength of his usual
prescription following this appointment.
• Following the man’s death, the family discovered from documentation
that prior to his period in custody he had been a police informant. The
family believed that a relative of the person he had informed on was
located at the same prison. They were concerned that he had suffered
adversely because of this.
4. The first three issues are addressed in the main body of the report and the
clinical review. In relation to the third point, I should say at this point that the
man was not prescribed any further medication following his appointment.
5. My investigator looked into the final issue. She established that the prison was
not aware that the man had been a police informant. However, the prison
would not have been party to this information unless the police had raised it as
a concern. There was no evidence that he had been bullied or harassed whilst
at Ford.
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HMP FORD
6. HMP Ford is a category D open prison with an emphasis on resettlement. It
stands on the site of a former Fleet Air Arm station and was converted to an
open prison in 1960.
7. Further buildings have been added including a gate complex, chapel, education
and probation. There are two main sites for the accommodation blocks – A and
B wing. A wing has six residential blocks of single rooms. B wing has 24 billets
of single and shared rooms. The prison has an operational capacity of 541.
8. Healthcare at HMP Ford has seen significant improvement since responsibility
for the delivery of services was transferred to Western Sussex Primary Care
Trust in April 2005. The healthcare unit is open from 7:45am until 5:30pm,
Monday to Friday. It provides a good range of nurse-led clinics, including
mental health support. However, this is currently only one registered mental
health nurse to 541 prisoners. This is not adequate, a matter further
highlighted within the clinical review at Annex 2.
9. There are two GPs at the prison whose duties are split to provide cover five
days a week. Out of hours cover, including the weekend, is provided by the
Primary Care Trust. A dentist also holds weekly clinics and an optician attends
once a month.
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KEY FINDINGS
Chronology
10. The man was arrested in December 2005 although was not remanded into
custody at this time. During January 2006 he spent time as a general
psychiatric inpatient at a private clinic, The Priory, in South West London. He
was admitted for assessment due to his impulsive behaviour including
excessive drug and alcohol misuse, which had resulted in a suicide attempt. At
the clinic, the man was the patient of a psychiatrist. He diagnosed the man as
having:
• generalised anxiety disorder
• post traumatic stress disorder
• pathological gambling
• cocaine and alcohol abuse.
17. The psychiatrist offered a differential diagnosis of bipolar disorder and also
attention deficit hyperactivity disorder (ADHD). He did not think that the man’s
mood swings were directly related to drug abuse, although he felt this possibly
exacerbated his behaviour.
18. The psychiatrist prescribed methylphenidate (Ritalin), semi sodium valproate,
and venlafaxine. He also referred the man to a psychologist for cognitive
behavioural therapy and treatment for his post-traumatic stress disorder.
19. The man discharged himself from the clinic on two weeks later. He was not
complying with group work and questioned his medication. The man went to a
couple of his outpatient follow-up sessions but then stopped attending.
20. During early March, he was remanded into custody at HMP Wandsworth. This
was his first time in prison. During the reception procedures, both a discipline
officer and a member of the healthcare team assessed the man (this is the
usual course for someone entering the prison system). The nurse who
completed the first reception healthscreen noted the man’s mental health and
self-harm history, as well as his drug and alcohol misuse. The assessment
concluded that he was “not depressed and not suicidal”. He was referred for
detoxification and prescribed chlordiazepoxide together with thiamine and
vitamin B compound forte for acute alcohol detoxification.
21. The man did not receive a medical follow up until three weeks later on 28
March when a referral from one of the registered mental health nurses was
received by the in-reach mental health team. Until this point, the man had not
come to the attention of the in-reach service. They discussed his case and
referred him to the dual diagnosis team for further assessment.
22. On 7 April, the dual diagnosis nurse saw the man. Notes from this assessment
were made available to my investigator, but were incomplete, wrongly dated
and unsigned. However, they did include a reasonably detailed clinical history
and a note that information had been sought from the man’s previous GP and
8
his psychiatrist. A symptom score and risk assessment was completed and this
indicated a low suicide risk. The man was not referred to any other services,
but follow-up assessment by the dual diagnosis team was arranged.
23. On 19 April, the man was seen by a consultant in dual diagnosis, who noted his
history (as outlined above) but questioned the diagnosis of ADHD. The
consultant found the man to be depressed and suffering from insomnia.
Despite this, the man presented as being relatively optimistic. He talked about
the future and returning to his wife. The consultant diagnosed ‘adjustment
disorder’. (An adjustment disorder is psychological disturbance that develops
in response to stress or an unexpected negative event.) The medication
prescribed by the psychiatrist at The Priory was not given. Instead, the man
was prescribed three days of sleeping tablets and was referred to a
psychologist for support.
24. The dual diagnosis nurse next saw the man on 26 April. An entry in his medical
records states, “[the man] says he’s been much improved without being on
medication. Appears very calm and relaxed.” Despite his calm presentation, it
appears that the man had been worried that his medication prescribed at the
private clinic in London had been discontinued. His psychiatrist from The Priory
wrote to the man on 26 April, expressing concern that he was not receiving the
treatment needed. The psychiatrist copied this letter to the man’s solicitor and
the chief medical officer at HMP Wandsworth. There is no record of any
subsequent action taken by healthcare or the dual diagnosis team.
