Individual at Holme House

Circumstances surrounding the death of a man at
HMP Holme House in June 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2006
This report considers the sad death of a man at HMP Holme House on 6 June 2004.
The man was aged 34.
I would like to express here my condolences to the man’s family and all those
touched by his passing.
The circumstances of the man’s death are very unusual in that two experienced
pathologists have been unable to find a definite cause. The Home Office pathologist
has recorded formally that the cause of the man’s death is unascertained. A second
pathologist, instructed by the family, has said that the sudden unexpected death of a
young man is a well recognised, but relatively rare, phenomenon. He writes that
such cases have been termed the “sudden adult death syndrome”.
In line with transitional arrangements agreed between my office and the Prison
Service and in operation during 2004, the primary investigation into the man’s death
was conducted by a senior investigating officer appointed by the Prison Service. He
interviewed staff at HMP Holme House, where he also examined records. I am
grateful to him for his detailed and comprehensive work. This report is substantially
as he drafted it, but I have made some amendments and additions, and the sections
on post mortem reports and a review of the man’s GP records in November 2006
have been added by one of my assistant ombudsmen. The senior investigator and
my assistant ombudsman also visited the man’s relatives.
A further part of the investigation was the commissioning of a clinical review, which
was written by a doctor working for North Tees Primary Care Trust (PCT). Further
clinical information has been supplied by a Principal Officer in the Healthcare Centre
at HMP Durham, by my deputy ombudsman and by a second doctor commissioned
by North Tees PCT.
I wish to thank the Governor at Holme House at the time of the man’s death and his
staff for the help and cooperation received by the investigators in the course of their
work. Facilities were made available and all staff participated fully and readily with
the inquiry.
I am very sorry indeed that the investigation has been such a protracted affair. My
investigators have done their best to answer questions posed at a number of
different stages by the man’s family and their solicitor. They have also obtained
detailed information about the man’s medical history in the community as well as at
Holme House. I have been mindful of the need to establish as much reliable
information as possible about the circumstances of a death, the cause of which
remains a mystery. I trust that endeavour will be of some small comfort to the man’s
family.
2
This report makes a number of recommendations, some related to the availability of
detoxification and other medication and to other healthcare matters. However,
judged overall, I believe the man had good access to healthcare and was looked
after well.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN December 2006
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CONTENTS
Summary
Report of Senior Investigating Officer
Description of HMP Holme House
Investigation Process
Events leading up to the death of the man
Summary of medical interventions
Comments
Contact with the man’s family and questions raised by them
Post Mortems after the man’s death
The second clinical reviewer’s review
Findings
Recommendations
4
SUMMARY
1. At the time of his death, the man was 34 years of age. He had been received
at HMP Holme House on 11 May 2004, having been sentenced to four
months imprisonment at Teesside Magistrates’ Court the same day for an
offence of driving whilst disqualified.
2. At the man’s reception screening on 11 May he was described as looking ‘fit
and well’. He spent the night of 11 May as an inpatient in the Healthcare
Centre due to information supplied by him in relation to his alcohol
consumption.
3. Subsequently, the man was held on House Block 4 DDU (Drug Detox Unit).
He shared Cell A3-6 with a cellmate.
4. Between his arrival at Holme House on 11 May and his death on 6 June, the
man had regular contact with the establishment’s medical services in relation
to a variety of ailments - mainly consisting of generalised aches and pains,
including a sore throat. Records show that blood tests and a previous x-ray
were requested on two separate occasions. The results eventually arrived at
Holme House on 26 May, some ten days before the man’s death, and
highlighted abnormally raised liver functions on two of the five screenings.
5. On the morning of 6 June, the man’s cell mate awoke about 5.15 am to use
the in cell toilet. He observed that the man had not stirred despite his flushing
the toilet, and checked to see if he was all right. Finding that the man was not
moving and icy cold, the cellmate raised the alarm by pressing his cell bell to
attract the night officer.
6. Contingency plans were activated resulting in CPR being administered by a
nurse and a night patrol officer. This was continued until the ambulance crew
arrived at 5.50 am with the man being pronounced dead at 6.43 am by the
duty doctor.
7. A clinical review of the man’s medical treatment was requested from North
Tees Primary Care Trust. A further in-depth assessment from a prison
perspective is contained within this report. It was prepared by a Healthcare
Principal Officer (PO) from HMP Durham. The same PO assisted in the
investigation.
8. I received a copy of the Toxicology Report from Cleveland Police on 20
August 2004. A scientist from the Forensic Science Service stated that the
man had ingested Diazepam and Paracetamol at some time prior to his death.
The scientist commented as follows:
5
“Diazepam (Valium) is a prescription only drug often used in the
treatment of anxiety related conditions but is also widely abused. The
concentration of Diazepam and its metabolite were ‘very low’ and
would not be expected to have any significant effect on the man at the
time of his death. As Diazepam and Desmethyldiazepam are
eliminated from the body very slowly, it is possible that these findings
could relate to the use of Diazepam some days earlier.
“Paracetamol is a widely used painkiller. The trace amount present in
the blood would not be expected to produce any adverse effects on the
man.”
The conclusion to the scientist’s report reads as follows:
“From the tests carried out there were no indications that alcohol or
drugs were a factor in the death of the man.
“The concentrations of diazepam and paracetamol present in his blood
would not be expected to produce any significant adverse effects.”
9. The report from the Home Office pathologist states that no definite
explanation for the man’s death has been found. The pathologist adds:
“In a very small proportion of sudden deaths in young, otherwise
healthy people no cause is ever found. These deaths are sometimes
labelled sudden adult death syndrome and are probably mostly a result
of abnormalities of the electrical rhythm which causes the heart to beat
which is undetectable at post-mortem examination. The cause has to
remain as unascertained.”
10. A post-mortem report was commissioned from a second pathologist by
the man’s family. The second pathologist carried out his examination on 11
June 2004 and submitted his final report on 29 October 2004. He reported
that the man had apparently been a healthy young man with no anatomical
evidence of any natural disease to cause or accelerate his death or to cause
his collapse. The second pathologist added that the sudden unexpected
death of an apparently healthy young individual is a well recognised
although relatively rare phenomenon. He added, “such cases have been
termed the “sudden adult death syndrome” and they are generally
considered to be due to a sudden failure of the heart’s pumping action
brought about by disorder or normal orderly electrical activity within the
heart.”
