Individual at Leicester

A death in custody at
HMP Leicester in July 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2004
This is the report of an investigation into the circumstances of the
death on 18 July 2004 of a remand prisoner at HMP Leicester. The
man’s primary cause of death was cardiac failure.
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) to
bring independence and greater consistency to the task.
The investigation was carried out by one of my Senior Investigators.
A clinical review into the prisoner’s care and treatment was
commissioned from a doctor from Eastern Leicester Primary Care
Trust.
We would like to extend our condolences to the man’s family for
their loss. I would like to thank the Governor in charge of HMP
Leicester, and his staff for their help.
The report commends the care offered to the prisoner by Healthcare
staff, while raising questions about the expectations of other
healthcare professionals as to the quality of provision actually
available in a prison setting. The report also draws attention to the
very good practice of the prison in successfully tracing the prisoner’s
sister. She is grateful for their kindness and so am I.
Stephen Shaw
Prisons and Probation Ombudsman November 2004
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Contents
SUMMARY
INVESTIGATION PROCESS
THE EVENTS LEADING UP TO THE MAN’S DEATH
POST INCIDENT RESPONSE
LEVEL OF COMPLIANCE
FINDINGS
CONCLUSIONS
RECOMMENDATIONS
GOOD PRACTICE
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Summary
The man died at the age of 56 at HMP Leicester while on remand
accused of assault. The man died from cardiac failure. His death
was not connected to the fact that he was in prison or to the level of
care that he received there.
The man was a person with both social and medical problems. He
had had many criminal convictions, dating back to 1967, although
most of his convictions were for petty crimes such as being drunk
and disorderly. The man was of no fixed abode, but was originally
from Malvern in Worcestershire where his sister, his next­of­kin, still
resides. My investigator spoke to her by telephone.
HMP Leicester made commendable efforts in tracing the man’s sister
following his death. Healthcare staff at the prison are also to be
commended for the level of care provided to the man in the final
days of his life.
This report makes a number of recommendations in relation to
healthcare provision within prison for those who are seriously ill.
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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 HMP Leicester on 22 July 2004 when he
visited the Healthcare unit where the man had been treated in the
final days of his life. My investigator spoke informally with the
Deputy Governor, the Senior Medical Officer and the Head of
Healthcare. My investigator was given copies of all relevant records
including the medical records.
My investigator also met the Chairman of the local Prison Officers’
Association (POA) and the Chair of the Independent Monitoring
Board (IMB). The POA representative did not have any issues that
she wished to draw to my investigator’s attention. The Chair of the
IMB raised the question of whether the ,man should have been sent
into hospital at some point in the final hours of his life.
My investigator contacted the man’s sister by telephone and letter.
She had no specific concerns to raise about her brother’s treatment.
A doctor of Eastern Leicester Primary Care Trust carried out a
clinical review.
No formal interviews with staff were conducted. This report is based
upon a thorough review of all relevant paperwork and upon the
clinical review.
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The Events Leading Up To The Man’s Death
On 28 May 2004, the man was taken into a Police Station where he
was charged with assault. The offence had occurred on 31 March
2004, however the man had failed to attend court to answer the
charge. He was kept in a police cell overnight. He was due to
attend Magistrates’ Court on 29 May 2004, but that morning he was
found to be too unwell to do so. Instead, following a clinical
examination by a police surgeon, the man was remanded into
custody at HMP Leicester. The police surgeon wrote a referral letter
for the attention of the Healthcare unit in HMP Leicester, stating:
“This poor man has multiple serious illnesses … I cannot
converse with him because of his severe stroke … He clearly
cannot look after himself and I am sure on humanitarian
grounds alone, prison hospital is the best place for him.”
On 2 June 2004, the man was taken from HMP Leicester to the
Magistrates’ Court when he was remanded into custody until 16
June 2004. The Court’s recorded reasons for not granting bail
included that the man might not reappear at court and that he might
re­offend. On 16 June 2004, the man was further remanded until
30 June 2004. He was unable to attend court on 30 June 2004 as
on the day before, 29 June 2004, he had been taken from HMP
Leicester into a hospital for assessment of suspected worsening of
his condition of congestive cardiac failure (CCF) with a degree of
infection.
The man remained in hospital until 8 July 2004 when he returned to
HMP Leicester with a confirmed diagnosis of CCF. The man’s next
court appearance was set for 14 July 2004, but on that day too his
health was too poor to allow him to appear. Over the following few
days, the man’s clinical records indicate that his condition was
continuing to deteriorate.
On the morning of Saturday 17 July 2004, a Healthcare nurse made
a note in the man’s clinical records that he needed specialist nursing
intervention and had asked for him to be reviewed by the duty
doctor. The duty doctor examined the man and then telephoned
first the deputy Governor, and then telephoned at home the Senior
Medical Officer (SMO), to discuss a possible transfer to hospital. The
SMO asked the duty doctor to review the man’s condition in the
afternoon and to contact him (the SMO) again if he was still
concerned about the man’s condition. The duty doctor reviewed him
at 4.20pm that afternoon and did not contact the SMO again.
