Individual at Gartree

Circumstances surrounding the death of a man, who was a
prisoner at HMP Gartree, in August 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2008
This is the report of an investigation into the death of a man who was a prisoner at
HMP Gartree and who died from natural causes on 8 August 2007. He was 68 years
old.
I would like to add my personal condolences to those already expressed to the
man’s family on behalf of this office by one of my Family Liaison Officers.
This investigation was undertaken by one of my investigators. He and I would like to
thank the Governor of HMP Gartree and her staff for their assistance. A doctor was
asked by Leicestershire County and Rutland Primary Care Trust to undertake a
review of the man’s clinical care and I also much appreciate his help.
The man had long-standing health problems and there is no reason to suppose that
his death was in any way related to the fact that he was in custody. The clinical
review assesses that his treatment was equivalent to what he would have received
had he been at liberty.
I have noted the issues highlighted by the clinical reviewer and I endorse the
recommendations made in his clinical review. The Primary Care Trust and the
prison will need to develop an action plan to address the matters raised.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2008
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CONTENTS
Summary 3
The investigation process 4
HMP Gartree 5
Key events 6
Clinical review 9
Conclusions 11
Recommendations 12
2
SUMMARY
The man was born in 1939. He was 68 years old when he died on 8 August 2007 at
HMP Gartree. The man died from natural causes as a consequence of severely
stenotic coronary atherosclerosis (narrowing of the heart arteries).
The man had been received into prison custody as a remand prisoner on 1 August
1997 after he had been charged with murder. On 22 May 1998, he was sentenced
to life imprisonment at Newcastle Crown Court. The man was initially held at HMP
Durham before being transferred to Gartree on 13 July 1999.
During his initial health screen it was noted that the man had injured his feet in an
accident in 1980. He had also been diagnosed with Dupuytren’s contractures (a
deformity of the hands).
In May 2007, after the man had been complaining of pains in his chest, a referral
was made to the local hospital. He was later diagnosed with suspected angina.
Around 8:10am on 8 August 2007, a prisoner on the healthcare wing at Gartree
heard a noise emanating from the man’s cell. The prisoner looked into the man’s
cell and saw that he was lying face down on the floor. The prisoner immediately
informed the Mental Health Nurse Manager. The Mental Health Nurse Manager and
the Head of Healthcare entered the man’s cell and put him into the recovery position.
As the man was not breathing they immediately commenced cardio-pulmonary
resuscitation (CPR). They were then joined by a nurse and the prison doctor. Whilst
the Mental Health Nurse Manager and Head of Healthcare continued with CPR, the
prison doctor checked for vital signs. The prison doctor could not find evidence of a
pulse and requested that an ambulance be called. When a paramedic arrived at
around 8:27am he took over the man’s care. At 8:45am it was decided that the
resuscitation attempts should stop and death was pronounced.
The clinical review concludes that the man’s clinical care was comparable to that
available in the community. I have endorsed the five recommendations made in the
clinical review.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 9 August 2007 when my investigator issued
notices announcing the investigation to staff and to prisoners. The notices
included an invitation to those who wished to submit information relating to the
man’s death to make themselves known to my investigator. In the event,
nobody came forward. My investigator also studied all relevant prison records
relating to the man. These included his main prison record, medical records
and statements made by staff.
2. My investigator visited Gartree on 15 August and discussed aspects of the
man’s treatment with staff at the prison. He also interviewed the man’s
personal officer who was able to provide background information concerning
the man and his activities whilst in custody. My investigator was unable to
interview the prisoner who raised the alarm on the day the man died. This was
because the prisoner had already transferred to another prison, where he
himself died just a few days later on 20 August.
3. The Leicestershire County and Rutland Primary Care Trust commissioned a
General Practitioner (GP) Investigator/Reviewer to carry out a review of the
man’s clinical care. I am grateful for the review being undertaken.
4. 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.
5. One of my Family Liaison Officers contacted the man’s family. This gave them
the opportunity to discuss the purpose of the investigation and to raise any
concerns or questions they would like explored or addressed. The man’s
family mentioned that they had spoken with him on the phone the day before
his death and he had complained about the pain he was experiencing. They
have since received documentation from the Coroner about the cause of the
man’s death which correlates with the symptoms he had described. The man’s
family did not wish to raise any specific concerns about the treatment he
received while in custody. Indeed, they were very positive about the help and
support they had received from the prison. I hope that this report helps the
family better understand the events leading up to the man’s death.
