Individual at Hull

Investigation into the circumstances surrounding
the death of a man
at HMP Hull on 11 April 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 male prisoner at HMP Hull on 11
April 2006, he was 58.
He had a long standing heart condition, and the post mortem comments that there was
sufficient heart disease for him to die suddenly and unexpectedly. He was frail and
needed extra assistance, and I am pleased that the prison was able to provide suitable
accommodation for him. My colleagues and I would like to extend our condolences to
this man’s friends and family for their loss.
This office investigates all deaths of prisoners in custody, including those due to natural
causes. In this case, the investigation was carried out by one of my investigators. The
clinical review was carried out by the Director of Professional Development for Eastern
Hull Primary Care Trust and the Clinical Adviser (Medical) for the Trust. I am most
grateful for their help. Their reports are annexed to this one.
I would also like to thank a Principal Officer at HMP Hull for his help in ensuring all the
relevant information was passed promptly to my investigator.
I make two recommendations, the first concerning arrangements for prisoners to attend
out-patients appointments and the second regarding appraisals of the doctors working
at Hull. I have also commended the man’s cell allocation and access to a wheelchair as
examples of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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Contents
Summary 4
The man 5
HMP Hull 6
The investigation process 7
Key findings 8
Issues considered during the investigation 11
Recommendations and Good Practice 13
3
SUMMARY
The man at the centre of this report died suddenly on 11 April 2006 at HMP Hull.
The man had been in custody since 5 November 2002. He had a long term heart
condition, and had had previous operations. He regularly attended healthcare for
appointments, and was an outpatient at Royal Hull Infirmary and Castle Hill Hospital.
An appointment was booked for 26 March 2006, but was cancelled because the man
was assessed as lower priority than four other prisoners, and the prison is only able to
facilitate four outpatient appointments each day. The appointment was re-scheduled for
13 April, but by that time the man had already died. The clinical reviewer is satisfied
that, notwithstanding the missed appointment, the man’s treatment and referrals were
appropriate, but some concerns have been raised regarding his primary and
preventative care.
The man was sensibly allocated a cell on the bottom landing of J wing, which is also
where the food servery and treatment hatch are located. This meant that he did not
have to use stairs to get his meals or medicines. He took part in ‘in-cell’ education and
had gained several qualifications. (He had previously attended classes, but had found it
physically demanding and so opted to work ‘in-cell’.)
To help with mobility, prisoners have access to wheelchairs. There were a good
number of these for I and J wings, and the man had access to them if he needed to
move elsewhere within the prison.
The man had a group of friends with whom he associated regularly on the wing. It is
these friends who found him on 11 April and called for the assistance of officers. All
those to whom my investigator spoke said that the response was immediate.
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The man
1. This man was born in Nottingham. He left school at the age of 15 with no
qualifications. He was self-employed, working at car boot sales, auctions and
taxi driving. He described himself in reports as a “jack of all trades, master of
none”. He had three children, two daughters who lived with his ex-wife and a son
who had lived with him.
2. The man misused alcohol. It was recorded in prison assessments that this
misuse had led to some of his offending and poor money management.
However, he said that it was under control before coming to prison and did not,
therefore, engage in any work to address this. He also declined to attend other
offending related courses, but did attend education classes and had achieved
certificates in history and computers. He initially attended education classes on
another wing in the prison, but changed to ‘in-cell’ education as it was physically
easier for him.
3. The man had a history of health problems including blocked arteries in his legs
and groin and was waiting for an operation. He smoked and had tried on several
occasions to stop or cut down. He attended smoking cessation classes which
had varying degrees of success, and appears to have stopped smoking in late
2005. He had access to a wheelchair if he needed to get from one area of the
prison to another during ‘freeflow’ (the movement of prisoners to and from work,
education, etc.).
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HMP HULL
4. In the late 19th century, HMP Hull was a prison for both men and women. It was
used as a military prison in 1939 and later as a Civil Defence Depot. It reopened
in 1950 as a closed male borstal and in 1969 became one of the first maximum
security dispersal prisons. In 1986, its role was changed again to the current role
as a male local prison/remand centre.
5. The prison was expanded in 2002 to include four new wings and a new
healthcare centre amongst other facilities. Refurbishment was also carried out to
existing areas. The prison now has nine residential units. It holds remand,
sentenced and convicted adult males (except category A) and young offenders.
As of 31 January 2006, the operational capacity (maximum crowded capacity)
was 1,000.
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THE INVESTIGATION PROCESS
6. My investigator requested all the relevant prison records relating to the man who
had died. These included his medical records and core prison record. She also
visited the prison and interviewed several members of staff and prisoners.
7. The Director of Professional Development at Eastern Hull PCT and the Clinical
Adviser for the Trust undertook the clinical review on behalf of the PCT. They
both made themselves readily available to my investigator to answer any queries,
and their assistance was much appreciated.
8. HM Coroner for East Riding and Kingston upon Hull was informed of the Prisons
and Probation Ombudsman’s investigation. He kindly provided my office with the
post mortem report. The Coroner received a copy of this report when it was
completed.
