Individual at Durham

Investigation into the circumstances surrounding the
death of a man
at HMP Durham in January 2011
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2012
This is a report of the investigation into the circumstances surrounding the death of a
man, a prisoner at HMP Durham. He died in January 2011. He was 27 years old. I
offer my sincere sympathy and condolences to his family for their loss.
The investigation was carried out on my behalf by an investigator. I would like to
thank the Governor of Durham and his staff for their co-operation. I apologise for the
delay in issuing this report.
A clinical review of the man’s health care was commissioned by the local PCT. A
clinical reviewer was appointed and attended some of the interviews with the
investigator. I would like to thank her for her review.
The man had been in custody in Durham before and was known to some of the staff.
On this occasion, he admitted to taking and mixing different drugs in the community
and he agreed to take part in a drug and alcohol withdrawal programme. He
appeared to comply with the programme until one night in January, when his cell
mate said that he took two dihydrocodeine tablets as well as drug and alcohol
medication.
The next morning his cell mate and prison staff were unable to rouse the man and it
became apparent that he had died. The post mortem could find no anatomical
cause of death, but attributed it to methadone toxicity combined with diazepam,
dihydrocodeine and chlordiazepoxide which were also found in his body.
My office has investigated an increasing number of deaths in custody apparently
caused by the combination of methadone with other illicit medication. Evidently,
such combinations can have dangerous effects, and the results can be fatal. I have
raised the issue with the National Offender Management Service and I pleased that
senior staff have taken the matter seriously. They have commissioned an
investigation to increase understanding of the issue and to see what steps may be
needed to help prevent further sad and untimely deaths such the man’s.
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.
Nigel Newcomen CBE
Prisons and Probation Ombudsman May 2012
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CONTENTS
Summary
The investigation process
HMP Durham.
Key events
Issues
Conclusion
Recommendations
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SUMMARY
1. The man was recalled into custody on 5 January 2011 and returned to
Durham prison. His previous prison records contained relevant information so
they were merged with his current file.
2. During the reception health screen the man gave a urine sample and tested
positive for buprenorphine (subutex) and benzodiazepine (diazepam or
valium, used to treat anxiety disorders). He admitted that his drug and alcohol
use had escalated since his last time in custody and agreed to undertake a
detoxification programme. He signed a disclaimer and agreed to abide by the
terms and conditions of the programme. This included an agreement not to
take any illicit drugs.
3. For three days the man was regularly monitored by healthcare staff and
support workers and checked for any symptoms of withdrawal. He suffered
from some stomach cramps and sleeping problems, but these were consistent
with somebody withdrawing from drugs. Neither he, nor healthcare, were
overly concerned about this.
4. The man received his detoxification medication regularly and at the
appropriate times. However, there were problems with his clinical notes
which were not always signed and dated by staff.
5. On an evening in January, the man illicitly acquired two dihydrocodeine
tablets. These tablets are generally used as a painkiller. He offered one of
these tablets to his cell mate, who was also on a methadone programme. His
cell mate refused as he was worried about it reacting with the methadone they
had both been prescribed. He took both tablets.
6. The man appeared very sleepy that evening and went to bed at approximately
6.30pm. He snored heavily. His cell mate heard him get up in the night to
switch the television off, but heard nothing more. In the morning, he noticed
that there were signs that he had been sick during the night. He appeared to
still be asleep.
7. Just before 9.00am, an officer came to the cell to collect prisoners to take
them for their medication. He asked the man’s cell mate to rouse him, but he
was unable to do so. On closer inspection the officer found that he appeared
to have died. He was blue in colour and mottled and rigor mortis had set in.
An ambulance was called and paramedics pronounced him dead at 9.25am.
8. Three recommendations are made. Two are to the Head of Healthcare and
relate to clinical records and reminding prisoners of the dangers of mixing
methadone with unprescribed drugs. The other is to the Governor and
concerns the policy on requesting an ambulance in an emergency situation.
