Individual at Lewes

Investigation into the circumstances surrounding the death of
a prisoner at HMP Lewes, in April 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2005
This is the report of an investigation into the circumstances of the death a
prisoner at HMP Lewes who died from apparently natural causes in hospital in
April 2005. He was 81 years of age.
I would like to extend my sincere condolences to those touched by the man’s
death.
I am grateful to the Governor of Lewes prison and his staff for their assistance
in this investigation. All documentation relating to the man’s death was
meticulously completed, and readily available. Particular thanks go to the
liaison officer. I must also express my appreciation to the Sussex Downs and
Weald Primary Care Trust for undertaking a comprehensive clinical review
into the man’s healthcare needs whilst he was in custody.
I was pleased to find that Lewes had acted on a recommendation from a
previous Ombudsman’s investigation as to their handling of a death in custody
that occurs at an outside hospital. Furthermore, Lewes has put in place
arrangements to ensure considered and compassionate assessments in
relation to escorting prisoners to hospital. I have highlighted these as
examples of good practice.
The man who died was an elderly and frail man with chronic health problems.
In the main, he was cared for well in Lewes although there are some
improvements to be made in managing prisoners with chronic illness.
There appears to have been a delay in admitting the man to hospital due to
the refusal of the ambulance crew to transport him. This causes me concern.
I welcome the fact that the Sussex Ambulance Service are undertaking their
own review into this matter, and trust the outcome will be an improved service
to acutely ill prisoners.
I make eight recommendations, and highlight two examples of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2005
Contents
2
Summary 4
Investigation process 5
Background 6
Events leading up to the man’s death 7
The day the man died 8
Findings and conclusions 9
List of recommendations 12
Examples of good practice 13
3
Summary
The man who died was sentenced to imprisonment in February 2004, and died aged
81 in April 2005 in hospital.
He was an elderly and frail man who had a long history of heart problems and
unstable diabetes. In the main, the man was treated appropriately for his conditions.
However, this investigation has revealed some problems regarding the consistent
management of chronic illnesses when a prisoner is located on a wing rather than in
healthcare.
On late in April, the man began to feel unwell. He was suffering nausea, and could
not face food. The following day he either fell from his bed, or collapsed. Staff
attended him but he gradually deteriorated. A few days later, the prison doctor felt it
was necessary for the man to be admitted to outside hospital, and an ambulance was
called.
The ambulance crew felt it was inappropriate that they were called as an
emergency, and left without the man. It is unclear whether they examined
him. This delayed his admission to hospital. Whilst his condition did not
appear further to deteriorate in this time, he was acutely ill. He was
transported in the prison van some hours later. The van was not appropriate
for transporting such an ill man. However, risk assessments regarding
restraints, and escort arrangements at Lewes enabled the man to be treated
as compassionately as possible in the final hours of his life
The man arrived at hospital at 4pm and died at 6.20pm. The post mortem
report records the cause of death as:
1. Cardiac arrest
2. Cardio-genic shock
3. Acute myocardial infarction
There was also evidence of ischaemia, myocardial fibrosis, congestive/chronic
cardiac failure and coronary arteriosclerosis.
I conclude that the man’s condition on the day of his death was well identified
by healthcare staff, and attempts were made to ensure he received the best
care possible. However, protocols need to be established with Sussex
Ambulance Service to ensure the smooth transfer of acutely ill prisoners to
hospital in appropriate transport.
4
Investigation process
I appointed one of my investigators to conduct the investigation. Notices were
issued to prisoners and staff inviting comment.
My investigator spoke with prisoners and staff and examined all of the man’s
prison records, including his medical records.
A clinical review was carried out by a representative from Sussex Downs and
Weald Primary Care Trust.
One of my family liaison officers contacted the man’s son. He said he had no
questions about the care his father had received at present but would like to
receive my report.
5
Background
The man who died was born in November 1923 in Surrey. He was part of a large
family. He spent some time in the navy where he qualified in electrical engineering
which later became his trade.
On 6 February 2004, he was sentenced to 7 years imprisonment and started his
sentence at HMP Highdown. The man was transferred to HMP Lewes on 12
November 2004, where he remained until his death at the age of 81.
