Individual at Holme House

The death of a man in hospital on 20 April 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2005
Foreword
This is a report of an inquiry into the circumstances of the death of a man in
hospital on 20 April 2004 whilst a serving prisoner at HMP Holme House.
All deaths of prisoners in custody are investigated, including those due to natural
causes. The responsibility for carrying out these investigations traditionally fell to
the Prison Service itself, but has now been passed to the Prisons and Probation
Ombudsman (PPO) to bring independence and greater consistency to the task.
In this case an investigator from the Prisons and Probation Ombudsman’s staff
carried out the investigation.
This investigation is into the death of a man who died in hospital following a brain
haemorrhage. The man was serving a 4-month prison sentence at HMP Holme
House at the time of his death.
My colleagues and I would like to extend our condolences to the man’s family for
their loss. We would also like to thank the Governor of HMP Holme House, and
the other members of his staff who assisted us for their help. We found staff
generally helpful. In particular, all the documentation we might require had
already been gathered together for us.
Stephen Shaw CBE
Prisons and Probation Ombudsman
April 2005
Report on the death of a man on 20 April 2004
The man died in hospital in the early hours of 20 April 2004. At the time he was
serving a sentence of 4 months imprisonment which had been imposed on 15
April 2004 but he was granted Release on Temporary Licence on 19 April after a
risk assessment had been conducted at HMP Holme House.
The man was received at HMP Holme House on 31 March 2004. He was held
on remand for one day then on 1 April he was convicted of 2 charges of breach
of an Anti Social Behaviour Order and one count of being drunk and disorderly.
He was sentenced to 4 months imprisonment at Guisborough Magistrates Court
a fortnight later. The Pre-sentence report written for the magistrates on14 April
stated that he had a long history of alcohol misuse, which had escalated over the
years.
My investigator visited HMP Holme House on 11 May 2004 and had detailed
discussions about the circumstances of the man’s death with the liaison
governor, Healthcare Manager and governing governor.
The Reception Health Screen completed when the man first arrived at Holme
House on 31 March 2004 noted that he had suffered from alcoholic fits 12
months previously so he was located in the prison’s Healthcare Centre. The man
remained in the HCC until on 18 April at approximately 0805 he was found not to
be responding when called for treatment. Nursing staff went to check him and
suspected that he had suffered a heart attack. An ambulance was called and the
man was taken to a hospital in the community. He was given a brain scan and it
was discovered that he had suffered a brain haemorrhage.
The decision to grant Release on Temporary Licence to the man was taken on
19 April by the duty governor at Holme House and the man died at 0115 the
following morning. On reception at the prison the man had indicated that his next
of kin was his son who lives in Hampshire.
.
When the man was transferred to hospital his son was informed that he was
gravely ill. The Head of Regimes at the prison then informed the man’s son of his
father’s death at approximately 0715 hours on 20 April. The son subsequently
attended the prison to collect his father’s belongings.
My investigator wrote to the man’s son on 17 May 2004 and asked him if he had
any concerns about his father’s treatment. He did not reply. On 9 June 2004 my
Family Liaison Officer rang the man’s son. He told her that he had no concerns
about the way his father had been treated.
In February 2005 a clinical review was undertaken by the Deputy Prisons and
Probation Ombudsman. She is a qualified nurse and reaches two findings and
conclusions at the end of her report. She observes that although the man had
suffered alcohol induced fits and still drank heavily there is no evidence that he
was prescribed an alcohol detoxification regime on arrival at Holme House. She
also commends the actions of a Staff Nurse who commenced cardiac
compressions promptly at the prison although the extent of the man’s brain
haemorrhage meant that deterioration was inevitable.
In the light of the Deputy Ombudsman’s conclusions I recommend that Holme
House review its procedures for commencing alcohol detoxification regimes and I
also recommend that the nurse be formally commended for his determined
efforts to revive the man.