Individual at Lewes

Investigation into the circumstances surrounding the
death of a man at HMP Lewes in February 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
September 2006
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
This is the report of an investigation into the death of a man. The man died
from apparent natural causes on 10 February 2006 at HMP Lewes. He was
73 years old.
I would like to add my personal condolences to those already expressed to
the man’s family by my Family Liaison Officer.
This investigation has been undertaken by one of my investigators. I would
like to thank the Governor of HMP Lewes and his staff for their participation
and support. Sussex Downs and Weald Primary Care Trust identified
someone to undertake a review of the man’s clinical care, and I appreciate
her assistance.
I have noted the concerns raised by the clinical reviewer and there are clearly
lessons to be learnt in the clinical management of patients in prison. I
endorse the recommendations made in the clinical review.
Emma Bradley
Deputy Prisons and Probation Ombudsman September 2006
1
CONTENTS
Summary 3
The Investigation Process 4
The man 5
HMP Lewes 6
Key Findings 7
Issues raised by family 8
Clinical Review 9
Conclusion 12
Recommendations 13
2
Summary
1. The man was born in 1932. He was 73 years old when he died on 10
February 2006.
2. The man was received into custody after being sentenced to four years
imprisonment for indecent assault. He was initially held at HMP High
Down, and transferred to HMP Lewes on 20 August 2004.
3. During his first reception health screen, it was noted that the man had
diabetes and angina. As a result of his health problems, the man was
prescribed a range of medication, which he was allowed to keep in his
possession.
4. On 10 February 2006, at 5:00pm, the man was seen by a Staff Nurse. He
was told the nurse that he had not taken his medication and that he felt
hypoglycaemic. The man took a dextrose tablet and apparently felt
better.
5. Around 8:35pmtwo Staff Nurses were called to the man’s cell. While one
nurse gave the man oxygen she requested that her colleague call for an
ambulance. While the other nurse was organising an ambulance the man
collapsed. Cardio pulmonary resuscitation (CPR) was commenced and
this was continued by the ambulance crew after they arrived on the wing.
6. As the ambulance crew were unsuccessful in their attempts to resuscitate
the man CPR was stopped at 9:46pmand the prison medical officer
pronounced death at 10:48pm.
7. The clinical reviewer highlighted a number of areas where improvements
could be made in the care provided to prisoners. I endorse her
recommendations.
8. One of my Family Liaison Officers contacted the man’s family. Their
concerns are centred on the man’s clinical care whilst he was in custody.
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The investigation process
9. My investigator visited Lewes prison and studied all relevant prison
records relating to the man. These included his main prison record, his
medical records and statements from prison staff.
10.The Sussex Downs and Weald Primary Care Trust (PCT) carried out a
clinical review of the care the man received while in prison. I am grateful
that this review was completed in a most timely manner.
11.My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request 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.
12.One of my Family Liaison Officers contacted the man’s family. The family
told himof their concerns, which are considered later in the report.
13.My investigator discussed aspects of the man’s treatment and the issues
raised by his family with both staff at Lewes and the clinical reviewer.
4
The man
14.The man was born in England in 1932. He was divorced and was the
father to three children.
15.The man initially worked in printing before joining the Royal Air Force. He
was in the RAF until 1969 and then worked in telecommunications before
being made redundant.
16.The man was convicted on 20 August 2004 and sentenced to 4 years
imprisonment. The man had one previous conviction nearly thirty years
ago, but this was his first experience of prison life.
17.Before being arrested and remanded into custody the man had heart
problems requiring surgery and had been diagnosed with severe arthritis
and hearing difficulties.
5
HMP Lewes
18.Lewes is a Victorian prison built in 1853. It is a local prison which houses
trial/remand and sentenced adults and additionally a small number of
Young Offenders committed from local courts in the Sussex area. It has
an operational capacity of 558 prisoners.
