Individual at Kirkham

Investigation into the death of a man, who died in hospital
on 20 May 2005 whilst a prisoner at HMP Kirkham
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2006
This report concerns the death from apparent natural causes of a man in hospital in
the early hours of 20 May 2005. He was aged 50, was a prisoner at HMP Kirkham.
The man suffered from liver disease. He had been taken from Kirkhamto a medical
centre on 30 April after complaining of abdominal discomfort and reduced urine
output. From there he was admitted to hospital where he remained until his death.
During his time in hospital, the man had fluid drained from around the liver and
underwent emergency surgery for an incarcerated umbilical hernia. On 10 May, his
condition was reported to have deteriorated and on 11 May he was transferred to
the Intensive Care Unit. Unfortunately, the man’s condition continued to deteriorate.
The post mortem report concluded that he died from pneumonia secondary to
cirrhosis of the liver.
I would like to extend my condolences to the man’s family for their loss. During this
investigation, the family raised a number of concerns that I hope this report
addresses.
I thank the duty governor and the other staff members at Kirkhamwho assisted my
investigators. I am also grateful to Fylde Primary Care Trust for their review of the
man’s clinical care.
Four recommendations are made in this report. I have also identified three
examples of good practice.
This version of my report, published on my website, has been amended to remove
the names of the deceased and the names of staff and prisoners who were involved
in my inverstigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2006
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Contents
Summary
The Investigation
The Man
HMP Kirkham
Events leading up to 30 April 2005
Events from 30 April 2005 to 20 May 2005
Events after the man’s death
Key Findings and Conclusions
Recommendations
Good Practice
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Summary
The man was born on 31 January 1955. He had a history of drug and alcohol use
and had serious liver problems for which he was undergoing clinical investigation in
the community.
On 4 April 2005, his was sentenced to nine months imprisonment for possession of
a ‘firearm’, which was in fact a CS gas canister and an attempt to convey these
items into prison. He was received into HMP Preston, where he underwent a
detoxification programme. When this was complete, he transferred to Kirkham
prison on 22 April.
The man’s health gave cause for concern whilst at Kirkham. He was given
medication for pain relief, but continued to be unwell. On 30 April 2005, he attended
the prison healthcare centre complaining of abdominal discomfort. The nurse who
examined himconsidered it necessary to refer him to a local medical centre and he
was admitted there some hours later.
From the medical centre, the man was transferred to hospital where, over several
days, he was treated for liver problems. He underwent emergency surgery for an
incarcerated umbilical hernia on 9 May. Subsequently, the man’s condition
deteriorated and he was admitted to Intensive Care on 11 May. He died there on 20
May, with his family around him.
The post mortem report concluded that the man died from pneumonia and cirrhosis
of the liver. A clinical review carried out by Fylde Primary Care Trust concluded that,
although the surgery for hernia was not expected or planned, it was necessary and
appropriate. It also indicated that the man’s particular health issues significantly
affected the outcome of what would normally have been a routine operation.
I judge that he received healthcare that was comparable to that which he could have
expected if he was living at home. However, I raise a question about the medication
with which the man was issued for pain relief and a recommendation is made to
provide additional safeguards in this area. I have made three other
recommendations and identified three examples of good practice.
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The Investigation
The investigation was opened on 2 June when one of my investigators contacted the
appointed prison liaison officer, a governor, to arrange to an initial visit to Kirkham
on 27 June.
One of my Family Liaison Officers made contact with the man’s partner to establish
what concerns she wished the investigator to follow up on her behalf. The man’s
partner was concerned about how quickly her partner’s health had deteriorated in
hospital between 9 and 10 May. She was also concerned that he was not able to
keep a hospital appointment for a biopsy. She also said that, until she phoned at
9.45pm on 30 April, she had not been informed by the prison that he partner had
been taken to hospital earlier that day.
My investigator visited Kirkham on 27 June to familiarise herself with the prison,
particularly the houseblock where the man resided. She returned on 13 July and
spoke with members of the healthcare centre staff. She also examined prison
records and documentation and spoke with relevant staff.
An independent clinical review of the man’s healthcare was carried out by Fylde
Primary Care Trust.
In January 2006, after submitting a draft report, one of the investigators stopped
working for my office. This investigation was subsequently passed to the second
investigator to complete.
In order to complete the report and answer a number of outstanding questions, my
colleague spoke with healthcare staff who were involved in the man’s care. She
also contacted the Clinical Reviewer ­ Fylde NHS PCT, the Prison Duty Governor,
and the Coroners office.
