Individual at Leeds

INVESTIGATION INTO THE DEATH OF A MAN ON 21 JANUARY 2005
WHILST IN THE CUSTODY OF HMP LEEDS
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
SEPTEMBER 2005
This is the report of an investigation into the death of a man who died from
natural causes at the Leeds General Infirmary on 21 January 2005.
The man who is the subject of this report had been remanded into custody on
16 December 2004. He was held at HMP Leeds and it was there that he was
taken ill on 29 December and then transferred to hospital.
This investigation has been undertaken by one of my investigators. I would
like to thank the Governor of HMP Leeds and his staff for their participation in
this investigation. A doctor from Leeds (West) Primary Care Trust was
commissioned to undertake a review of this man’s care, and I appreciate his
assistance. I was pleased to learn that the man’s clinical care was
appropriate and his transfer to hospital timely.
The loss of a loved one is always distressing. I would like to add my
condolences to the man’s family to those already expressed by my Family
Liaison Officer.
This report includes one recommendation.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2005
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CONTENTS
Summary 3
Background 4
HMP Leeds 5
Conduct of investigation 6
Key findings 7
Recommendations 9
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Summary
1. The man was born in 1963 and was 41 years old when he died from
natural causes in Leeds General Infirmary on Friday 21 January 2005.
2. He arrived at Leeds on 16 December 2004. He was remanded into
custody after committing a robbery, while released on licence. At his First
Reception health screen, it was noted that he had a number of health
problems and that he had recently suffered a cerebro­vascular accident (a
stroke).
3. On arrival at Leeds, he was admitted to the healthcare centre and it was
there that he was discovered collapsed in his cell during the morning of 29
December. Later that day, when his condition deteriorated, he was
transferred to Leeds General Infirmary where he was later diagnosed as
having a malignant brain tumour.
4. Whilst an in patient at the hospital, a bedwatch was carried out by prison
officers. Due to the seriousness of his medical condition, and as it was
considered he was no further risk to the public, physical restraints were not
used. In the light of his physical deterioration, the prison were
investigating whether he could be granted early release. They were in the
process of liaising with probation and social services to try to achieve this,
but unfortunately he died in the hospital before this could be achieved.
5. The clinical review carried out and concludes that the man’s care whilst in
prison was appropriate and of a good standard. The doctor who carried
out the review also considers that the man’s referral to Leeds General
Infirmary was appropriate and timely.
6. My office was not informed about the man’s death until 23 May 2005. This
was after the prison received an enquiry from the Coroner’s officer about
progress on the investigation. My investigator immediately made contact
with the prison and formally opened this investigation.
7. On 17 June 2005, one of my Family Liaison Officers contacted the man’s
family. This was to give them the opportunity to meet with her and the
investigator to discuss the purpose of the investigation, and to raise any
concerns or questions that they would like explored and addressed.
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Background
8. The man was born in Yorkshire in 1963. He was one of three children. He
had an older brother and younger sister. In 1965 his family moved to the
United States of America and lived in Brooklyn, New York.
9. The man returned to the United Kingdom in 1994, married two years later
and lived a settled life with regular employment. After his marriage broke
down, he started to have debt problems. This resulted in him getting into
trouble with the police and led to him serving a custodial sentence of three
years.
10.He was released on licence in April 2004 and went back into employment.
During the following summer, he started to become ill. He had seizures
and subsequently suffered a cerebro­vascular accident in October.
11.On 14 December, when the mental health crisis team visited himat home,
he disclosed that he had been involved in a serious criminal incident. As a
result, the police were called and he was arrested. He appeared at
Bradford Magistrates’ Court on 16 December and was remanded into
custody at Leeds.
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HMP Leeds
12.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 all adult male prisoners remanded from the
West Yorkshire area until trial, and convicted prisoners for short periods
following sentencing.
13.The healthcare centre at Leeds can accommodate 55 patients. It provides
a 24 hour comprehensive primary care service and has provision for
secondary care and treatment in a range of hospitals in the surrounding
area. The relationship between patients and staff is described as good.
14.It should be noted that the man was transferred to the Leeds General
Infirmary on 29 December and only spent fourteen days in the prison
before he was transferred to hospital as an in­patient.
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Conduct of the investigation
15.There was a delay before the Prisons and Probation Ombudsman’s office
was notified of this man’s death and so the investigation was not opened
until 25 May. My investigator studied all the relevant prison records
relating to the man. These included his main prison record, Inmate
Medical Record and the Bedwatch Logs covering the period he spent in
hospital between 29 December and 21 January. My investigator also
studied instructions at Leeds on the arrangements to be followed when
prisoners are escorted outside the prison.
16.A Clinical Review of the care of the man whilst in custody was
commissioned from Leeds (West) Primary Care Trust. I am grateful to the
doctor for undertaking this review in a prompt and timely manner.