11. I commissioned a further review from North Tees PCT to establish whether
there was any information of significance in the medical records held by
the man’s GP. In his summary of the man’s medical history, the reviewing
doctor recorded an influenza infection and pneumonia in July 1986 which
was treated with antibiotics. In July 1986, the man was found to have
tachycardia (an abnormally rapid heart rate) but no treatment was given and
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it was not clear from his medical records whether an echocardiogram
requested by the consultant cardiologist had actually been arranged.
12. The man attended his GP’s surgery in April and May 2003. On 15 April
2003, an x-ray of his chest showed atelectasis (partial collapse of the lung)
but a later x-ray of his chest on 28 May 2003 showed that his lungs were
clear.
13. Shortly before his death, the man wrote from prison to his GP to tell him that
a recent blood test showed that his liver was badly damaged. He thought it
best to tell the doctor about his symptoms “just in case my condition gets
worse.” The undated letter was not received at the GP’s surgery until 9
June 2004, three days after the man’s death.
7
DESCRIPTION OF HMP HOLME HOUSE
14. HMP Holme House is a purpose built local Category B prison which opened
in May 1992. It expanded in the late 1990s with the building of two further
house blocks providing 235 additional places. The prison serves the
communities of Tees Valley, South West Durham, East Durham and North
Yorkshire. It has a certified normal accommodation (CAN) of 854, and an
operational capacity (maximum crowded capacity) of 994. On the morning
of the man’s death, the unlock figure was 964. The accommodation
consists of six self contained living units with integral sanitation, with a
mixture of single and double cells.
15. A snapshot of the convicted population on 22 July 2004 shows the following:
Less than 6 months = 78
6 months - less than 12 months = 67
12 months - less than 2 years = 104
2 years - less than 3 years = 122
3 years - less than 4 years = 164
4 years - less than 10 years = 217
10 years less than life = 11
Life Sentence = 7
Total = 770
16. The remainder of the population was made up of unconvicted or unsentenced
prisoners.
17. The regime offers prisoners a variety of employment opportunities within its
modern workshop complex. These are complemented and supported by a
purpose built education department, offering both part time and full time
classes.
18. The prison has a first night centre that provides support to prisoners when
they are first received into the establishment.
19. A Listener scheme operates on a 24 hour basis and is fully integrated into
prison arrangements for those in need of support. (Listeners are prisoners
who provide support for their peers, each Listener having received training
from the Samaritans.)
20. My investigator had sight of a very comprehensive policy document on ‘Safer
Custody’, which included everything from suicide prevention to anti-bullying,
with many references on referrals or access to help.
21. He examined a report entitled ‘An Unannounced Follow Up Inspection of HM
Prison Holme House 31 March – 3 April 2003’ by HM Chief Inspector of
Prisons, and reviewed compliance with recommendations during the course of
the investigation.
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INVESTIGATION PROCESS
22 The senior investigator visited Holme House on 25 June 2004 when he met
the nominated Liaison Officer and set out the parameters of the investigation.
The senior investigator and my assistant ombudsman visited the man’s
relatives at their request. Deleted: ¶
4.2
23. On 12 and 19 July 2004, the senior investigator returned to Holme House with
the Healthcare PO and examined all available documentation in relation to the
man’s treatment in prison and some core documents. He also interviewed a
number of members of staff.
24. As Ombudsman, I issued my draft report in January 2005. In September
2005, the man’s sister wrote to me, indicating that the family wished to raise
some further concerns after considering the draft report. In response to these
concerns my deputy ombudsman produced a short supplementary report in
February 2006. My deputy is a trained nurse.
25. In May 2006, the solicitor acting for the family wrote to my assistant
ombudsman expressing the hope that a number of issues might be resolved
from the man’s GP medical records, “including what, if any, treatment the
doctor was giving or enquiries being pursued with regards to any problems
with the man’s liver and secondly did the doctor [the man’s GP] receive a
letter directly from the man seeking help with regards to the medical problems
that the man was experiencing.”
26. On receipt of the solicitor’s letter, my assistant ombudsman wrote to the Head
of Risk Management at North Tees PCT, asking for a report on the clinical
care the man received in the community prior to his reception at Holme
House. The Head of Risk Management commissioned a review from the
Clinical Governance Clinician at the neighbouring Middlesbrough PCT. Once
written consent had been obtained from the family, the second reviewer
accessed the medical records held by the man’s GP and submitted his report
to the Head of Risk Management on 6 November 2006.
27. At the time that the senior investigator wrote his draft report, he did not have
access to the post-mortem reports written by the Home Office pathologist and
the second pathologist. An early version of the second pathologist’s report
was kindly made available to me by the man’s family on 30 June 2004. The
second pathologist’s final report, dated October 2004, was disclosed to my
office by the family’s solicitor in May 2006. The Home Office pathologist’s
report was disclosed to me by the coroner in late 2005.
9
EVENTS LEADING UP TO THE DEATH OF THE MAN
28. In interview, the man’s cell mate outlined the evening of Saturday 5 June
2004. He said, ‘The man and myself had been watching the football
highlights. I can recall it because it was the night President Reagan died. We
both commented on what a good innings he had.’ The man then went to
sleep whilst his cellmate stayed up and watched a film about a dingo stealing
a baby. He said that the film finished at approximately 2.00 am and the man
appeared to wake up. The cellmate said that the man sat up in his bed and
was ‘fighting for breath’. The cellmate offered him his inhaler but got no
response or acknowledgement. The man lay back down on the bed and then
appeared to be breathing normally.
29. The cellmate then went to sleep and woke up at approximately 5.00 am to go
to the toilet. He observed that the man appeared to be in exactly the same
body position as when the cellmate had last seen him prior to going to sleep.
