Individual at Leeds

Investigation into the circumstances surrounding the death
of a male prisoner at HMP Leeds in December 2005
Report by the Prisons and Probation Ombudsman
For England and Wales
June 2006
This is the report of an investigation into the circumstances of the death of
a male prisoner, in December 2005 at HMP Leeds. He was aged 37, and
died of natural causes as a result of ischaemic and hypertensive heart
disease.
My colleagues and I would like to extend our sincere condolences to his
family and friends for their loss.
One of my investigators conducted the investigation. A clinical reviewer
carried out a clinical review on behalf of Leeds West Primary Care Trust.
I am grateful to the Governor of Leeds and his staff for their full co-operation
with my investigator. I am especially indebted to the prison liaison officer who
ensured that all the necessary documentation was gathered. I would also like
to thank the members of the Prison Officers’ Association (POA) Committee
who assisted my investigator by arranging interviews with staff, and suitable
venues for these interviews to take place.
I have made no recommendations but have commented very favourably on
the actions of staff after the prisoner was discovered. I would be grateful if the
Governor would draw my comments to the attention of all his staff.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2006
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CONTENTS
Summary 4
Investigation methodology 5
Background 6
The prisoner 6
Leeds Prison 6
Key findings 7
Events leading up to the death of the prisoner 7
Events on the morning of 18 December 2005 7
The care of the prisoner’s cellmate 8
Clinical review 10
Conclusions and Recommendations 11
Annex: Clinical Review
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Summary
The prisoner died from natural causes in HMP Leeds in December
2005. He was aged 37 and was serving a sentence of 12 years
imprisonment imposed at Leeds Crown Court just over two months
earlier.
On arrival at Leeds prison, he had been given a reception health
screen at which it had been identified that he suffered from sleep
apnoea and had used a monitor. He was also found to be overweight
and at risk of coronary heart disease. Clinical investigations were
being carried out and he had started receiving treatment for
hypertension.
In the small hours of 18 December, the prisoner’s cellmate called for
staff assistance as the prisoner had collapsed in their cell. The night
staff attended the cell almost immediately, radioing for support from the
night orderly officer and the nurses.
The night orderly officer arrived at the wing at the same time as the
nurses. They joined other officers and entered the cell to attend to the
man who was lying face down on the floor. One of the nurses asked
for paramedics to attend the prison.
One of the night officers escorted the cellmate from the cell and took
him to the Listeners Suite, which is situated on the ground floor, where
he could be comforted.
The nurses commenced Cardio Pulmonary Resuscitation (CPR),
assisted by the officers, which continued until the paramedics arrived.
The paramedics stopped CPR, confirming that the prisoner had died
and nothing further could be done.
One of my family liaison officers prepared letters for the prisoner’s
sister and partner to inform them of the Ombudsman’s investigation,
but unfortunately they did not receive them. Following the issue of the
draft report another family liaison officer was able to make contact with
his family and invited them to comment on the report and some
changes were made as a result.
The post mortem report concluded that the prisoner died as a result of
ischemic and hypertensive heart disease. I make no
recommendations.
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Investigation Methodology
1. All the initial indications were that this was a death from natural
causes.
2. My investigator was given access to all the man’s prison records,
including his medical records.
3. Notices to staff and prisoners were sent to a governor, the liaison
officer appointed by Leeds, to be displayed around the prison. These
announced the investigation and invited staff and prisoners to submit
to my investigator any concerns or views they wished to express.
4. My investigator conducted interviews with the prisoner’s cellmate, as
well as with wing staff and those involved in trying to resuscitate. The
staff incident reports were also made available. The night patrol
officer on the evening of the prisoner’s, has since resigned from the
Prison Service and was therefore unavailable for interview.
5. Leeds West Primary Care Trust (PCT) was invited to undertake a
review of the clinical care the man received while in custody. A
doctor was asked to carry out the review and it can be found in full as
an annex to this report.