9. One of my Family Liaison Officers spoke to a family member to ask if they had
any comments or concerns. Nothing was raised, although the family have asked
to see a copy of this report so that they have more information about what
happened to their relative.
2. Notices to staff and prisoners were supplied and displayed by the prison. These
invited anybody with information to talk to my investigator. In this instance, only
those staff and prisoners already identified by my investigator made
contributions.
11. When one prisoner was interviewed, his account of the sequence of events
differed considerably from others. However, he has subsequently amended his
interview transcript and it is now consistent with what other prisoners and staff
had to say.
12. A draft copy of this report was issued to the man’s family and to HMP Hull for
them to make any comment. The family has not made any comments. Hull has
commented on the recommendations made.
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KEY FINDINGS
13. The man was remanded on 5 September 2002 by Nottingham Crown Court to
HMP Leicester. He spent most of his time at Leicester in the segregation unit, at
his own request and for his own protection, because of the nature of his offence.
14. He transferred to HMP Hull on 5 November 2002 and was located on the
Vulnerable Prisoner Wing. His wing records do not offer a lot of information
about him, but from speaking to staff and other prisoners it appears he was a
quiet, polite individual. He had a circle of friends with whom he associated during
most of his time at Hull.
15. The man attended education classes and had gained several qualifications. He
had initially attended classes on I wing which runs opposite J wing, where his cell
was located. However, he later opted to continue with ‘in-cell’ education as it
was less physically demanding.
16. There are many medical events throughout the man’s time in custody, and these
are detailed more fully in the clinical review. It is clear that he had existing health
problems prior to his imprisonment. This included claudication in his legs (a
cramp-like pain usually caused by blockage or narrowing of arteries).
Intermittent claudication is pain in the calves which can be felt after walking
certain distances.
17. J and I wings have several wheelchairs for prisoners' use. The man had access
to these if he needed to move around the prison for example to Healthcare or to
work. He was himself was located on the bottom landing. This made getting his
meals and medication easier as the servery and medical hatch are also located
on the bottom landing.
18. The man’s prison medical records show that he had a history of peripheral
vascular disease (disease of the arteries in the extremities). A letter from his
consultant vascular surgeon, dated 30 January 2004, suggests that there was
disease and that the man would be suitable for an aorto-bifemoral graft (bypass).
19. The man continued to be seen at Hull Royal Infirmary under the care of another
consultant vascular surgeon. There are regular letters filed between this
surgeon, the man and the Medical Officer at Hull outlining the man’s health
problems.
20. These included the claudication and blocked arteries and, in late October 2004, a
hugely distended stomach. Arrangements were made for the man to have an
ultrasound before treatment for his blocked arteries.
21. In January 2006 the medical officer at Hull asked the consultant physician at Hull
Royal Infirmary to review the man for heart failure. An appointment was offered
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for 28 March. However the man did not attend this appointment as the prison
has a policy of allowing only four prisoners out at one time. On this occasion, the
allocation was already full so the appointment was rebooked for two weeks later
on 13 April. The clinical reviewer comments that, had the man attended this
appointment, it might have led to changes in his medication which in turn could
have improved his prognosis.
22. A more detailed report of the man’s health and treatment is given below. This
report shows that although the referrals to specialists and subsequent treatments
were appropriate, there were failings in the man’s primary and preventative care.
Areas such as treatment for high blood pressure and cholesterol levels have
been highlighted as not being appropriately dealt, with, thereby not reducing his
risk of cardiac events.
11 April 2006
23. April 11 was the man’s birthday, and in the morning another prisoner took him a
birthday card. In interview, this prisoner described the man as looking pale. He
saw him again at lunchtime and said he looked better. The prisoner commented
that the man had looked like this in the mornings for about the previous nine or
ten weeks, but looked better as the day went on. A second prisoner, who was in
the cell next to the man’s, also commented that over the past few weeks the man
had not looked well and was grey in pallor.
24. During the association period that afternoon, the first prisoner and a second
prisoner went to see the man. The three men had been friends for some time in
the prison and would often play cards and associate together. Just prior to this, a
third prisoner was returning from his work and looked through the man’s
observation panel. He saw what he thought was the man bending over to pick
something up. The second prisoner did not say anything and continued to his
cell. Shortly afterwards, he went back to see if the man had some cigarette
papers.
25. The first prisoner and second prisoner arrived at the man’s cell first, followed by
the third prisoner. They report going to the cell and immediately realising that the
man was not well. The second prisoner, who has some knowledge of first aid,
shouted to the others to get the officers. He then tried to put the man into the
recovery position.
26. Two officers were in different areas on the landing, but heard the calls for help
and responded immediately. They initially thought they were attending a fight.
When the officers arrived at the cell, they could see that the man was in a serious
condition. The first officer checked for a pulse and breathing, and a call went out
over the radio for medical assistance. The officers commenced cardiopulmonary
resuscitation (CPR), and shortly afterwards a nurse responded to the radio call.
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The three members of staff continued to try and resuscitate the man. The nurse
used the defibrillator, a machine that can administer electric shocks.
