Individual at Hull

The Death in Custody of
a man at
HMP Hull – December 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2005
This is the report of an investigation into the circumstances of the
death of a man at HMP Hull on 13 December 2004. The man’s cause of
death was an intra-cerebral haemorrhage (bleeding into the brain
following rupture of an artery). The man was 55 years old.
The investigation was carried out by one of my colleagues. A clinical
review into the man’s care and treatment was carried out by the
Director of Professional Development at Eastern Hull Primary Care Trust
(PCT).
The man complained about a headache on the morning of 12 December
2004 for which he was given painkillers. The clinicians involved could
not have been expected to recognise that the man’s headache was in
fact the onset of an intra-cerebral haemorrhage as this is a difficult
condition to diagnose in a primary care setting. However, the
investigation has revealed potentially dangerous clinical decision
making practices. The standard of clinical record keeping at Hull has
also been found to be deficient.
I extend my condolences to the man’s friends and family for their loss.
I would like to thank the Governor of HMP Hull, and his staff for their
help.
Stephen Shaw October 2005
Prisons and Probation Ombudsman
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Contents
SUMMARY
INVESTIGATION PROCESS
HMP HULL
THE EVENTS LEADING UP TO THE MAN'S DEATH
AFTER THE MAN'S DEATH
LEVEL OF COMPLIANCE WITH PRISON SERVICE REQUIREMENTS
FINDINGS AND CONCLUSIONS
RECOMMENDATIONS
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Summary
The man died in HMP Hull on 13 December 2004, at which time he was
55 years-of-age. His cause of death was an intra-cerebral
haemorrhage. The man was serving a seven-year sentence, having
been convicted in April 2002 on a number of serious sexual offences.
From the information given by the man during a preliminary health
check upon his arrival at Hull, it would seem that he enjoyed
reasonably good health. Although the man’s clinical records show that
he consulted healthcare quite regularly, all his consultations until his
final one had been about non-serious clinical conditions such as his
condition of chronic psoriasis.
On 12 December 2004, the man complained to staff that he had a
headache. The only other time that the man’s records contain a direct
reference to a headache had been 12 months earlier when he had
influenza. A healthcare nurse visited the man at 10.30am and gave
him ibruprofen, a painkiller. The Healthcare Nurse was not qualified to
prescribe medication, however it seems that a qualified Staff Nurse had
issued the ibruprofen to the Healthcare Nurse after the drug had been
prescribed by a doctor. The doctor could not, however, recall writing a
prescription and no record has been found of the man ever having been
prescribed ibruprofen.
The Healthcare Nurse saw the man again at midday in order to take
clinical observations of temperature, pulse and blood pressure. The
Healthcare Nurse noted that the man was then complaining of feeling
nauseous, which had not been the case earlier that morning. The
Healthcare Nurse made arrangements for the man to see a doctor two
days later.
At 7.30pm that evening, the man was found collapsed on his cell floor.
The man was rushed into hospital where a brain scan revealed that he
had suffered an intra-cerebral haemorrhage. Unfortunately, the
haemorrhage was found to have been too large to allow for an
operation and all the hospital could do was to keep the man as
comfortable as possible during his final hours. The man died at 5.30am
on 13 December.
The clinical review of the man’s care and treatment on 12 December
points out that an intra-cerebral haemorrhage is a very difficult
condition to diagnose. Nevertheless, there are a number of issues
relating to the man’s treatment that day that give me cause for
concern. The first issue relates to how the man came to be prescribed
ibruprofen. From the information obtained during the clinical review, it
would seem that decisions about the diagnosis and treatment of the
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man’s condition had already been made before he was visited by the
Healthcare Nurse at 10.30am. The information leading to the diagnosis
and treatment decisions presumably consisted of a telephoned report
from wing staff that the man was complaining of a headache. This
would seem to be an extremely unsatisfactory way in which to practice
medicine.
Furthermore, the clinical reviewer found from her interviews with
nursing staff that they did not use assessment tools, such as decision-
making algorithms, in their clinical decision-making. Nor did staff
follow Nursing and Midwifery Council (NMC) guidelines, or any other
guidelines on the administration of medication. The clinical reviewer
also criticised the general standard of record keeping by healthcare
staff.
The report makes a number of recommendations relating to the
delivery of healthcare at Hull. These include recommendations on
medication prescribing practices and on standards of record keeping.