25. In spite of not receiving this medication, the man continued to remain stable at
Wandsworth. He received regular assessments by a dual diagnosis nurse and
was given zoplicone (sleeping tablets) as and when required. During these
months, the man actively participated in the prison’s regime and made an
application for employment. There were no concerns about his behaviour or
demeanour.
26. There is an entry in the man’s medical record on 14 June that alludes to a visit
with the psychiatrist from The Priory on 13 June, but there is no actual record of
such a meeting. The man told his dual diagnosis nurse on 14 June that the
psychiatrist he had seen the previous day was concerned that he was not
receiving the medications prescribed he had prescribed in January. The dual
diagnosis nurse notes a ‘plan of care’ in the man’s medical record which would
consist of meetings with a dual diagnosis nurse every three weeks and monthly
meetings with the consultant psychiatrist.
27. The man appeared at court on 23 June and was sentenced to three years and
eight months in prison. He then returned to Wandsworth.
28. At his dual diagnosis check up on 10 July, the man was still noted to be coping
“fairly well” without his medication. However, during this session the man said
that his solicitors were still writing to him asking why he was not taking his
previously prescribed medications. The dual diagnosis nurse told him that his
current physical and mental state did not warrant any of his previous
medications.
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29. On 24 July, the man was transferred to HMP Ford as a category D prisoner.
He was allocated a room in billet R2 on B wing. The man’s full medical record
was transferred with him. A cursory healthscreen was undertaken on reception
to establish whether there were any concerns requiring immediate medical
attention. The note in the medical record simply says “HMP Ford. Labour 1”
and is unsigned. My investigator spoke to the Head of Healthcare to see if this
was an acceptable entry for a cursory healthscreen. The Head of Healthcare
confirmed that it was not satisfactory and she would expect the entry to reflect
that there were no concerns raised. As the man was not seen for a full
healthscreen until the following day, it is assumed that he was stable and well
during this assessment.
30. A nurse performed the full reception healthscreen on 25 July. During this
assessment, the man referred to his mental health history. It was noted that a
mental health nurse would see him the following week. A doctor’s appointment
was made for the following day as the man was complaining of earache. The
man said he would also like to be referred to the Counselling, Assessment,
Referral, Advice, Throughcare team (CARATS) and also take part in voluntary
drug testing.
31. On 26 July, one of the prison’s GPs saw the man. They discussed his mental
health, including his previous diagnoses. The man raised concerns that he had
not received the medications prescribed by The Priory whilst he was at
Wandsworth. He said that over the last five months he had experienced a few
lows, but had mostly felt stable. The GP decided to refer him to a psychiatrist
for further assessment. The following day, he wrote to a consultant psychiatrist
at the Bedale Centre, asking him to see the man and offer a second opinion on
the diagnoses given at The Priory.
32. The man quickly settled at Ford. He made friends with other prisoners and
gained employment in the induction workshop. The man had a couple of
appointments with the doctor regarding continuing earache and jaw pain, but
had no contact with healthcare regarding his mental health until 21 August. On
that day, he told a nurse that he felt low in mood. He again explained that he
had not received any medications for his diagnosed bi-polar disorder since
March. The nurse made an appointment for the man to see the doctor the
following morning and referred him to the registered mental health nurse.
There is no record of him seeing a GP the following day. His next contact with
healthcare was on 29 August when he saw the mental health nurse.
33. During his session with the mental health nurse, he said that he was “not
feeling right”. He felt his mood had become unstable and this was of concern
to him. The nurse suggested restarting his medications and said she would
discuss this with the GP. An entry was made in the man’s medical record to
monitor him and reiterated that an appointment had already been scheduled for
him to see the psychiatrist at the Bedale Centre at 10.00am on a date in
September. After discussing the issue of restarting medications with a GP it
was agreed to this course of action and the man was given venaflaxine and
semi sodium valproate.
10
34. The mental health nurse next saw the man in September. During this session,
he told her that he had stopped taking the venaflaxine, believing it was giving
him headaches. The nurse noted that psychiatrist would advise on this during
the man’s appointment. The man also explained that he was feeling tired and
lethargic. In addition, he was having difficulty dealing with the unresolved
nature of the relationship with his wife with whom he had no contact in the
previous six months. This left him feeling “bitter, angry and hurt”. The nurse
scheduled a follow up session to take place in two weeks.
35. A few days later, the man ended his contact with his CARATS worker as he felt
he no longer needed the support. The man had a history of negative voluntary
drug tests and there was no evidence of any ongoing substance misuse issues.
He had also successfully completed a cocaine awareness workshop during
August. The CARATS worker agreed with his request and his file was closed.
36. A member of healthcare saw the man for his continuing earache in September.
He also complained of left eye pain and was prescribed 400mg of ibuprofen for
seven days.
37. The mental health nurse saw the man for a follow up session. They discussed
how he was feeling emotionally “cold” and how he seemed to be “cutting off”.
