Individual at Holme House

Circumstances surrounding the death of
a prisoner at HMP Holme House in July 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
October 2006
This is the report of an investigation into the death of a prisoner who died in
July 2006 at HMP Holme House. The man was a remand prisoner who had
not been in prison before. The post mortem indicates that he died from
suppurative bronchitis and pneumonia due to chronic obstructive pulmonary
disease. He was 82 years old.
I offer my sincere condolences to the prisoner’s family.
I am grateful to the Governor of Holme House and his staff for their co-
operation during this investigation. I would also like to thank the North Tees
Primary Care Trust that conducted the clinical review into the prisoner’s care
and treatment whilst in prison.
The Prison Service is increasingly expected to care for very elderly prisoners.
Indeed, the man was the oldest prisoner ever received at Holme House. The
clinical review indicates that he was monitored well during his time there. He
had regular access to nursing and medical staff as required, and was given
appropriate medications for his conditions.
I have made two recommendations. They focus on obtaining information at
the earliest possible opportunity in respect of a prisoner’s mental health, and
the importance of holding a timely debrief for all relevant staff following the
death of a prisoner. I also endorse the recommendation made by the clinical
review in regard to the completion of medical records. However, I have also
highlighted the good practice demonstrated in the way in which the prisoner’s
family were told of his death, and the sensitivity shown to them generally by
the prison.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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CONTENTS
Summary…………………………………………………………………..4
The investigation process….…………………………………………..5
HMP Holme House ………………………………………………………6
Key Events ……..……………………………………………………..…..7
Events after the prisoner’s death …………………………………….10
Clinical review and post mortem report…………….……………….12
Issues …………………………………………..……………………….…13
Recommendations and Good Practice………….……………………15
Annexes……………………………………………………………………16
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SUMMARY
The prisoner was pronounced dead in a single cell in the Healthcare Centre at
HMP Holme House in July 2006. He was 82 years old. The post mortem
indicates that he died from suppurative bronchitis and pneumonia due to
chronic obstructive pulmonary disease.
The man was a remand prisoner who had been at Holme House for about one
month. Prior to his arrival at Holme House, he had been a voluntary inpatient
at a local Mental Health Unit. Despite a lengthy stay at the unit he was never
diagnosed as suffering with any mental health problems.
The man entered prison with a number of serious health problems that
included chronic obstructive pulmonary disease (COPD), ischaemic heart
disease (IHD), as well as diabetes. He was given the appropriate medication
for these conditions and, in view of his age and clinical needs, it was decided
that he should stay in the healthcare centre. The clinical review states that
the prisoner was well monitored at Holme House and received the appropriate
medication for his conditions.
At about 11.10am in early July, healthcare staff and the prison doctor entered
the prisoner’s cell in order to assess him, following some concern from staff
that he was not loo well. The man was lying on his bed, not breathing and
unresponsive. Cardio Pulmonary Resuscitation (CPR) was started. Despite
resuscitation attempts, the doctor pronounced him dead at about 11.20am.
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THE INVESTIGATION PROCESS
1. The investigation into the circumstances surrounding the prisoner’s death
was opened by one of my investigators, when he visited HMP Holme
House on 27 July. My investigator spoke to healthcare staff and a
prisoner who knew the prisoner. Notices had been issued to staff and
prisoners informing them of the investigation and giving them the
opportunity to speak with my investigator. No prisoners or staff came
forward in response to my notices.
2. The Governor and his staff produced the prisoner’s core record, his
medical record and a number of other documents for review.
3. North Tees Primary Care Trust were commissioned to conduct a clinical
review into the care and treatment that he received whilst at Holme House.
This is attached to this report as an annex.
4. One of my Family Liaison Officers contacted the man’s daughter in law
(the family’s representative) on 13 July, to offer the family the opportunity
to meet with him and the investigator to discuss the purpose of the
investigation, and to raise any concerns they would like addressed. The
family raised no issues concerning the prisoner and were complimentary in
regard to the way in which the prison and, in particular, the prison’s family
liaison officer had dealt with them.
5. My investigator contacted Her Majesty’s Coroner by letter to inform him of
the nature and scope of the investigation and to request a copy of the post
mortem report. My final report will be sent to the Coroner to assist him
with the inquest into the prisoner’s death.
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HMP HOLME HOUSE
6. Holme House is a purpose built local Category B prison, which opened in
May 1992. It holds unconvicted and convicted male adult prisoners and
unconvicted young male adults. Prisoners are accommodated in six self-
contained living units with integral sanitation, in a mixture of single and
double cells. The prison primarily serves the communities of Tees Valley,
South West Durham, East Durham and North Yorkshire.