The man was on his front, with the blanket only partially covering him. The
cellmate said during interview that, after using the toilet, he closed the cell
window as it was cold. He thought that the man might be cold as his blanket
was not covering him. He also thought it strange that the man had not stirred
after he flushed the toilet. When the cellmate checked on him ‘he felt icy
cold’, so he put the cell buzzer on to summon assistance and kicked the door
a few times to attract the night patrol officer.
30. The night patrol officer came to the door and instructed the cellmate to shake
the man and check for a pulse. When he got no response, the cellmate was
told to sit on his own bed and wait for assistance. The cellmate also
confirmed that this was the first time during the week when either he or the
man had cause to press the cell buzzer. The night patrol went to the centre
office and raised the alarm via the Orderly Officer who alerted the Healthcare
Centre.
31. Within five minutes, the Orderly Officer arrived with a male nurse and two
assistants. The nurse entered the cell to assess the situation but got no
response from the man. There were no signs of life, no spontaneous
respiration or pulse. The nurse and the night patrol officer commenced CPR
on the man. The nurse attached a defibrillator to assess him further. This
indicated ‘no need to shock’. The two staff therefore continued administering
CPR until the ambulance arrived.
32. The cellmate, who appeared very shocked at this time, was put into the ‘crisis
suite’ cell where he had assistance from the on call Listener.
33. An officer escorted the ambulance into the prison. The prison’s medical
officer was contacted and asked to attend the prison. He declined, saying
that another doctor was on call.
10
34. The Orderly Officer obtained statements from all members of staff involved.
At 6.40 am, the duty doctor arrived to examine the man and at 6.43 am he
pronounced life extinct. At 9.25 am, a Senior Officer arrived in company with
three detectives and a Police Liaison Officer. The Coroner’s Officer arrived at
11.00 am. The undertakers removed the man’s body at 11.45 am for post
mortem later the same day. A ’hot debrief’ for staff was conducted by the duty
governor.
35. The prison authorities initially had problems establishing and contacting
the man’s next of kin. His core record recorded his next of kin as his mother,
but with an incomplete address. Police in Wales were asked by Holme House
to try and supply details to very little effect. At approximately 10.45 am, the
prison was contacted by the man’s estranged wife. She had been contacted
by another prisoner from Holme House who had told her about the man’s
death. Back records from a previous sentence the man had served in 2002
show that he had given her name then as his next of kin.
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SUMMARY OF MEDICAL INTERVENTIONS
36. This chapter contains a summary of all the man’s contact with medical
services, from his first reception at Holme House on Tuesday 11 May 2004
until his death on Sunday 6 June 2004.
37. On 11 May 2004, the man was convicted and received at Holme House at
approximately 3.00pm. A modified First Reception Healthscreen and
secondary health assessment was carried out by nursing staff. During this
interview process, the man volunteered information regarding his medical
background. The following information was identified as a result of these
questions:
• previous prison history.
• recent visit to his GP, complaining of fluid on his lungs. States
prescribed Amoxil tds.
• prescribed treatment for asthma. States prescribed Becotide Inhaler.
Listed as Asthmatic.
• recently stopped smoking.
• heavy drinker. 4 bottles of wine per day.
• drug user, now and again, specifically cocaine.
• weight recorded as 73kg.
• states problems with cholesterol, but not specified or treated.
• blood pressure recorded as 126/80.
• nurse’s comment, “Looks fit and well”.
• action after interview, refer to nurse-led clinic, “Drug detox unit”.
38. The man also had an interview later the same day with the medical officer at
Holme House. This consisted of a stamped tick box in the medical notes.
The medical officer noted the man’s asthma and excessive drinking, and
passed him fit labour 1, which means fit for any work or activity within the
prison. The man was admitted to the Healthcare Centre later that day, as per
the protocol for people with alcohol problems at Holme House. No
Chlordiazepoxide detox was started at this stage.
39. On the morning of 12 May, some time before 10.00am, the medical officer
saw the man for a more in-depth interview and examination. The following
information was identified as a result of this consultation:
• The man suffered from asthma and used inhalers. He was prescribed
Becotide Inhaler and this was given to and signed for by the man, in-
possession.
• He suffered from fluid on his lungs. Amoxycillin 250mgs tds was
prescribed not in-possession. Prescription sheet indicates it was not
given until teatime that day, 24hrs after first reception.
• The medical officer noted that the man had had an x-ray taken at a
local hospital one month previously.
• Physical examination notes good, nothing else noted.
12
Action points, noted in the Inmate Medical Record (IMR) by the medical officer
as a result of above consultation:
1. To ring the hospital to obtain x-ray report. Formatted: Bullets and
2. Chlordiazepoxide detox to start. Prescription sheet indicates not given Numbering
until teatime that day, 24hrs after first reception.
3. Thiamine 100mgs od 28days. Prescription sheet indicates not given
until teatime that day, 24hrs after first reception.
4. Bloods requested for LFT’s [liver function tests].
5. Pharmacy dispensing sheet indicates time of dispensing at 10.57am,
12 May 2004.
40. The man was discharged from the Healthcare Centre on the morning of 12
May at 10.00am. The next contact with medical staff, according to medical
notes/prescription sheet, was at teatime treatments on house block four, when
the man received his first dose of Chlordiazepoxide, Thiamine and
Amoxycillin. (That is some 24hours after initial reception.) The inmate
medical record (IMR) and a healthcare centre discharge sheet accompanied
the man.
41. Some time during 13 May, a Healthcare Officer who works on the DDU
completed a detoxification unit pathway of care nursing record. A
comprehensive general history was taken for this document, spanning several
pages of mostly fixed field questions. This document noted that the man
informed staff that he drank excessively at weekends and occasionally used
cocaine. However, no signs of withdrawal were noted. There was no record
in the IMR or DDU diary of the x-ray report or the request to the local hospital
for it, or for anyone to action this. Neither was there a record of bloods taken
for LFT’s on this occasion.
42. The next recorded intervention by medical staff noted in the IMR was on 23
May. The man was seen on a follow up appointment, complaining of stomach
pains, sore throat and general malaise. “No signs of withdrawal noted, to
have Paracetamol PRN, see again in one week”, was recorded. On the
following day, the man was triaged by a nurse, having complained of pain all
over his body, especially his throat. He also said the glands under his arms
were up. Later that day, at a time not stated, he was seen by the medical Deleted: on
officer who carried out a physical examination.