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HMP GARTREE
6. Gartree is a category B prison whose principal function since 1997 has been to
accommodate and rehabilitate adult male life sentence prisoners. The average
tariff (minimum time to serve) for these prisoners is 15 years. Around 18 per
cent of the population now consists of prisoners sentenced to indeterminate
sentences for public protection. These prisoners typically have much shorter
tariffs.
7. In common with the rest of the Prison Service, places on offending behaviour
related courses, which lifers must necessarily complete in order to progress
towards release on licence, are at a premium. It is not uncommon for prisoners
to have to wait up to three years to gain a place on some courses.
8. Gartree is part way through a major refurbishment that will continue for the next
two years. When complete, it will give Gartree the ability to accommodate
some 680 prisoners and make it the biggest lifer centre in Europe.
9. The commissioning of healthcare within Gartree is the responsibility of the
Leicestershire County and Rutland Primary Care Trust. The healthcare centre
has 14 cells, provides 24 hour nursing care and has doctors from a local
practice who visit daily. Only two cells in the healthcare centre are for in-
patients as the remainder form part of the prison’s Certified Normal
Accommodation (CNA).
10. Medication is administered on a weekly and/or monthly basis to those prisoners
who have been risk assessed as suitable for holding it in their own possession.
It is administered on a daily basis to other prisoners, when either they are
considered to be at risk or the medication is considered unsuitable to be held in
their possession.
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KEY EVENTS
11. The man arrived at Gartree on 13 July 1999, after being previously held at
HMP Durham. On first reception in prison, the man had two established
medical conditions. First, he suffered from Dupuytren’s contractures in both of
his hands. (This is a condition causing scarring of the soft tissues of the palm
in tethering of the affected fingers.) He also had painful feet as a result of ankle
or feet fractures deriving from an accident in 1980. These caused a reduction
in his mobility. A range of medications was prescribed for the man and he was
allowed to keep these in his possession for self administration.
12. On 9 December 2004, the man moved into the healthcare centre and was
given a job as a part-time cleaner. The healthcare centre has 14 cells but only
two cells are for in-patients. The remainder are used to help Gartree
accommodate prisoners, like the man, who are elderly, who cannot be housed
elsewhere and whose behaviour does not raise any concerns.
13. Around 8:30am on 24 May 2007, a nurse was called to the man’s cell as he
had been complaining of pains in his chest. The man told the nurse that he
had been experiencing the pain for around three weeks but he had decided not
to bring it to the attention of staff. The nurse carried out an electrocardiogram
(ECG), and the man was also seen by a prison doctor who made a referral to
the local hospital. The man was seen at the local hospital on 6 June where
tests and x-rays were carried out. He was diagnosed with suspected angina
and prescribed aspirin, bisoprolol and simvastatin to reduce the number of
angina attacks and the risk of having a heart attack. He was also issued with a
GTN spray which provides rapid relief after an angina attack or can be used to
prevent an anticipated attack.
14. On 15 June, the man attended the specialist chest clinic at another local
hospital. A letter dated 21 June from a Senior Specialist Cardiac Sister,
summarised a discussion she had had with the man about his diagnosis of
suspected angina. The Sister confirmed that the man had been added to a
waiting list for further treatment and additional tests would need to be carried
out. The Sister said that she had stressed to the man the need to seek
assistance if his chest pain lasted longer than 20 minutes and was not resolved
by using the GTN spray.
15. On 23 July, the man was seen by a prison doctor due to more frequent
episodes of chest pain. He had his observations repeated and another ECG
was carried out. The man’s chest pain was still relieved quickly by the use of
his GTN spray so he did not warrant transfer to outside hospital. A longer
acting nitrate medication, similar to his GTN spray, was started to treat his
angina. Again the man was advised to report any prolonged periods of chest
pain that did not respond to his GTN spray, and he was also advised not to
perform any heavy manual labour.
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16. On 5 August, the man was seen by Healthcare Officer A following a further
episode of chest pain that had been relieved by using his GTN spray. The man
was advised that he was no longer fit to continue in his part-time cleaning role,
and an appointment was made to see the prison doctor. Despite being listed
for an appointment on both 6 and 7 August, the man declined to attend. On 7
August, the man rang his brother’s home and, during a conversation with his
sister-in-law, said that he had stopped taking his medication and was feeling a
lot better.
17. Around 7:30am on 8 August, Healthcare Officer A carried out a roll check of
prisoners on the healthcare centre. Whilst carrying out this task he looked into
the man’s cell (number 13). Healthcare Officer A observed the man was out of
his bed and standing at his washbasin and they spoke briefly. At around
8:00am, Healthcare Officer A unlocked the man’s cell but the two men did not
speak on this occasion. At around 8:10am, a prisoner (who was located in cell
number 11) on the healthcare centre heard a strange noise emanating from the
man’s cell. The prisoner looked into the man’s cell and saw that he was lying
face down on the floor. There was blood underneath him.