7. The prison was most recently inspected by HM Chief Inspector of Prisons,
Ms Anne Owers, in April 2005. Holme House was deemed to be a largely
safe and well-ordered establishment, and suicide and self-harm prevention
was found to be well managed. Many of the prisoners most likely to be at
risk of self-harm were diverted to beds in the healthcare centre upon
reception.
8. The healthcare centre has 28 in-patient beds, approximately half of which
are occupied by prisoners undergoing detoxification. Ms Owers noted in
her 2005 report that there was a good range of clinical services at Holme
House delivered by a well qualified, experienced and committed
healthcare team.
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KEY EVENTS
9. On 8 June 2006, the man was remanded into custody at Holme House.
On reception he went through the standard induction procedure for new
prisoners, which included an initial health screen interview. This
established that prior to his arrest he had been a voluntary in-patient in a
local Mental Health Unit for approximately 12 months. The health screen
also established that he suffered with chronic obstructive pulmonary
disease, type two diabetes, and ischaemic heart disease, for which he had
been ta appropriate medication. The prisoner had use of a subutamol
inhaler to relieve breathlessness. Whilst in custody, he continued to
receive his medication. In light of his age and clinical needs, the man was
placed and monitored on the prison’s Chronic Disease Management
Register.
10. It was also noted during reception that in June 2005, the prisoner might
have attempted to hang himself. He denied any present thoughts of self-
harm, and was not considered to need a regime designed to support those
prisoners who are in crisis and who may injure themselves. As a
consequence, he was not the subject of any formal mental health
observations whilst in healthcare.
11. During his reception, the prisoner submitted an application under Prison
Rule 45. Because of the nature of his alleged offences, he wanted to be
managed as a vulnerable prisoner. (Vulnerable prisoners are those whose
offences or behaviour are such that they may need to be segregated from
other prisoners for their own safety and protection.) His application was
approved on the basis that he would have been moved to a residential
block after discharge from the healthcare centre. However, due to his
clinical needs, the prisoner was never discharged to a residential block.
12. A nurse told my investigator that on reception the prisoner looked
underweight, dishevelled and frail in appearance. My investigator also
learnt that he was the oldest prisoner that Holme House have had to
manage and care for. Because of his age and medical needs, it was
decided by the healthcare manager to continue to monitor him in
healthcare. The prisoner was located in a relatively spacious single cell in
the in-patient facility.
13. On 9 June, the medical record notes that he was only eating small
amounts of food and needed prompting with his personal hygiene. At the
initial health screen, the prisoner had told staff that he was incontinent at
night and appropriate protective measures and monitoring was put in
place. The man was also referred for a mental health assessment
following the information that he had been an in-patient at a local Mental
Health Unit.
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14. The medical record notes that, on 11 June, the man was eating and
drinking reasonably well and was checked frequently by nursing staff for
incontinence. No problem was reported. It was also determined that,
whilst he had experienced some breathlessness on effort, he had the use
of his inhaler at all times. My investigator was also told by a prisoner that
he was given assistance with his personal hygiene and cleaning.
15. On 13 June, the man’s property from the local Mental Health Unit was
received by Holme House. The medical record notes that the nurse in
charge at the unit, stated that the prisoner had been at the hospital since
June 2005, following an incident whereby he had suffered injuries to his
neck that were not necessarily self-inflicted. During his stay at the unit, the
prisoner was not diagnosed with a mental illness, but he had been a very
problematic resident and a very difficult man to manage. The medical
record notes that, whilst at the Mental Health Unit, he was incontinent of
faeces and urine as a form of protest rather than due to any medical
problem. The nurse in charge of the unit also told a nurse at Holme House
that the prisoner had recently attacked a member of staff as well as
another resident, and that he would openly masturbate in front of female
staff. The nurse at Holme House told my investigator that the prisoner
continued to do this whilst in healthcare. In effect, the man was
considered to be a threat to female staff. Following the disclosure from the
nurse at the Mental Health Unit, healthcare staff (who were predominantly
female) were more wary of dealing with the prisoner. My investigator also
established that previous attempts to obtain information from the Mental
Health Unit at an earlier stage were unsuccessful.
16. The medical record notes that, on 16 June, a letter was sent to the
prisoner’s doctor requesting details of his chronic disease management,
mental health history, hospital consultations and operations. A response
to the letter giving a comprehensive clinical history was received at Holme
House on 22 June.