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Investigation Process
My practice in cases of deaths from apparently natural causes is to
conduct an initial review to determine the extent of investigation
required.
My investigator visited HMP Hull on 20 December 2004 when he spoke
informally with the Governor, the Head of Healthcare and the
Healthcare Nurse. The investigator was given access to the man’s
records, including his medical records.
My investigator also met a member of the Independent Monitoring
Board (IMB) who said that he had spoken with the IMB Chair about the
man’s death. The IMB had no issues of concern to raise either about
HMP Hull in general, or about the man’s care and treatment in
particular.
The man’s appointed next-of-kin was a friend. One of my Family
Liaison Officers spoke to the friend by telephone. The friend said that
that she had last visited the man in November 2004, two weeks before
his death. The man told her that day that he had been suffering from
severe headaches, but medical staff would only give him one pain-
killing tablet at a time which did not seem to help. After this visit, the
friend spoke with the man by telephone on two occasions when he said
his headaches were no better. He said his headache was coming and
going and the friend thought he said that it was centred over his right
eye.
The Director of Professional Development at Eastern Hull Primary Care
Trust (PCT) carried out a clinical review.
No formal interviews with staff were conducted. This report is based
upon a thorough review of all relevant paperwork, informal discussion
with two members of staff and the clinical review.
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HMP Hull
HMP Hull is a predominantly Victorian prison that first opened in 1870.
Hull is a local prison holding remand, sentenced and convicted adult
males (except category A prisoners) and young offenders. It has an
operational capacity (maximum crowded capacity) just in excess of
1,000.
Healthcare provision at Hull includes 18 in-patient beds. The unit is
staffed 24 hours per day by a range of nursing staff supported by
healthcare officers. All clinical staff in healthcare have the authority to
admit a prisoner into an in-patient bed. Since 1 April 2005, the local
PCT has assumed commissioning responsibility for the provision of
healthcare.
If a prisoner asks at a medication round for non-prescribed one-off
medication, for instance because of a headache, he should only be
given medication following examination by a doctor or based upon
telephone advice from a doctor following an assessment by a nurse.
If medication is issued in this way, a prescription must be written-up
within 24 hours of the medication being issued.
When my investigator visited Hull, he had an informal discussion with
the healthcare Clinical Team Manager. She told him, among other
things, that she was concerned about standards of clinical record-
keeping by healthcare staff.
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The man
The man was born in June 1949 and grew up in West Yorkshire. The
man’s mother had many children whom she found difficult to raise and
several, including the man, were taken into care. The man, together
with one of his brothers, was placed in a children’s home, where he
remained from the age of five up to the age of 16. During this time,
the man had minimal contact with his parents.
The man left the children’s home in 1965 at the age of 16 without
qualifications. He was taken into a foster home, but he was unable to
settle there so he was moved into a second foster home where he did
settle and where he remained for around 10 years. In 1976, the man
was befriended by the mother of a friend. The man moved into the
family home and that remained his home from then onwards. His
friend’s mother is the person who the man nominated as his next-of-kin
when he entered the prison system.
The man worked in both light and heavy industry.
In April 2002, the man was convicted on a number of counts of rape
and sexual assault against the same victim – offences which had
occurred between 1972 and 1979. The man was sentenced to seven
years imprisonment.
The man had one previous conviction for which he was sentenced to
three years imprisonment in 1979. The man had pleaded guilty at trial
for this offence, but always maintained that he was innocent of the
offences that resulted in his conviction in 2002.
When interviewed by a probation officer in 2002, the man said that he
believed that both of his parents were deceased.
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The Events Leading up to the Man’s Death
The man was received at Hull in April 2002. During his first reception
health screen interview, the man reported that he smoked 20
cigarettes per day, had never used illicit drugs and drank only a
moderate amount of alcohol. The man said he had no worries about
his health and the only clinical condition from which he suffered was
psoriasis.
During his time in Hull, the man consulted clinical staff infrequently and
always for minor ailments, most often in connection with his skin
condition. The man consulted healthcare about this condition on 12
November 2004 and again on 10 December 2004. On this second
occasion, which was three days before his death, the man also reported
that he was suffering from a cold for which he was given two
paracetamol tablets.