18. The prisoner rushed up to the Mental Health Nurse Manager and informed him
what had happened. The Mental Health Nurse Manager shouted for
assistance and asked a Staff Nurse, who was in the corridor, to press the
emergency alarm bell. A Prison Officer, who was in the healthcare wing office,
was asked to press the emergency alarm bell which he did immediately. The
Mental Health Nurse Manager then entered the man’s cell and called his name
twice but did not get a response. The Mental Health Nurse Manager was
joined by the Head of Healthcare and they put the man into the recovery
position. The Mental Health Nurse Manager noted that the man was not
breathing. They turned the man onto his back and immediately commenced
cardio-pulmonary resuscitation (CPR).
19. Another Staff Nurse and the prison doctor joined them, having brought
emergency equipment, oxygen and a defibrillator. The Mental Health Nurse
Manager and the Head of Healthcare continued with CPR whilst the prison
doctor checked for vital signs. The prison doctor could not find evidence of a
pulse and asked that an ambulance be called. The Staff Nurse placed the
defibrillator pads onto the man’s chest, administered adrenaline and provided
oxygen. At no stage did the defibrillator advise that a shock should be given.
While this was happening, prisoners were locked back into their cells by prison
officers who had attended healthcare in response to the emergency alarm bell.
Two of the officers were then asked to be available to escort the man to
hospital. They were briefed by the Head of Operations about the intended
arrangements.
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20. When the paramedic arrived at around 8:27am, he took over the man’s care.
The defibrillator was changed and the rhythm strip showed the man was
asystole (his heart had stopped). The paramedic administered atropine (a drug
that can be used to speed up the heart rate) but there was no change in the
man’s condition. At 8:45am, it was decided that the resuscitation attempts had
been unsuccessful. They were stopped and death was pronounced by the
paramedic.
21. At 8:50am, the two officers were informed by the Head of Operations that they
would no longer be required for escort duty as the man had died. The officers
then went to each cell on the healthcare wing to tell prisoners individually what
had happened. They also asked each prisoner whether they required anything
or wanted to speak to a Listener (a prisoner who has been trained by the
Samaritans to give support to their peers). One prisoner asked to see a
Listener and the officers immediately organised this for him.
22. Gartree made arrangements for staff from HMP Frankland to contact the man’s
family. A family liaison officer from Frankland visited the family and informed
them that the man had passed away. A Senior Officer was appointed as
Gartree’s own family liaison officer. He contacted the family on the day after
the man’s death to offer condolences and support. The Senior Officer
maintained contact with the family and assisted with the arrangements for the
funeral. The prison provided financial assistance with the cost of the funeral.
The man’s popularity was demonstrated by a collection organised by prisoners
on his wing which raised £20. This was used to buy flowers.
23. When my family liaison officer contacted the man’s family, they spoke very
positively about the help and support they had received from staff at Gartree.
The family could not fault the prison and described staff there as ‘wonderful’.
The family felt that staff at Gartree treated the man with the utmost respect and
not just as ‘another number’. Gartree had also kept in regular contact with the
family following his death, and offered support and advice when needed. The
family wrote to the Governor to express their gratitude and asked if reference to
the kindness demonstrated by Gartree could be made in this report. I am
happy to do so.
24. The post mortem report records the man’s death as being due to natural
causes as a consequence of severely stenotic coronary atherosclerosis
(narrowing of the heart arteries).
8
CLINICAL REVIEW
25. A review of the man’s medical care was undertaken by a clinical reviewer on
behalf of Leicestershire County and Rutland Primary Care Trust. The review
found that the man had suffered from significant long-term chronic diseases.
26. From the medical records, it was clear that the man was seen regularly by
healthcare staff and, when necessary, referred to secondary care services.
The clinical review concludes that there are no circumstances indicating that
death could have been anticipated or prevented, but makes some
recommendations for improvements to clinical practice.
27. The clinical reviewer judges that Gartree should seek medical summaries for all
new prisoners from their registered General Practitioner (GP). Typically,
prisoners do not access primary healthcare whilst in the community and
therefore they suffer from significant health inequality. The clinical reviewer
feels that this could be addressed by the prison healthcare system.
HMP Gartree should seek medical summaries for all new prisoners from
their registered General Practitioner (GP).
