Individual at Kirkham

A death in custody at
HMP Kirkham – June 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2004
This is the report of an investigation into the circumstances of a
death of a man at HMP Kirkham on 19 June 2004. The man’s cause
of death was intracerebral haemorrhage (bleeding inside the brain).
All deaths of prisoners in custody are investigated, including those
due to natural causes. The responsibility for carrying out these
investigations traditionally fell to the Prison Service itself, but has
now been passed to the Prisons and Probation Ombudsman (PPO),
as I can bring greater independence to the task.
The investigation has been carried out by one of my investigators
and my Deputy carried out a review into the man’s clinical care and
treatment.
We would like to extend our condolences to the man’s family for
their loss. We would also like to thank the Governor in charge of
Kirkham, and the other members of his staff who assisted with this
investigation. We found staff helpful and all the documentation we
might require already gathered together for us.
Stephen Shaw October 2004
Prisons and Probation Ombudsman
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Contents
SUMMARY......................................................................................................................................4
BACKGROUND...............................................................................................................................5
HMP KIRKHAM.............................................................................................................................7
INVESTIGATION PROCESS.........................................................................................................8
THE INCIDENT AND EVENTS LEADING UP TO THE DEATH...............................................9
POST INCIDENT RESPONSE......................................................................................................11
LEVEL OF COMPLIANCE..........................................................................................................13
FINDINGS......................................................................................................................................14
CONCLUSIONS.............................................................................................................................15
RECOMMENDATIONS................................................................................................................16
RESPONSE TO RECOMMENDATIONS.....................................................................................16
GOOD PRACTICE........................................................................................................................17
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Summary
The man was born on 17 January 1965 and was 39 years old when
he died on 19 June 2004 from an intracerebral haemorrhage. At the
time he was serving a four­year sentence at HMP Kirkham, an open
prison near Preston.
The man’s records were checked by PPO staff and a clinical review
was carried out. We have found that the man’s death was not
connected to the fact that he was in prison, or to the level of care
that he received there.
This report makes a recommendation in relation to general record
keeping systems in Healthcare at HMP Kirkham.
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Background
The man was arrested on 27 July 2003 and charged with two
offences: wounding with intent to cause grievous bodily harm and
theft. He was remanded into custody at HMP Forest Bank. The man
appeared in court on 13 October 2003 and was committed to Crown
Court and granted bail to appear at a later date. On 14 January
2004, he was convicted for the offence of wounding with intent to
cause grievous bodily harm, but cleared of the second charge. He
was sentenced to four years in prison and had an EDR (Earliest Date
of Release) of 13 January 2006. The man had previously been in
prison, but this had been many years ago.
The man lived in Manchester with his partner, (who since his death
has taken on his surname) and their two children. The man had
named her as his next­of­kin when received at Kirkham. He also
had two other children from an earlier relationship who live with
their mother.
Both of the man’s parents are living, as are five brothers and four
sisters. It is a large supportive family and relations between his
partner and his blood relations are good.
The man’s father was asked by PPO staff whether he had any
specific concerns about the circumstances surrounding his son’s
death. He said that he was concerned that, when his son reported a
migraine headache on 18 June 2004, his treatment consisted only of
being given some medication with advice to rest in bed. He
wondered whether his son’s life could have been saved had he been
taken to hospital and a scan conducted. He said that his own life
had been saved a while ago when a scan had detected a
haemorrhage, which had been successfully operated upon. PPO
staff contacted the man’s partner who was also asked whether she
had any particular concerns. To date, she has not informed the PPO
of any such concerns.
My investigator spoke to three prisoners who knew the deceased.
My investigator was told that the man was a person who was always
laughing and joking and who was very popular. The prisoners asked
for their condolences to be sent to his family. Prisoners also made a
collection for his partner, which raised a large amount of money.
One of the prisoners to whom my investigator spoke said that the
man often seemed to be suffering from headaches and would walk
around holding his head in his hands. He added that Healthcare
staff often dismissed prisoners’ complaints believing that prisoners
were trying to avoid work.
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Another prisoner said that even though prison management had
spoken to prisoners as a group following the man’s death, he felt
that individual counselling should have been offered.
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HMP Kirkham
HMP Kirkham is a category ‘D’ open training prison with
accommodation for around 600 adult males. Kirkham is a working
prison with workshops, a farm and gardens. It occupies the site of a
former Royal Air Force Technical Training Establishment which was
built during the 1939­45 war and used post­war as a major
demobilisation centre. The facility was taken over by the Home
Office in the early 1960s and has been in use as a prison since
1962. Starting in 1990, the original accommodation blocks have
gradually been replaced with modern blocks each accommodating
around 20 prisoners. All prisoners occupy single bedded rooms.
The prisoner’s room was in block F7. Locking and unlocking of the
main door to each block is controlled by prison staff, although
prisoners hold individual keys to their own rooms for which prison
staff hold master keys. Less than 100 metres from block F7 is a
permanently staffed prison wing office.