He had serious heart problems and had suffered myocardial infarctions (heart
attacks) in 2002 and 2003. He often suffered with bronchitis, and was an insulin
dependent diabetic. His diabetes was frequently unstable. The man was also
incontinent of urine. In July 2004, he was diagnosed with pleural effusion to his right
lung, bi-ventricular impairment, aortic valve disease, pulmonary hypertension and
mild mitral valve regurgitation.
On his admission to Lewes on 12 November, he underwent an initial
healthcare screening. He was referred to pharmacy in light of his medication
requirements, and to the chiropodist.
Between November 2004 and April 2005, there are few medical notes regarding the
man, other than episodes to haematuria (blood in the urine) and urinary tract
infections. During this period, he was due to attend several appointments at
hospitals outside of prison for various ailments, but only in fact attended one.
Although it appears that the man himself chose not to attend most of these, the
reasons behind his refusals are unclear, and there were several cancellations for
unknown reasons.
One of his friends at Lewes reported that he used to help the man with day to day
tasks that he found difficult, such as fetching meals and helping make his bed. The
man’s friend reported that the man received a high level of care from healthcare staff,
and that he often praised them for their help.
6
Events leading up to his death
On Monday 25 April 2005, the man’s friend fetched his lunch at 11.30am, and
went back to see him at 2pm. The man has not eaten his meal as he said he
had an upset stomach. His friend collected his evening meal and took it to him
at 4.30pm, and went back at 6pm. He reported that the man looked unwell,
with a white face and had not eaten his evening meal. When the man’s friend
suggested he ask to see someone from healthcare, he said he would be okay.
The following day, after checking on him in the morning and at lunch, the
man’s friend went back with his evening meal and talked to him for some time.
He reported being so worried about the man that he went and asked the
Principal Officer on the wing to call healthcare, which he did straight away.
A nurse attended. The man told her that he had been exercising and not
eating and his blood sugars had been high. The nurse arranged for the man
to see the doctor the following day, and returned to check on him at 7.30pm.
On this visit, his blood sugar was very high at 23.2mmols (the normal levels
are between 4 and 8 for an insulin dependent diabetic). The man reported
that he had eaten five biscuits instead of eating his dinner. The nurse
documented this visit on her return to the healthcare centre at 8.45pm, and
requested that the man be reviewed by night staff in approximately 30 minutes
time. It is not clear if this occurred.
At approximately 11pm, another nurse went to see the man following a call
from wing officers after he had either fallen out of his bed or possibly
collapsed. The nurse reported that the man was alert. He felt as if his blood
sugars were low but in fact they were still high at 21.2mmols. He administered
insulin to himself and appeared calm and stable after five minutes. The nurse
found no other physical injuries, but did notice that the mattress was
overhanging from the bed and was not a good fit. The nurse felt this could
have contributed to the man’s fall. The nurse said that the man was to report
to the nurse in the morning and be monitored by wing staff.
7
The day he died
The Senior Healthcare Officer (SHCO) called the wing at approximately 9.30am to
request that the man be brought to the healthcare centre to see the doctor. A little
later, an officer contacted healthcare to say the man was unwell and could only be
transported by wheelchair. The SHCO discussed the situation with a doctor and
decided the man should be admitted to healthcare so his eating and glucose levels
could be monitored. Unfortunately, a bed was not immediately available.
At approximately 11am, the SCHO visited the man on the wing. his blood
sugar was recorded as 15.2mmol. He said that he had been vomiting and not
eaten since the day before. He was not drinking because he felt nauseous
and was concerned fluid might be gathering in his lungs as he had
experienced this before. The SCHO found the man to be dehydrated, with a
dry and furred tongue, cracked lips and dry skin, and found his blood pressure
to be barely recordable. After a thorough examination, the SCHO felt that the
man should be admitted to outside hospital, and called the doctor. The doctor
attended with a nurse and agreed that the man should be admitted to the
hospital.
The SHCO returned to the healthcare centre at approximately 12.10pm and
was advised that the Sussex Ambulance Service had arrived and been
escorted to the wing. However, the crew had been unhappy with the
emergency 999 call, as they did not consider the man’s transfer to hospital to
be an emergency. They also queried whether it was more appropriate for the
man to go to a different hospital. The reason for this is unclear. It also
appears that the ambulance crew may have made this assessment without
having examined the man as he was locked in his cell at this time.
According to the SCHO, the ambulance crew felt that normal prison transport
could be used, but recognised this could take between two and three hours.