43. The LFT blood results arrived at the prison on 26 May and showed
significantly raised levels of ALT 84 (Range 0-40), Gamma GT 194, (Range 8-
61). On 27 May, the medical officer had sight of the LFT results and noted
they were abnormal due to alcohol abuse. He asked for them to be repeated
in three to four weeks. The following day (28 May), the man was seen by the
medical officer and complained of generalised aches and pains. Paracetamol
(two tablets, eight-hourly) was prescribed.
44. On 30 May, there was a note in the IMR: “attended gym before coming down
to get his treatments.” However, according to the gym log, the man had not
13
attended the gym during this sentence. A similar entry was made the
following day, but again it was not confirmed in the gym log.
45. The man was seen in the healthcare centre twice on 4 June. First, he was
seen on triage by the nurse as he complained of generalised pain. Later, he
was seen by the medical officer when complaining of acid reflux. The man Deleted: en
was prescribed Gaviscon 10mls tds 14 days. A request for H-Pyloric test was
made which had an action noted in the DDU diary for Monday 7 June.
46. There are no further entries in the man’s medical notes with regard to his
general health, or any other written interventions, until the morning of 6 June.
47. Healthcare staff were called at approx 5.30am to attend the man’s cell. Upon
arriving, staff stated he was unresponsive. The male nurse said that the man
was lying on his side and was unresponsive, with no detectable breathing or
pulse. The nurse immediately commenced CPR, assisted by the night patrol
officer. They continued this for approx 15-20 minutes until ambulance
paramedics arrived. The paramedics asked the staff to stop CPR whilst an
ECG heart trace could be connected through three chest leads. This showed
an Asystole reading, which indicates no electrical activity in the heart. They
felt further CPR was not indicated. The duty doctor arrived shortly after, about
06.34am. After examination of vital signs, he pronounced life extinct.
48. Two post mortems have been carried out, the second at the request of the
man’s family. Both were inconclusive, with no cause of death established.
The toxicology results have provided no other additional information.
14
COMMENTS
49. The man had numerous contacts with medical services at Holme House in the
short time he was there, showing a good level of access and availability. The
medical officer’s medical notes were good and show evidence of
comprehensive physical examinations on two occasions. The response and
care given to the man in his cell on the morning of 6 June 2004 were of a high
standard and a credit to the nurse and prison officer involved. .
50. However, I believe that the man had to wait too long after initial reception to
receive detox, vitamin and antibiotic medication. A delay of 24 hours is too
great, especially in the case of those considered to misuse alcohol. In
addition, the x-ray and liver function tests requested in the IMR, in-patient
discharge sheet and ward round book, should have been followed up and not
left until the man reported ill some 11 days later before being made. There
were also some discrepancies between the reception interview and DDU
pathway of care interview as to the level of alcohol the man said he drank.
51. Nursing medical notes/comments in the IMR about the man going to the gym
before attending for medical treatment may be inappropriate and, in any
event, upon investigation were found not to be factual. A referral to the
CARATS (drugs) team was recorded in the DDU pathway of care form, but no
action was taken and the senior investigator found no evidence of CARAT
intervention on this sentence.
15
CONTACT WITH THE MAN’S FAMILY AND QUESTIONS RAISED BY THEM
52. On 7 June 2004, the family’s solicitors requested documents relating to the
man and his care within Holme House. These were dispatched on 8 June by
the duty governor.
53. The duty governor also arranged for the family to attend Holme House on 8
June. Eight members of the family attended and a meeting was held in the
Learning Centre outside the jail. The family was offered the opportunity of
visiting the cell where the man had died, and told that a cheque in the sum of
£61.50 had been collected by fellow prisoners and would be sent to the man’s
nephew to be given to his children.
54. At the request of the man’s family, my assistant ombudsman made
arrangements to visit the family at their home at a convenient time and date.
The nephew who was acting as the spokesperson for the family invited my
assistant ombudsman and the senior investigator to his aunt’s home. The
visit took place on the evening of 30 June. The functions of an Ombudsman’s Deleted: presentative and Mr
investigation were explained, together with its likely scope. Agnew visited the family as
requested
55. The family asked the investigators to look in some detail at a number of
issues. I have outlined below those questions and what my investigation has
uncovered.
The family had information that during the night of 5-6 June help was
requested for the man from a named night patrol officer but he did not supply
it.
The night patrol officer said in interview that his set of nights was generally
quiet, with only the odd cell bell requesting toilet rolls or Paracetamol. He said
that, prior to answering the cell bell at approximately 5.30am on 6 June,
neither the man nor his cell mate had used the cell bell call system during that
week for any reason. When alerted by the cellmate that something was
wrong with the man, the night patrol officer gave instructions through the door
and quickly summoned medical help. When the nurse arrived, both the night
patrol officer and the nurse commenced CPR on the man and kept this up
continuously until the paramedics arrived. (As a relatively new officer, the
night patrol officer was well in date with his first aid qualification and took his
lead from the nurse. Both these members of staff are to be commended for
their prompt action and skill in trying to save the life of the man.) I have
uncovered no other evidence suggesting that help was requested for the man
during the night of 5-6 June.
Was the man transferred to an outside hospital prior to his death and if so
why?
Between the dates of 11 May 2004 and 6 June 2004, the man did not visit an
outside hospital. The night of the man’s reception was the only one he spent
as an inpatient in the Healthcare Centre.
16
The family expressed concern about bruises noted on the man’s arms during
the second post mortem.
I am unable to provide an answer to this question. However, I am aware from
many of my investigations that apparent injuries can result from resuscitation
efforts.
The family expressed concern about the presence of a few small petechiae
around the eyes noted at the second post mortem.
I am unable to provide an answer to this question.
The family supplied a list of prisoners at Holme House who had relevant
information and would be willing to assist the Ombudsman’s investigation.
The senior investigator interviewed several prisoners named by the family.