At 10.30am on Sunday 12 December 2004, the Healthcare Nurse was
called to see the man in his cell. This was a single cell. The Healthcare
Nurse noted that the man was complaining about a headache, but also
noted that the man’s colour was satisfactory, his speech was not
slurred, he had movement in all his limbs and he was able to grasp
with his hands. The Healthcare Nurse gave the man ibruprofen and
asked the wing staff to contact healthcare if they had any concerns
about the man’s condition.
At midday, The Healthcare Nurse returned to see the man again. It is
not entirely clear why the Healthcare Nurse went to see the man for a
second time. When my investigator visited Hull on 20 December he
spoke to the Healthcare Nurse who said that he had gone back to the
man in order to take clinical observations. He said that he had not
been carrying the equipment needed for taking observations when he
visited the man at 10.30am. However, there is some suggestion that
the Healthcare Nurse’s return might have been prompted following a
further call to healthcare by the wing staff. In his record of this second
visit, the Healthcare Nurse recorded the man’s temperature, pulse and
blood pressure. He also noted that the man was then complaining
about feeling nauseous. However, the Healthcare Nurse also recorded
that the man still had no slurring of speech and that there was no
deformity in his facial expression. The Healthcare Nurse made an
appointment for the man to see a doctor two days later.
Wing staff had not noticed anything untoward during that afternoon,
however at roll call at 7.30pm, the man was found collapsed on his cell
floor. He was breathing very loudly, his eyes were fixed and dilated
and staff could not rouse him. An emergency ambulance was called
and the man was taken to Hull Royal Infirmary where a computed
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tomography (CT) scan revealed that the man had suffered a brain
haemorrhage.
The man was accompanied to the hospital by two prison officers.
Hand-cuffs were not used. At 10.35pm, one of the prison officers
accompanying the man made a note that he had been moved into the
acute assessment unit and a doctor had advised that the man’s
haemorrhage had been too large to allow for surgical intervention. All
that could be done would be to keep him comfortable until he passed
away.
At this point, a senior officer from the prison spoke by telephone to the
adult daughter of the man’s friend to inform her that the man was in
hospital and that the doctors had given him little time to live. The
officer gave the friend’s daughter the telephone number of the ward in
which the man was being nursed.
The man was pronounced dead at 5.30am on 13 December. His death
having been caused by an intra-cerebral haemorrhage.
The clinical reviewer interviewed a number of healthcare staff. She
was told at interview that, before going to see the man, the Healthcare
Nurse had spoken with the Staff Nurse, who is a more experienced
nurse (the Staff Nurse is a level one nurse and the Healthcare Nurse is
a level two nurse). The Staff Nurse gave the Healthcare Nurse
ibruprofen tablets for the man that had been prescribed by a prison
doctor. When contacted by the clinical reviewer, the doctor was unable
to recall prescribing ibruprofen for the man and no record of that
prescription has been found. Nor do the prison’s pharmacy records
show the man ever having been issued ibruprofen.
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After the man’s Death
In compliance with its contingency plan relating to the deaths of
prisoners, Hull notified the coroner, the IMB and other official parties of
the man’s death.
Hull’s Head of Residence and one of its chaplains spoke by telephone to
both the man’s friend and her daughter. The Head of Residence also
wrote to the friend with his condolences and to offer her the
opportunity to visit the prison and to meet with staff who knew the
man. Hull appropriately assisted with funeral expenses.
When my investigator visited Hull on 20 December, all necessary
information had been gathered together for the purposes of the
investigation. Arrangements were made for my investigator to speak
with relevant members of staff.
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Level of Compliance with Prison Service Requirements
Standards of clinical care in prison are intended to mirror those
available in the outside community. The clinical review has identified
clinical assessment practices and prescribing systems at Hull that are
less than adequate. The review acknowledges, however, that an intra-
cerebral haemorrhage is a difficult condition to diagnose, particularly in
a primary care setting.
The post-incident response by Hull was fully compliant with Prison
Service instructions and policies on managing a death in custody.
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Findings and Conclusions
The man was of middle-age and seemingly had no major clinical
problems. Over the course of the man’s 20 months at Hull, all of his
healthcare consultations before his final one had been for minor
complaints.
At 10.30am on 12 December 2004, the Healthcare Nurse was called to
see the man who was complaining about a headache. The Healthcare
Nurse examined the man and gave him ibruprofen.