27. In the meantime, an ambulance had been called and the nurse asked for a
doctor to attend in case intravenous medication might be required. The doctor
arrived at the same time as the paramedics. After several more attempts by the
paramedics to administer CPR, it was decided not to continue and the man was
pronounced dead at 4.30pm.
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ISSUES CONSIDERED DURING THE INVESTIGATION
Access to healthcare
28. The clinical reviewer states that there appears to have been reasonable access
to primary care provided by doctors and nurses at the prison. However, there
are only a few blood pressure readings recorded each year. Given that these
were almost all high, indicating poor control, then best practice would have been
more intensive and regular monitoring.
29. The reviewer also considers that the man was promptly and appropriately
referred to specialists in relation to his dyspepsia, peripheral vascular disease
and suspected heart failure.
30. The exception was the difficulty taking the man to an outpatient appointment at
the heart failure clinic in March 2006. The clinical reviewer is of the opinion that,
had the man attended, it might have led to changes in his medication which could
possibly have improved his condition and influenced subsequent events.
31. My investigator discussed the arrangements for prisoners to attend outpatient
appointments with a governor at HMP Hull. The governor said that every day the
prison is staffed to escort up to four prisoners to planned appointments
(emergencies are dealt with separately). There is a protocol with Healthcare staff
that they prioritise all the appointments and re-arrange those which have to be
re-scheduled. Appointments for life threatening conditions are deemed to be
high priority and take precedence over routine appointments. On this occasion,
the man’s appointment was cancelled and replaced with a date two weeks later.
He died before the appointment could take place.
32. I understand the need for predictable arrangements to cover outpatient
appointments. However, it is important that the policy is kept under review, both
in respect of prisoners with routine conditions who may regularly be pushed to
the back of the queue, as well as those with serious conditions.
I recommend that the Governor and Primary Care Trust review the policy
for escorts to outpatient appointments, balancing prison and hospital
resources to provide the best healthcare for prisoners.
Quality of Clinical Care
33. The man had high blood pressure, but there does not appear to have been any
attempt to reduce it by changing his medication. It would have been best
practice to adjust his mediation to attempt to achieve better blood pressure
control.
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34. For patients like this man, with a diagnosis of peripheral vascular disease
(hardening and blockage of the arteries), it is usual practice to attempt to reduce
other risk factors. In this man’s case, this included smoking. The clinical
reviewer notes that he was offered support and did manage to reduce the habit.
35. The man’s records show that his cholesterol level was raised, specifically the
proportion of the cholesterol which was of the harmful (LDL Cholesterol) type,
which would be of particular concern for patients with peripheral vascular
disease. It would have been best practice to have offered cholesterol lowering
treatment, which could have reduced his risk of a heart attack.
36. In summary, the clinical reviewer concludes that the clinical care of the man’s
blood pressure and the risks he was exposed to did not meet best practice
standards. He considers that appropriate care and treatment was provided by
the community doctors and specialists, but that there are concerns about the
quality of the primary and preventative care, and improvements might have
increased the man’s life expectancy. The Clinical Adviser for the Trust believes
that the prison’s reliance on locum staff and the lack of clear management
protocols and guidelines has led to these failings. He comments that a
revalidation process began in 2004 which requires prison GPs, like others, to be
subject to appraisals which should address any deficiencies in their practice.
The clinical reviewer also comments that the prison’s Healthcare Centre relies on
locum doctors, which does not assist the provision of thorough and consistent
care for prisoners.
I recommend that the Primary Care Trust ensures that prison doctors,
including locums, are appraised and work to clear protocols and guidance.
37. I am pleased to note that HMP Hull has recognised the need to develop
healthcare provision. It has improved the treatment room facilities, and recruited
a dedicated support team to work within the medical clinics and with visiting
consultants. The prison has also established a better appointment and recall
system. A dedicated GP to undertake general medical services is to be
appointed to work four sessions a week, and an Emergency Care Practitioner is
also being introduced. Finally, a system has been set up to agree any changes
of out patient appointments with the prison.
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RECOMMENDATIONS
1. I recommend that the Governor and Primary Care Trust review the policy
for escorts to outpatient appointments, balancing prison and hospital
resources to provide the best healthcare for prisoners.
HMP Hull has accepted this and the PCT have now introduced a system where
all prisoners who leave the establishment for hospital appointments are seen by
Healthcare staff prior to leaving and on their return from the hospital.
Forthcoming appointments are reported to the relevant discipline department to
allow adequate notice and covering of escorts.
2. I recommend that the Primary Care Trust ensures that prison doctors,
including locums, are appraised and work to clear protocols and guidance.
HMP Hull has accepted this recommendation and an information pack for doctors
has now been produced and is inclusive of prescribing protocols and formulary.
GOOD PRACTICE
1. The prison ensured that the man’s social and mobility requirements were
met. His cell was on the first floor landing, close to the food servery and
medical treatment hatch, which meant that he did not face the physical
demands of using the stairs. He had the use of a wheelchair when he
needed to get from one part of the prison to another.
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