They also suggested that the doctor telephone the other hospital to inform
them of the transfer as this might speed up the process. The SCHO visited the
man to inform him what was happening. At this point, he was able to stand,
and pass urine.
Dr Mangat informed Dr Simon Jones at the Princess Royal Hospital of Peter’s
transfer to them. A thorough risk assessment was completed and it was
decided that there was no need for Peter to wear handcuffs given his medical
condition. Peter left the prison at 2.30pm in the prison van accompanied by a
nurse and two officers.
At 6.05pm, Peter suffered a massive heart attack, and was pronounced dead
at 6.20pm. The post mortem report records the cause of death as 1. Cardiac
arrest, 2. Cardio-genic shock, 3. Acute myocardial infarction. There was also
evidence of ischaemia, myocardial fibrosis, congestive/chronic cardiac failure
and coronary arteriosclerosis.
8
Findings and Conclusions
Peter was held on the vulnerable prisoner unit in the prison. Staff appeared
aware of Peter’s needs, and were quick to contact healthcare with any
concerns. However, there do not appear to be any comments to this effect in
Peter’s wing record. Where healthcare staff asked wing staff to keep an eye
on Peter, I would have expected to see some comment as to the events
leading to such a request, for example Peter’s apparent fall or collapse.
My investigator was pleased to find that Peter’s cell was on the same landing
as the healthcare treatment room and servery. However, it was noted that the
mattress on Peter’s bed was too large for the bed and was considered by
Nurse Hayden to have contributed to his fall on 26 April. In caring for an
elderly or frail prisoner, continued attention needs to be paid to any specific
needs as well as ensuring that their accommodation is appropriate for these
needs.
Healthcare issues leading up to 26 April
Peter remained independent and appeared to have a good understanding of
his chronic illnesses. He also appeared to be receiving medication
appropriate for his conditions and this was, in the main, monitored well.
However, it is noted in the clinical review that the drug spironolactone is
known to have a side effect of hyperkalaemia (high levels of potassium in the
blood). Peter’s blood test on 12 January showed that potassium levels were
at the top end of the normal range. The British National Formulary
recommends spironolactone should be discontinued when hyperkalaemia
occurs.
Furthermore, the clinical review notes that the blood test result from 12
January indicated a raised level of urea of 8.6mmol/l (the normal range is 2.7
to 7mmol/l), and a raised level of creatinine of 145mmol/l (the normal range is
55 to 110 mmol/l). Hyperkalaemia, raised levels of urea and creatinine could
have been an indication of renal impairment and should have prompted
further investigation. There also should have been regular monitoring of these
levels.
I recommend that the head of healthcare reminds healthcare staff that
on receipt of test results from the laboratories, they are to be examined
and acted upon appropriately.
Peter often declined health appointments. However, it is not clear why he did
so. There is no policy in place to follow this up and to establish the reasons
behind such refusals although Lewes’s consent policy number 45 makes
some reference to this.
I recommend that, where a prisoner refuses to attend an appointment, a
reason for refusal should be sought and documented in the medical
records, signed by the patient and witnessed by staff. Refusals to
attend should be brought to the attention of a Senior Nurse manager.
9
The medical records indicate that Peter was seen by healthcare staff on 28
occasions between his reception on 12 November 2004 and the end of March
2005. Most of these relate to an ulcer on his foot, and none note deterioration
in his condition. There are no entries between 1 April and 26 April 2005.
There appear to be no known problems reported to healthcare staff.
The clinical review also indicates that it is sometimes difficult to decipher who
has made the entries in the medical records, as there are only signatures,
names are not printed and there is no signature covering sheet.
I recommend that the healthcare manager reminds staff either to print
their name next to their signature in medical records or provide a
signature sheet at the front of the medical records.
The clinical review notes that the layout of the prison and the needs of
security do not make it easy for prisoners on the wings to be monitored. The
healthcare centre is usually full making it difficult to transfer prisoners from the
wings to the healthcare centre when there is an immediate need.
Furthermore, the management of chronic disease within the healthcare centre
and wings is unclear and insufficient.
I therefore endorse the following recommendation from the clinical review,
I recommend that as part of the National (Health) Service Framework for
Long Term Conditions/Chronic disease management, all prisoners with
a chronic disease should have a care plan which considers how their
condition will be managed whilst in custody, wherever they are located
in the prison.