The main gist of their interviews is contained in this report. However, all
talked of being aware that the man had problems with fluid on the lungs and
some chest pain. All confirm the man had been seeing the doctor and nursing
staff, although some believe the care could have been better. (I have
uncovered nothing more to substantiate that view.) One of the interviewees
made reference to the man staying in his cell during association periods, but
suggested that had been some two weeks prior to his death. All said they
saw the man earlier on the Friday/Saturday prior to his death and commented
‘he seemed fine,’ and ‘looked okay’.
The family expressed surprise that PE staff at the prison were not aware of
the man’s death soon after the event.
Having checked through the attendance records for the gymnasium, it
appears that the man did not in fact attend the gym. This is corroborated by
his cell mate and the other four prisoners interviewed at the family’s request.
(The man did attend the gym on previous sentences at Holme House.) As to
PE staff not being aware of the man’s death, notices to staff and prisoners
were properly displayed around the establishment.
The family complained that the duty governor at the prison had lied about the
identity of the man’s cell mate at the meeting on 8 June 2004.
During interview with the duty governor, the senior investigator asked about
the meeting she had with the man’s family on 8 June. He judged that the
notes she made at the time were very helpful. At the time, the family had
understood that the man’s cell mate was called Mr X. However, the duty
governor was correct when she said that the man’s cell mate was not Mr X.
As noted in this report, the man’s cell mate at the time of his death was Mr Y.
The duty governor’s decision not to divulge the cellmate’s name at the time
was not unreasonable as the Prison Service also had a duty of care to him.
During interview, it became apparent that the cellmate had been good friends
with the man and was very shocked by the tragic events.
17
The family observed that the man’s weight at the time of his death was much
lower than they would have expected
The man’s weight is recorded on his medical records during screening on his
reception in Holme House as 73kg. In the second post mortem requested by
the family, the man’s weight at death is recorded as 67kg. The difference
between his reception weight and his weight at death is thus some 6kg. I
have found no evidence to show whether this loss in weight was caused by a
change in eating habits or lifestyle, or for other reasons.
56. A number of other issues raised by the family in relation to the timing of the
second post mortem, alleged delay on the part of the Home Office pathologist,
and the way in which the man was presented at the mortuary, are outside my
remit.
57. In addition, I made contact with the man’s mother in Wales. She was his
nominated next of kin. She was obviously very sad about the loss of her son
as, according to a letter found in his cell, he had been planning to relocate to
Wales. I have, as agreed, passed on to her copies of her son’s last known
letters.
58. In September 2005, the man’s sister wrote to my office and set out a list of
further questions that the family wished to raise. These further questions
were:
1. Why did medical staff state in the records that the man had frequently
attended the gym when this clearly was not the case?
2. Why did the man weigh 6 kilograms less at the time of his death than
when he began his prison sentence only 4/5 weeks previously?
3. Why did the doctor not arrive until 6.36am when the alarm had been
raised at 5.30am on the morning of the man’s death?
4. The man was seen by a doctor on a number of occasions and the family
believe that his visits were not taken seriously enough. He was only
prescribed Gaviscon and Paracetamol, which are both medications that
can be bought over a shop counter, despite the fact that blood tests had
returned showing abnormalities.
5. Did chest x-ray results ever arrive at the prison?
6. Was there any indication that the man was taking Methadone?
59. In response to these further issues raised by the family, I commissioned a
report from my deputy ombudsman, who is a trained nurse. Her responses to
the family questions are as follows:
1. Frequent attendance at the gym? – My deputy reports that the
healthcare staff would have based their entry regarding the man’s
18
attendance at the gym on the information he gave them. Unless there
was a clinical reason for him not to attend the gym, they would have no
reason to check what the man told them.
2. The man’s significant weight loss – My deputy cannot explain the
differences in the man’s weight, although she points out that the scales
used in the prison and the mortuary were not the same. She notes that,
in the first post-mortem conducted by the Home Office pathologist, the
man does not appear to have been weighed although the pathologist
indicated in the External Examination section of his report that the man
“was of average build.”
3. The doctor did not arrive until 6.36am – My deputy comments that she
would not have expected the doctor to be called initially as a 999
ambulance call had been made. She adds that this is entirely consistent
with community based primary care. I have, however, made a
recommendation about the need for an effective system to ensure that all
managers are aware which doctor is on call.
4. The man’s visits to Healthcare were not taken seriously enough – My
deputy observes that the man presented at Healthcare on a number of
occasions. She considers that the care he was afforded was entirely
appropriate to his presenting symptoms. Full examinations were
undertaken and tests were ordered accordingly. The majority of his
blood results were within normal limits. The Liver Function tests were
slightly raised and the man was scheduled to have them re-screened.
5. Chest x-ray results – there is no evidence that these x-ray results ever
arrived at the prison.
6. Was the man prescribed Methadone? – My deputy comments that the
man was never prescribed Methadone and that the Methadone chart
belonged to another prisoner.
My deputy ends her report by stating her belief that an improved system
needs to be put in place for following-up tests and examination requests.
60. The man’s sister expressed disappointment that his family in the north east
learned of his death as a result of telephone calls made by other prisoners to
their families. She was aware that the man had nominated his mother as his
next of kin, but the family suggested that prisoners should be asked to put two
or three people as next of kin. Clearly, prisoners should not be pressurised
into naming more contacts than they would choose to do. However, I think
there is some merit in the proposal and draw it to the attention of Holme
House and to the Prison Service generally.
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POST MORTEMS AFTER THE MAN’S DEATH
61. The first post-mortem after the man’s death was conducted on 6 June 2004
(the day of the man’s death) by the experienced and highly qualified
pathologist who is a Senior Lecturer in Forensic Pathology at the University of
Newcastle and Home Office Pathologist for the North-East of England. In his
report to the Coroner of 9 November 2004, the Home Office pathologist wrote
that the cause of death was in his opinion unascertained. In the History
section of his report, he noted that the man had a past medical history of
asthma, reflux and abnormal liver function tests thought to be due to alcohol
excess.
62. In the initial Toxicology section of his report, the Home Office pathologist said
that samples of blood, urine and stomach contents were sent to the Forensic
Science Laboratory at Chorley. The Home Office pathologist noted the
comment of a scientist at that laboratory that the results provided no indication
that alcohol or drugs were a factor in the man’s death.