19.Throughout the forties and fifties Lewes was used as a centre for Young
Offenders and eventually a Borstal experiment was tried in 1963. This
worked well, but pressure on the London prisons meant that Lewes once
more had to accommodate adult prisoners. In the early seventies it
became a training prison (with one wing devoted to lifer prisoners), whilst
retaining its remand function for the Sussex courts. This function
continued until 1990 when the prison once more became a ‘Local'
establishment, housing mainly short – term prisoners and remands.
20.In March 2002, Lewes lost the court commitment to receive and hold
Young Offenders, although a small group of such prisoners are held as a
remand facility to the local Court area. As part of this change the prison
has now opened a large wing (F Wing) to accommodate Vulnerable
Prisoners.
21.The provision of healthcare within the prison is the responsibility of Sussex
Downs and Weald Primary Care Trust. Primary care at out patients is
delivered by medical staff and registered nurses and the healthcare centre
has the opportunity to draw upon the broader expertise of the range of
healthcare services within the local NHS Trust. Medication is administered
on a weekly and/or monthly basis to those prisoners who have been
assessed as suitable to manage their own administration. It is
administered on a daily basis to other prisoners, when either they are
considered to be at risk or the medication is unsuitable to be held in their
cell.
22.There is an in patient ward with 18 beds and a constant watch cell. This is
staffed by registered nurses and provides for both the physical and mental
health needs of those patients requiring a 24 hour nursing presence.
6
Key Findings
23.The man arrived at Lewes on 20 August 2004 and, after induction, it was
decided that he should be given Vulnerable Prisoner status because of his
age and the nature of his offence.
24.During his health screen interview it was noted that the man had diabetes
and angina. Due to his health problems, the man was prescribed a range
of medication, which he kept in his possession
25.On 10 February 2006 at 5:00pm, the man was seen by a Staff Nurse as he
was feeling drowsy and tired. The man told the nurse that he had not
taken his medication and that he felt hypoglycaemic (deficiency of glucose
in the blood). After the man took a dextrose tablet he felt better.
26.Around 8:35pmtwo nurses were called to the man’s cell. They found the
man sitting on the edge of the lower bunk in his cell. The man was
breathless and perspiring profusely, he also had pale and cyanosed (blue)
lips. While one nurse gave the man oxygen she requested that her
colleague call for an ambulance. While this was being organised, the man
collapsed. Two prison officers and the two nurses lowered the man onto
the floor of his cell and then commenced cardio pulmonary resuscitation
(CPR). One nurse assumed responsibility for the man’s airway and the
other carried out chest compressions.
27.When the ambulance crew arrived they took over responsibility for CPR.
As they were unable to resuscitate the man resuscitation attempts were
abandoned at 9:46pm. The man was pronounced dead by the prison
medical officer at 10:48pm.
28.The Duty Governor and a representative from the prison’s Chaplaincy
visited the man’s family to inform them of his death and to offer their
condolences and support.
29.The prison maintained contact with the family and made arrangements for
the funeral. The prison’s chaplain conducted a service on the residential
unit on which the man had been located.
30.The post mortem states that the cause of death was due to natural causes
as a consequence of myocardial infarction (heart attack), due to coronary
arterial thrombosis (blood clot within the arteries) and coronary arterial
atheroma (a degenerative change in the middle and outer coats of the
arteries).
7
Issues raised by the family
31.The man’s family told my Family Liaison Officer that their concerns were
focussed on the clinical care provided during his time in Lewes. Their
concerns were:
I. Whether the man had purposely not been taking his medication.
II. What systems were in place in relation to the administration and
management of medication at Lewes.
32.My Family Liaison Officer agreed to forward their concerns onto the clinical
reviewer.
33.The family also described the representative from the chaplaincy at Lewes
as having been “fantastic” and drew attention to some of the positive
practices he employed. These included:
I. His many visits to the family including when he was on annual leave.
II. Arranging for the man’s younger son to visit his father’s cell.
III. Handing back the man’s belongings in a timely manner.
8
Clinical Review
34.The man had suffered from significant long­term chronic diseases,
including diabetes and angina. The man appeared to have a good
knowledge to manage these prior to his imprisonment. Whilst the man
saw health care professionals on a regular basis to manage and control
these conditions, it is not evident that there was a formalised and
documented pathway of care.