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THE INVESTIGATION PROCESS
9. Another investigator opened the investigation at HMP Durham on 20 January
as she was already visiting the prison that day on another matter. She met
with the Governor, the Head of Healthcare, Head of Safety and Decency, a
representative from the Prison Officers’ Association (POA) and from the
Independent Monitoring Board (IMB). She also took the opportunity to
interview the man’s cell mate. She collected copies of all prison
documentation relating to him.
10. Notices of the investigation were issued to both staff and prisoners, inviting
those who wished to provide further information regarding the man’s death to
make themselves known to the investigator. No further witnesses came
forward. Another investigator visited the prison on 8 and 9 March to carry out
interviews with staff. She also spoke informally with the man’s brother, who
was also in custody at Durham when his brother died.
11. The investigator wrote to the local PCT to commission a clinical review into
the healthcare received by the man. They asked a clinical reviewer to carry
out the review. She received a copy of the relevant medical documents and
accompanied the investigator during the interviews on 8 March. The review
was received in this office on 16 May. The delay in the publication of this
report was caused by workload pressures in this office. .
12. The investigator also wrote to HM Coroner to inform him of the nature and
scope of the investigation. A copy of this report will be forwarded to the
Coroner to assist with his enquiries into the death of the man.
13. The investigator provided feedback to the Governor on 9 March and again in
writing on 17 March. At that stage, the issues that were identified were that
the man had taken drugs which had not been prescribed for him, the prison’s
in-possession drug policy and lack of communication between staff when
calling for an ambulance. The Governor responded by letter on 31 March,
and discussed the initial findings with the investigator on the telephone.
14. One of the Ombudsman’s family liaison officers contacted the man’s family at
the beginning of the investigation. She informed them of the investigation
process and offered them the opportunity to raise any questions or concerns
they would like addressed during the investigation. (Another family liaison
officer took over as family liaison officer in April 2011.) The family were
concerned that a local newspaper recorded the man’s time of death differently
to the information given by the prison, and they asked for more clarification
about what took place and specific timings.
15. The investigator also wrote to the man’s family on 23 June, with a report of
her initial findings. This was in response to a family member’s request for
early information due to personal circumstances.
16. The family received a copy of the draft version of the report as part of the
consultation period. I am grateful to the family of the man for their
5
involvement in the Ombudsman’s investigation and the time they have taken
to consider my findings.
6
HMP DURHAM
17. HMP Durham is a category B prison which can hold up to 1000 prisoners,
both convicted and unconvicted. On arrival at the prison, prisoners are risk
assessed and given a category based on their offence and the risk they pose
to the public, should they escape. Category B prisoners are those for whom
the highest security conditions are not necessary but for whom escape must
be made very difficult. The prison consists of nine wings including those
specialising in drug treatment, segregation and healthcare.
18. Healthcare services at Durham are provided by North Darlington and Tees,
Esk and Wear Valley NHS. It is nurse led, with access to general
practitioners and specialists such as psychiatrists and dentists. There is also
an integrated drug treatment service and some inpatient beds.
HM Inspectorate of Prisons
19. Her Majesty’s Chief Inspector of Prisons carried out an unannounced follow
up inspection by the then Chief Inspector in October 2009. In the introduction
to the report, she commented that: “ … methadone administration dominated
the prison’s regime, with insufficient administration points for the numbers
involved.” She added that: “…the arrangements for the high proportion of
prisoners on IDTS were extremely unsatisfactory and potentially unsafe, and
illicit drug use was very high.”
Independent Monitoring Board
20. Each prison in England and Wales has an Independent Monitoring Board
responsible for monitoring day-to-day life in the prison and to ensure that
proper standards of care and decency are maintained. The latest report
published by the IMB for December 2008 to November 2009 stated that:
“Substance misuse, drugs and alcohol misuse, psychology, drugs testing,
Detox and CARATS all seem to be working satisfactorily, being well
organised and controlled. Staff are motivated and demonstrate a good
level of understanding and requirements.”
Buprenorphine (Subutex)
21. Buprenorphine, known by the trade name Subutex, is an opiate substitute that
is used to treat addiction to stronger opiates, such as morphine, diamorphine
(heroin) and methadone. Buprenorphine prevents the physical withdrawal
symptoms which occur when these drugs are stopped, including physical
cravings. Over time the dose of buprenorphine is gradually reduced until it
can be stopped completely.