6. One of my family liaison officers made attempts to contact the
prisoner’s relatives, but unfortunately they were unsuccessful.
Following the issue of the draft report another family liaison officer,
did contact them and invite their comments on the report, since when
some amendments have been made.
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Background
Leeds Prison
7. The main part of Leeds prison was built in 1847. It is one of the
largest local prisons in the country. The prison comprises six wings
and a healthcare centre. It takes adult male prisoners remanded
from the West Yorkshire area until trial, and convicted prisoners for
short periods following sentencing.
8. Her Majesty’s Chief Inspector of Prisons (HMCIP) undertook an
unannounced inspection of Leeds between 22 and 26 August 2005.
The report commented that Leeds is a large overcrowded prison,
operating at 75 per cent above its certified normal accommodation,
with a transient and usually short stay population.
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Key Findings
Events leading up to the death of the prisoner
9. The prisoner was sentenced to 12 years imprisonment at Leeds
Crown Court on 7 October 2005. He was then taken to Leeds prison.
On arrival at Leeds, he was interviewed as part of the reception
health screening process. This identified that he suffered from sleep
apnoea and used a monitor. He was noted to be overweight and at
risk of coronary heart disease. He was prescribed medication for
hypertension.
10. The man was then allocated to a cell on E wing, and settled into the
prison routine. On 1 December, he made an application to work in
the prison kitchens as well as being a wing cleaner. However, he
failed a drug test within the prison and his application was turned
down.
Events of the morning of his death in December 2005
11. At approximately 1:55 am on the morning in December, the prisoner’s
cellmate rang the cell bell. This was answered by an Operational
Support Grade (OSG) who was told that he had collapsed. The OSG
immediately contacted two Night Patrol Officers, who in turn called
the Orderly Officer to say that a prisoner was reported to have
collapsed in cell E 504. (The Orderly Officer is the duty Senior Officer
who is in charge of the prison for the night period.) The Senior
Officer (SO) and another officer answered the radio call to attend E
wing. While the SO was on his way to the cell, he called on the radio
for medical staff to attend. The SO and the other officer arrived on
the wing at the same time as the medical staff. They were joined by
the two Night Patrol Officers and they all made their way to cell E
504.
12. The cell door was unlocked by the SO, allowing the Night Patrol
Officers along with a nurse to enter the cell. They gave immediate
attention to the prisoner who had collapsed and was lying face down
on the floor. They found that he had stopped breathing and could not
find a pulse. The Night Patrol Officers assisted the nurse to place the
man on to his back, and his pulse and breathing were checked again.
13. At this point, the cellmate was taken from the cell and the other officer
decided that he should be placed in the PALS Suite. A governor,
Head of Corporate Business at the prison, explained that PALS is the
term for the prison’s Prisoner Active Listener Scheme. There is a
PALS Suite, which is a large cell containing three beds in which two
prisoners, trained as Listeners, are located. A Listener is a prisoner
trained by the Samaritans in the counselling. He also explained that
a prisoner, deemed to be in a crisis, will be placed in the suite, and
allocated the third bed. One of the Listeners will remain awake,
working in shifts, to talk to them. The governor appointed by Leeds
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as a liaison officer said that there are many advantages, the main one
being that constant counselling can be given without a huge impact
on the prison, especially whilst on night state.
14. At 2:04am, the nurse instructed the SO to call for an ambulance. She
also requested extra medical equipment which was collected by
another nurse and a Healthcare Officer (HCO).
15. The nurse commenced Cardio Pulmonary Resuscitation (CPR)
assisted by the Night Patrol Officers. They were re-joined by the
other nurse and CPR continued until the paramedics arrived.
16. At 2:10am, the paramedic car arrived at the prison. The paramedic
was collected from the prison gate and taken straight to E wing by an
officer. He returned to the gate to collect the ambulance that arrived
at 2:15am. At 2:20am, the paramedics decided to stop CPR,
confirming that the prisoner had died and nothing further could be
done.
