Individual at Littlehey

INVESTIGATION INTO THE CIRCUMSTANCES
SURROUNDING THE DEATH OF A MAN IN
HOSPITAL ON 4 JUNE 2005 WHILST IN THE
CUSTODY OF HMP LITTLEHEY
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2005
This is a report into the circumstances of the death of a prisoner in an outside
hospital in June 2005. The man who died was a prisoner at HMP Littlehey
and, at the time of his death, he was 30 months into an eight­year sentence.
He had been taken to hospital in the morning and died later that day.
The man’s post mortem recorded the cause of death as a ruptured abdominal
aortic aneurysm.
A doctor from the Huntingdonshire Primary Care Trust carried out a clinical
review and I am very grateful for the promptness of his report. The doctor
reports that four per cent of elderly men are thought to have an aortic
aneurysm and that there are usually no obvious symptoms.
The investigation was carried out by one of my colleagues. One of my family
liaison officers spoke on the telephone to the man’s daughter, who said her
contact with the prison after the death of her father had been helpful. The
exception to this was the way in which she learnt about his death. I have
concerns about the failure to notify the man’s family of his emergency
admission to hospital in a timely manner. I make a recommendation in
relation to this matter.
I would like to extend my sincere condolences to the man’s relatives and
friends for their loss. I would also like to thank the staff at HMP Littlehey for
their help during this investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman December 2005
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Contents
Summary
The investigation
HMP Littlehey
Events leading up to the man’s death
Events the day he died
Issues considered during the investigation
Conclusion and recommendations
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Summary
The man who died was a 69 year old man serving an eight year sentence at
HMP Littlehey. He died in June 2005 in an outside hospital having been
admitted earlier that day. The man died from a ruptured abdominal aortic
aneurysm.
The man suffered from hypertension which had been diagnosed just prior to
going into custody and was controlled by medication. He had been very
healthy for most of his life and had not seen a doctor for 30 years when he
went into custody. For most of the time he was at Littlehey, he was well.
In April 2005, the man collapsed in his cell. He underwent a thorough
examination and was told to bed rest for seven days. Although his private
diaries appear to indicate that he suffered from dizziness, he does not seem
to have told staff about these episodes.
The day he died, the man was unable to get out of bed and was found to be
suffering from severe abdominal and back pains. He had gone to bed early
the night before having not felt well. After an assessment by the nurse, an
ambulance was called at 9.45am and he was taken to hospital, arriving at
11.15am. Unfortunately, his condition worsened during the day and he died
at 9.33pm that evening.
Contrary to HMP Littlehey’s own policy, the man was not asked about his next
of kin and attempts were not made to contact his daughter until it was evident
that he was very ill. Staff were then unable to locate the man’s daughter for
some hours because the prison had not updated its records with her change
of address. She learnt of her father’s death in a telephone call from a
member of prison staff at 11.30pmthe day he died.
The clinical reviewer made no criticism of the medical care that the man
received in respect of his final illness. However, he concluded that there were
aspects of his care which could have been improved in relation to the chronic
management of hypertension, smoking cessation and renal disease detection.
I make four recommendations and note one area of good practice.
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The investigation
My practice in cases of death from apparently natural causes is to conduct an
initial review to determine the extent of investigation required.
There had been a regrettable delay in contacting my office after the man’s
death and, although in June, I did not learn of it until July. The investigation
began, therefore, on 15 July 2005 when my investigator contacted the prison.
The same day, notices were issued to staff and prisoners announcing the
investigation and inviting anyone with information relevant to the man’s death
to contact my office.
The man’s prison records and other documentation were sent to my office
following the contact made by my investigator.
Having reviewed the documentation my investigator visited Littlehey on 1
September and spoke with a number of wing staff, a prisoner and friend of the
man who died. A clinical review of the man’s health care was requested and
undertaken by Huntingdon Primary Care Trust.
One of my Family Liaison Officers (FLOs) made contact with the man’s
daughter and next of kin to establish what concerns, if any, she had regarding
her father’s care in custody. She did not want the FLO to visit her at home at
that time but did want to be kept informed about the investigation and to see
the report.
