Individual at Hull

Investigation into the death of a man at HMP Hull on 25 May 2004
Report by the Prisons and Probation Ombudsman for England
and Wales
November 2005
I commissioned this enquiry and report into the death of a man in the
Healthcare Centre of HMP Hull on Tuesday 25 May 2004.
The Head of Residence at HMP Leeds was commissioned as the Senior
Investigator. The Yorkshire and Humberside Area Manager’s Support Team
assisted him. Liaison and support was provided by an investigator from my
office.
I offer my sincere condolences to the family and friends of the man who is the
subject of this report and to the staff and prisoners of HMP Hull following his
tragic death.
Despite being a distressing and difficult time for all those who knew the man
or who have assisted in the events surrounding his death, the enquiry team is
grateful for the consistent support and co-operation received during their work.
My investigators would like to extend their gratitude to the Director of
Professional Development at Eastern Hull Primary Care Trust for undertaking
the clinical review.
I thank Humberside Police for their assistance during the course of this
enquiry. I am also grateful to the former Governor of HMP Hull and his
colleagues for their assistance.
This report includes extensive recommendations to the prison and I have also
written to the Governor to express concern about the alleged lack of
appropriate action by two of the nurses on duty on the morning of the man’s
death. Subsequently I have been informed that the prison and Primary Care
Trust have jointly commissioned a disciplinary investigation, which is still
proceeding.
This version of my report, published on my website, has been amended to
remove the name of the deceased and the names of staff and prisoners who
were involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2005
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Contents Page
Summary 4
Background 6
The man who is the subject of this report 7
Conduct of the investigation 8
Post Incident response 9
Compliance with Prison Service procedures 10
Findings 13
Conclusions 14
Recommendations 15
3
Summary
1 The man was born in November 1958 and was 45 years old at the
time of his death. He was a sentenced prisoner serving ten years for
arson and was first received at HMP Hull on 26 February 2002. At the
time of his death he was subject to F2052SH management, the
current document having been open since 10 January 2004.
2 On the evening of 24 May 2004 the man went to bed as normal. He
was observed throughout the night and comments were made in his
F2052SH indicating he had been moving throughout the night which
would have satisfied night staff that he was alive and well.
3 At approximately 7:10am the nursing assistant checked the man’s cell
and noticed he was a ‘funny colour’. This was reported to the night
staff, who are also reported to have commented ‘he is always an odd
colour’ and no further action was taken at the time. The nursing
assistant then completed the F2052SH and commented ‘the man
appears to be sleeping on his stomach, breathing evident but had
poor colour, slightly bluish’.
4 At approximately 7:40am, during the issue of breakfast packs, the
man did not respond when a Prison Officer arrived at his single cell to
speak to him. The officer thought something was wrong and went to
get help, which was the quickest method of raising support. He
entered the cell with a Healthcare Officer who said that the man was
dead and the alarm was raised using the radio net. An ambulance
was called immediately. The Healthcare Manager also attended the
scene.
5 In view of the man’s condition (rigor mortis and pooling of blood) a
team decision was made not to resuscitate. The Healthcare Manager
was supervising at this time. Paramedics attended at 08:08 and
pronounced death at the scene.
6 The cell was sealed and investigations into the man’s death
commenced.
7 On 30 September 2004 a meeting was held at Hull PCT to discuss
the procedures and developing practices for Prison investigations
within the Hull / Humberside area.
Present at the meeting were representatives from:
Prisons and Probation Ombudsman (PPO)
Eastern Hull Primary Care Trust
HMP Hull
Investigation Team
4
Note:
Two points cause concern and remain unanswered.
1. If the Nursing Assistant was correct and the man was alive and
breathing at 7:10am when she reported to the trained staff on duty that
he looked ‘a funny colour’, action at that time might have altered the
outcome.
2. Uncertainty about the time of the man’s death questions the accuracy
of the Nursing Assistant’s observation that he was alive and breathing
at 7:10am.