Despite these feelings, his mood appeared stable. The nurse noted that he
would be seeing a psychiatrist in two days. She also suggested a referral to
the dentist for an x-ray to establish the cause of his ear and jaw pain. This
appointment was made for 8:30am the following day.
38. The man travelled, unescorted, by train to Bognor Regis for his appointment at
the Bedale Centre. After his appointment he returned to the prison, arriving at
reception at approximately 1.00pm. An officer was on reception duty that
afternoon and performed a rub down search on the man. (All prisoners leaving
and entering the prison are subjected to a search to make sure they have no
contraband.) In interview, he recalled the man asking if he could go back to the
train station as he had left his jumper there. The officer explained to the man
that he could not leave the establishment again as his temporary release
licence had expired. A prisoner who was in reception and about to leave the
establishment offered to pick up the man’s jumper and bring it back later that
afternoon.
39. The man left reception and returned to his billet where he saw his friend, a
fellow prisoner in billet R2. The man told his friend that he had been to
hospital regarding the pain in his ear and jaw. He said that he had been
prescribed painkillers which he had with him. His friend next saw the man at
approximately 4:45pm when they went to dinner together. After dinner they
returned to their own rooms until the 6.00pm roll check. At 6:25pm, his friend
went to the gym. The friend saw the man there with one of their mutual friends
(who occupied the room opposite the man’s in billet R2). An hour later, both
friends left the gym together without the man and returned to the billet. After
making a drink, the first friend noticed that the man had also returned. The
friend remained in his room until the 8:45pm roll check. Meanwhile, another
11
prisoner and friend of the man, visited him at the billet. The visitor told my
investigator that he spoke with the man and he seemed fine. The man told his
visitor that he had been to the doctor earlier that day and had been given
antibiotics. He did not reveal the real nature of his appointment to either any of
his friends.
40. After the evening roll check, the man watched television with one of his friends.
The other friend who occupied the room opposite the man told my investigator
that the man and his friend watched the evening film with the door open. He
could clearly see the open door from his own room. At approximately 11:30pm,
the man’s friend returned to his own room and the man went to bed and closed
his door. In his statement to the police, the friend who watched television with
the man said that he had no concerns about him that night and he appeared to
be his normal self. He did not see the man take any medication.
41. During the night, operational support grade staff (OSGs) made random checks
on all the billets. There were two OSGs responsible for making checks that
night. A check was carried out between midnight and 1.00am. One of the
OSGs told my investigator that he noticed nothing unusual about any of the
prisoners in billet R2. The OSG recalls that he did not have to use a torch to
shine through the observation panel to check on the man. He remembers that
the television was on and this gave enough light to see into the room. The man
was on his bed. Two further checks were performed during the night, one at
approximately 2.00am and another at around 5.00am. On both occasions there
was nothing noteworthy about the man; he just appeared to be asleep.
42. At 7:30am on the day the man died, an officer performed the morning roll check
in billet R2. This was the first check performed by day staff after the night
OSGs went off duty. At the weekend, the check at this time of day is visual.
Officers are not required to obtain a verbal response from the prisoners as they
are entitled to get up later on weekend mornings. The officer recalls seeing the
man and he appeared to be sleeping.
43. Later in the morning, prisoners are allowed to leave their rooms and go to
breakfast. During interviews with officers, my investigator was told that it is not
unusual for prisoners to take this opportunity to have a lie in and miss
breakfast. At around 8.00am, the friend in the room opposite to the man’s left
his room and went to the communal washrooms. On his return, he looked into
the man’s room through the observation panel. He saw that the man appeared
to be asleep. He was lying on his bed in his underwear.
44. After breakfast, the visitor from the previous evening went to billet R2 to see the
man again. He saw that the man’s door was closed, so he looked through the
observation panel to see if he was in there. The visitor told my investigator that
the man appeared to be asleep. He knocked on the door to try and wake him,
but the other residents in the billet asked him to stop and keep the noise down.
The visitor left the billet and went round to the man’s window to try and get his
attention. The visitor called to him through the open window. On getting no
response, he decided to try and wake the man by throwing some clothes pegs
that happened to be nearby. At this stage, the bell was rung for the 11:30 roll
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check and visitor had to return to his own billet. He believed that the man was
sound asleep and he would speak to him later.
45. At around 11:32am, the officer performed a second roll check in billet R2. He
instructed all prisoners to stand by their doors to be counted. On reaching
room 2, he noticed that the door was still shut and the man had not come out.
At this point friend who lived opposite said “he’s fast asleep in there”. The
officer then unlocked the man’s door and entered the room. He found the man
lying on his bed in his underwear, with the window open. The officer tried to
rouse the man by raising the foot of his bed slightly and shaking it, at the same
time talking to him to try and get a response. The man did not stir so he tried
again to get a response. On failing to wake him, the officer placed his hand on
the man’s upper right arm. He immediately the man’s cold temperature and
that he was very stiff. The officer checked his wrist for a pulse but found none.
It appeared that the man had been dead for some time and was beyond
resuscitation.
46. Using his radio, the officer placed a call for urgent assistance. In a matter of
seconds, six officers arrived at the hut, one of whom was senior officer (SO).