Methadone
22. Methadone is one of a number of synthetic opiates that are manufactured for
medical use to treat addiction to opiates such as heroin. It is prescribed for
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pain relief and prevents withdrawal symptoms. The normal prescription starts
at 10ml and gradually increases to an appropriate level.
Chlordiazepoxide (Librium)
23. Chlordiazepoxide is used in the treatment of alcoholism for its sedating and
anxiety-relieving effects, which help relieve the symptoms of acute alcohol
withdrawal. Chlordiazpoxide is from a class of drugs known as
benzodiazepines, often used to treat anxiety and help people sleep. The
usual prescription in prison starts at a certain level and then decreases as the
prisoner detoxifies from alcohol.
Integrated Drug Treatment System (IDTS)
24. Integrated Drug Treatment System (IDTS) is an initiative that aims to improve
and increase the volume and quality of clinical treatments for substance
misuse available to prisoners. Its aim is to ensure that professionals work
together in the co-ordination of a prisoner’s care, with particular emphasis on
the first 28 days in custody. This is achieved by increasing the range of
treatment options available in prison, including the prescription of drug
substitutes for those with addictions to heroin and other opiates.
Listeners
25. Some prisoners are trained by the Samaritans to be Listeners. They are able
to sit with other prisoners who are in a state of distress or feeling vulnerable to
offer them support.
Release on licence and recall to prison
26. Once released on licence a prisoner can be recalled to prison at anytime if
they breach their licence. The Parole Board will consider the details of the
breach and make a recommendation to the Secretary of State on whom the
final decision rests.
Counselling, Assessment, Referral, Advice and Throughcare services
(CARATS)
27. Organisations specialising in the treatment of substance abuse have drug and
alcohol workers based in most prisons. CARATs workers can run
programmes, offer counselling, support and referral to rehabilitation centres to
prisoners and on release. Access to CARATs is voluntary and by application.
Previous deaths at HMP Durham
28. The man’s death was the first attributed to substance misuse at Durham in
2011. In May of that year another prisoner, who was also on a detoxification
programme, died although his cause of death was not the same. Although
some of the issues in the cases are similar, the specific details of his death
are not the same.
8
KEY EVENTS
29. The man was released from Durham on 20 December 2010 (and had also
been in custody there in 2006 and 2009). He was recalled to prison on 5
January 2011, following a further offence which breached his licence
conditions. The prison documentation from his last time in custody at Durham
remained relevant and merged with his current prison file. Despite this, as
with all prisoners entering a prison, he underwent the standard reception
procedures.
30. A Cell Sharing Risk Assessment (CSRA) was undertaken to assess the level
of risk the man presented to a cellmate. It identified no concerns and classed
him as low risk and able to share a cell with another prisoner.
31. During reception, the man was seen by a staff nurse, a registered mental
health nurse. He answered a number of standard questions and gave a urine
sample which was analysed for drugs. He tested positive for buprenorphine
(subutex) and benzodiazepine (diazepam or valium). He said he had a
history of benzodiazepine misuse and had been prescribed mirtazapine for
depression whilst in the community. He told the nurse that he did not have a
psychiatric nurse or care worker in the community. He discussed his alcohol
and drug problems and said he used benzodiazepines (20 to 30 tablets a day)
and subutex, which he had started taking a year before. He said he also
injected steroids and drank between ten and fifteen cans of lager a day. He
consented to being referred to the Substance Misuse Service and also to the
Specialist Alcohol Service.
32. Prison Officer A working in the CARATS team completed a Substance Misuse
assessment whilst in reception. The man confirmed that he had been taking
benzodiazepines and subutex and injecting steroids. The officer said during
interview with the investigator that he remembered him from his previous time
in custody, but in the past he had never tested positive for opiates or subutex.
On this occasion, he did test positive for subutex. He told the officer that he
had used subutex, as well as valium tablets and injected steroids. The officer
arranged to see him the next day.