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HMP Littlehey
HMP Littlehey is a category C training prison holding up to 706 adult male
prisoners. It was opened in 1988 with four wings A ­ D. Two other wings, E
and F, were added some years later and a further ‘quickbuild’ wing, G, has
since been put in place. There is also a drug rehabilitation wing, H wing.
About 10 per cent of the population are life sentence prisoners and a high
proportion (about 30 per cent) are sex offenders, but the regime encourages
integration of all categories of prisoners throughout the prison.
Healthcare has been provided by Huntingdonshire Primary Care Trust (PCT)
since April 2004. All healthcare staff working at Littlehey are medically
qualified. There are no in­patient beds at Littlehey. The prison has a visiting
community based GP and nurses providing primary care during the day.
Secondary care is available through out­patient services in the community.
Appointments to see a doctor are triggered by a wing application.
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Events leading up to the man’s death
Following sentencing on 30 January 2003, the man was taken to HMP
Nottingham. At the health reception screening, the prison medical staff had a
copy of a report from a doctor which had been requested by the man’s
solicitors for his court hearing. The report detailed the man’s medical history
and concluded that he was a very fit man with no past medical problems.
However, at the time of the doctor’s examination he was found to have raised
blood pressure and the presence of protein and blood in his urine. The doctor
recommended that further assessments should be undertaken to determine
the significance of these as a matter of urgency. He suggested that the
‘concomitant urinary abnormalities would raise questions of possible kidney
disease (which may cause high blood pressure)’. Examination of his
abdomen was normal.
The health screening form at HMP Nottingham makes reference to this report.
The entry in his continuous medical records by the doctor during this
screening process records his blood pressure and that he ‘needs U & Es
(routine blood screening) and PSA – prostate (test to see if he has prostate
trouble)’. Later that day, the man was seen again by medical staff after
collapsing in his cell. A plan outlined in the notes recommended that his
blood pressure be taken daily and that bloods be taken. Bloods were taken
on 3 February 2003 and medication for high blood pressure started on the
same day. His blood pressure continued to be monitored. On 13 February,
he was recorded as feeling well but still suffering from dizzy spells. The
results of the blood tests were attached but not referred to in the continuous
record.
On 20 February 2003, he was deemed fit for transfer and moved to HMP
Littlehey. He was noted as suffering from hypertension upon reception. The
next entry of significance is on 4 February 2004 when he reported feeling
wobbly and was diagnosed with influenza and prescribed antibiotics. There
are no further entries until 27 April 2005 when he saw the doctor after
reporting that he had collapsed. According to the clinical review, the
examination by the doctor was thorough and there was nothing of any
concern. The man was told to bed rest for seven days. On 20 May, the
results of his blood tests were found to be within a normal range.
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Events of 4 June 2005
According to a neighbouring prisoner and friend, the man had felt poorly the
evening before and had gone to bed at around 5pm. During unlock the next
morning, at 8:40am, a prison officer saw himstill in bed. This was not
unusual as it was a Saturday and prisoners were not expected to be up early
at the weekend. The fellow prisoner went to the man’s cell, as he did every
morning, and found him lying across the bed, half dressed. He immediately
went to get the officer and they returned to the cell. The man appeared
confused and the officer promptly summoned help from healthcare.
A nurse attended from healthcare at 9:30am. The man stated that he had
been vomiting and was suffering from abdominal and back pain. The nurse
thought it likely that the man was suffering from an internal bleed. She
returned to healthcare and telephoned the on­call doctor. As it was a
Saturday, the nurse was the only medical member of staff in the prison. She
then phoned for an ambulance at 9.45am. Wing staff took the man to
healthcare in a wheelchair at 10:10am and the paramedics arrived soon
afterwards. The ambulance left the prison at 10:45am, arriving at
Hinchingbrooke Hospital in Huntingdon at 11.15am. An escort risk
assessment was carried out by the duty governor at 12:45pm. He concluded
that two officers using a single cuff should be retained and that restraints
should be removed for essential treatment. This was due to the man’s length
of sentence and nature of his offence.
From the escorting officers’ bedwatch record, it seems that the man was
taken to the x­ray department at 2:10pm and admitted toWillow Ward. At
8:06pm, his condition worsened. The restraint, a single cuff, was removed
and doctors attended. At 8.55pm, he was moved to the intensive care ward.
