Individual at Littlehey

The death in custody of a man
who died in hospital
in February 2005
Report by the Prisons and Probation Ombudsman for England and Wales
December 2005
This report concerns the death from apparent natural causes of the man.
The man had been discharged from the hospital to Littlehey prison on 8 February
following an admission, which commenced on 30 January, for treatment of a
chest infection. He was unwell on return to the prison and on the morning of 10
February, his condition gave sufficient cause for concern for him to be returned to
hospital by emergency ambulance. Between 9.10pm and 9.20pm that evening,
his condition suddenly deteriorated and he required resuscitation. Despite the
efforts of the hospital’s cardiac team, he died.
A subsequent post mortem on 14 February concluded that the cause of death
was cardiac arrest, ischaemic heart disease, recent myocardial infarct, coronary
atheroma and chronic obstructive pulmonary disease.
I would like to extend my condolences to his family for their sad loss. I would
also like to thank the Governor of Littlehey and the Governor’s secretary, who
was duty governor on 10 February, and the other staff members who assisted my
investigators with their enquiries. We found everyone very helpful and co-
operative.
The investigation was carried out by my Investigator and her assist. We are very
grateful to Huntingdon Primary Care Trust for their review of the clinical care of
the man.
I make two recommendations and commend the professionalism of Littlehey in
respect of communication, record keeping and prisoner care as consistently very
good practice. I hope the Governor will share that finding with her staff.
STEPHEN SHAW CBE July 2005
PRISONS AND PROBATION OMBUDSMAN
Contents
Summary
The Investigation
Littlehey prison
Events leading up to and following 10 February 2005
Events of 10 February 2005
Events after the man’s death
Key Findings and Conclusions
Recommendations
Summary
The man was quite disabled by the effects of a serious injury to his leg that had
taken place as a child, and by longstanding lung disease. He was convicted of
sex offences in November 2002, aged 61. It was his first conviction. He was
sentenced to nine years imprisonment on 18 December. He transferred from
Norwich to Littlehey on 4 June 2003.
The man did not admit his offences and therefore refused to participate in
treatment programmes. Records show that he was a very quiet prisoner,
compliant with the regime and never breaching prison rules. He was on the
standard level of the incentives and earned privileges scheme (IEP). He
undertook light work and participated in education classes which enabled him to
improve his literacy skills. He had regular visits and correspondence from his
wife and two of his daughters while at Littlehey.
Records show that the staff were concerned about the man’s frailty. He was
admitted to hospital on 30 January 2005 for treatment of a chest infection. He
was discharged on 8 February. He was unwell on return to the prison and, on
the morning of 10 February, his condition gave further cause for concern and he
was returned to hospital by emergency ambulance. That evening, his condition
suddenly deteriorated and he passed away despite the efforts of the hospital’s
cardiac arrest team.
A post mortem on 14 February concluded that the causes of death were cardiac
arrest, ischaemic heart disease, recent myocardial infarct, coronary atheroma
and chronic obstructive pulmonary disease. A clinical review by Huntingdon
Primary Care Trust concluded that he had received care and attention whilst in
custody comparable to that available in the community.
This report makes two recommendations and commend’s Littlehey for good
practice.
The investigation
The investigation began on 11 February when my investigator, contacted the
Governor’s secretary. The Duty Governor had made contact with the man’s
widow to inform her of his death and make funeral arrangements according to
her wishes. On 11 February, notices were issued to staff and prisoners
announcing the investigation and inviting anyone with information relevant to his
death to contact my investigator.
One of my Family Liaison Officers (FLO), made contact with his wife on 22
February to establish what concerns, if any, she would wish my investigator to
follow up on her behalf. His wife did not want the FLO to visit her at home at that
time but she did want to be kept informed about the investigation and to see the
report.
My investigators visited Littlehey on 9 March, familiarising themselves with the
prison, particularly A wing where he had resided. They returned on 1 April 2005.
Three staff were interviewed. On 13 May, a final visit was made and three more
staff were interviewed. Records of the interviews were forwarded to Littlehey for
staff to check, amend as necessary and sign.
An independent clinical review of his health care was undertaken by Huntingdon
Primary Care Trust.
The investigation was completed on 31 May 2005.
HMP Littlehey
HMP Littlehey is a purpose built Category C training prison for men. The certified
normal accommodation is 664. The operational capacity is 706 with a typical
occupancy around 690. The prison was opened in 1988 on the site of the former
Gaynes Hall Youth Custody Centre. It has been extended by the addition of two
‘ready to use’ units, one in 1997 and one in 2003.
Approximately 10 per cent of the prisoners are serving life sentences. A small
proportion of the prisoners are Category D which enables them to work outside
the prison. The prison offers a sex offender treatment programme as well as
extensive industrial work and education opportunities.
Records show that three Littlehey prisoners died in custody in the six months
prior to his death. The circumstances of all those deaths were investigated by
my office and all were from natural causes.
Events leading up to and following 10 February 2005
The man was convicted of sex offences at Bury St Edmonds Crown court and
was received into custody. On reception, his healthcare needs were assessed
and he was noted to have a history of hypertension (high blood pressure),
asthma and back pain. His medication was noted and he was admitted to the
healthcare centre for assessment. Throughout his time in Norwich, there is
documentary evidence of regular healthcare and medication reviews, including
requests for information from his general practitioner (GP).
On 18 December, he attended Norwich Crown Court where he was sentenced to
9 years imprisonment. He returned to Norwich and was transferred to Littlehey
on 4 June 2003. On arrival at Littlehey, a reception health screen was carried
out and his treatment plan was noted.