17. On 18 June, the man was prescribed Ensure protein drinks by the doctor
in order to build up his strength. The medical record also notes that he
had to be continually prompted to shower and clean his cell. On 19 June,
the medical record notes that the prisoner was covered in excrement and
refused to clean his cell.
18. On 20 June, the man was assessed by a Registered Mental Nurse (RMN).
She told my investigator that the prisoner told her to ‘F*** off’. She could
not find any evidence that the man was suffering from a mental illness and
told my investigator that he could be a ‘manipulative and obnoxious man’.
19. By 23 June, the medical record notes that the prisoner was being
encouraged by staff to eat and drink more, but would not speak to staff.
My investigator spoke to a wing cleaner who said that the man did not
really associate and would spend a lot of time in his cell. The medical
record notes that whilst the prisoner had a degree of mobility and could do
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things for himself, he would often pretend that he could not do anything at
all.
20. On 1 July, the prisoner had an electrocardiogram (ECG), (this is used to
monitor the electrical activities of the heart). The clinical review was
unable to establish why he needed an ECG, but following the ECG reading
the medical record notes that consideration would be given to referring him
to a cardiologist.
21. At about 3.15pm on 1 July, the medical record notes that the prisoner was
found sitting on the floor of his cell. He had sustained bruising to the left
side of his forehead. The man said he had slipped off his bed. He was
assessed by healthcare staff who recorded that he was alert and
orientated.
22. At about 8.10am on 2 July, the prisoner was given breakfast and
medications at his cell door. Breakfast things were collected from his cell
at about 8.40am by officers and a wing orderly. No concerns were raised.
23. At 10am, the medical record notes that a nurse offered the prisoner a
shower, but he grunted in response which was not considered out of the
ordinary. At about 11am, the medical record notes that he was
encouraged in regard to his food and fluid intake. The nurse also told my
investigator that at this time she was slightly concerned about him as he
did not look well. She asked the doctor to see him later on that morning.
24. At 11.10am, a nurse and the doctor entered the prisoner’s cell in order to
assess his needs. The man was lying on his bed unconscious, not
breathing and unresponsive. There were no vital signs. The nursing staff
commenced cardio pulmonary resuscitation (CPR) whilst a defibrillator
was brought by another member of the nursing staff to the cell. My
investigator established that nursing staff were up to date with their CPR.
Despite their efforts to resuscitate the prisoner, he was pronounced dead
by the doctor at 11.20am.
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EVENTS AFTER THE PRISONER’S DEATH
25. Following the prisoner’s death, Holme House implemented their
contingency plan in the event of a death in custody. This included
notifying the Area Manager, the Prison Service’s National Operations Unit,
the Independent Monitoring Board and the police. A nurse notified North
Tees Primary Care Trust of a Sudden Untoward Incident by telephone.
My investigator subsequently contacted Cleveland Constabulary who have
confirmed that the prisoner’s death was not suspicious and not the subject
of a criminal investigation.
26. A Principal Officer (PO) the prison’s family liaison officer, was contacted at
home and told of the man’s death. The PO then attended the
establishment (on his day off) in order to prepare to break the news of the
prisoner’s death to his family. However, it was established that the
prisoner had not provided a contact number or address for his next of kin.
In light of the nature of the man’s offences, Durham Constabulary were
contacted for their advice. An officer from Durham Constabulary, who was
aware of the case and family sensitivities, accompanied the PO to the next
of kin’s home address and other members of his immediate family to break
the news. The family were made aware that a Prisons and Probation
Ombudsman’s investigation into the prisoner’s death would take place.
27. The man’s daughter in law subsequently told my family liaison officer that
the PO was sensitive and very considerate in dealing with the family, and
that the prison had offered to pay for travel to the chapel of rest and
funeral expenses. The family were aware that the prisoner was not a well
man and have not raised any issues in regard to his care or treatment
whilst in prison.
28. Staff were told of the prisoner’s death by a notice from the Governor. My
investigator also spoke to a prisoner on the healthcare centre who
confirmed that an officer informed prisoners on the wing of the man’s
death later that day.
29. Because of other operational matters, a ‘hot debrief’ for staff who had
been involved in the care and resuscitation attempts on the prisoner could
not be held. My investigator was told by a nurse that, whilst care and
support was available to staff, she felt a timely debrief of events soon after
the prisoner’s death would have been useful and reassuring to her -
especially as she was worried that she had not referred the man sooner to
the doctor that morning. My investigator noted that a letter had been sent
by the duty governor acknowledging and thanking her for her efforts.