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The Man
The man was born on 31 January 1955. He had a history of drug and alcohol use
dating back to his youth, and had appeared before the courts on numerous
occasions mainly concerning offences relating to his dependency on drugs. The
man had held several jobs. However, his drug use, and later his health problems,
diminished his ability to hold down a job and before his conviction he had been
unemployed for a number of years.
His family described him as a caring person who lived for his close knit family. He is
survived by his daughter aged 26 and son aged 16 who deeply feel his loss. The
man had struggled for much of his life with addiction. He was hoping that his
detoxification while in custody would have enabled him to turn his back on Heroin.
He leaves a huge gap in the family and he was will be greatly missed”.
The man had serious liver problems and was undergoing clinical investigations for
these. A probation report dated 31 March 2005 stated that he told his probation
officer that he had been frightened by recent symptoms and was trying to cut down
on his drinking as a result. He was also seeking help for his drug dependency.
On 4 April 2005, the man was sentenced to nine months imprisonment for
possession of a firearm, namely a CS gas canister, and an attempt to convey this
and other items into prison. He was received into HMP Preston on 4 April and
transferred to HMP Kirkham on 22 April.
The man had been in Kirkham only a short time before his admission to hospital on
30 April. However, he had a good friend in the prison and had maintained regular
contact with his partner and his family, who were supportive. The man received
regular visits whilst in prison and latterly whilst in hospital.
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HMP Kirkham
HMP Kirkham is a category D training prison for adult men. Accommodation is
provided in single­storey houseblocks; workshops and a sports centre are provided
on site.
Kirkham provides accommodation for approximately 590 prisoners. Facilities enable
a daytime, evening and weekend education programme to be delivered. Prisoners
are employed in the prison’s workshops, farm, garden and works departments, and
there are opportunities for some prisoners to gain paid employment, community
work and college placements in the local community.
Healthcare is provided by qualified nurses between the hours of 7.30am and 5.30pm
Monday to Friday, 9am – 3pm Saturdays and 10am – 4pm Sundays and Bank
Holidays. There is no inpatient facility. Prisoners are referred to a medical centre if
they have a medical problem which requires a doctor’s opinion or to Accident and
Emergency at the local hospital in case of emergency. Prisoners generally attend
healthcare for medical problems, but in case of emergency the nurse visits them in
their residential blocks.
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Events leading up to 30 April 2005
The man was sentenced to nine months imprisonment on 4 April 2005 at Preston
Crown Court. He was received into HMP Preston the same day and his healthcare
needs were assessed. It was noted that he had cirrhosis of the liver and that he had
a hospital medical appointment arranged by his own GP for 25 April. The man was
already being prescribed methadone for his drug dependence and was noted to
have concerns about the detoxification programme along with his liver problems.
He was seen again by healthcare staff on 5 April. A drug assessment was carried
out and a reduction programme recommended. It was also noted that, because the
man knew the date and time of his appointment for a liver biopsy, his appointment
would be rearranged for security reasons.
On 15 April, the man was noted to be on the transfer list for Kirkham prison.
However, he was unable to transfer at that time as his opiate reduction programme
had not been completed. It was recorded that this was explained to the man who
accepted the explanation. It was arranged that he would be transferred when his
programme was complete.
No further entries were made in his medical record during his time in Preston.
However, his medication administration record chart indicates that he was given
paracetamol on 19 April, presumably for pain relief.
On 22 April, the man was transferred to Kirkham. A health check was carried out on
reception which noted ‘alcoholic liver disease’. It was also recorded that he had an
outstanding appointment, but that he did not know when this was.
A Sports Centre Action Plan dated 25 April 2005 states that the man discussed his
hernia with a Physical Education Officer (PEO). He had been told that he was not to
attend the gym until he had seen the doctor and been given the okay. A copy of the
‘Sports Centre Weights Room Induction Competence Sheet’ shows that the man
demonstrated a safe technique when using gym equipment. This was assessed
using 1kg weights and was considered safe taking into account the man’s medical
history.
On 25 April, he saw healthcare staff and requested a referral due to an umbilical
hernia and chronic liver disease. He said that he had undergone two unsuccessful
biopsies in the past. On 26 April, healthcare staff telephoned the man’s consultant,
and were told that she did not want to see him again. Healthcare staff requested a
letter confirming this. A letter dated 4 May was subsequently received. It stated that
The man had been listed for liver biopsy, but that the consultant had cancelled the
appointment as she did not feel that it would add any further information. Her only
question at that time was whether it was safe to treat his Hepatitis C. She noted that
the man had a further appointment at her liver clinic on 3 August 2005.