28. The clinical reviewer draws attention to the fact that modern general practice is
closely scrutinised, with annual audits of quality markers as part of payment by
results. The clinical reviewer recommends that Gartree should self audit using
the same standards on an annual basis to demonstrate progress in improving
healthcare. He feels that this should be a simple process with the arrival of new
computerised records. It will also allow identification of areas of need and
priority setting in healthcare improvement.
HMP Gartree should self audit services using the national standard
markers on an annual basis to demonstrate progress in improving
healthcare.
29. The clinical reviewer recommends that healthcare staff at Gartree should
screen prisoners for the major chronic diseases to ensure that disease
registers are as accurate as possible. The clinical reviewer judges it highly
likely that there are large numbers of prisoners who could benefit from the offer
of cardiovascular risk reduction.
HMP Gartree should screen the prison population for major chronic
diseases to ensure that disease registers are as accurate as possible.
30. The clinical reviewer further recommends that protocols for monitoring,
intervention and medication change to manage chronic diseases should be
developed in conjunction with the prison General Practitioners. He says this is
an ideal area for the nursing staff, with appropriate training and support, to
make a real difference to the health of the prisoners. He also recommends
that activity in this area should be recorded on the electronic record for audit
purposes.
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Protocols for monitoring, intervention and medication change to manage
chronic diseases should be developed in conjunction with the prison
GPs. Activity in this area must be recorded on the electronic record for
audit purposes.
31. The clinical reviewer notes that, despite the best efforts of staff, there will
always be a delay in the paramedic response to a cardiac arrest due to the
security arrangements and geography of the prison. Balanced against this is
the availability of trained staff to use resuscitation medication and to administer
it to the patient. The clinical reviewer recommends that Gartree considers
stocking first line resuscitation drugs. This medication is exempt from the usual
prescribing restrictions for nurses when used in an emergency situation. The
clinical reviewer also says pre-filled syringes would protect staff from injury.
HMP Gartree should consider stocking first line resuscitation drugs.
32. The clinical reviewer concludes that the man was offered appropriate
medication to treat his heart condition. He was satisfied that the role and side
effects of the medication had been explained to the man on a number of
occasions. As a competent adult, it was entirely up to the man whether he
continued with the medication. On 7 August 2007, prison officers became
aware, through security monitoring of communication from the prison, that the
man had stopped taking his medication. In the clinical reviewer’s opinion it is
not the role of officers to intervene in such a personal decision. Given that the
man had severe atherosclerosis, the clinical reviewer says it is difficult to say
whether the man’s death was directly related to his decision to stop taking his
medication.
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CONCLUSIONS
33. The man moved to Gartree in July 1999 and this is where he died of natural
causes in August 2007.
34. Given the generous collection following his death and the comments made by
staff and prisoners at Gartree, it appears the man was a respected and well
liked prisoner.
35. I commend Gartree and Frankland for the arrangements whereby staff from
Frankland contacted the man’s family to inform them of his death. I also
commend Gartree for the support they gave to the man’s family subsequently.
It has been both pleasing and encouraging to hear such positive comments
from a family about how they were treated after the death of their loved one.
36. Although the man’s care was equitable to what he would have received in the
wider community, the findings of the clinical review and my own investigation
highlight that improvements to medical practices at Gartree could be made. I
have endorsed the recommendations from the clinical review. These will need
to be addressed by the Leicestershire County and Rutland Primary Care Trust
in partnership with the Governor of Gartree.
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RECOMMENDATIONS
Medical
1. HMP Gartree should seek medical summaries for all new prisoners from
their registered General Practitioner (GP).
Partially accepted - All prisoners at Gartree have been in at least one other
establishment prior to transfer to HMP Gartree and GP details should have
been noted. Many prisoners are not registered with a GP prior to coming
into custody. However, on the health reception screening completed on the
second day, it would be possible to check if this information is available.
2. HMP Gartree should self audit services using the national standard markers
on an annual basis to demonstrate progress in improving healthcare.
Accepted - Self audit services are included in the prison health
performance indicators as a target to be developed with the Leicestershire
County and Rutland Primary Care Trust.
3. HMP Gartree should screen the prison population for major chronic
diseases to ensure that disease registers are as accurate as possible.
Accepted - A chronic disease register is kept up to date as part of
development of the clinical IT system.
4. Protocols for monitoring, intervention and medication change to manage
chronic diseases should be developed in conjunction with the prison GPs.
Activity in this area must be recorded on the electronic record for audit
purposes.
Accepted - Protocols to be developed with Leicestershire County and
Rutland Primary Care Trust in conjunction with the chronic disease
register.
5. HMP Gartree should consider stocking first line resuscitation drugs.
Not accepted - First line resuscitation drugs are used by GPs and
paramedics, not Healthcare Centre staff.
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