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30. The prisoner’s funeral took place in July. It was paid for by the prison. His
family chose not to attend. The PO and another representative from
Holme House were present.
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CLINICAL REVIEW AND POST MORTEM REPORT
31. The clinical review concludes that the man was an 82 year old diabetic
with a history of IHD and COPD, who was monitored well during his stay at
HMP Holme House. He had regular access to nursing and medical staff
as required and was given appropriate medications for his conditions. The
record keeping was of good standard, but all entries should be timed and
the reason why investigations were undertaken should be recorded.
32. A post mortem was carried out in July. It indicates that the prisoner was
an elderly man who died as a result of the acute effects of an infection
involving the air passages within the lungs and the substance of the lungs
themselves. The infection was regarded as a complication of his chronic
chest problems, and which the examination defined as the underlying
cause of the man’s death.
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ISSUES
Security
33. The prisoner was an unknown quantity when he was received on 8 June.
Indeed, he was unique in the sense that he was the oldest prisoner that
Holme House had ever had to manage and care for. He was described as
a frail man and dishevelled in appearance. The clinical review establishes
that he received appropriate care and treatment for his health, although it
emerged that the reasoning behind some clinical investigations in respect
of the prisoner’s heart condition were not timed or fully recorded.
34. It was established on reception that the man had been a voluntary in-
patient in a mental health unit for the preceding 12 months, although
information regarding his mental health status could not be obtained until
13 June. It was not until that date that information concerning the
prisoner’s behaviour was disclosed that indicated that he could still be a
threat to female staff. The delay in obtaining this information from the
mental health unit could have had serious consequences for staff dealing
with him.
The Governor and the Healthcare Manager, in conjunction with the
North Tees Primary Care Trust, should continue in their efforts to
obtain information at the earliest possible opportunity regarding a
prisoner who may have mental health problems to ensure that the
appropriate security precautions are put in place.
Family Liaison
35. Details of the man’s next of kin were incomplete, but the prison’s family
liaison officer was quick to establish that there might have been
sensitivities in telling the family of his death because of the nature of his
alleged offences. In liaison with an officer from Durham Constabulary who
was supporting the victims, the PO attended the next of kin’s address and
broke the news in a sensitive and very professional manner. This has
been the subject of praise and comment from the prisoner’s family and I
am pleased to record that. It also highlights the challenging, but essential
and rewarding, role of the family liaison officer in such circumstances.
The Governor should commend the Family Liaison Officer, for the
way in which he broke the news of the death of the man to his family,
and for the high level of sensitivity, professionalism and compassion
that has been displayed.
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Post incident debrief
36. The investigation highlighted the need to provide adequate debriefing to
staff following a death in custody in line with Prison Service Order 2710.
This enables timely discussion and early identification of potential learning
opportunities. Whilst it was clear that care and support was available to
staff affected by the prisoner’s death, and that other operational matters
took precedence, a hot debrief would have been useful, particularly to the
nurse who treated the prisoner.
The Governor should remind senior colleagues of the importance of
a timely formal debrief of key staff following a death in custody in
accordance with Prison Service Order 2710.
37. The clinical review was unable to establish the reasons why the prisoner
needed an ECG, as this was not recorded in the prisoner’s medical record.
All entries in the medical record should be timed and the reasons
why investigations were undertaken should be recorded
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RECOMMENDATIONS
1. The Governor and the Healthcare Manager, in conjunction with the
North Tees Primary Care Trust, should continue in their efforts to
obtain information at the earliest possible opportunity regarding a
prisoner who may have mental health problems to ensure that the
appropriate security precautions are put in place.
This recommendation has been accepted by the Prison Service
2. The Governor should remind senior colleagues of the importance of
a timely formal debrief of key staff following a death in custody in
accordance with Prison Service Order 2710.
This recommendation has been accepted by the Prison Service
3. All entries in the medical record should be timed and the reasons
why investigations were undertaken should be recorded.
This recommendation has been accepted by the Prison Service
GOOD PRACTICE
4. The Governor should commend the Family Liaison Officer, for the
way in which he broke the news of the death of the man’s next of kin
and the high level of sensitivity, professionalism and compassion
that has been displayed.
This recommendation has been accepted by the Prison Service
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ANNEXES
Documents considered during the investigation
A The prisoner’s medical record.
B Statements from staff who discovered the prisoner on 2 July 2006
C Clinical review commissioned by the North Tees Primary Care Trust
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