On 27 April, he was issued with 16 paracetamol tablets and 12 ibuprofen tablets for
pain relief. During interview, the pharmacy technician in the healthcare centre
confirmed that this was routinely issued to all patients as a two­day supply. She
also confirmed that, prior to issuing medication, the pharmacist will ask the patient if
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they are allergic to any medication. She relies on patient reporting and information
on allergies noted in red on the front of the patient record for information, rather than
information received from the reception health screen. The pharmacy technician
agreed that paracetamol would not usually be prescribed for patients with liver
disease. It is impossible to establish the quantity (if any) of the medication that the
man took during the next couple of days, as during cell clearance following his death
it was noted that ‘a quantity’ of medication was found. However, it is unlikely that
the medication would have had a particularly detrimental effect on the man’s clinical
condition.
On Friday 29 April, at 10am, he attended the healthcare centre complaining of loin
pain. The nurse who attended to him noted that he could not take paracetamol and
therefore gave himibuprofen. Unfortunately, the attending nurse has since left the
prison and it is impossible to establish from where this information was gained. At
4pm the same day, the man returned to healthcare complaining of back pain and an
increase in abdominal swelling. Ascites (a collection of fluid in the abdominal cavity)
was noted. He was given advice regarding his diet – namely, to reduce his salt
intake and to limit his daily fluid intake to 1500mls. An appointment was made for
him to see the doctor after the Bank Holiday weekend. He was also advised to
return to healthcare if his condition worsened in the meantime.
The man did return to healthcare the following day at 1pm, complaining that the
distension of his abdomen was getting worse. His medical record noted that he was
unable to provide a specimen of urine. The nurse who examined him confirmed
during an interview that on examining the man, he was concerned that the renal
system might have become compromised. He considered this to be an emergency
situation and therefore made a referral to the medical centre. The nurse also
confirmed that the man was not complaining of problems with the hernia at that time,
and that he noted no problems with the hernia other than it being pushed out by the
ascites.
The man was taken to the medical centre at 3pm that day. From there he was
moved to hospital for investigations/assessment. The prison did not notify his
partner of this move. At 9.45pm that evening, the man’s partner telephoned to
enquire how her partner was and was told he was in hospital and would be staying
there overnight. She was given the details to enable her to contact the ward directly.
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Events from 30 April 2005 to 20 May 2005
After assessment at the medical centre, the man was admitted to a hospital medical
assessment unit.
The prison held a Release on Temporary Licence (ROTL) board on 30 April at 2pm.
A decision was made to release the man from prison custody during his stay in
hospital. This meant that prison staff were not required to accompany himand
handcuffs were not used.
The man was moved onto ward 14 for further investigations and assessment at
12pm on 1 May. Prison staff informed the man’s partner of this move and passed
on the direct telephone number for the ward.
The prison maintained regular contact with the hospital and information received
about his condition was recorded in his prison records.
An entry in the man’s prison medical record on 6 May indicates that an ascites drain
had been inserted and one litre of fluid drained. The record also states that he was
possibly to be scheduled for a liver biopsy. On 8 May, it was noted that the ascites
drain had been removed. An entry on 9 May states that he had moved wards
following surgery for ‘encarcerated’ [incarcerated] para umbilical hernia. He was
reported to be in a little pain but otherwise settled.
An officer visited the man in hospital on 10 May. He was unable to give the man his
‘allowance’ (money allocated for use whilst in custody) and was concerned by his
condition. The man was heavily sedated and unable to speak to the officer. The
ward sister had described him as ‘poorly’. The officer contacted prison healthcare
staff who contacted the hospital to be told that he was very poorly. Prison staff were
also informed that the man’s partner had visited the previous day. One of the man’s
partners concerns was how quickly her partner’s health deteriorated between 9 and
10 May. The documentation suggests that these concerns were also shared by the
officer.
On 11 May, prison healthcare staff made several telephone calls to the hospital.
They were informed that the man had been moved to the Intensive Care Unit and
had been put on a ventilator. His family had been informed and were due to see him
shortly.
The man remained seriously ill. On 12 May, he had a CT Scan of his brain which
revealed no abnormalities. Due to the apparent seriousness of his condition, a staff
nurse, in the prison, made sure that the hospital was aware of the procedure to
follow if the man died. A governor was also informed of how ill the man was.
On 16 May, he was reported to be deteriorating. On 18 May, prison healthcare staff
reported that hospital nursing staff were concerned about giving information over the
telephone. A password system was therefore set up which healthcare staff and the
prison communications department were made aware of. This ensured timely and
appropriate communication between the prison and hospital.