He went into cardiac arrest and resuscitation was started at 9.15pm. Sadly,
this was unsuccessful and he was pronounced dead at 9.33pm.
At 8pm, having been told of the man’s deteriorating condition, the duty
governor requested that the next of kin be contacted. The night orderly officer
(NOO) was only able to locate an address from the prison records. She
contacted Lincolnshire police by fax at 8.27pm to ask them to visit the man’s
daughter to tell her of her father’s critical condition. After visiting the address
given by the prison, the police discovered that she had moved. A mobile
phone number was obtained and the NOO rang her at 11.30pm to inform her
of her father’s death.
The prison then followed the contingency plans for a death in custody. The
man’s daughter was not offered any contribution towards the cost of her
father’s funeral.
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Issues considered during the investigation
Informing the next of kin
At 8:00pm in the evening, prison staff started to attempt to contact The man’s
next of kin. However, a Littlehey Governor’s Operational Order, dated April
2002, states that,
When a person is escorted to outside hospital as an emergency he should be
asked whether he wishes his next of kin to be advised unless it is clearly a
minor injury. The Orderly Officer should establish who the prisoner wishes
the information to be passed on to and advise the Duty Governor. The Duty
Governor will arrange for the next of kin to be informed.
It is not clear why this operational order was not followed on this occasion. If
the man had been asked when he was first taken out of the prison, he might
have been able to tell staff how to contact his daughter. Unfortunately, a letter
that his daughter had written to the prison on 7 March 2005, informing them of
a change of address, did not get passed to the right department and hence
his records had not been updated. A copy of this letter was amongst the
documentation given to my investigator. The man’s daughter had moved from
Lincolnshire to Scotland and might not have been able to make arrangements
to travel to the hospital immediately. However, it is unfortunate that she was
not given an opportunity to do so.
Incident reports
Given that the man died within 12 hours of being admitted to hospital, staff
involved in finding and assessing himshould have written a statement about
their involvement. This did not happen.
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Conclusions and recommendations
The man was a 69 year old man who, although suffering from hypertension,
appeared to be relatively healthy. When he was found unwell on 4 June, staff
acted promptly and an ambulance was called in a timely manner. Sadly, his
condition worsened during the day and he died later that evening. The clinical
reviewer indicates that aortic aneurysms are usually present without obvious
symptoms. It is often only once the aneurysm enlarges, leaks or ruptures that
the patient experiences severe abdominal pain which radiates through to the
back.
When the man was first taken out to hospital,staff should have asked about
his next of kin in accordance with the Governor’s Operational Order.
Local recommendation 1: The Governor should re­issue the operational
order regarding notifying next of kin of emergency hospital admissions.
The man’s daughter had written to Littlehey to inform them of her change of
address. This letter did not make its way to the right department and the
man’s computer records were not updated. My investigator discussed this
with a number of administrative staff at Littlehey. She concluded that this was
a very unfortunate, one­off mistake rather than indicative of a common
problem.
Incident reports were not prepared by any staff members involved in
discovering or assessing him for medical treatment on 4 June.
Local recommendation 2: The Governor should remind senior colleagues
that all staff, including medical staff, present at an incident should write and
sign a statement.
The man’s daughter was not offered financial assistance towards the cost of
her father’s funeral arrangements. This is contrary to current Prison Service
policy as laid out in PSO 2710 ‘Follow up to deaths in custody’ and the advice
of Safer Custody Group.
Local recommendation 3: The Governor should consider making an
approach to the man’s daughter with regard to funeral costs and remind
senior colleagues of Prison Service policy as laid out in PSO 2710.
The clinical review concludes that the man’s care was of a reasonable
standard in that his blood pressure was effectively reduced and his complaints
sympathetically dealt with. The clinical reviewer thought the history taking
and influenza follow­up was impressive. However, he urges the Prison
Service to review the way in which it offers chronic disease management as
regards smoking cessation, management of hypertension and renal disease
detection. I endorse this view.
National recommendation 1: The Prison Service should review the
instructions it provides to prisons about chronic disease management clinics,
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particularly with regard to smoking cessation, management of hypertension
and renal disease detection.
Good practice
A representative from the prison attended the man’s funeral and his
possessions were returned in a timely manner to his daughter.
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