33. A doctor at Durham also saw the man and referred him to the Mental Health
Team. He prescribed him zispin (an antidepressant) to manage his
depression and also prescribed him eye ointment for conjunctivitis. During
their discussion, it was identified that he had issues with alcohol and drugs
and he agreed to undertake a detoxification regime to begin the next day. He
was prescribed a seven day alcohol withdrawal programme, which consisted
of 30mg of chlordiazepoxide three times a day. This was to be administered
by a nurse as the tablets could not be held in his possession. However, he
was permitted to keep a course of thiamine (vitamin B1, used to boost the
immune system) in his possession, and told to take one 300mg tablet daily.
34. The man also began a five day Methadone stabilisation regime as part of his
drug detoxification. This was to be administered by a member of healthcare.
9
He received ten ml of methadone for drug detoxification that night, along with
30mg of chlordiazepoxide.
35. Following these assessments, the man was located in the First Night Centre
on E wing (this is where all new prisoners stay when they first come into
prison, irrespective of whether it is their first time in custody at Durham). He
was in a shared cell with another prisoner.
36. The man completed the usual induction procedures on the First Night Centre.
He was given a smoker’s pack, and issued with crockery and cutlery. He was
monitored throughout the night at various intervals to check how he was
coping. At 00.58am it was recorded that he was still awake and talking to his
cell mate. On the other occasions that staff checked him it was noted that he
was asleep. The night passed without incident.
37. The next morning at approximately 8.10am, the man received, and signed for,
10ml of methadone. The signature of the person who administered the
methadone is illegible.
38. Later that day, the man was seen by a healthcare support worker (HSW) in
the Substance Misuse Team. She worked through the first stage of the
Integrated Drug Treatment Strategy (IDTS) care plan with him and discussed
the treatment procedures. These included attending the treatment hatch for
medication at the correct time and displaying acceptable behaviour towards
treatment staff. He agreed to abide by these conditions and signed a form to
indicate this.
39. The man also met with Officer A again. The officer said that, because they
knew each other quite well they had a “good chat”. He said he had no issues
but did not want to work with the CARATS team, which was his decision. He
did not want to discuss why he had started taking subutex. He said he was
receiving sufficient help and treatment by being on the methadone
programme and signed a disclaimer to this effect.
40. The HSW also assessed the man against the alcohol/benzodiazepine
withdrawal monitoring scale. This involves monitoring a prisoner’s pulse and
checking whether they have a tremor, are perspiring, suffering from insomnia,
appear agitated or anxious and whether they have any perceptual or
orientation difficulties. He said he found it hard to sleep and had a pulse rate
of 103, which is quite high.
41. The man received and signed for 10ml of Methadone at 3.00pm. The
signature of the member of staff who administered this is illegible, and it was
not witnessed by anyone else. Later that day, the records indicate that he
was given 30mg of mirtazipine (an antidepressant) but on this occasion no
signature was recorded, so it is unclear whether this medication was actually
administered.
42. Another HSW went onto the wing at approximately 8.30am the following
morning. She recalled the man because he suffered from conjunctivitis and
10
she remembered his sore eyes. He seemed pleasant and chatty and she had
no concerns about him. She monitored his drug and alcohol withdrawal and
what effect it had on him. His sleep seemed to be interrupted and he
complained of stomach pains, but that was not unusual with prisoners
withdrawing from substances. He had no other problems and was compliant
when taking his medication. He was given 15ml of Methadone and 20mg of
chlordiazepoxide.
43. Approximately an hour later, the man underwent an opiate withdrawal
observation with the HSW. His pulse rate was lower than the day before, but
he complained of stomach cramps. He also said he had some joint pain, but
there were no major concerns about any of his withdrawal symptoms. She
then carried out the alcohol /benodiazepine withdrawal monitoring scale. On
this occasion, he complained of insomnia and appeared to be suffering from
mild withdrawal symptoms. Later that day he received 15ml of methadone
and 30mg of mirtazipine.