The Healthcare Nurse returned to the man at midday and recorded his
temperature, pulse and blood pressure. The man was complaining by
then that he was feeling nauseous, however the Healthcare Nurse also
recorded that that there was no slurring in the man’s speech and no
deformity in his facial expression. The Healthcare Nurse made an
appointment for the man to see a doctor two days later, but he clearly
did not consider that the situation was serious.
At 7.30pm, the man was found collapsed in his cell and he was rushed
to outside hospital. A CT scan showed that the man had had a brain
haemorrhage and it quickly became apparent that he would not
survive. He died in the early morning of 13 December.
When the clinical reviewer interviewed healthcare staff for the purpose
of her clinical review, she was told that before visiting the man for the
first time the Healthcare Nurse had spoken with the Staff Nurse who is
more experienced nurse. The clinical reviewer was told that the Staff
Nurse had given the Healthcare Nurse the ibruprofen to take to the
man; the drug having been prescribed by a healthcare doctor. When
the clinical reviewer spoke with the doctor, he was unable to recall
prescribing ibruprofen and no record of the prescription has been found
either in the man’s medical records or in the prison’s pharmacy
records.
If the information given to the clinical reviewer about the way in which
the man came to be prescribed ibruprofen is correct, it means that his
treatment had been decided upon before he was seen by a clinician.
The only information that healthcare staff would have had before the
Healthcare Nurse’s visit at 10.30am would have been a message from
wing staff, presumably none of whom are medically qualified, that the
man had a headache. This seems to be a rather unsatisfactory, even
dangerous, way of practising medicine.
The clinical reviewer is critical of a number of issues relating to
standards of healthcare at Hull. None of the healthcare staff
interviewed were found to use any screening tools, such as decision-
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making algorithms, to support the clinical assessment process. In
particular, neither the Healthcare Nurse nor the Staff Nurse followed the
principles for the administration of medication set out in NMC guidelines
or in any other guideline or directive. Instead, the Healthcare Nurse, a
second level nurse, administered the medication following oral
instruction from the Staff Nurse. The clinical reviewer also expressed
concern in her report about the general standard of record keeping by
healthcare staff.
Having made those comments about the shortcomings she had
identified, the clinical reviewer went on to point out that the condition
from which the man died, intra-cerebral haemorrhage, is a difficult
condition to recognise unless the health professional is trained to look
for the specific symptoms associated with it. The clinical reviewer
added that an intra-cerebral haemorrhage is a fairly rare event that can
be easily missed by primary care practitioners.
The man’s friend said that he had been complaining of headaches for
several weeks before his death. The man consulted healthcare on 12
November 2004, and again on 10 December 2004, in connection with
his condition of psoriasis. On neither occasion is any reference made in
his healthcare record of him also reporting a headache. However, at
the second of those consultations, the man had reported a cold and he
was given paracetamol. The paracetamol was given, I assume, for the
symptoms often associated with a cold, such as general aches and
pains which can include headache. Whether or not the man’s
symptoms on 10 December did include a headache, there is certainly
no specific reference to that symptom and no written evidence to
suggest that he had been complaining of headaches over a period of
time.
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Recommendations
I make the following recommendations, all of which have been taken
from the clinical review:
1. The PCT and Head of Healthcare should ensure that validated
screening/triage tools and/or algorithms are used to support the clinical
decision-making process.
2. The PCT and Head of Healthcare should take steps to raise
awareness of healthcare staff to the use of other agencies to support
clinical decision-making, such as NHS Direct, Emergency Care
Practitioners and Tees, East and North Yorkshire Ambulance Service
(TENYAS).
3. The PCT and Head of Healthcare should remind healthcare staff
about the requirements set out in the NMC’s guidelines for records and
record keeping. In particular, that each entry in the records should be
legible, signed, dated, timed and name of practitioner printed with
grade or job title. Also, that medical record note and data sheets
should be clearly identifiable to the prison premises.
4. The PCT and Head of Healthcare should remind healthcare staff of
the requirements set out in the NMC’s guidelines for administration of
medicines.
5. The PCT and Head of Healthcare should arrange a review of the
training needs of the Staff Nurse and the Healthcare Nurse. The
training needs identified should be reflected in the specific performance
and development objectives of these staff.
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