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Throughout his time in hospital and previously whilst in prison, the man’s family
visited him regularly and when he had moved to intensive care, they ensured that a
family member was with him at all times.
The man remained very ill. At 1.10am on 20 May the prison was informed that he
had died at 12.50am that morning, with his family at his bedside.
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Events after the man’s death
At 1.14am on 20 May, the duty governor was informed of the man’s death and went
to the hospital. Incident logs completed by the Night Orderly Officer and duty
governor record the various contacts made.
The duty governor was appointed family liaison officer and contacted the family at
9.30am that morning to make arrangements for visits. The man’s partner declined a
home visit, but arranged to visit the prison later that day. The chaplain was also
informed and asked to contact the family to offer support. Following a further
telephone call, the family rearranged to meet the family liaison officer and the
chaplain at the hospital.
At 11.00am, the duty governor was contacted by the Coroner’s Office requesting
confirmation of the man’s status as a serving prisoner. During this conversation, the
duty governor was informed that the man’s sister had raised concerns regarding him
being made to lift weights at the prison gym, despite having a hernia.
At 11.15am, the duty governor entered notes having interviewed the Physical
Education Officer (PEO) and reviewed written documentation regarding these
concerns. As noted above, a Sports Centre Action Plan dated 25 April 2005 states
that the man discussed his hernia with the PEO and that he had been told that he
was not to attend the gym until he had seen the doctor and been given the all­clear.
A copy of the ‘Sports Centre Weights Room Induction Competence Sheet’ shows
that the man demonstrated a safe technique when using gym equipment. The
assessment includes lifting weights of approximately 1kg, which the PESO
confirmed would be less than a ‘bag of shopping’. Completion of the induction
competence was not contra­indicated by the man’s reported medical condition. The
medical grading given by healthcare to himduring their initial healthcare assessment
was 1B. This does not prohibit prisoners from lifting weights but does stop them
from taking part in contact sports. The PE department staff carry out their own
assessment based on healthcare’s grading. The grading is entered by healthcare
staff on the reception health screen form and communicated to the PE department.
At 11.50am, the duty governor spoke to all the prisoners on the man’s former billet,
E4, and informed them of his death. All were offered support but only one prisoner,
who knew, the man was at work in the kitchen. The duty governor visited the
prisoner in the kitchen to tell him of his friend’s death. The prisoner was offered
support and time off work, but he declined both. Staff were briefed to offer support if
needed later.
At 3pm, the duty governor and chaplain went to the hospital in the expectation of
meeting with the man’s family. In the event, the family had been refused permission
by the Coroner to view his body and had understandably decided not to attend. The
family were offered a home visit, which they chose to decline.
On 26 May, confirmation was received of the post mortem findings and the release
of the man’s body for the funeral. The duty governor personally delivered the man’s
belongings to his partner at her home.
Incident sheets and other documentation specifically relating to a death in custody
were completed, dated and signed where appropriate. Notices to prisoners and staff
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were displayed informing them of the man’s death and advising on who to contact
for support if required. A Critical Incident Debrief was held for prison staff. This was
also extended to members of the hospital staff.
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Key Findings and Conclusions
The man had a known, serious medical condition that had existed for some time
prior to coming into custody. The evidence from my investigation indicates that the
healthcare he received whilst in prison was comparable to that which he could have
expected to receive if he was living at home. He had access to prison healthcare
quickly when feeling unwell, and was referred promptly and appropriately to
secondary care when his condition gave cause for concern.
The man was issued with paracetamol and ibuprofen tablets for pain relief. He kept
these in his possession. This was confirmed by prison healthcare staff as being
common practice unless there is specific evidence of allergies noted on the patient’s
file or reported by the patient. This investigation did not find any evidence to
suggest that paracetamol was specifically contra­indicated in his case, although it is
common for patients with liver disease not to be prescribed this drug and the prison
healthcare pharmacist confirmed this to be the case. It should also be noted that
there was no evidence to confirm whether the man had, in fact, taken any of the
medication issued to him. The cell clearance report states that ‘a quantity of
medication’ was found. It is therefore impossible to say how many tablets (if any)
the man had actually taken.
The presence of liver disease was clearly noted on the man’s initial health screening
documentation both at Preston and Kirkham, although it appears that these
documents are not routinely seen by the pharmacist at Kirkham prior to dispensing
medication. ‘Liver disease’ was not documented in the appropriate section on the
front of the drug chart. Reviewing the procedure for thorough documentation on
drug charts regarding medical conditions, and access to such documentation by the
pharmacist, may provide some additional safeguards.