44. On the morning of 8 January, the man received further doses of methadone
and chlordiazepoxide. Later that day, he was seen by a nurse, to carry out
the opiate and alcohol withdrawal assessment. She noted that the only
symptom he had from the opiate withdrawal was mild stomach cramps. On
this occasion, no readings of blood pressure or pulse were recorded. At
3.30pm, he received another dose of methadone, and later that evening was
given mirtazipine.
45. That night, the man told his cell mate that he had acquired small tablets which
he described as “DF’s” (dihydrocodeine, a painkiller). He offered one to him,
who refused. (He was also prescribed methadone and did not want to mix it
with the medication.) He said he had two 240ml tablets which he had got
from someone on the wing. He took both pills at about 4.30pm and, as he
said he felt very sleepy, he went to bed at approximately 6.30pm.
46. The man’s cell mate recalled that the man snored heavily during the night
and, as he had snored the previous nights as well, believed him to be fine.
He also remembered that at some point during the night the man jumped
down from his bed (the top bunk) and switched the television off.
47. The next morning the man did not get up for his breakfast, but his cell mate
assumed it was just because he was still tired. The cell mate went to get his
breakfast and made a cup of tea for himself and for the man, as he was due
to get up soon to take his medication. He also noticed that the man had been
sick as there were signs around the toilet bowl, which he said he was going to
ask him to clean up when he got up.
48. Just before 9.00am, the cell was unlocked by an officer for the prisoners to go
to the treatment room to be given their medication. He saw from the doorway
that the man was still in bed, and asked his cell mate to rouse him. He
shouted to him to ask whether he was getting up for his medication. He got
no response so he walked over to him and called him again. As he again
received no response he pushed him, but he did not move.
11
49. The officer entered the cell and pulled down the man’s bed covers. He saw
immediately that something was wrong and pulled the covers back up. He
said that he could tell by the feel of him, the fact that he was rigid and the
colour of his skin, that he had been dead for some time. He asked the cell
mate to leave the cell and called the communications room by radio to inform
them that there was an emergency. He used the “code black” radio code. (A
code black means a prisoner is unconscious and unresponsive.) He called
out to another officer to take the cell mate to another cell, but he had already
made his way to the treatment room for his methadone. (Subsequently, he
was located in another cell, on another wing, with two Listeners.)
50. A Senior Officer (SO), who was in charge on the wing that weekend, heard
the emergency call over the radio and immediately went to the man’s cell.
Within seconds of her arriving, members of healthcare staff had also arrived.
51. Nurse A responded to the call over the radio, accompanied by Nurse B.
Nurse B said at interview that another member of healthcare picked up the
emergency bag and defibrillator, which they took to the cell. She recalled at
interview that the man was lying in bed, on his left side and looked as if he
were asleep. Nurse A checked for signs of life, but found none. He noted
that rigor mortis was present.
52. A Principal Officer (PO), a security manager, also heard the radio call and
went to the cell. He recalled one of the healthcare staff asking if an
ambulance had been called. He contacted the communications room to
check this was the case, and was told that they were waiting for confirmation
that one was required. He confirmed that it was (and should have been
requested immediately a Code Black was called).
53. In the meantime, while the HSW administered methadone to the cell mate, he
mentioned to her what had happened to the man. He told her “I think he’s
died”. She immediately made her way to the cell. When she got there she
saw him lying on his left side, looking as if he were asleep. Healthcare staff
had already arrived and were assessing him. (As healthcare staff were
managing the situation, she left the cell).
54. The paramedics arrived approximately ten minutes later. They carried out a
number of checks on the man and confirmed that he had died at 9.27am.
55. The duty manager also heard the emergency call over the radio and went to
the cell. Once the man’s death had been confirmed, the cell was sealed and
a log keeper assigned to note who entered and left the cell. He then attended
the command suite with another manager to instigate contingency plans for a
death in custody. This includes informing relevant departments about the
death, appointing a family liaison officer and arranging for the man’s family to
be notified of his death.
56. A hot debrief was held at 12.30pm and was chaired by the Governor. The
security manager raised the issue of the ambulance not being called when the
12
code black emergency call was made. An action point was noted for use in
future emergency situations:
“ .. that an ambulance must be summoned immediately a Code Black
alarm is raised and not wait until confirmation from HCC staff once at the
incident scene.”