The SO requested (via radio) that the duty governor attend and that the
communications room call for an ambulance. He also requested that the police
attend. Approximately two minutes later, a principal officer (PO), who was
acting as orderly officer that day, arrived and instructed the first officer to
retrieve the scenes of crime kit bag. The decision was made to leave the room
and wait for the police. Prisoners were moved out of the billet and the chaplain
attended to provide support.
47. The ambulance arrived at the prison at 11:45am, shortly followed by the police.
After the ma had been pronounced dead, the police took over the enquiries.
Statements were taken from prisoners and staff who had recent contact with
the man or who had been present after he was discovered. On searching the
man’s room the police found a bottle of vodka (unopened), a wrap of brown
powder, a small amount of cannabis resin, a mobile phone and his prescription
medication – venlafaxine, valproic acid and ibuprofen. All items apart from the
vodka were taken away for examination.
48. The police also said that they would inform the man’s next of kin and the
coroner’s officer. The man’s wife had been listed as his next of kin and the
police experienced some difficulty in contacting her during the afternoon.
49. The coroner’s officer and undertaker removed the man’s body from the prison
at 7:35pm that evening.
50. A Detective Sergeant telephoned the prison the day after the man died to let
the Governor know that the man’s wife had been contacted. She had
recommended that they contact his brother and sister. The police passed the
family’s details to the prison and the prison’s family liaison officer spoke with
the man’s brother later that day. The Governor personally telephoned the
man’s brother and offered her condolences the following day. She offered full
support in assisting with funeral arrangements (including a financial
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contribution), the return of his belongings and a visit to the prison should he and
his sister so wish. (They visited the prison a few days later.)
51. During this time, the police continued with their enquiries before ruling out any
suspicious circumstances surrounding the man’s death. Test results on the
brown powder found in the man’s room proved the substance to be heroin
based (diamorphine). Efforts were made to try and trace any telephone calls
made, however no SIM card could be found.
52. A toxicology report was requested and the police tried to establish where else
the man had been on the day he died. Unfortunately, the enquiries proved
fruitless and it was not possible to determine what had happened to him. A
toxicology report completed in October revealed that he had levels of morphine
and ethanol in his body consistent with heroin use and a high level of alcohol
consumption. The combination at these levels is consistent with fatal toxicity.
53. The man’s funeral took place on 26 October and a memorial service was held
at the prison on 29 October.
Clinical findings
54. The Clinical Governance Lead for the Western Sussex PCT (which has since
merged with other organisations to become West Sussex PCT) conducted a
clinical review. Western Sussex PCT assumed responsibility for medical
services in HMP Ford in 2002.
55. The full report of the clinical review is at Annex 2. This is an account of the key
findings and conclusions.
Medical history
56. The man’s psychological and psychiatric histories are of major significance in
this case. In late 2005, prior to his arrest, the man tried to take an overdose of
alcohol, cocaine and amitriptyline but survived. Intermittently over the year
before his death, he had had recurrent suicidal ideation, but does not appear to
have been assessed as a high suicide risk.
57. He was admitted to The Priory in January 2006, prior to being remanded into
custody, for assessment of his impulsive behaviour, which had led to the
suicide attempt. A medical report by his psychiatrist at the clinic lists his
diagnoses as:
• generalised anxiety disorder,
• post traumatic stress disorder,
• pathological gambling,
• cocaine and alcohol abuse.
58. The man had a long history of symptoms of anxiety and pathological gambling.
The alcohol and drug abuse started after the death of his mother, closely
followed by that of his father. The post-traumatic stress symptoms related to
14
these events. In particular, he had discovered his mother’s body following her
suicide.
59. The man’s psychiatrist offered a differential diagnosis of bipolar disorder,
particularly in view of rapid mood swings, and also attention deficit hyperactivity
disorder (ADHD), which in the past had responded to methylphenidate (Ritalin).
He did not think that the man’s mood swings were directly related to drug
abuse, although they were possibly exacerbated by this behaviour.
60. The man was prescribed methylphenidate (Ritalin), semi sodium valproate (for
bipolar disorder), and venlafaxine (an antidepressant). He was also referred to
a psychologist for cognitive behavioural therapy and treatment for his post-
traumatic stress disorder.
61. The clinical reviewer interviewed the psychiatrist by telephone on 4 December
2006. He confirmed the details in his report, adding that he thought the man
had a borderline psychopathic personality but also had the diagnoses listed.
62. Prior to his period in custody, the man had also been under the care of an NHS
GP, whose report notes that his binge drinking dated back to at least the year
2000, and that he had received treatment in the past from the community drug
and alcohol team in Richmond. The clinical reviewer did not interview this GP.
Issues
63. On entry to HMP Wandsworth in March 2006, the man was prescribed
chlordiazepoxide, together with thiamine and vitamin B compound forte for
acute alcohol detoxification. No medical follow up note was made for three
weeks, but on 28 March referrals were made to the dual diagnosis and
substance misuse teams. The gap of three weeks in record keeping is of some
concern, particularly as his alcohol detoxification had not been followed up.
64. The notes made available from the man’s first session with the dual diagnosis
nurse in HMP Wandsworth were incomplete, wrongly dated and unsigned.