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The first entry made in the man’s clinical records on the morning of
18 July 2004 was to note that he appeared to be physically weaker
than he had been on the previous night. He was reviewed by the
duty doctor that morning and was monitored by nursing staff. The
man died at 2.15pm that afternoon.
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Post Incident Response
HMP Leicester followed its contingency plan relating to deaths of
prisoners. Statements were taken from staff; the IMB and other
parties were notified of the man’s death.
Following the man’s death, a procedure was introduced at the prison
for Healthcare nurses to involve themselves in the planned
discharge back to prison of prisoners deemed fit to leave outside
hospital. The Healthcare nurse will satisfy him or herself that the
prison’s Healthcare unit is indeed able to provide the patient with
the necessary level of care.
As the man had not been able to identify any living next­of­kin, the
prison Governor arranged for an advert to be placed in a local
newspaper, which covered his home town of Malvern in
Worcestershire. This led to the man’s sister being traced in time for
her to attend her brother’s funeral. This took place at Leicester
Crematorium and was attended by the Governor and others from
HMP Leicester. As previously mentioned, the man’s sister was
extremely grateful to prison staff for this.
On arrival at the prison by my investigator, all the necessary
information had been gathered together for the purposes of the
investigation. Arrangements were made for my investigator to
speak to relevant members of staff.
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Level of Compliance with Prison Service Requirements
Standards of clinical care in prison are intended to mirror those
available in the outside community. The man’s records indicate that
while in prison he received an appropriate level of care, and his
clinical needs were recognised and adequately dealt with. The
clinical aspects of the man’s care are described in the independent
clinical review which demonstrates that the man was well cared for
and that Healthcare staff had attended to him with dedication and
sensitivity. The clinical review does highlight, however, the difficulty
faced by a prison Healthcare unit in looking after high intensive­care
patients.
The post­incident response by HMP Leicester was fully compliant
with Prison Service instructions and policies on managing a death in
custody. The prison made commendable efforts in tracing the man’s
sister.
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Findings
Within the context of this investigation it has not proved possible to
piece together the man’s life. However, it is clear that his had not
been an easy one. His social problems included a history of alcohol
abuse, self­neglect and homelessness. His body had marks
indicating old gun shot injuries. This social history would
undoubtedly have had an impact on the man’s health, with the
clinical review showing him to have been a person with multiple and
extensive health problems. The man’s health and social problems
were such that, when he was examined by a police surgeon at a
Police Station on 29 May 2004, that clinician wrote that, in his view,
prison hospital was the best place for him.
Apart from a nine­day spell in hospital, the man spent the remaining
weeks of life from 28 May 2004 in either police or prison custody.
Although he was scheduled to appear at court on a number of
occasions to answer charges, he was never well enough to do so,
continuing as a remand prisoner instead. His condition was such
that throughout his time at HMP Leicester, he remained within the
Healthcare unit.
From the clinical review, it is evident that the man received good
quality healthcare while in HMP Leicester and it is unlikely that the
outcome for him would have been any different had he been cared
for throughout in a NHS hospital. Having said that, facilities are
available at NHS hospitals that make easier the care of patients with
intensive needs.
While commending Healthcare staff in HMP Leicester for their
dedication in caring for the man, the clinical review does highlight
the difficulties involved in providing high intensity nursing care
within a prison setting.
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Conclusions
The man was well cared for in HMP Leicester. The care he received
there was probably at least as good as it would have been in a NHS
hospital, and was undoubtedly much better than it would have been
had he been outside in the community.
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Recommendations
The clinical review found that the man had been well cared for
within the Healthcare unit at HMP Leicester. However, the
reviewing doctor highlighted the difficulties that a prison Healthcare
unit will encounter when attempting to provide high intensity care
to those who are very unwell, including those such as this man, who
are terminally ill and nearing the end of their lives. While
acknowledging that the man’s care was not compromised, I
nevertheless make a number of recommendations, which have been
taken directly from the clinical review:
1. Healthcare staff at HMP Leicester should be involved in any
discharge planning from a NHS acute unit (this has already
been instigated by the prison).
2. While recognising the need for individual assessments and
decisions, clear guidance should be established between the
Healthcare unit and the prison administration in relation to
admission to hospital, while taking account of prison security
requirements.
3. Advanced management plans, agreed, where possible with
the patient, should be devised in relation to the management
of terminal illness.
4. There should be clarity on the scope and level of appropriate
Healthcare provision within a prison setting with support
provided to make this possible. This includes appropriate
access to the patient and facilities relevant to the level of care
required.
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Good Practice
Healthcare staff are to be commended for their commitment in
attending to the man’s nursing needs while in the Healthcare unit in
HMP Leicester.
The prison’s efforts in attempting to contact relatives of the man
through a press advertisement, which proved to be successful, was
an example of extremely good practice.
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