63. The Home Office pathologist’s report recorded that he attended the mortuary
for a second time on 11 June 2004. He was met there by the pathologist
instructed by the man’s family. The two pathologists discussed the
circumstances of the man’s death and the second pathologist then examined
the man’s body. The Home Office pathologist observed that a number of
bruises had become visible since his previous examination. Two bruises
were noted on the upper part of the man’s right arm. A bruise was also seen
on the man’s right elbow and on the upper part of his left arm. Two further
bruises were observed on his right forearm.
64. In the summary and conclusions part of his report, the Home Office
pathologist notes that the man was found dead in his cell on the morning of 6
June, after he had been heard wheezing some hours previously. He had a
past history of asthma, alcohol and cocaine abuse and had recently
complained of abdominal and other pains. The principal findings at post-
mortem were:
1. Occasional small recent bruises
2. No natural disease
3. No significant toxicological findings.
65. The concluding paragraph of the Home Office pathologist’s report is
significant and I reproduce it in full.
“Thus, despite a full and detailed post-mortem examination including
microscopy and toxicology, no definite explanation for the man’s death
has been found. There was, however, no evidence whatsoever that he
died as a result of either injury or poisoning and by exclusion at least it
appears likely that his death was from natural disease. It is well
recognised that in a very small proportion of sudden deaths in young,
20
otherwise healthy people no cause is ever found. These deaths are
sometimes labelled Sudden Adult Death Syndrome and are probably
mostly a result of abnormalities of the electrical rhythm which causes
the heart to beat which is undetectable at post-mortem examination.
The cause, at least in terms of certification, however, has to remain as
unascertained. The occasional small bruises present on the arms in no
way provide a cause of death and do not indicate an assault.”
66. The man’s family kindly made available to my investigators an early version of
the report written by the pathologist they had instructed. The second
pathologist’s early conclusions were that post-mortem examination had shown
no obvious anatomical evidence of any lesion to account for the man’s death.
It appeared to the second pathologist that a death from violence could be
excluded, “although the presence of a few small petechiae [minute
discoloured spots on the surface of the skin caused by an underlying ruptured
blood vessel] around the eyes has to be noted.”
67. In May 2006, my colleague wrote to the solicitor acting for the man’s family.
He enquired whether a copy of the second pathologist’s final report might be
made available to my office and this was duly supplied. The second
pathologist’s report, dated 29 October 2004, explains that he conducted a
second examination of the man’s body on 11 June 2004 after a post mortem
had been carried out on 6 June 2004 by the Home Office pathologist on
behalf of the Coroner. The second pathologist’s report begins by saying that
the Home Office pathologist provided him with a draft version of his report.
The Home Office pathologist also attended the second pathologist’s
examination and they re-examined the body jointly. The two pathologists
discussed the findings in the case together “in some detail.” Further technical
assistance was provided to the second pathologist in the form of microscope
slides, sight of the report on the toxicological examination, and photographs
taken in the prison and at the mortuary during the first post-mortem
examination.
68. The second pathologist’s detailed commentary at the end of his report begins
thus:
“The post-mortem examination in this case has shown that this has
apparently been a healthy young man, with no anatomical evidence of
any natural disease to cause or accelerate his death or to cause his
collapse. Specifically, despite the history of mild asthma, and indeed of
some form of breathing abnormality prior to his demise, there was no
evidence that the deceased died during the cause of an asthma attack,
and a death from asthma can effectively be ruled out.”
69. In the second paragraph of his commentary, the second pathologist observes
that “only very occasional trivial nondescript external marks of injury were
present about the body” and there were no internal indications of injury at all.
The second pathologist concludes that “a death from violent injury can
therefore be ruled out, insofar as it is ever possible to do this.”
21
70. In the third paragraph, the second pathologist writes that, despite the history
of alleged drug abuse, there were no signs of intravenous drugs abuse about
the body. He therefore concludes that a toxicological cause of death can be
excluded.
71. In the fourth paragraph, the second pathologist writes that the man’s death
has no anatomical cause and in the next paragraph he writes about “sudden
adult death syndrome” as follows:
“The sudden unexpected death of apparently healthy young individuals
is, however, a well recognised although relatively rare phenomenon.
Such cases have been termed the ‘sudden adult death syndrome’ and
they are generally considered to be due to a sudden failure of the
heart’s pumping action brought about by disorder of the normal orderly
electrical activity within the heart, and occurring in the absence of any
structural abnormality of the heart.”
72. At the end of his commentary, the second pathologist writes that, in some
cases of sudden adult death syndrome, clues to the tendency to sudden
cardiac death can be found in the clinical history. His final paragraph notes
that, “there was certainly no evidence of any overt disease, treatment of which
could have effected a happier outcome.”
73. A letter of 31 May 2006 from the family solicitor to my colleague said that at
that stage he did not have any copies of the man’s GP medical records. The
solicitor speculated that a number of issues might be resolved from the
medical records including what, if any, treatment the doctor (the man’s GP)
was giving, or what enquiries were being pursued with regard to any problems
with the man’s liver. The GP records might also show whether the doctor
received a letter directly from the man seeking help for the medical problems
he was experiencing.
74. On receipt of the solicitor’s letter, my assistant ombudsman wrote to the Head
of Risk Management at North Tees Primary Care Trust. He said that he
would be grateful for any information and analysis that the PCT was able to
submit in connection with the clinical care the man received in the community
prior to his reception at Holme House on 11 May 2004. The Head of Risk
Management made a request to the Clinical Governance Clinician at
Middlesbrough PCT for a clinical review into the GP notes to be undertaken.
After written consent for access to the man’s GP record had been supplied by
his sister, a second clinical review was duly undertaken. The second clinical
reviewer submitted his report to the Head of Risk Management on 6
November 2006.
22
THE SECOND CLINICAL REVIEWER’S REVIEW
75. The second clinical reviewer’s review says that he received photocopies of
the man’s GP medical record from North Tees PCT in October 2006. He also
obtained copies of x-ray results and blood tests carried out in 2002/03 from
the Medical Centre which the man had attended. The GP medical records
contained manual and computer medical records along with the copies of
blood results, x-ray reports and hospital correspondence.
