Individual at Frankland

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING
THE DEATH OF A MAN AT UNIVERSITY HOSPITAL, DURHAM,
IN NOVEMBER 2005 WHILST IN THE CUSTODY OF
HMP FRANKLAND
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
APRIL 2006
This is the report of an investigation into the death of man who died from
natural causes at University Hospital, Durham on 2 November 2005, whilst a
prisoner at HMP Frankland. He was 51 years old.
The man was serving a sentence of life imprisonment and had been in
custody for over 19 years at the time of his death. He suffered a series of
seizures in his cell on 9 October, when he was taken to hospital. Sadly, his
physical health deteriorated whilst he was in hospital and he passed away in
his sleep during the afternoon of 2 November.
This investigation has been undertaken by two of my colleagues. I would like
to thank the Governor of HMP Frankland and his staff for their participation in
this investigation. I once again appreciate the assistance of the doctor
commissioned by Northumberland Primary Care Trust to undertake a review
of the man’s care. I was pleased to learn that the man’s clinical care on the
day he suffered the seizures was appropriate and his transfer to hospital
timely.
The loss of a loved one is always distressing. I would like to add my
condolences to the man’s family to those already expressed by my family
liaison officer.
I make two recommendations, both of which are directed to Durham and
Chester-le-Street Primary Care Trust.
I also draw attention to two examples of good practice. The man who is the
subject of this report was a sad and isolated man who had spent most of the
previous ten years in segregation units. Despite that, during his final days of
life he was treated in a kind and sensitive way by Frankland staff.
Stephen Shaw
Prisons and Probation Ombudsman APRIL 2006
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Contents
Summary
The investigation process
Background
HMP Frankland
Key findings
Issues arising from the investigation
Recommendations and good practice
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Summary
1. The man was convicted of murder in April 1987 and received a life
sentence. After pursuing an unsuccessful appeal against his conviction,
he refused to co-operate with the prison authorities. Consequently, he
served a significant proportion of the 19 years he spent in custody in
segregation units.
2. He was transferred from HMP Long Lartin to HMP Frankland on 19 May
2005. On 22 September, he complained to medical staff that he was
experiencing abdominal pain, nausea and vomiting. He refused to be
examined by a doctor and the problem was only diagnosed and treated
more than a week later.
3. On 9 October, the man suffered a seizure in his cell and was taken by
ambulance to University Hospital, Durham. Whilst at the hospital, he
refused to accept medication or undergo tests and consequently his
health deteriorated. Both prison and hospital staff made concerted
efforts to persuade him to change his mind, but he continued to reject
treatment. During the morning of 2 November, the man slipped into
unconsciousness and he died at 5:40pm.
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The investigation process
4. My investigator considered the man’s prison records, including his
medical records, before formally opening the investigation at HMP
Frankland on 14 December 2005. On 15 December, he and his fellow
investigator met with the deputy governor, and the chair of the prison’s
Independent Monitoring Board. Various members of staff were
interviewed.
5. Prior to my colleagues arriving at Frankland, notices were issued to staff
and prisoners announcing the investigation and inviting anyone who had
information relevant to the man’s death to make themselves known to
the investigation team. In the event, nobody came forward.
6. One of my family liaison officers contacted the man’s next-of-kin to offer
them the opportunity to participate in the investigation.
7. An independent clinical review of the healthcare he received whilst in
custody was carried out at the direction of the Durham and Chester-le-
Street Primary Care Trust.
8. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of the investigation and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner
to assist him in his enquiries.
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HMP Frankland
9. HMP Frankland is a maximum-security establishment holding Category
A and Category B adult male prisoners. It is part of the high security
directorate of the Prison Service.
10. Frankland opened in October 1980 as a temporary prison, staffed by the
army. After three months the establishment was closed for modification.
It reopened as a fully operational high security prison in April 1983. Two
further wings were opened in 1998, bringing the establishment’s certified
normal accommodation (uncrowded capacity) to 653. Prisoners are held
in single cell accommodation in six wings, four of which house vulnerable
prisoners. Frankland is one of only six establishments assessed by the
Prison Service as being a ‘High Performance Prison’.