However, they did include a reasonably detailed clinical history and noted that
the man’s GP and psychiatric records had been requested. It appears that an
appropriate symptom score and risk assessment was made by the dual
diagnosis nurse at this time and indicated a low risk of suicide or self-harm.
65. The man was further assessed 19 April 2006 by a consultant in dual diagnosis.
The consultant questioned the diagnosis of ADHD and did not prescribe the
medications suggested by the man’s previous consultant psychiatrist. He felt
that the man had an ‘adjustment disorder’. He prescribed three days of
sleeping tablets and referred him to a ‘psychologist for psychological support’.
66. Despite the man’s view (in a meeting with his dual diagnosis nurse on 26 April)
that he was “much improved without being on medication” and his appearance
of being calm and relaxed, it seems that the man continued to be concerned
about not receiving his previous prescriptions. A letter from the consultant
psychiatrist at The Priory to the man on 26 April suggests that he had contacted
15
him, or someone else had on his behalf, regarding his medications. Neither my
investigator, nor the clinical reviewer, had sight of any initiating
correspondence. The consultant psychiatrist’s reply expressed concern that
the man was not receiving treatment needed for his bipolar disorder, attention
deficit disorder and pathological gambling. This letter was copied to the man’s
solicitor and to the Chief Medical Officer at Wandsworth, but there is no record
of any subsequent action.
67. Despite the letter, the medication was not prescribed, but it appears that the
man remained quite stable at Wandsworth during May and June until his court
case on 23 June. An entry on 14 June describes him as “feeling very well and
looking forward to going to court next Thursday”.
68. On transfer to HMP Ford, the man received timely contact with a GP (to discuss
his medical and psychiatric history. Appropriate referrals were made at this
stage for follow-up support with the mental health nurse and to seek a second
opinion on his diagnoses with the local psychiatric services, historically
provided by the Sussex Partnership Trust in the Bedale Centre, based in
Bognor Regis.
69. The clinical reviewer and my investigator interviewed the GP on 17 January
2007. The GP confirmed the details of his initial consultation with the man, and
also mentioned that at that time the mental health care worker at the prison was
on holiday. The appointment at the Bedale Centre was booked for a date in
September, two months after referral. This is a fairly typical waiting time for a
non-urgent outpatient appointment for NHS psychiatric services in West
Sussex.
70. The mental health nurse was asked to see the man on 29 August, following her
return from annual leave. At this stage, his mood was thought to be “unstable”.
The man apparently said that he was “not feeling right”. The decision was
made to restart some of his medication, and the following day he started semi
sodium valproate and venlafaxine. When he was next seen he had stopped the
venlafaxine because he thought it was giving him bad headaches. The man
was feeling down due to the breakdown of his relationship with his wife, whom
he said had not contacted him in six months. The notes show he was feeling
“bitter and angry and hurt”. Two weeks later, the mental health nurse saw him
again and observed that his mood was stable, although he described himself as
“cold” emotionally. The nurse thought he was “cutting off emotionally”, and
noted that he was due to see the psychiatrist in three days. The next entry in
the medical notes records the man’s death the previous night.
71. My investigator and the clinical reviewer interviewed the mental health nurse on
17 January 2007. The nurse confirmed that the clinical details recorded in the
notes were accurate. She explained that she was the sole mental health care
worker at Ford, and had only started her job full-time in July 2006. It had
become clear that her predecessor had struggled with the role, and there had
been a lot to sort out after she arrived.
16
72. When asked about links with secondary care and other NHS psychiatric
services, she felt that the links were far from perfect. There was no formal
service level agreement (SLA) with the Sussex Partnership Trust for provision
of consultant cover, and it appeared that the referrals to the Bedale Centre
were made on a goodwill basis. Consequently, there were no regular visits to
the prison by a psychiatrist or psychologist, and there was difficulty in
accessing drugs and substance misuse services.
73. As the only registered mental health nurse, there was no cover when she took
annual leave. This aside, she found the pressure of work quite intense. The
nurse suggested that having two mental health nurses would be both practical
and realistic for a prison the size of Ford, particularly as a large number of
prisoners suffer from psychiatric and/or drug and alcohol problems. The nurse
also felt isolated from her peers, having no links with other primary mental
healthcare workers or community mental health care teams. Moreover, both
she and the GP felt that the links with the Bedale Centre were far from ideal.
Communication and follow-up was often difficult and no collaborative plans
were usually put in place.
74. Notes from the man’s outpatient appointment made by psychiatrist show that
he had considered the reports provided about the man’s psychiatric history over
the last few years. During the appointment, the psychiatrist found the man to
present with no evidence of current depressive, hypomanic or psychotic illness.
He considered previously documented features of his personality, and when
discussing his view of long-term interpersonal relationships noted that the man
said: “If I don’t get the right reaction, I would want to kill myself.”
75. It was the psychiatrist’s opinion that the man presented with a pattern that fitted
the borderline personality disorder, but felt that at this point other disorders
could not be ruled out. Despite the man’s comment, he did not think he
presented a risk to himself or to others, or that it was reasonable to commence
psychotropic medication. The man was not given a follow-up appointment and
no action plan was suggested other than re-referral if any other psychiatric
disorders developed.