17.My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and my investigator requested a
copy of the Post Mortem report. Upon completion, this report will be sent
to the Coroner to assist him in his enquiries into the man’s death.
18.One of my Family Liaison Officers contacted the man’s family. They did
not raise any concerns about his care and treatment at HMP Leeds.
19.My investigator visited Leeds and discussed aspects of the man’s care
with staff. The Primary Care Trust found that his clinical care was
appropriate and his transfer to hospital timely. However, I do have
concerns about the completion of the Bedwatch Logs and make a
recommendation concerning this.
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Key Findings
20.The man arrived at Leeds prison on 16 December 2004. During his initial
health screen interview he told staff that he had poor health and, as staff
were concerned for his well being, they admitted him to the healthcare
centre for an assessment period. As he had previously threatened to
harm himself, he was placed on an open F2052SH (Self­Harm)
observation regime. The cell sharing risk assessment assessed him as
high risk and so he was placed in a single occupancy cell.
21.On 21 December, after being reviewed by medical staff, he was
considered fit for normal location and was moved into the main prison. At
this stage, the F2052SH remained open. On 24 December, he was
reviewed again by medical staff and, due to his continued ill health, was
subsequently re­admitted to the healthcare centre.
22.On 29 December at 8:30am, he went to collect his medication and a Nurse
noticed that he appeared to be unsteady on his feet. She decided to carry
out thirty minute checks on him. Later on at about 11:30am, she was
doing her rounds on H3 landing in the healthcare centre. When she
arrived at the man’s cell she looked through the observation hatch and
saw that he was laying on the floor. He was not moving and had a cut to
his right eyebrow. The nurse alerted her colleagues and the cell door was
opened. He was placed back on his bed and first aid was given to his cut.
23.At 1:00pm, his blood pressure gave staff cause for concern and, as he
was unresponsive, it was decided to transfer him to Leeds General
Infirmary.
24.Over the next three weeks, doctors discovered that he had serious health
problems and an operation was performed to alleviate pressure on his
brain. His condition improved for a short time, but it was later confirmed
that he had a malignant cerebral glioma (a brain tumour) and that he only
had a matter of months to live. His brother, who was his next of kin, was
told that even with further surgery and radiotherapy he could die at any
time.
25.In light of his deteriorating health, the prison began to identify what
arrangements could be made to care for this man in the community.
Sadly, he passed away on 21 January 2005 before the arrangements
could be finalised.
26.The duty governor was immediately informed of the death. A member of
the prison chaplaincy, and a member of staff, representing the Governor,
immediately went to the hospital to offer their condolences and support to
the man’s brother.
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27.The Reverend maintained contact with the family. The prison also offered
to assist with the funeral arrangements (including financial support), but
the man’s family chose not to take up this offer.
28.The post mortem report states that the cause of death was natural causes
as a consequence of a malignant cerebral glioma. The report added that
the mortality rate from such tumours is high even with treatment.
29.The Clinical Reviewer concluded that the care while he was in prison was
of a good standard and that medical issues were dealt with in a timely and
appropriate manner.
30.My investigator carefully studied the Bedwatch Logs completed by prison
officers during the time that the man spent in hospital. My investigator was
shown a copy of the guidance made available to staff undertaking escorts
outside the prison. The guidance states that, if the escort develops into a
“bedwatch”, they should maintain an Occurrence Log. The guidance also
gave a basic list of what is to be entered into the log. There is no
guidance about what the log should or should not contain or about the
language and tone of the entries. The majority of the entries were
appropriate and suitable, but my investigator found one that was lacking in
respect and decency.
31.It hardly needs stating that entries in all prisoner records should be
accurate, factual, sensitive and respectful. But all the more so in the case
of a man in the final stages of a terminal illness. The Governor will wish to
review and strengthen existing procedures at Leeds for management
checks and the monitoring and support of staff on bedwatch duty.
32.This man entered his last term of custody with a very serious undiagnosed
physical health problem. Although his condition was being monitored and
assessed regularly by the healthcare centre at Leeds, the underlying
malaise was not identified. It was only after his condition deteriorated that
the prison referred himfor further investigation at the Leeds General
Infirmary, where it was established that he had a malignant brain tumour.
The disease was extensive and the prognosis poor. In light of this
development the prison was trying to make arrangement to assist in his
release on compassionate grounds. The prison acted appropriately and
sympathetically by making arrangements for himto be released back into
the community.
33.I am also pleased that the prison gave permission for physical restraints
not to be used. This will, I hope, reassure the man’s family that he was
given some privacy and dignity in the last days of his life.
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Recommendations
I recommend that the Governor conducts a review of bedwatch instructions to
include improved guidance and training for staff on what to write and how to
write it when on bedwatch duty. The review should reflect on whether
additions are required to the existing Visiting Manager’s Bedwatch Checklist.
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