11. The most recent published inspection report by HM Chief Inspector of
Prisons, dated March 2003, described Frankland as offering a safe
environment, based upon good relationships between staff and
prisoners, with appropriate levels of interaction and good staff
understanding of individual prisoners and their needs. Some concerns
were expressed about the nature of the relationships between staff and
prisoners in the segregation unit, although it was acknowledged that
maintaining a balance between care and control in this environment is
particularly difficult. It was also recognised that the problems identified
were not restricted to Frankland, and that the criticisms were equally
applicable to other institutions in the high security estate.
12. According to the governor in charge of the segregation unit, a more
recent inspection, as yet unpublished, has found that the problems
described above have been effectively dealt with. In particular,
relationships between staff and prisoners are said to be much improved.
13. The Standards and Security Audit carried out by the Prison Service
during February and March 2003 gave an overall “good” rating for both
categories. Good is defined as an establishment that performs to a high
level and there is evidence which gives assurance that risks are being
effectively managed.
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Key findings
14. The man was arrested for the murder of his best friend during the
evening of 24 October 1986. It would appear that an argument took
place which resulted in the victim receiving three stab wounds to the
chest. He was subsequently found guilty at Nottingham Crown Court
and received a sentence of life imprisonment.
15. In the early stages of his imprisonment, the man refused to accept his
conviction, maintaining that he was guilty of manslaughter not murder.
He pursued an appeal, but this was turned down. Initially, prison staff
and other professionals felt that he was pursuing his appeal so rigorously
because he could not deal with the prospect of serving life. Over time,
this opinion was revised as it became increasingly evident that he could
not cope with the fact that he was responsible for killing his friend.
16. In due course, the people working with him became increasingly aware
that he believed he deserved to suffer indefinitely for what he had done.
In June 1989, he cut his throat with a broken razor blade, leading to a
hospital admission. Further episodes of serious self-harm took place in
February 1990 and October 1995, the latter resulting in him losing more
than three pints of blood and another spell in hospital. During one of
these periods in hospital, he successfully managed to remove his
handcuffs.
17. In March 1993, the man collapsed and suffered what was apparently a
tonic-clonic (or grand mal) seizure whilst a prisoner at HMP Wakefield.
After the incident, he disclosed to staff that he had suffered “four or five”
other ‘fits’ since the mid-1970s. The underlying cause of the seizures
was never established, although one theory put forward at the time was
that they were related to his previous substance misuse. He apparently
had no further seizures until 9 October 2005.
18. Having decided that punishment was all he deserved, the man set about
acting in ways that would ensure he was denied anything other than the
most basic prisoner privileges. He consistently refused to participate in
prison activities and refused to work. He would not co-operate with
prison regimes, refused to participate in assessment boards or interviews
with professionals, and on more than one occasion assaulted prison
officers. The nature of his behaviour meant that the Prison Service had
no choice but to hold him away from the main prisoner population. From
May 1997 until his admission to University Hospital, Durham on 9
October 2005, the man was located exclusively in segregation units. On
more than one occasion, he stated that he preferred being segregated
from the rest of the prison population. He further increased his sense of
isolation by refusing visits, not responding to letters and declining to use
the telephone. He also specifically asked his supervising probation
officer not to contact any member of his family on his behalf.
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19. The man arrived at Frankland from HMP Long Lartin on 19 May 2005 as
an authorised ‘Seg to Seg’ transfer (meaning that he was received at
Frankland without undergoing the reception procedures that apply to
prisoners on ‘normal’ location). One of the routines of the segregation
unit is that prisoners are seen on a daily basis by medical staff from the
Healthcare Department. Upon his arrival, his attitude of deliberate non-
compliance continued, as shown by his refusal to attend eight out of the
ten ‘segregation reviews’ that took place and his appearances at
adjudication (disciplinary hearings). He also rebuffed concerted efforts
made by the psychology team and other staff members to engage him
more fully in prison life.