76. The clinical reviewer interviewed the psychiatrist from the Bedale centre by
telephone on 22 November 2006. The psychiatrist confirmed that he had had
access to the psychiatric report from The Priory prepared in January 2006. He
said that, after his consultation with the man in September, he did not feel that
he had any ongoing psychiatric illness, and that the predominant problem was
a borderline personality disorder. He therefore discharged him to the care of
the medical team at Ford.
77. The man was found dead, having apparently taken an overdose of morphine
and alcohol the evening after his appointment at the Bedale Centre.
78. On speaking to officers who responded to the discovery of the man’s body, it
became clear that some discussion had taken place as to whether resuscitation
should have been attempted. An officer who was fully conversant in first aid
and cardio pulmonary resuscitation had been concerned that no attempt had
17
been made. However, it was clear that rigor mortis had set in and that the man
had been dead for some time. In this instance, it is correct that CPR was not
initiated.
Post mortem results
79. Post-mortem results dated 24 November 2006 recorded the cause of death as
toxic effects of alcohol and drugs, specifically there was a blood ethanol level of
264 mg per decilitre and blood morphine level of 0.392 mg per litre. There was
no evidence of injection marks on the man’s body.
Concerns
80. On reception to Wandsworth, the man was placed on an alcohol detoxification
medication. It seems that there had been no obvious planned follow-up for
three weeks. The guidance for alcohol detoxification in a custodial setting
requires the prisoner to have their blood pressure and pulse monitored
throughout the first 72 hours. There is no documented evidence that this took
place. Indeed, the next entry in the man’s medical record is 28 March, some 20
days after his detoxification started. However, the prescription chart for his
detox medication is complete.
The Head of Healthcare at HMP Wandsworth should instruct staff to
correctly record and monitor the detoxification process, in line with the
guidelines for alcohol detoxification in a custodial setting.
81. The first reception healthscreen form used by Wandsworth specifies that if
“acute mental health problem suspected, or any recent/current deliberate self
harm, then refer to a medical officer”. The man was not referred to a medical
officer at this stage. Even though he had said that he did not feel like harming
himself, given the diagnosis and list of prescriptions that followed him from the
Priory, the clinical reviewer and I would have expected him to have been
referred to the GP sooner.
82. The overriding concern emerging from this investigation and clinical review is
the link between the prison mental health care service and that of the NHS.
Although reports were received from NHS services prior to the man’s admission
to Wandsworth, medication was not continued. In this case it may not have
affected the outcome, but the ramifications in other cases could be serious.
The Head of Healthcare at Wandsworth should try to ensure continuity of
care for any prisoner entering prison. Where there are differences in
opinion, particularly concerning mental health, a second opinion should
be sought and discussion held with the previous responsible clinician to
make sure that reasoned and informed judgements are made.
83. Equally in Ford, the lack of a service level agreement between the prison and
the mental health care trust is a serious deficiency. On a clinical level,
communication has been historically poor and closer collaboration between
consultant/specialist services and primary mental health care workers at Ford is
18
recommended. Specifically, regular visits to Ford by a consultant psychiatrist
(and possibly a psychologist) should be considered, as well as more support for
the primary mental healthcare worker. This should include cover for holiday
and other absences. The mental health care worker should also be engaged in
peer support through links with local NHS community mental health care teams.
The Governor and Head of Healthcare should work with Western Sussex
Primary Care Trust and Sussex Partnership Trust to establish a service
level agreement to formalise links between prison healthcare and external
consultant and specialist services.
The Head of Healthcare should consider employing an additional primary
mental healthcare worker to support the existing post and provide cover
in their absence.
The Head of Healthcare should ensure that the primary mental health care
worker receives peer support though links with local NHS community
mental health care teams.
Findings relating to policy and procedure
84. I have no concerns about the response of the discipline staff to finding the man.
He had evidently been dead for some time before being discovered. The
nature of the checks performed on weekend mornings (only visual checks are
required at the 8.00am roll check) were such that staff on duty were confident
that he just appeared to be sleeping. Indeed, fellow prisoners have also
confirmed that, when they saw the man through the observation panel in the
door, or through his window, he seemed to be asleep. The decision not to
resuscitate was correct as rigor mortis had clearly set in. This is in line with the
prison’s suicide and self-harm policy which states that resuscitation should not
be initiated in such instances. To begin resuscitation under such
circumstances would be disrespectful to the deceased and an unreasonable
expectation of staff.
85. In making enquiries about how discipline staff responded to discovering the
man, my investigator asked whether officers had current first aid training. The
majority did not. I have concerns about this as Ford does not have 24 hour
healthcare cover and therefore staff, who may not feel confident in their first aid
skills, would rely on the arrival of paramedics. My investigator discussed this
with Governor. She confirmed that refresher first aid training was in planning
and an in-house training course would be rolled out when the physical
education instructor had completed her training instructor course. The
Governor also told my investigator that resuscitation aids are available to all
officers to be carried on their belts.