57. Another issue raised at the debrief was that there seemed to be some
confusion over who was the duty care team member and how staff could
contact them. (The staff care team are available to any member of staff who
feels in need of further support and wishes to talk in confidence about how
they are feeling.) However, this did not seem to have an adverse effect on
the staff on duty that day, and the situation was remedied the next day.
Liaison with the man’s family
58. The SO was appointed as the prison’s family liaison officer and asked a
chaplain to assist her in her duties. She collated information regarding the
man’s next of kin. They found that his bother was also on another wing in
Durham. They went to see the man’s brother to inform him of what had
happened. He also gave them the next of kin details but explained that, as
his mother was very poorly, his aunt should be contacted instead.
59. Staff on the wing were made aware of the man’s brother’s bereavement and
were asked to keep a close eye on him. He spoke to the investigator on 9
March. He said he had been offered the services of Listeners and the
Samaritans. He also said he was awaiting a referral to the mental health
team. The investigator spoke to staff who arranged for an urgent referral to
be undertaken, as well as a family visit be granted to provide further support.
60. The SO and chaplain arrived at the family’s address at approximately 2pm
and broke the news of the man’s death. They explained their role and the
support that was available to them and told them what they could of the
circumstances surrounding his death. They arranged to return his belongings
and to assist with funeral costs. The funeral was held on 2 February 2011,
and the family declined the SO’s offer to attend.
Support for prisoners
61. After the man’s death, a notice was issued to all prisoners, informing them
what had happened and who they could speak to if they felt affected by his
death. Also, all prisoners who were subject to suicide monitoring procedures
were reviewed to ensure they were not adversely affected by his death.
Support for staff
62. A critical incident debrief was held approximately two weeks after the man’s
death, although the staff the investigator interviewed could not remember the
exact date. All those staff who knew him and were involved in the discovery
of him were invited to attend.
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Post mortem
63. A post mortem was held on 10 January 2011. The examination was unable to
find an anatomical cause of death. Tissue samples sent for a toxicology
examination indicated: “therapeutic concentrations of mirtazapine, diazepam,
chlordiazepoxide and paracetamol, together with a concentration of
methadone”. The report added that: “methadone use is associated with a
depressant effect on the central nervous system and such effects can be
exacerbated by diazepam, dihydrocodeine and chlordiazepoxide even if
present only in therapeutic doses. In view of this, the opinion of the
toxicologist and the lack of a competing cause of death at post mortem it is
my opinion that the cause of death is more likely than not due to methadone
toxicity in the presence of diazepam, dihydrocodeine and chlordiazepoxide”.
Security issue
64. A Security Information report (SIR) was submitted by an officer regarding a
prisoner dealing medication on E wing after the man had died. The officer
raised the issue because he had concerns that a prisoner may have been
selling or handing out medication. When the officer heard that the man had
taken some “DFs”, this raised his suspicions further as he knew the prisoner
he suspected had been prescribed dihydrocodeine. The officer made further
investigations and found that some of the prisoner’s medication was missing.
However, the prisoner was transferred to another prison before a full
investigation could take place. The officer reiterated that he did not have any
firm evidence at that time and further enquiries would have been necessary
reach any conclusions. (This was an on-going issue when the man died.)
14
ISSUES
Clinical care
65. The clinical reviewer finds that, during the time that the man was in custody at
Durham he received a high standard of care, equal to that of a National
Health Service patient in the community. The prison’s detoxification team
were able to prescribe and administer to him split doses of methadone,
allowing him to be monitored throughout the day before giving him his
remaining dose, which is good practice.
In possession medication
66. It is Durham’s policy to allow prisoners to be responsible for their medication
unless there are clearly identified factors that this should not be the case.
Some medication is not suitable to be kept ‘in-possession’ such as
methadone (therefore the man did not keep his medication in his possession,
aside from the vitamin tablets). Sometimes it is the suitability of the individual
prisoner that informs the decision not to permit the medication to be held by
them.