5
Background
HMP Hull
8 Hull is a Victorian prison opened in 1870 to hold both men and
women. It is now a Category B local prison serving courts in East and
North Yorkshire and North Lincolnshire. A major expansion
programme, completed in late 2002, added 356 places to the prison’s
operational capacity and a further 40 places were added in March
2004. The certified normal accommodation is 812 but the operational
capacity (the maximum number of prisoners who can be held) is
1071.
9 The Health Care Centre (HCC) at the prison is a new purpose built
two storey building which opened in April 2003. The HCC provides
24-hour nursing care with the in-patient unit being located on the
upper level of the building.
10 The last audit by the Prison Service Standards of compliance with
Suicide Prevention and Self Harm Reduction standards which are
incorporated into the standard on Safety were rated as Good 84%.
The overall rating for the Establishment was Good.
11 In her recent report, Her Majesty’s Chief Inspector of Prisons states:
Some good work was being undertaken in the areas of suicide and self harm prevention
and anti-bullying.
The comprehensive policy relating to the management of those prisoners at risk of suicide
and self-harm was reviewed annually and the suicide and self-harm prevention committee
met regularly. These meetings were well attended and there was good interrogation of
statistics along with clear follow-up action of identified points of concern. F2052SH (self-
harm) documentation contained good entries and there were effective management
checks. Given that around 40 prisoners were the subject of F2052SH documentation at
any time, it was impressive that many staff had a clear understanding of the prisoners for
whom they were responsible and who needed support. Reviews were conducted on time
but sometimes took place without the required number of staff being present or with staff
who were not familiar with the prisoner. Some support plans were poor. A good listener
scheme was in place.
It says a great deal for the prison’s managers and staff that they had nevertheless
managed to retain a largely safe and decent environment in the prison. Hull was a well-
run prison, with some good suicide and self-harm, anti-bullying and diversity work. It
was providing good quality education, training and PE, and strengthening its
resettlement work. A new unit, the Minos centre, had recently been opened to bring
together all elements of reintegration work and provide interventions to meet prisoners’
needs. A new regime ensured that prisoners were out of their cells for a considerable
period each day, unlike in many local prisons that we inspect.
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The man who is the subject of this report
12 The man was born in November 1958 and was aged 45 at the time of
his death. His details indicate that he had no stable home and was
registered as ‘no fixed abode’. No details of his next of kin were
available to the Prison Service. He was described as a loner who
suffered from depression. He had, in the past, taken part in therapeutic
programmes aimed at ‘beating the blues’ and had also participated in
counselling groups.
13 From 10 January 2004 he was subject to day-to-day management on a
F2052SH. (F2052SH is a Prison Service procedure which provides
staff support and vigilance to prisoners thought to be at risk of harming
themselves.) He had a history of refusing meals and also anti-
depressant medication whilst he was on E Wing.
14 He was located in the Healthcare Centre from 5 April. Since his
admission to healthcare he was subject to care planning via three
systems – F2052SH support plan and review system, Healthcare PCT
care plans and the Risk Management Plans written by the Mental
Health In-Reach team (MHIRT). Following his admittance to the
Healthcare Centre, formal F2052SH reviews ceased and were replaced
by clinical reviews. The last review was on 9 April.
15 Throughout his stay in the Healthcare Centre the man was described
as barely eating. He ate and drank just enough to maintain his health.
He had a good relationship with the Chaplaincy department and
attended services in the Healthcare Centre.
7
Conduct of the Investigation
16 Conduct of the investigation drew upon both written documentation and
interviews with key witnesses and other interested parties. Members of
the enquiry team interviewed prison staff, who were given the
opportunity to have a work colleague or a trade union representative
with them, and a member of the local staff care team was available for
support. To ensure the accuracy of the team’s recollection of the
events, all interviews, with the consent of the staff involved, were
taped.