76. The man was born in 1969 and the second clinical reviewer’s review refers to
one entry in the GP records in 1970, a gap between 1970 and 1979 and then
complete records from 1979 until 2003.
77. In the Summary section of his report, the second clinical reviewer writes that
the man made multiple attendances at Accident and Emergency for multiple
musculo – skeletal injuries, including stab wounds with a machete on 29 May
1995. In addition to the machete attack in 1995, the man had been admitted
to Accident and Emergency in August 1986 after being hit on the left side of
his chest. He was discharged five days later. In March 1990, he sustained a
road traffic accident when he fell off a motorbike. He was discharged from
hospital four days after his arrival with a diagnosis of head injury, facial
injuries and fracture of left zygoma (the bony arch of the cheek.) The third
paragraph of the second clinical reviewer’s summary observes that the man
had haemophilus influenza infection and pneumonia in July 1986 and was
treated with antibiotics. He was seen by a chest physician in August 1986
and no treatment was given. In an earlier section of his review, the second
clinical reviewer reveals that the man was referred to the chest physician
because of haemoptysis (the coughing up of blood).
78. The fourth paragraph of the second clinical reviewer’s summary indicates that,
in July 1986, the man was found by his GP and a chest physician to have
tachycardia (an abnormally rapid heart rate). A 24 hour ECG showed
supraventricular tachycardia. No treatment was given and the second clinical
reviewer says it is not clear from the medical records whether an
echocardiogram was arranged. An earlier section of the review notes that a
consultant cardiologist agreed to arrange an echocardiogram after a few
months. The second clinical reviewer’s note of this 1986 agreement by the
consultant records that there is no further correspondence in the medical
records to confirm whether this was actually arranged. Nor are there any
results from an echocardiogram.
79. In terms of more recent general practitioner consultations, the second clinical
reviewer’s review shows that the man attended the GP surgery on 24 June
2002 when he felt depressed and tired. Blood and urine tests showed no
abnormality and liver function tests showed a slight increase in gamma-gt at
85 (normal being up to 65).
80. On 10 April 2003, the man attended the surgery with shortness of breath,
which was worse on exertion, during the previous three weeks. On
examination, his chest was clear but he was prescribed a Salbutamol inhaler
23
and a chest x-ray was arranged. On 15 April 2003, the chest x-ray showed
atelectasis (partial collapse or incomplete inflation of the lung) in the right
lower zone.
81. On 21 May, the man was seen in the surgery and prescribed antibiotics and a
Salbutamol inhaler. On 28 May, an x-ray showed that his chest and lungs
were clear. A note on 20 June states that the patient was reviewed and his x-
ray was explained. The man appears to have been seen for the last time at
the surgery on 28 October when he had a sore throat. He was prescribed Co-
codamol, Salbutamol and Erythromycin.
82. The last piece of information to which reference is made in the second clinical
reviewer’s review is very poignant. It is an undated letter sent by the man
from Holme House and addressed to Dear Doctor. The second clinical
reviewer reports that the letter was received at the surgery of the man’s GP
on 9 June 2004, three days after the man’s death. It was scanned into his
medical records. In the letter, the man says:
“I am a patient of yours and I am not feeling too good. I have been
feeling bad for a long time as you can see from my files, inhalers, x-
rays, blood test. I had a blood test last week and the results show my
liver is badly damaged. Does this explain why my eyesight is bad and I
feel irritable and have pins and needles on the top of my crown ... I just
thought doctor it’s best to tell you just in case my condition gets worse.
Yours sincerely, …………….”
83. It has already been noted (at paragraph 45) that the man’s liver function tests
arrived at the prison on 26 May and showed significantly raised levels of ALT
and gamma-gt. On 27 May, the medical officer had sight of these results and
wrote in the clinical record that they were “abnormal due to alcohol problems.”
He requested that the tests be repeated in three to four weeks time.
24
FINDINGS
84. The man arrived at Holme House on 11 May 2004 after receiving a sentence
of 4 months from Teesside Magistrates’ Court for an offence of driving whilst
disqualified. Due to information supplied by the man in relation to his alcohol
intake, he was admitted overnight into the prison’s Healthcare Centre. He
was initially medically assessed using the ‘Grubin Tool’ (an assessment
procedure named after Donald Grubin, Professor of Forensic Psychiatry at
Newcastle University). During that assessment, he said that he had recently
seen his doctor in relation to ‘fluid on his lungs’. His weight was then
recorded as 73kg. The man said that he was prescribed a ‘Brown Inhaler’
and Amoxil from his GP. The following day he was prescribed
Chlordiazepoxide (Detox), Thiamine and Amoxycillin.
85. The medical officer’s notes show the man advised him that he had had a
chest x-ray about a month prior to coming to prison. The doctor requested a
chest x-ray be obtained from a local hospital, and asked for blood samples to
be taken for ‘liver function tests’. The medical notes were good and showed Deleted: im’s
evidence of comprehensive physical examinations on two occasions.
86. Waiting for 24 hours after initial reception to receive detox, vitamin and
antibiotic medication is too long, especially in the case of suspected
alcoholics.
87. The x-ray and liver function tests requested in the IMR and inpatient discharge
sheet and ward round book should have been followed up and should not
have been left until the man reported ill some 11 days later, when they were
requested again. There were some discrepancies between reception
interview and DDU Pathway of Care interview as to the level of alcohol the
man stated that he drank.
88. Although a referral to the CARATS Team was mentioned in DDU Pathway of
Care form, no action was taken and there was no evidence of CARAT
intervention during this sentence.
89. On 12 May, after one night in Healthcare, the man was allocated to House
Block 4, Drug Detox Unit. He shared his cell there with an unconvicted
prisoner (his cellmate).
90. Some nursing medical notes/comments in the IMR may be inappropriate and
upon investigation were found not to be factual.
91. Blood samples were again requested to be taken from the man for liver
function tests to be done on 24 May. On 27 May 2004, the results from LFT’s
were received and showed abnormalities in two of the five results.