The complaint/diagnosis section of the prescription chart, as well as the
‘allergy’ section, should be completed and checked by personnel prior to
prescribing/issuing medication.
The man was scheduled to have a liver biopsy at the time he was in custody in
Kirkham. However, documentary evidence on file shows his consultant cancelled
the biopsy due to an already confirmed diagnosis of cirrhosis of the liver. The man
did have an appointment to attend the Liver Clinic on 3 August.
A clinical review into the care the man received whist in prison and hospital was
conducted by Fylde Primary Care Trust. Whilst in hospital, he had surgery for a
hernia, which was not expected or planned, but which the clinical reviewer felt was
both appropriate and necessary. The review concluded that the outcome of the
man’s hospital admission was not as would normally be expected. However, in his
case, there were factors relating to his current medical conditions and the need for
powerful pain relief that made his case more complicated. Although we did not have
access to the hospital clinical records, it is understood from the clinical reviewer that
large quantities of Morphine (approximately 80mg) were administered to the man
post operatively due to the pain he was suffering. It is apparently documented that
Naloxone was given in an attempt to reverse the effects of the Morphine. This will
have been a very difficult judgement call for the hospital medical staff to have made.
As he was unwell due to the cirrhosis of his liver, required emergency surgery due to
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the incarcerated umbilical hernia, and had a history of drug abuse, the dose of pain
relieving medication required may have been above average.
There was no toxicology report at the time of post mortem. I amunable, therefore,
to comment whether the medication administered to the man whilst in hospital
contributed to the deterioration in his condition. However, it is of concern that the
quantity of morphine given to himwas such that a drug (Naloxone) to reverse the
effects was required.
A copy of this report will be shared with the hospital requesting that they carry
out an internal investigation into the medication administered to the man post­
operatively.
There is evidence that, during the man’s time in hospital, prison healthcare staff
maintained good and effective contact between the hospital and the prison.
However, the man’s partner was concerned that she was not informed about his
admission to hospital and was told only when she contacted the prison herself that
evening to enquire how he was. Kirkham’s systems for maintaining contact with
families are generally effective and there is a clear policy for notifying the next of kin
where prisoners are admitted to hospital where there are issues of a serious or life
threatening nature. Due to the number of prisoner’s who are referred to hospital,
often returning the same day, contact is not made with the next of kin until they are
admitted. At the time of the man’s admission his condition was not considered life
threatening, and therefore the reason that his partner was not contacted at the time
of his admission. The prison were informed of the man’s admission to hospital, by
the escorting officer’s at about 9.30pm on 30 April 2005, shortly before the man’s
partner contacted the prison and before the Night Orderly Officer had a chance to
make contact with her.
The Governor should arrange to explain to the man’s partner the local policy
for notifying the next of kin in emergency situations and the reasons for not
immediately notifying the next of kin for routine hospital appointments.
The action taken by prison staff following the man’s death was appropriate and in
line with Prison Service policy. Incident reports were appropriately completed, dated
and signed and the procedures for informing the necessary parties were followed.
The prison family liaison officer personally visited the man’s partner to deliver his
belongings. Support was offered to the family, fellow prisoners and staff. Staff from
the hospital were invited to the prison post­incident debrief which I note as an
example of good practice.
The cell clearance was carried out by two officers, in line with prison policy.
However, due to the fact that the medication found was not identified, nor counted, it
is impossible to establish whether the man had taken any or all of the Paracetamol
and Ibuprofen issued three days prior to his admission to outside hospital.
The exact quantity and type of medication found during cell clearances should
be documented and healthcare informed.
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Recommendations
1. The complaint/diagnosis section of the prescription chart, as well as the
‘allergy’ section, should be completed and checked by personnel prior to
prescribing/issuing medication.
2. A copy of this report will be shared with the hospital requesting that they
carry out an internal investigation into the medication administered to the
man post­operatively.
3. The Governor should arrange to explain to the man’s partner the local
policy for notifying the next of kin in emergency situations and the reasons
for not immediately notifying the next of kin for routine hospital
appointments.
4. The exact quantity and type of medication found during cell clearances
should be documented and healthcare informed.
Good Practice
5. The ‘significant events/problems’ front sheet attached to the healthcare
notes is a useful way for healthcare staff to obtain information quickly.
This helps facilitate a high standard and continuity of care.
6. I commend the quality of communication between the prison and the
hospital, in particular the use of a password before passing on confidential
medical information.
7. I commend the inclusion of the hospital staff in the prison’s post­incident
debrief procedure.
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