17 Documentation pertaining to the man’s custodial history was examined
in detail, including:
Main prison record
History Sheets
F2052SH
Sentence Plan
Inmate Medical Records
18 In addition to the documentation relating directly to the man’s death,
enquiries were made to ascertain the level of compliance with relevant
local and national procedures. Further documentation relating to the
establishment’s policy on managing those thought to be at risk from
suicide and self harm was examined to establish its adequacy and the
degree to which it was implemented within the establishment.
19 The man’s family were visited by my PPO Investigator and the Senior
Investigator. My PPO colleague made a note of the concerns and
issues that the family wished to bring to the attention of the
investigation team.
20 The enquiry team had the opportunity to speak with the Police
investigation team and are grateful for their co-operation.
21 My investigator made arrangements for a clinical review of the man’s
case. I am grateful to the Eastern Hull Primary Care Trust for their
report.
22 A notice to both staff and prisoners was issued by the Investigation
team, extending an invitation to submit any relevant evidence
concerning the death of the man. I am obliged to the Chairman of the
Hull branch of the Prison Officers’ Association for his contribution.
8
Post Incident Response
23 The Duty Governor attended the Healthcare Centre when the alarm
was raised. The paramedic who attended the scene pronounced the
man dead at 8:08am. The prison’s contingency plans for a death in
custody were activated. The cell door was locked awaiting the arrival of
Police Officers.
24 At 9am Police Officers and Scene of Crime Officers attended and the
investigation into the death of the man commenced. The death was
notified to those persons and organisations listed in Hull’s contingency
plans. A hot debrief took place at 11.05am. Ongoing support for staff
was given by the staff care team.
25 The Police informed family members of the man’s death by telephone
whilst trying to establish next of kin details.
26 Notification of staff and prisoners took place through internal notices on
25 May and Hull’s Death in Custody action checklist was completed.
28 The Senior Investigator and my investigator visited family members on
5 July. The family did not wish to take up an offer to visit the prison.
9
Compliance with Prison Service procedures
Clinical Care
29 Standards of healthcare in prison are intended to mirror those available
in the outside community. The man’s prison records indicate that he
was given an appropriate level of care. The medical aspects of his case
are described in the independent clinical review.
30 There is obvious concern regarding staff’s reaction when notified by a
nursing assistant of the man looking a”funny colour”. The fact that this
comment was not delivered with any sense of urgency and contradicted
the subsequent entry in his F2052SH of “looking bluish” is a matter of
concern dealt with in this report.
Two points cause concern and remain unanswered.
1. If the Nursing Assistant was correct and the man was alive and
breathing at 7:10am when she reported to the trained staff on duty that
he looked ‘a funny colour’, action at that time might have altered the
outcome.
31 Uncertainty about the time of the man’s death questions the accuracy
of the Nursing Assistant’s observation that he was alive and breathing
at 7:10am.
Follow up to a Death in Custody
32 Prison Service Order (PSO) 2710 refers to each prison’s
responsibilities following a death in custody. These had to be
addressed in a letter from the author of this report with an apology
when the paperwork was reviewed on the investigation team’s arrival.
More care in relation to details supplied to external bodies should be
taken by managers completing this paperwork, as errors are
embarrassing to the Prison Service and cause distress to the family.
Contact with Family
32 There has been criticism from a family member over the way she was
informed of the man’s death, which was during a telephone call from
the police. The police, however, argue that this was unavoidable. The
man’s family was somewhat estranged from him. It was while
investigations were underway to establish next of kin details that the
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police found themselves talking with one of the man’s sisters. This put
them, again, in the unavoidable position of having to disclose his death
over the telephone. Once next of kin details were established these
were passed on to the prison, which made prompt contact and
established a liaison person.
Notifying other Prisoners
34 It is mandatory to notify other prisoners of a death, especially friends
and associates of the deceased in the establishment (PSO
2710.32.18).
35 It is clear that staff communicated the news of the man’s death to other
inpatients in the health care centre promptly. A notice to prisoners was
subsequently published notifying the rest of the establishment.
Support for Staff
PSO 2710 states at Chapter 5 that the prison’s Care Team must establish contact
with any member of staff who was involved in, or might be affected by, a death to
offer support. Some staff have complained that they were offered insufficient support.