20. On 22 September, the man was seen by medical staff from the
Healthcare Department after complaining to segregation unit officers of
abdominal discomfort, nausea and vomiting. However, he refused to be
examined by a doctor and did so on a further two occasions before 30
September. On 30 September, he consented to an examination and was
found to be experiencing tenderness in the abdomen. He was given
Cimetidine medication to suppress the secretion of acid in the stomach.
21. On 2 October, the man was forcibly removed from his cell after
attempting to assault a prison officer. Whilst detained in a special cell,
he complained of abdominal pain unrelated to his forcible removal but
refused the medication that was offered. He returned to his usual cell
later in the day.
22. At around 9:15am on 9 October, he was seen in the segregation unit by
a Registered General Nurse (RGN), as part of the day-to-day ‘rounds’
conducted by the Healthcare Department. Upon entering the unit, the
nurse was informed by segregation staff that the man was ill. He made
his way to the cell and saw that the man looked poorly. He asked him
how he was feeling and the man responded by saying that he could not
see and he felt unwell. Being concerned about the man’s condition, the
nurse decided that the on-call General Practitioner (GP) needed to be
called in order to assess him more fully. As the details of the on-call
doctor service are retained in the Healthcare Department, the nurse had
to make his way back through the prison from the segregation unit in
order to speak to the GP.
23. Having made contact with the on-call GP, the nurse outlined his
concerns about the man’s well-being. He says that he asked the doctor
to come to the prison “straight away”, and in his experience they
normally did so.
24. At approximately 10:00am, the nurse received a telephone call from a
prison officer on the segregation unit who stated that the man looked
worse and seemed to be experiencing some sort of ‘fit’. The nurse
summoned the assistance of one of his colleagues from the Healthcare
Department, and together they made their way to the segregation unit,
taking an emergency resuscitation pack with them.
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25. Upon entering the cell, the nurse noticed that the man was still on his
bed but was mumbling incoherently. He used an approved method of
pain stimulus to make an assessment of his state of consciousness.
This did not elicit a response. Almost immediately, the nurse observed
the man experience some sort of physical convulsion which lasted for
approximately 40 seconds. As he did not want him to cause himself any
damage, he and his colleague set up a ‘protective barrier’ with their legs
so that the man could not kick the wall adjacent to the bed.
26. When the convulsions first started, the nurse immediately asked a
member of segregation unit staff to phone for an ambulance. When they
subsided, the other member of staff fitted an airway to enable the man to
breathe more easily. He became noticeably calmer and the nurses
observed him until the paramedics arrived at the cell around 10.15am.
The nurses then briefed the ambulance crew and the man was removed
from the prison, arriving at University Hospital, Durham at 10.50am. He
was seen by a doctor at 10:57am and at 11:10am restraints were applied
with the approval of the doctor. Prison officers were stationed at the
man’s bedside as an escort and would attempt to engage him in
conversation right up until his death on 2 November.
27. The man was diagnosed with a kidney infection on 10 October, and on
12 October he was seen by a consultant who stated that he expected
him to remain in hospital for “one or two days”. However, his condition
deteriorated and by 18 October the source of the infection had still not
been traced. At this point, his compliance with the medication regime
started to wane and on 19 October, against medical advice, he refused
to have a ‘Venflow’ airway installed in his neck. On 20 October, he again
refused to have an intravenous line fitted. Meanwhile, his physical health
continued to get steadily worse.
28. On 22 October, the man was spoken to by nursing staff at University
Hospital and was encouraged to comply fully with medical treatment.
Later in the day, a doctor explained to him that he might die if he did not
allow the hospital to treat him.
29. Over the next few days, the man accepted medication intermittently but
he did not comply fully. On 26 October, he was spoken to again by a
doctor who explained the importance of submitting to treatment.
However, he continued to only accept medication sporadically and he
refused to give blood samples. His condition deteriorated.