Subsequently, on 4 June the man was triaged for generalised stomach ache
and was prescribed Gaviscon for abdominal pan and acid reflux, also H
Pyloric test required. Paracetamol was also prescribed.
25
92. The prisoners interviewed spoke of the man telling them he had a variety of
ailments. Several of the man’s friends within Holme House, some of whom
were also interviewed, commented that on the Friday/Saturday prior to his
death he seemed okay.
93. The man had numerous contacts with medical services at Holme House in the
short time he was there, showing a good level of access and availability.
94. The cellmate raised the alarm shortly after 5.00am on 6 June. The night
patrol officer answered the cell buzzer and gave advice to the cellmate, prior
to raising the alarm. The Night Orderly Officer arrived at the cell with a male
nurse. The nurse and a night patrol officer commenced CPR on the man.
The man’s cellmate was comforted by a Listener.
95. The medical officer did not attend, as he said that another doctor was on call.
The duty doctor pronounced death at 6.43am. An ambulance arrived,
escorted by a prison officer. The police arrived at 9.25am and the Coroner’s Deleted: .34
Officer at 11.00am, followed by the undertaker at 11.45am. Later a hot
debrief for staff was conducted by the duty governor.
96. Establishing contact with the man’s nominated next of kin proved extremely
difficult. At 10.45am, Holme House was contacted by the man’s estranged
wife who had been informed of his death by another prisoner.
97. The response and care given to the man in his cell on the morning of 6 June
2004 was of a high standard and a credit to the nurse and officer involved.
98. Two post-mortem examinations have failed to establish clearly the cause of
death. The Home Office pathologist’s report of 9 November 2004 observed
that, despite a full and detailed post-mortem examination including
microscopy and toxicology, no definite explanation for the man’s death has
been found. The Home Office pathologist wrote that there was no evidence
whatsoever that he died as a result of either injury or poisoning and, by
exclusion at least, it appeared likely to the Home Office pathologist that his
death was from natural disease. The pathologist explained that it is well
recognised “that in a very small portion of sudden deaths in young, otherwise
healthy people no cause [of death] is ever found. These deaths are
sometimes labelled sudden adult death syndrome and are probably mostly a
result of abnormalities of the electrical rhythm which causes the heart to beat
which is undetectable at post-mortem examination. The occasional small
bruises present on the arms in no way provide a cause of death and do not
indicate an assault.”
99. The second post-mortem report was conducted by another pathologist at the
request of the man’s family. The second pathologist’s commentary effectively
ruled out a death from asthma. He also ruled out a death from violent injury.
Despite a history of alleged drug abuse, there was no sign of intravenous drug
abuse about the man’s body and the second pathologist deduced that a
toxicological cause of death could be excluded.
26
100 The second pathologist added that the “sudden unexpected death of
apparently young individuals is, however, a well recognised although relatively
rare phenomenon. Such cases have been termed the ‘sudden adult death
syndrome’ and they are generally recognised to be due to a sudden failure of
the heart’s pumping action brought about by disorder of the normal orderly
electrical activity within the heart, and occurring in absence of any structural
abnormalities of the heart.”
101. In response to questions in May 2006 from the solicitor acting for the family, I
commissioned a further review from North Tees PTC. This review examined
the records held by the man’s GP and reported in November 2006.
102. The second clinical reviewer’s summary of the man’s medical history refers to
multiple attendances at Accident and Emergency for multiple musculo-skeletal
injuries, including stab wounds with a machete on 29 May 1995. The man
had influenza and pneumonia in July 1986 and was treated with antibiotics.
He was seen by a chest physician in August 1986 and no treatment was
given.
103. In July 1986, the man was found to have tachycardia. No treatment was
given and the second clinical reviewer reports it is not clear from the medical
records whether an echocardiogram was arranged.
104 The second clinical reviewer writes that the man last attended his GP’s
surgery in April 2003 with a chest infection which was treated with antibiotics.
X-rays showed some changes in the right lower zone but a repeat x-ray in
May 2003 showed that the lungs were clear. A later section in the second
clinical reviewer’s summary says that the man’s last attendance at the surgery
was on 20 October 2003 when he was seen with a sore throat.
105. The man’s cellmate was interviewed at Holme House on 22 July 2004. In
interview, the cellmate said that, on the Thursday before he died, the man
posted out a letter to his “outside doctor”. The cellmate’s evidence suggests
that the letter was posted on Thursday 3 June 2004. A letter was indeed
received by the surgery and was scanned into the man’s medical records.
The letter is undated but was apparently received at the surgery on 9 June,
three days after the man’s death. The man told the GP that he had been
feeling bad for a long time and that the results of a blood test “last week”
showed that his liver was badly damaged. He asked his GP if that explained
why his eyesight was bad and he felt irritable and had pins and needles on the
top of his crown.
27
RECOMMENDATIONS
Local
In respect of prisoners received at reception whose alcohol consumption is
high, consideration should be given to the immediate availability of an
appropriate detoxification regime, to prevent possible seizures and the risk of
fatalities in chronic cases.
Procedures should be in place to ensure prescribed treatment is collected
from the pharmacy and administered promptly, and within a morning or
afternoon period.
An auditable system should be put in place for administration staff at Holme
House to action instructions from doctors and nurses. This might be achieved
by attaching a request check list to the front of the clinical records.
A system should be considered to ensure referrals to CARATS are made
appropriately and promptly.
An effective system should be put in place to ensure all managers are aware
which doctor is on call, especially during out of hours periods.
All staff involved should be thanked for their professional conduct and prompt
actions during this incident. In particular, the nurse and night patrol officer
should be commended for their attempts to save the life of the man by
administering CPR.
As proposed in HM Chief Inspector of Prisons’ unannounced inspection
report, a system should be set up to ensure that convicted and unconvicted
prisoners who share cells sign a document to that effect.
All recommendations in the unannounced inspection which have not been
addressed in relation to the Healthcare Department should be re-visited and
implemented to ensure compliance.
National
The Prison Service should consider asking prisoners to give more than one
contact name and address when recording next of kin details.
28