86. The clinical reviewer has recommended in his clinical review that consideration
should be given to having at least one staff member with up-to-date certification
in CPR training on every shift. While I agree that this would be ideal, I
appreciate that in practice it might be impractical unless there were high
numbers of staff trained in CPR. Ford has low staffing levels and few staff have
19
current first aid training. I believe that Governor’s approach of having in-house
training is the most practical and effective way of addressing the situation. To
maximise the probability of having trained officers on each shift, it would be
sensible to prioritise training for senior officers as there is always one on duty.
87. As the post mortem results have indicated, the man died from excessive
amounts of alcohol and morphine. Levels in his blood stream are consistent
with that of fatal toxicity. It has not been possible to identify where he obtained
either substance, but interviews and police witness statements indicate that he
consumed them after going to bed on the night before he died. This seems
confirmed by what the police found in his room.
88. The availability of drugs and alcohol in prisons is a matter both of professional
and public concern. To a greater or lesser extent, it is a problem that affects
every establishment in the Prison Service. Clearly, it is particularly challenging
for an open prison where prisoners can leave the establishment, on licence,
and unaccompanied. My investigator discussed this with the security governor
at Ford to understand more about how the prison tackles this issue.
89. The security governor explained that the security department largely relies on
intelligence, coupled with staff patrols, to identify when and where contraband
is brought into the establishment. If staff suspect a prisoner is carrying or
hiding contraband, they would be challenged and the findings removed. HM
Chief Inspector of Prisons’ report on Ford in November 2005 notes a “good
intelligence system, with reasonably effective security for an open prison”. The
system is based on information provided by staff, prisoners and the police. The
security team have had some success in finding contraband left for prisoners
outside the prison grounds, but the size of the site can mean that much is
missed.
90. The security governor added that voluntary and mandatory drug test results are
also used as a guide for identifying what kind of drugs might have been brought
into the prison. Breathalyser tests can also be used by staff working on
reception if they suspect that a returning prisoner is intoxicated. Any prisoner
found to be under the influence of alcohol or drugs is moved back to a closed
prison. Ford used to have access to an area team of dogs for detecting drugs,
but expenditure on drugs dogs is no longer considered a priority for the area.
This was a decision taken by the Surrey and Sussex Area Office, which pre-
dates the current Kent and Sussex Area.
91. My investigator discussed the weakness in physical security with the Governor
of Ford. I am pleased to learn that this is being addressed in line with
recommendations in the Chief Inspector’s report, and that additional outside
lighting has been installed as well as a hedge of pyracantha (a thorny plant
often used to deter intruders) planted around the perimeter. There are a
number of identified ‘hot spots’ around the perimeter for leaving contraband that
is later smuggled into the prison.
92. In addition, as part of the resettlement programme, CARATS programme and
drug reduction strategy, prisoners have access to a relapse prevention course
20
and short-duration drugs programme (specifically for short term prisoners).
These courses address the dangers of using drugs when the user has reduced
tolerance levels. Unfortunately, there are no dedicated alcohol programmes.
Prisoners who need alcohol related treatment are referred to community drug
and alcohol centres for specific support for alcohol misuse. An Alcoholics
Anonymous group is held weekly at the prison.
93. The day before he died was the man’s first opportunity since sentencing to
return to the community. During the period that he was released on temporary
licence, he would have had the opportunity to obtain both drugs and alcohol,
although in doing so he would have been in breach of the conditions of his
temporary release.
94. Prior to this, it is likely that the man had five to six months with no alcohol or
drugs. His tolerance levels to these intoxicating agents would have reduced
considerably. The levels of alcohol and morphine in his bloodstream on 30
September seem to have been fatal. He may well have misjudged what he
could safely take after five to six months abstinence.
21
CONCLUSION
95. The man appears to have received good mental health care prior to his
admission to HMP Wandsworth. It is also apparent that, at each stage of his
care in custody, a genuine attempt at assessing his mental state and suicide
risk was made. Past documentation and medical records of his mental health
history were available on admission to both prisons.
96. It is the opinion of the clinical reviewer that appropriate questions were asked
about the man’s medication when mental health care workers saw him, and he
received prompt and appropriate psychiatric assessment and referral to
specialist services at HMP Ford.
97. All staff and prisoners interviewed confirmed that they did not have any
concerns about the man on the evening before he died. His demeanour did not
appear any different that day. My investigator spoke on the telephone with the
prisoner who last saw the man that night he died, and he confirmed that he had
no concerns about him that day or on any other occasion. They were good
friends and could talk freely with each other. The friend said that the man often
spoke about his uncertainty regarding his marriage, but he never said he was
depressed or felt like harming himself. Both of the man’s friends also confirmed
that they had never seen or heard of him consuming alcohol or using illegal
substances whilst at Ford. The trigger for his death therefore remains
inconclusive.
Response to comments on the draft report
98. In response to my draft report the Prison Service and the man’s family
submitted further comments for further clarification.