30. On 31 October, a doctor explained to him that his condition was now
very serious. He was also visited and spoken to by a prison officer on
the segregation unit who had a good relationship with him. This course
of action was instigated by a senior officer from the segregation unit and
was sanctioned by the governor. The express purpose of the prison
officer’s visit was to try and persuade the man to accept treatment.
During the course of their 20 minute conversation, the officer
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emphasised to him that his condition was now so grave that he would die
if he did not let the doctors treat him. The man indicated that he was
aware of the consequences of refusing medical care and then requested
that the officer ask him no more questions. The man declined to provide
the prison officer with the details of next of kin who could be contacted in
the event of his death.
31. At 4:45pm on 31 October, authorisation came from the prison to remove
the man’s restraints. This is good practice in that it meant that the man
could die with a degree of dignity. The decision was made at a relatively
late stage because of concerns originating from his previous successful
attempt to remove his restraints whilst under prison escort.
32. At 7:10am on 2 November, the man slipped into unconsciousness and at
5:40pm he quietly died. A doctor formally pronounced his death at
6:45pm.
33. Due to his refusal to provide the prison with the details of next of kin, his
family was not formally informed of his death by Frankland until 8:00am
on 4 November. This was after his supervising probation officer had
telephoned them with the news. This course of action had been
previously agreed between his supervising probation officer and his line
manager after the deputy governor at Frankland had informed them of
the man’s imminent death. Their decision was based on a desire to
respect the man’s wishes regarding family contact.
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Issues arising from the investigation
Contact between prison healthcare and University Hospital
34. Frankland’s Local Instruction on the management of hospital bedwatches
(2.20) states that ‘healthcare staff are expected to maintain regular
contact [with the hospital] to ensure continued outside hospital care is
required and [to] consider support plans for the eventual return of the
prisoner’. In the case of the man who died, senior officers from the
Healthcare Department maintained telephone contact with the local
hospital, although I have not been able to ascertain how frequently this
happened. Currently, the details of these discussions are not routinely
recorded in the clinical records. Such a situation limits the usefulness of
obtaining the information in the first place and means that subsequent
support plans are based on the personal knowledge of the staff.
Durham and Chester-le-Street Primary Care Trust should implement
a system whereby clinical discussions that take place between
Healthcare staff and hospital staff are recorded in the clinical
record.
Clinical Records
35. The Clinical Review conducted on behalf of Durham and Chester-le-
Street Primary Care Trust comments on the chaotic and disorganised
state of the man’s clinical records. It states that there is no way of
identifying what the key features of his medical history were and
concludes that records of this standard are potentially clinically
dangerous. I endorse the recommendation made in the Clinical Review
that medical record keeping across the prison estate needs to be
addressed and improved as a matter of urgency. In particular:
Clinical staff at Frankland should be reminded of the importance of
good record-keeping and of the views expressed in the Clinical
Review.
36. The Clinical Review also comments negatively upon the apparent lack of
contact between the prison Healthcare Department and the hospital after
the man became an in-patient on 9 October. As outlined above, the
Healthcare Department did actually maintain telephone contact
throughout the duration of the man’s stay. However, the fact that the
details of these discussions were not recorded in his clinical records
undermined the value of obtaining updates on his condition. I therefore
reiterate my earlier recommendation to Durham and Chester-le-Street
Primary Care Trust concerning the recording of clinical discussions.
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Recommendations
To the Primary Care Trust
1. Durham and Chester-le-Street Primary Care Trust should implement a
system whereby clinical discussions that take place between Healthcare
staff and hospital staff are recorded in the clinical record.
2. Clinical staff at Frankland should be reminded of the importance of good
record-keeping and of the views expressed in the Clinical Review.
Good practice
4. Regularly reviewing the need for restraints and eventually removing them
altogether when the man’s health deteriorated significantly ensured that
he died with dignity.
5. The efforts made by the prison officer to persuade the man to accept
clinical treatment were another example of good practice. He and the
senior officer who instigated this action should be commended by the
governor.
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