As part of the National (Health) Service Framework for Long­term
Conditions/Chronic Disease Management, all prisoners with diabetes
must have a care plan which considers how their diabetes will be
managed whilst in custody and on resettlement to ensure their
health is managed where possible by the prisoners themselves but
monitored regularly by the Prison Healthcare Service.
As part of the National (Health) Service Framework for Long­term
Conditions /Chronic Disease Management, all prisoners with chronic
cardiac/heart conditions must have a care plan which considers how
their condition will be managed in a seamless way whilst in custody
and on resettlement to ensure their health is managed where
possible by the prisoners themselves but monitored regularly by the
Prison Healthcare Service.
35.The medical record did not always provide clear evidence of who had
delivered care to the man. Furthermore, the entries in the medical record
are not always easy to read.
All Healthcare staff must be encouraged to write legibly in the Inmate
Medical Record (IMR), especially the medical staff.
There must be a record sheet in every IMR, which clearly records the
name of the individual against their signature. This sheet should be
available at the front of the IMR and each member of staff making an
entry in the IMR for the first time should record their name and
signature for future identification purposes. If electronic records are
implemented a record of staff names and their signatures should be
kept on file in an appropriate place.
36.The layout of the establishment and custodial processes can make it
difficult for staff to monitor prisoners with chronic diseases on a regular
basis. Whilst the man saw healthcare staff on a regular basis, it was
primarily when the need arose and not always as part of regular
monitoring and screening.
Implementation of Wing Nurses must be progressed as soon as
resources allow to improve the monitoring of prisoners’ health on a
day­to­day basis making it easier to access Healthcare and ascertain
true activity of daily living needs of prisoners with health
needs/impairments.
9
37.There are systems in place in relation to medicines management. When
prisoners arrive at the prison they are assessed for competency and
safety in terms of providing them with in possession medication. This
enables the prisoner to have an element of control in administering their
medication, as they would in the community. This medication is provided
in small quantities to improve monitoring and minimize the risk of selling
drugs as a form of prison currency.
38.It is clear that Healthcare staff were aware that the man did not always
collect his medication, his prescription chart stated that his medication
should be taken to him if he did not collect it. Furthermore, the man was
provided with a dossett box as a memory aid and given his in possession
medication on a weekly basis. The reviewer concluded that all these
measures facilitated a pro­active systemof medicines management.
Non­compliance of medication (and diet) must lead to closer
monitoring by perhaps reviewing use of in possession medication
and periods between dispensing same for those at­risk. Various
tools can be used to assess likelihood of compliance.
Implement pharmacy­led clinics when resources available to offer
advice and education to prisoners regarding their medication and
compliance.
39.The man was receiving treatment for his leg/foot ulcers and pain. The
man had been seen by an external consultant in vascular surgery, who
had intended to carry out further clinical investigations. The man was
receiving strong pain relief medication, which was reviewed regularly.
Healthcare staff were aware of the condition of his legs and feet and this
is clearly documented.
40.The clinical reviewer notes that access to specialist clinical services, such
as a diabetic nurse, tissue viability nurse and dietician would improve
patient outcomes, through a more comprehensive multi­disciplinary
approach to chronic disease management.
Further nursing resources are required to ensure improved
Healthcare provision is available to prisoners. Access to a tissue
viability nurse, diabetic nurse and dietician, who could all provide
sessions at HMP Lewes, would be advantageous to both staff and
prisoners.
10
41.The clinical reviewer drew attention to the post mortemreport which
appeared to indicate that the man may have suffered a heart attack on 9
February 2006. The reviewer stated that this would have been picked up
on an electro cardio gram (ECG), had it been taken at the time and would
have resulted in the man’s admission to hospital. This is usual procedure
with a patient who shows similar symptoms when attending a GP practice
in the wider community. It is not possible to say whether this would have
altered the outcome, however the reviewer felt that an ECG should be
routine in repeated episodes of angina.