Healthcare issues from 26 April
Although the incident was recorded in Peter’s medical records, healthcare
staff attending to Peter on 27 April appeared unaware of his fall or collapse
the previous night. I therefore endorse the following recommendation from
the clinical review,
I recommend that the healthcare manager reviews communication
between shifts in the healthcare centre to ensure all untoward events,
including those on the wings are communicated to the incoming staff.
On their arrival at Lewes, the Sussex Ambulance Service crew declined to
transfer Peter to hospital following the 999 call that was made. It is alleged
that the ambulance crew made this decision without examining Peter who was
locked in his cell at the time. Several issues are unclear about this incident.
The first issue is why the ambulance crew considered the call to be
inappropriate and why the transfer to hospital could wait. I am concerned by
this, and am pleased to learn that Sussex Ambulance Service is investigating
this matter further.
10
The second matter is why Lewes healthcare staff did not override the decision
and insist Peter be transferred. Finally, I am surprised that Lewes healthcare
staff did not report this to a higher authority at the time. Peter’s treatment for
his severe dehydration and hypertension at a hospital was delayed by several
hours as a result of the ambulance crew refusing to take him to hospital.
The prison van is used to transport prisoners to other prisons and to court,
and can be out for a whole day. The van is a gated van and not appropriate
for the transport of a very ill prisoner. There appeared to be no alternative
transport until the prison van returned. Peter’s condition did not appear to
deteriorate further in this time. However, it should be noted that the
healthcare staff had recognised that Peter required urgent hospital attention.
The confusion surrounding the method of transport appeared to disempower
them.
I therefore endorse the following recommendations from the clinical review:
I recommend that a protocol is developed between Lewes prison and
Sussex Ambulance Service to ensure appropriate transport is requested
and is available to ensure the needs of the patient are met in a timely
and appropriate manner.
I recommend that the senior healthcare officer or senior nurse should
have the authority to ensure prisoners are transferred to hospital
urgently when they have been found to be in need of an acute hospital
service.
I would further recommend that the Governor and head of healthcare carefully
consider all the issues included in the clinical review.
Escorts and use of restraints
A thorough risk assessment was undertaken as to whether restraints were
required to take Peter to hospital. The conclusion - that Peter did not require
restraints - was both compassionate and appropriate. Furthermore, the form
Lewes have created to assist the assessment is an example of good practice.
Peter was escorted by a nurse as well as two officers. The presence of the
nurse demonstrated a good understanding of the seriousness of Peter’s
condition and was appropriate given the length of the journey. This is another
example of good practice for which I commend Lewes.
11
List of recommendations
All recommendations are to be implemented locally and all relate to
healthcare.
I recommend that the head of healthcare reminds healthcare staff that on
receipt of test results from the laboratories, they are to be examined and acted
upon appropriately.
I recommend that where a prisoner refuses to attend an appointment, a
reason for refusal should be sought and documented in the medical records,
signed by the patient and witnessed by staff. Refusals to attend should be
brought to the attention of a Senior Nurse manager.
I recommend that the healthcare manager reminds staff either to print their
name next to their signature in medical records or provide a signature sheet at
the front of the medical records.
I recommend that as part of the National (Health) Service Framework for Long
Term Conditions/Chronic disease management, all prisoners with a chronic
disease should have a care plan which considers how their condition will be
managed whilst in custody, wherever they are located in the prison.
I recommend that the healthcare manager reviews communication between
shifts in the healthcare centre to ensure all untoward events, including those
on the wings are communicated to the incoming staff.
I recommend that a protocol is developed between Lewes prison and Sussex
Ambulance Service to ensure appropriate transport is requested and is
available to ensure the needs of the patient are met in a timely and
appropriate manner.
I recommend that the senior healthcare officer or senior nurse should have
the authority to ensure prisoners are transferred to hospital urgently when
they have been found to be in need of an acute hospital service.
12
Examples of good practice
A thorough risk assessment was undertaken as to whether restraints were
required to take Peter to hospital. The conclusion that Peter did not require
restraints was both compassionate and appropriate. Furthermore, the form
Lewes have created to assist the assessment is an example of good practice.
Peter was escorted by a nurse as well as two officers. The presence of the
nurse demonstrated a good understanding of the seriousness of Peter’s
condition and was appropriate given the length of the journey. This is another
example of good practice for which I commend Lewes.
13