• The Prison Service asked for clarification on whether the man had been an
inpatient at the Priory Hospital up until being remanded into custody at HMP
Wandsworth. If this was the case then it would have been unusual to
require an alcohol detoxification programme as the Priory would operate a
policy of abstinence for inpatients. The Priory Hospital confirmed that the
man was only an inpatient for a short period and discharged himself on 7
February. Therefore the man would have been able to access both alcohol
and illegal substances during the period between his discharge and being
remanded into custody.
• The Prison Service consulted the Drug Strategy Unit (DSU) for advice on
the draft report. In the initial draft, my investigator stated that the powder
found in the man’s room was white. The DSU commented that if the
powder was white and heroin based then it would be a rare form of heroin
and therefore easier to trace the source. My investigator sought clarification
from the police on evidence removed from the man’s room. The Detective
Sergeant stated that the wrap of powder found in his room was brown and
not white. On testing the substance it was found to be heroin based
(diamorphine). The level of purity was not tested.
22
• In addition, the DSU asked whether there were any injection marks found on
the man’s body or any injecting equipment found. Neither marks nor
injecting equipment were found or any other kind of paraphernalia to
indicate that the powder may have been snorted. This indicates that he
must have ingested the substance. The DSU commented that ingestion
may have been indicative of the intent to take his life based on a comment
that “it takes larger quantities of a drug administered orally to achieve toxic
blood levels. The apparent absence of any paraphernalia to take drugs
would tend to indicate that ingestion for ‘recreational’ use is less likely.” I
am reluctant to comment either way on whether the man used the
substance for recreational or self-harm purposes as this would be
speculation and not based on evidence considered by my investigator.
• The police found an unopened bottle of vodka in the man’s room. No empty
bottles were found, however from the toxicology report he would found to
have high blood/alcohol consumption. The DSU comment that the lack of a
used bottle does not provide an adequate explanation for the toxicology
findings nor support the contention that he must have consumed the drugs
and alcohol after going to his room. During the investigation all parties
spoken to confirm that the man did not behave suspiciously or appear under
the influence of intoxicating substances prior to going to bed that evening.
The evidence suggests that he consumed the alcohol and drugs during that
night. The lack of an empty bottle may mean that it was either removed by
another prisoner to conceal the fact that it had been consumed during that
night by the man and potentially other prisoners, or indeed that he had
drank some alcohol beforehand and simply did not appear intoxicated. The
police investigation found no foul play in connection to his death and
therefore my statement still stands on the fact that it is not possible to tell
whether his death was simply an accident or intentional on his part.
• The man’s family raised concerns about the connection with the visitor to his
billet on both the night before and the morning he was found dead. Both my
investigator and the police spoke to the visitor. Both parties were told that
the visitor was a friend. The man’s family have subsequently told my family
liaison officer that the visitor is the relation of a man that the man who died
allegedly informed on to the police. The family believe that as a result of
this the visitor would not have been a friend as suggested in the report. My
investigator found no reason to disbelieve the visitor’s statement and the
police found no evidence to be concerned about his involvement.
• The family wanted a further explanation as to why the prison staff that they
have subsequently spoken to believed that the man had a dental
appointment on the day before his death and not an appointment with a
psychiatrist. Prison staff would not be aware of the nature of any prisoner’s
medical appointment. This is a matter of medical confidence. The man told
several people different stories about the nature of his outside appointment
that day. It seems that he did not want his mental health issues publicised.
23
RECOMMENDATIONS
• The Head of Healthcare at HMP Wandsworth should instruct staff to
correctly record and monitor the detoxification process, in line with the
guidelines for alcohol detoxification in a custodial setting.
The Prison Service has partially accepted this recommendation stating:
“HMP Wandsworth does follow the guidelines as stated for alcohol detoxification
in a custodial setting, however, the practice needs to be made more consistent,
with all practitioners being aware of the policy and adhering to it. As of 1st June
2007, the new providers, Secure Healthcare, will take over the Health Services of
HMP Wandsworth and this procedure will be reviewed.”
• The Head of Healthcare at Wandsworth should try to ensure continuity
of care for any prisoner entering prison. Where there are differences in
opinion, particularly concerning mental health, a second opinion should
be sought and discussion held with the previous responsible clinician to
make sure that reasoned and informed judgements are made.
The Prison Service has partially accepted this recommendation stating:
“All new reception prisoners are seen by a primary case nurses on reception, a
GP and a detoxification nurse, they complete full first night procedures and again
are Health Screened and any concerns are referred to the In Reach team and/or
an appropriate person for on-going care. Currently the In Reach services and
Primary Care come under different management, but from 1st June all health
services will be managed by Secure Health. This should ensure that all
requirements for prisoner care are within one function and this should improve
the consistency and the timeliness of interventions, with particular reference to
second opinions.”
• The Governor and Head of Healthcare should work with Western Sussex
Primary Care Trust and Sussex Partnership Trust to establish a service
level agreement to formalise links between prison healthcare and
external consultant and specialist services.
• The Head of Healthcare should consider employing an additional
primary mental healthcare worker to support the existing post and
provide cover in their absence.
• The Head of Healthcare should ensure that the primary mental health
care worker receives peer support though links with local NHS
community mental health care teams.
The Prison Service has said that these three recommendations “will be discussed
with the Primary Care Trust and a position then taken.”
24