42.The reviewer concluded that, with the benefit of hindsight, the man should
have been transferred to hospital on 9 February when he had been
experiencing angina attacks. This did not happen as the man’s condition
appeared to improve after treatment. The reviewer added that medical
staff had considered transferring the man to hospital, should his angina
have continued.
A review of when to undertake an electro cardio gram (ECG)
recording and establish a subsequent protocol must be developed in
terms of complaints of chest pain or angina. This would also
empower nursing staff as part of their triage and management roles
following agreed algorithms, as medical staff are not always onsite.
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Conclusion
43.The man died from natural causes. Comments made by staff and
prisoners at Lewes, show that he was a respected and well liked man.
His popularity was further demonstrated by the many prisoners who
attended his memorial service and who made donations towards a
remembrance tree in his memory.
44.After talking to both staff and prisoners, neither my investigator nor the
clinical reviewer could find sufficient evidence to suggest that the man
was intentionally not taking his medication.
45.In light of the findings of the Clinical Review, and my own investigation, I
conclude that the man’s medical care was not entirely satisfactory. I
make nine recommendations to the Sussex Downs and Weald Primary
Care Trust to address in partnership with the Governor of Lewes.
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Recommendations
Medical
1. As part of the National (Health) Service Framework for Long­term
Conditions/Chronic Disease Management, all prisoners with
diabetes must have a care plan which considers how their
diabetes will be managed whilst in custody and on resettlement to
ensure their health is managed where possible by the prisoners
themselves but monitored regularly by the Prison Healthcare
Service.
Accepted ­ Charge Nurses G grade appointed and already in place.
Progressing CDM register, asthma, diabetes, and heart failure clinics
which are up and running.
2. As part of the National (Health) Service Framework for Long­term
Conditions /Chronic Disease Management, all prisoners with
chronic cardiac/heart conditions must have a care plan which
considers how their condition will be managed in a seamless way
whilst in custody and on resettlement to ensure their health is
managed where possible by the prisoners themselves but
monitored regularly by the Prison Healthcare Service.
Accepted
3. All Healthcare staff must be encouraged to write legibly in the
Inmate Medical Record (IMR), especially the medical staff.
Accepted
4. There must be a record sheet in every IMR, which clearly records
the name of the individual against their signature. This sheet
should be available at the front of the IMR and each member of
staff making an entry in the IMR for the first time should record
their name and signature for future identification purposes. If
electronic records are implemented a record of staff names and
their signatures should be kept on file in an appropriate place.
Accepted
5. Implementation of Wing Nurses must be progressed as soon as
resources allow to improve the monitoring of prisoners’ health on
a day­to­day basis making it easier to access Healthcare and
ascertain true activity of daily living needs of prisoners with
health needs/impairments.
Accepted ­ Staff vacancies being currently recruited and once in post
and effective this new role will be commenced.
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6. Non­compliance of medication (and diet) must lead to closer
monitoring by perhaps reviewing use of in possession medication
and periods between dispensing same for those at­risk. Various
tools can be used to assess likelihood of compliance.
Accepted ­ Considering Pharmacy Lead Clinic in next 6 to 12 months.
Tools being looked into to measure compliance.
7. Further nursing resources are required to ensure improved
Healthcare provision is available to prisoners. Access to a tissue
viability nurse, diabetic nurse and dietician, who could all provide
sessions at HMP Lewes, would be advantageous to both staff and
prisoners.
Accepted ­ PCT has agreed to increase resources as agreed cost
pressure, which are being recruited to now. With PCT reconfiguration
it is hoped access to specialists will be forthcoming.
8. Implement pharmacy­led clinics when resources available to offer
advice and education to prisoners regarding their medication and
compliance.
Accepted
9. A review of when to undertake an electro cardio gram (ECG)
recording and establish a subsequent protocol must be
developed in terms of complaints of chest pain or angina. This
would also empower nursing staff as part of their triage and
management roles following agreed algorithms, as medical staff
are not always onsite.
Accepted
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