The same chapter of the PSO goes on to say that:
‘’ If required, the Staff Care and Welfare Service will arrange for a Critical Incident
Debrief to take place – this is an opportunity for staff involved to meet together
informally with trained debriefers to review what they know of the incident, their
thoughts, impressions and feelings. Participants will have the opportunity to talk
about how they are coping and any concerns that they may have for the future.’’
There is no evidence that a Critical Incident Debrief took place or was even
considered.
Record Management and Incident Recording
36 Investigators were given copies of the man’s Inmate Medical Record,
Main record, previous and current F2052SH booklets, incident logs and
contingency action plans. In the event of a death it is good practice for
Prison Service staff who have been involved in the episode to prepare
a written statement promptly after the event.
37 These statements also assist the inquest at which staff might be
required to give evidence, as well as enabling the Prison Service to
demonstrate accurately the care provided to a prisoner who has died.
In this particular case there was a time delay of some days before
health care staff wrote accounts of the incident.
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Policies / Protocols
38 Suicide and Self-Harm
A current suicide and self-harm prevention policy document is in place.
Regular suicide prevention meetings take place, which are
appropriately minuted and circulated.
39 Medication
At the time of the man’s death there was no available protocol covering
the administration of medication to patients resident in the Healthcare
Centre. No written guidance was available to Healthcare staff on action
to take if there was doubt regarding the patient actually digesting his
medication.
40 Case reviews were conducted and recorded in care plans. The details
of these reviews were not transferred into the F2052SH, which would
have demonstrated appropriate interaction between medical and non-
medical staff who were involved in the man’s care.
Extract from PSO 2700
Routine case reviews are not required when a prisoner is located in the HCC on a regular
scheduled basis in recognition of the fact that the prisoner will in this circumstance have a
nursing care plan. However, it is good practice to do so when possible, and a nursing care plan must
not be used in place of the F2052SH. A case review must be conducted in the HCC:
• When a prisoner harms themselves (unless an alternative review level in the event of further self-harming is
specified in the support plan).
• Prior to the prisoner’s discharge to normal residential accommodation.
Contingency Plans
41 The establishment had in place contingency plans adequate for the
purpose. On being alerted to the incident the emergency services were
contacted. Following the man’s death the cell was sealed pending the
arrival of the police. A hot debrief was conducted for staff involved in
the incident.
42 Procedures following a death in custody as set out in PSO 2710 were
followed. The incident was reported as required, support for staff and
prisoners was in place, and follow up support for the family was
offered.
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Findings
43 The effective management of those at risk of self harm and suicide
within the Healthcare Centre is flawed due to the separation of PCT
Clinical reviews, support plans, MHIRT assessment and support plans
from the F2052SH process. Continuity of communication and support
does not appear to be adequate.
44 Comments and observations in F2052SH were, in some cases,
inappropriate and incomplete. Subsequent management checks
failed to highlight or challenge these issues.
45 There is a blurring of boundaries, accountability and responsibilities
regarding the management of PCT nurses, prison employed nurses
and Healthcare Officers, which should be addressed to ensure clarity.
A standardised approach to working practices and protocols and a
more balanced and focused method of operation and delivery are
required.
46 There are no working protocols for the issuing of medication within the
Healthcare Centre.
47 There are systems in place where prisoners are allocated the status of
special unlock procedure where two and three discipline staff are
required to unlock and supervise prisoners. It has been found that the
Inpatient Centre has operated on a regular daily basis with a single
Prison Officer on duty.
48 The Healthcare Centre is an important part of the establishment but it
seems to have been left to function independently, devoid of a tangible
link to provide effective support, which is necessary to ensure complete
compliance with Prison Service standards and integration into the wider
regime at the prison.
49 The written reports of the incident by staff at the scene and those who
had managed the man over the weeks were brief and lacked clarity and
detail.