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Investigation process
My practice in cases of apparent deaths from natural causes is to
conduct an initial review to determine the extent of investigation
required.
My investigator visited Kirkham on 23 June 2004 and he went to
block F7 where the man was held. My investigator spoke informally
with a number of staff to outline the facts relating to the man’s
death and was given access to all of his prison records, including the
medical records.
The prison had taken statements from all staff who had had any
significant involvement with the man immediately before, and then
following, his death.
My investigator was given copies of all relevant records.
My investigator met the Chairman of the local Prison Officers
Association (POA) and spoke by telephone to the Chair of the
Independent Monitoring Board (IMB). Neither had any issues which
they wished to draw to the PPO’s attention.
My staff sent letters to the man’s partner and father. Both were
also contacted by telephone. The only specific concern that was
raised by either was the father’s question about whether his son
should have been referred to hospital for a scan.
The Deputy Ombudsman, a qualified nurse, carried out a clinical
review.
No formal interviews with staff were conducted. This report is based
upon a thorough review of all relevant paperwork, including the
written statements made by staff and the man’s clinical records.
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The Incident and Events Leading up to the Death
When the man first arrived at Kirkham on 14 January 2004 he
underwent health screening as part of a standard induction process.
The man reported having no concerns about his health. It was
recorded that he did not have a GP. At a further health check
completed several days later, a record was made that the man had
a past history of suffering migraine headaches and that he wished to
avoid working in bright light. The medical record showed that the
man attributed his migraine headaches to a road traffic accident in
which he had been involved in 2001.
Further evidence that bright light affected the man’s condition is
that on 23 May 2004 he was moved to a different room within his
block as his original room was too light. On 6 June a note was made
that the man had had no further problems following his room
change.
From the time of his arrival at Kirkham, and up to 17 June 2004, the
man consulted Healthcare on five occasions. Most of these
consultations were for complaints other than migraine, although he
did complain about migraine on 4 and 5 February 2004 for which he
was appropriately prescribed brufen, paracetamol and propranolol.
After 5 February, the man did not again consult Healthcare about
migraine type symptoms until Friday 18 June.
On the morning of 18 June, the man saw a Healthcare Staff Nurse,
who recorded that the man had symptoms of headache, nausea and
a sensation of seeing flashing lights: all of these symptoms of
migraine. The man was given brufen and paracetamol and an
appointment was made for him to be reviewed by a doctor later in
the day. At about 1pm that afternoon a doctor confirmed the man’s
symptoms, diagnosed migraine and prescribed cocodomol. The man
then returned to his room to rest in bed and a notice was affixed to
the room door stating that he was authorised to rest in his billet.
At the afternoon roll call, which took place at around 3.45pm, the
man was not standing at his room door, as should have been the
case. Instead, he was lying awake in bed. The Prison Officer who
was conducting the roll call asked the man if he was all right, to
which he answered that he was. At 8.45pm, the same Prison Officer
carried out the final roll call of the day. Once again the man was
lying awake in bed and he again informed the Prison Officer that he
was all right.
The man’s room door was still locked at the time of the 10.45am roll
call on Saturday 19 June 2004. He would have locked the door
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himself, presumably on Friday night. The Prison Officer who was
conducting that roll call looked through the observation window and
saw the man lying in bed. He appeared to be asleep. This did not
arouse any suspicion in the Prison Officer’s mind as prisoners were
allowed to sleep late at weekends. Having completed the roll call,
the Prison Officer returned to the wing office. A few minutes later a
friend of the man knocked his door to wake him, as at weekends
brunch was served at 11.15am and he would not have wanted to
miss this meal. Unable to obtain a response, the other prisoner
realised that something was wrong and he pressed the alarm button
setting off an alarm bell in the wing office. The time was then
10.55am. A Prison Officer went immediately from the wing office to
block F7. He unlocked the man’s door and, on entering, found him
to be unresponsive although his body was still warm to the touch.
The Prison Officer radioed for assistance, including support from
Healthcare. During this call he was asked whether the man was
conscious, whether he had a detectable pulse or signs of breathing,
whether an ambulance was needed. The Prison Officer was unable
to detect a pulse or signs of breathing, but before he was able to do
anything else, the Staff Nurse, together with a Student Nurse,
attended the scene. The Staff Nurse commenced cardiopulmonary
resuscitation (CPR). The time was now 11.00am. Ambulance
service paramedics arrived on scene at about 11.20am and they
joined in with the attempts to resuscitate him. Unfortunately all
efforts proved unsuccessful and attempts to resuscitate were ceased
at 11.40am.
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Post Incident Response
The Governor was not on duty on 19 June 2004, but he went into
the prison when notified of the man’s death. Among other things,
the Governor needed to consider how best to break the sad news to
the man’s partner. As it was the weekend, the prison was operating
with reduced staffing levels, including a reduced number of senior
staff. Moreover, it would have taken over an hour to travel to
Manchester and the Governor did not want the partner to hear the
news from a third party. On balance, the Governor considered that
the best option was to ask for officers from Manchester Police to
visit.