67. According to the prison’s ‘Medication in possession policy’, a formal risk
assessment is not necessarily made about every prisoner, but the prescriber
will review the risk every time the medication is prescribed.
68. Prison staff who suspect that in possession medication is being sold or shared
with other prisoners should complete a Security Information Report (SIR)
highlighting the suspected misuse. Two SIRs were completed following
reports that a prisoner was selling or sharing dihydrocodeine medication at
the time of the man’s death. This was one of the medications found in his
body at the post mortem. However, although he was not prescribed
dihydrocodeine by a doctor, it is not clear that he obtained the drugs from that
source.
69. The investigation found that Durham followed the in-possession policy as
directed. It appears that it was the actions of the man that led to his death by
illicitly obtaining and taking medication from (presumably) another prisoner.
The clinical reviewer takes the view that it would be desirable for prisoners on
detoxification programmes to have the message of the danger of mixing drugs
emphasised.
The Head of Healthcare should ensure that patients receiving
methadone are advised and educated regarding its use and the need to
comply strictly with its prescription, as non-compliance could be fatal.
70. The clinical reviewer also suggests that consideration should be given to the
use of alerts on the clinical computer system, to identify if a prisoner has
misused in-possession medication. It is unclear how actionable this
suggestion is given the software involved, but it is brought it to the attention of
the Head of Healthcare for their consideration. Certainly relevant information
15
regarding the misuse of medication should be recorded wherever relevant,
regardless of whether it is achievable by means of an alert.
Standard of clinical record keeping
71. The clinical reviewer identifies that, throughout the administration of the man’s
medication, staff repeatedly failed to document and sign the paperwork
regarding the methadone dispensation. Neither was a second member of
staff present to witness that the methadone had been administered. For that
reason the clinical reviewer’s recommendation is endorsed:
The Head of Healthcare should ensure that all clinical staff document
and sign paperwork when administering methadone and ensure that a
second member of staff is present to witness this.
Requesting an ambulance
72. There appeared to be a breakdown in communications between the staff
attending to the man and the communications room on 9 January. It was
thought that using a code black radio code would automatically trigger a
request for an ambulance. However, staff in the communications room
awaited confirmation from a member of healthcare staff before doing so.
There is no suggestion that an earlier request for an ambulance could have
changed the outcome for him, but that would not be so in every case.
The Governor should ensure that staff in the communications room
follow the procedures for automatically calling an ambulance following
an emergency call.
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CONCLUSION
73. Recommendations are made by the clinical reviewer regarding reducing the
risk of methadone toxicity. However, when the man entered the detoxification
programme at Durham he agreed that he would not take any illicit drugs whilst
he was receiving treatment. Unfortunately he did not adhere to this
agreement and the post mortem found that he had taken dihydrocodeine,
diazepam and paracetamol in addition to his prescribed medication.
74. However, it is recommended that the prison reinforce to prisoners the dangers
of taking other drugs whilst on the methadone and alcohol programme. It is
also recommended that healthcare staff take greater care and accuracy when
recording clinical notes.
75. We recognise that Durham makes great efforts to alleviate the problem of
prisoners selling their prescription drugs, sharing their medication with other
prisoners or abusing the use of their medication. The prison has an in-
possession drugs policy which assesses the risk of a prisoner being permitted
to hold their own medication; they also conduct cell searches and use prison
intelligence to try to resolve this problem. However, Durham, like most other
prisons, faces an enormous challenge to eliminate this risk.
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RECOMMENDATIONS
To the Head of Healthcare:
1. The Head of Healthcare should ensure that patients receiving methadone are
advised and educated regarding its use and the need to comply strictly with its
prescription, as non-compliance could be fatal.
The prison accepted this recommendation and is now in place.
2. The Head of Healthcare should ensure that all clinical staff document and sign
paperwork when administering methadone and ensure that a second member
of staff is present to witness this.
The prison accepted this recommendation and is now in place.
To the Governor:
1. The Governor should ensure that staff in the Communications Room are
aware of the procedures for calling an ambulance following an emergency
call.
The prison accepted this recommendation and is now in place.
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