13
Conclusions
50 According to the published post mortem report the man’s death was
due to a Chlorpromazine overdose. This is not completely in accord
with the toxicology report, which does not confirm death due to
overdose but the enquiry team accepts the view of the Post Mortem
that the cause of death was a Chlorpromazine overdose.
51 There is serious concern over the response of healthcare professionals
when the initial indication of a potential medical emergency was raised.
This should be considered by the appropriate regulating professional
body.
52 The arrangements for issuing medication to inpatients were not
standardised nor do they refer to any increase in risk to prisoners who
may be identified for not taking, storing or abusing medication. The
breakdown in the successful identification of an increase in risk,
regarding formal assessments, lies within the communication problems
between the PCT, MHIRT and Hull Prison.
53 Management of the F2052SH documentation within the Healthcare
centre is flawed by a lack of coordination and understanding. During
the course of this investigation the Senior Investigator found repeated
errors. He addressed these with the individuals and departments
concerned and the Suicide Prevention Coordinator.
54 The contingency planning procedure at Hull is good and was effective
in this case. The Post Incident response following the confirmation of
death was generally good. However, arrangements for attending to the
care and welfare of staff involved have been difficult to confirm and
there is no evidence that consideration was given to holding a Critical
Incident or operational debrief.
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Recommendations
Local
1. Eastern Hull Primary Care Trust should take full responsibility for the
management of the provision of nursing resources within HMP Hull.
Prison Officers should be retained within the Healthcare Centre to provide
the necessary application of mandatory systems regarding security, order
and control and compliance to Prison Service Standards, Audit
requirements and KPT delivery.
Pending implementation of recommendation 1, immediate action should be
taken by PCT Nurses, Healthcare Officers and the prison employed nurses
to standardise the practice, management, enquiry and accountability for
the following issues:
o Duty of Care
o Healthcare standards
o Clinical Governance
o Prison Security
o Prison Service Standards and Audit procedures
o Mandatory Training
2. Consideration must be given to the commissioning of a full discipline
investigation to enquire into any lack of care given by the two Grade E
Nurses, in accordance with the professional standards laid down by the
Nursing and Midwifery Council.
3. Complete and comprehensive multi – disciplinary F2052SH reviews
should be conducted while prisoners are in-patients in Healthcare with
appropriate representation from all concerned.
4. A system should be put in place for routine checks of F2052SH
documentation throughout the working day by managers working in the
area. Checks should consider the compliance of observations against
the support plan, and risks reassessed.
5. A named member of the prison’s Senior Management Team should be
provided as a formal mentor/supporter in addition to the PCT
Healthcare Management Team, ensuring that nursing is fully integrated
into the establishment. Clear terms of reference for mentorship/support
should be drawn up and agreed by both parties. The mentor should
attend the monthly healthcare meetings to assist with the management
of any issues that may crossover or compromise different healthcare
and prison priorities.
6. The mentor should participate in the compilation of action plans in
response to Prison Service and PCT audits and reports, ensuring that
neither body is compromised by failing to understand each others
governance responsibilities.
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7. A joint review of systems, protocols and procedures within the
Healthcare Centre should be a priority for the Management Team in
partnership with the PCT. All these protocols should incorporate
management checks to ensure they are overseen, managed and
auditable.
8. All Prison Service standards and local audit applicable to the
Healthcare centre should be managed as part of the local self - audit
system. Information gained during the self – audit process must be
shared with the relevant agencies involved in the delivery of care.
9. Prisoners deemed to be subject to special unlock procedure should be
appropriately risk assessed and allocated achievable levels of
supervision. Where supervision cannot be sustained for any reason,
alternative systems must be introduced which ensure continuity of care.
10. An audit of the F2052SH system should be completed and the results
included in the training plan.
11 The training plan should also include training on report writing and
standards for record keeping and should be available to all staff.
12 The Governor should review arrangements for attending to the care and
welfare of staff after the death of a prisoner. In particular he should ensure
that the prison is compliant with the requirement set out at paragraph 5 of
Chapter 5 of PSO 2710 for consideration to be given to setting up a Critical
Incident or operational debrief after any such incident.
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