When police officers visited the address they had been given they
found the house boarded up and they informed the Governor about
this. Shortly afterwards, the Governor was told that a letter from
the man’s partner had been found in the post room in which she
gave her new address. The Governor contacted Manchester Police
again to ask for a visit to be made to the new address. Before the
visit could be made, however, the man’s partner’s daughter
telephoned the prison as she had heard from other sources that her
father had died. Very shortly after this call Manchester Police
confirmed that they had visited the man’s partner at her new
address and had informed her of the death. Shortly afterwards, the
man’s partner telephoned Kirkham and spoke to the Governor.
Later that same day the Governor also spoke to the man’s father
when he too telephoned the prison.
The man’s family were offered the opportunity to visit the prison and
to see the man’s room, however the family did not take up this
offer.
The Governor at Kirkham, accompanied by the prison’s Head of
Operations and Principal Officer, spoke to the prisoners as a group
about the man’s death. Prisoners were reminded about the support
that was available to help them cope with the incident: Listeners;
the duty officer; the chaplaincy; their own friends in the prison. The
Governor spoke individually to two prisoners whom he considered
potentially the most vulnerable – one was the man who had tried to
rouse the man and had then raised the alarm when unable to do so;
the second was a prisoner who was understood to be related to the
man. During the remainder of 19 June 2004 and through the
following day prison staff made a point of being around and
available for prisoners to speak to them if they wished to do so.
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A notice about the man’s death was posted in all residential areas in
Kirkham inviting prisoners to contact staff or a listener if they felt
they needed counselling.
To ensure preservation of evidence, the man’s room was sealed as
soon as it was practicably possible to do so. Statements were taken
from relevant staff on the day of the incident. All the necessary
information was gathered together for the purposes of an
investigation.
The man’s death was confirmed at post mortem to have been
caused by an intracerebral haemorrhage.
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Level of Compliance
Standards of health care in prison are intended to mirror those
available in the outside community. The man’s records indicate that
while at Kirkham his health care needs were dealt with adequately.
This aspect of his care is described in the independent clinical
review, which concludes that he was well looked after and there
were no major areas where his care could have been improved.
Record keeping, however, was less than adequate.
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Findings
When the man arrived at Kirkham he reported a past medical history
of migraine headaches and one of the other prisoners told my
investigator that the man seemed to suffer from frequent
headaches. Despite this, the man’s records show that he only very
rarely consulted Healthcare about this condition, although his
records do show a number of consultations with Healthcare for a
condition that might have been piles.
Regardless of why the man only rarely consulted Healthcare about
migraine headaches, the clinical review has indicated clearly that the
healthcare he received at Kirkham had been appropriate. This
included the man’s treatment on 18 June 2004 when he did report
symptoms indicating the onset of a migraine headache. The man’s
father wondered whether his son’s symptoms should have triggered
referral to hospital where a scan could have been carried out. I am
satisfied, however, that the man’s presenting symptoms did not
indicate that such a response would have been appropriate at that
time, particularly given his past medical history of migraine.
Although the clinical review found that the man’s care and treatment
at Kirkham had been appropriate, a number of deficiencies in record
keeping have been identified.
I note that Kirkham asked Manchester Police to deliver the sad news
of the man’s death to his partner. This was in line with practice in
many jails and I entirely understand why the Governor reached the
decision he did. However, I also note that the man was a relatively
young man, and his death was entirely unanticipated. Preston and
Manchester are not very far apart, and I believe that, had the
Governor or a member of his senior staff delivered the sad news in
person, this would have constituted very best practice.
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Conclusions
The man was well cared for in Kirkham and the healthcare he
received there was probably at least as good as it would have been
outside in the community. There were no indications to staff that the
man had a developing condition that ultimately proved to be fatal.
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Recommendations
I recommend that a full review of record keeping systems in the
Healthcare department take place as soon as possible. Good record
keeping promotes best practice in patient care, but also provides
safeguards in the case of legal or disciplinary action. Both the
General Medical Council and the Nursing and Midwifery Council are
resolute on this matter.
Response to recommendation from HMP Kirkham
In response to the recommendation on record keeping made in the
PPO’s draft report, the Governor at Kirkham wrote that the following
would take place:
¨ During September/October 2004 an internal audit of Inmate
Medical Records (IMRs) and pharmacy will take place which
will be consistent with Nursing and Midwifery Council (NMC)
guidelines.
¨ All Staff Performance and Development Records will include
specific reference to standards and responsibilities in relation
to record keeping, with immediate effect.
¨ A sampling exercise will occur twice yearly to ensure
compliance with NMC guidelines. There will also be a feedback
report to the Senior Management Team meetings, twice
yearly, to monitor progress in this area.
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Good Practice
A full investigation might have revealed aspects of the man’s
treatment that amounted to good practice, but in this case, where
the death was clearly due to natural causes, the more limited type
of investigation that has been conducted has not brought these to
light.
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