17. At 2:25am, all staff left the cell, which was sealed, awaiting the arrival
of the police. The paramedics left the prison at 2:50am. The police
arrived at the prison at 3:30am, and the Scenes of Crime Officer
(SOCO) arrived at 4:30am. The cell was unlocked to allow the
SOCO to take photographs and then relocked.
18. At 5:30am, the funeral directors sent two female staff to remove the
prisoner’s body from the prison. Because he was a heavy man, the
assistance of eight prison staff was needed to take him down the two
floors to the ground floor of the wing. The staff involved said that they
found this to be extremely distressing and tiring. As they reached
ground level, they felt physically and emotionally exhausted.
19. The governor appointed by Leeds as a liaison officer visited the home
of the prisoner’s sister, who was his nominated next of kin, to tell her
of his death. The visit took place at 9:35am and this governor was
accompanied by the prison’s family liaison officer (an SO), and a lady
from the chaplaincy.
20. The post mortem examination concluded that the prisoner had died
as a result of ischaemic and hypertensive heart disease.
The care of the prisoner’s cellmate
21. My investigator visited Leeds to interview the cellmate on 21
February to ask about the care and support he had received. In the
interview a number of concerns were expressed:
• He felt that he had not been given adequate support by the
prison;
• The Listener he was placed with also suffered from a heart
complaint;
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• Whilst he was with the Listeners, the observation flap on the cell
door was left open and staff checked him every 20 minutes
throughout the night which he found disruptive;
• He found it distressing that, when the prisoner’s body was
brought down stairs, it was placed on the floor at the bottom of
the stairs in full view of himself, who was in the PALS suite;
• Prior to a visit to the cell by the prisoner’s family, the cellmate
said that he was told to clean the cell and make it ready for them
to visit. He also found this very distressing and asked a friend to
assist him.
22. My investigator spoke to an SO, who is one of the wing Senior
Officers. He was asked what support had been offered to the
cellmate following the prisoner’s death. This SO said that he along
with his staff had offered support on the days following, all of which
was recorded in the cellmate’s history sheet. However, he said that
the cellmate declined all the offers of help. He said that the cellmate
was also seen by the lady from the chaplaincy, who offered additional
support. This too had been declined.
23. My investigator uncovered no supporting evidence for the allegation
that the cellmate was told to clean the cell before the family visit.
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Clinical Review
24. A doctor completed a clinical review into the care of the prisoner at
Leeds. During the course of the review, he interviewed the Head of
Prison Heathcare and the Clinical Director of General Practice
Development.
25. In his review, the doctor says that there is nothing to suggest that the
medical care the prisoner received was inappropriate, or that any
appropriate interventions had not been taken. He concludes that the
medical records were clear and detailed, and staff actions and
interventions were appropriate.
26. The doctor does not make any specific recommendations arising
from the death of the prisoner. He says that healthcare staff should
continue to identify prisoners at risk of coronary heart disease and
take appropriate steps to address this.
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Conclusions and Recommendations
27. The prisoner died of natural causes as a result of ischaemic and
hypertensive heart disease. The clinical reviewer concludes that the
medical records were clear and detailed, and that the staff actions
and interventions were appropriate.
28. My investigator found no additional evidence to substantiate the
claims by the cellmate that he was unsupported in the days following
the prisoner’s death or that he was asked to clean their cell in
preparation for the family visit. It was appropriate and commendable
that the cellmate was placed with Listeners after leaving his own cell
whilst staff tried to resuscitate the prisoner.
29. Neither have I been able to substantiate the claim that the cellmate’s
door flap was left open while staff continued to manage the situation.
However, it is clearly good practice for staff to check that all cell flaps
are closed in such circumstances, not least to provide dignity for the
deceased.
30. I commend the actions of the staff involved in trying to resuscitate the
prisoner. I also pay tribute to the assistance they gave to the
undertakers and the distressing circumstances in which this took
place.
31. I make no recommendations.
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