He remained in generally poor health throughout his time in Littlehey. He was
quite disabled by his longstanding lung disease and spent eight days as an in-
patient in hospital in December 2003. He had periods where he was unable to
leave his cell due to shortness of breath and it was reported that other prisoners
would help by bringing his food to his cell and spending time talking to him.
He attended the Chronic Obstructive Pulmonary Disease (COPD) clinic at the
hospital as an out-patient in January and February 2004. During these
appointments he was reviewed by the Respiratory Nurse Specialist for COPD
and by the Consultant Physician.
In January 2005, he developed a chest infection for which he was prescribed
antibiotics. It was noted that he sometimes forgot to take his medication and
wing staff were instructed in writing to check that he had taken his medication
and to inform the healthcare centre of any problems. On 30 January 2005, he
was still unwell and was taken to the Accident and Emergency Department (A&E)
, complaining of shortness of breath. He was diagnosed with a chest infection
and admitted as an in-patient.
He was discharged from this period in hospital on 8 February. The officer, who
was on bed watch the previous evening, stated at interview that the man had
been told by the doctor that he could be discharged the following day provided
his test results were fine. There is also an entry in the bed watch record to this
effect. As far as the officer on bed watch was aware, the man had diarrhoea up
until the evening of 7 February but the next morning he was not complaining of
any illness. The bed watch officer and another officer then escorted him back to
the prison on the morning of 8 February. During the journey, he was quiet, which
was not unusual for him and he seemed alright.
An entry in his wing record on 8 February, however, stated that he had returned
from hospital and ‘has diarrhoea and feels unwell’. This entry was made by the
senior officer although, from his interview it appears that the entry was made on
the basis of information passed to him by another officer. The other officer
confirmed at interview that she had been concerned that the man was still very
unwell on his return from hospital. She stated that he was in his bed, he looked
ill and said he felt unwell. He was sick and he had diarrhoea. The other officer
stated that the healthcare staff were aware that the man was still unwell and that
he was being monitored.
The officer who wrote an entry in the observation book dated 9 February 2005
stated that the man was quite ill and requested wing staff to observe him
overnight and during the day. At 4.50pm, wing staff contacted the health care
centre and asked Healthcare Officer (HCO) to see him. The HCO confirmed at
interview that he saw the man, who was complaining of diarrhoea and vomiting.
HCO monitored his blood pressure, gave him some medication and advised him
about taking his medication and eating and drinking. He said at interview that he
scheduled a follow-up visit for the next morning.
Events of 10 February 2005
The nurse confirmed at interview that she saw the man in his cell at 9.20am on
10 February. Wing staff were concerned that the man was still unwell. He had
refused breakfast and was complaining of pains. An officer had been concerned
and had telephoned for healthcare staff to attend.
On arrival at the wing, the nurse was immediately concerned for the man’s
health. She could smell vomit in the room and the man described the vomiting
as black in colour and increasing in frequency. She carried out a physical
examination, which was fully documented. She informed the prison doctor, who
was in the health care centre and who was familiar with the man’s condition. The
doctor advised an ambulance be called and the nurse remained with the man
until the ambulance arrived. According to the nurse, the ambulance crew
remained with him for some time and he was taken to hospital at 9.58am.
The man was anxious about going into hospital as his wife was due to visit the
following day (11 February). An entry in his record indicates that his wife was
informed that he was being taken to hospital and advised to contact the prison
before visiting.
The bed watch record indicates that the man arrived in A&E at 10.40am. A risk
assessment was carried out by the prison with regard to the level of security
appropriate for the man’s escort. During his treatment, permission was
requested and given for restraints to be removed so that a drip could be inserted.
The man was told by the doctor that he would be staying in and that they were
not sure what was wrong.
The man remained poorly and on intravenous fluids. The officer, who was with
him, said at interview that he was coughing a lot and seemed in a lot of pain. At
9.10pm he was moved to a side ward, in his bed and with drips attached. The
bed watch report stated that there was no change and there were no concerns.
The next entry in the bed watch record is at 9.20pm and states that the cardiac
team were with the man and were attempting cardio-pulmonary resuscitation
(CPR). At interview, another officer said that when the man was moved to the
side ward the hospital staff made him comfortable and started to do some tests.
The officer said he then ‘took a turn for the worse’ and staff present began CPR.
The officer remembers equipment being brought in and several attempts to
resuscitate were made. CPR continued until 9.30pm when doctors made the
decision to stop and pronounced that the man had died.
Events after the man’s death
One of the prison officers escorting the man, contacted the prison at 9.35pm to
inform the Night Orderly Officer (NOO) of his death. The NOO followed
Contingency Plan 5: Death in Custody, because there was no specific plan in
place for dealing with a death in hospital.
At 9.45pm the officer phoned the prison to say that the hospital was having
difficulty contacting the man’s wife on the number they had. At 10.11pm, the
NOO informed the duty governor of the problems contacting the man’s wife. The
duty governor eventually managed to contact his wife at around 10.50pm to
inform her of her husband’s death.
A post-mortem examination was carried out on 14 February and the findings
were faxed to the prison on 15 February. The pathologist had concluded that the
man had died of cardiac arrest, ischaemic heart disease, recent myocardial
infarct (heart attack), coronary atheroma (hardening of the arteries) and chronic
obstructive pulmonary disease. There was no evidence in the man’s medical
record to suggest a recent heart attack, nor were prison healthcare staff, prison
custodial staff or his wife aware of any heart problems.
The man’s cell was cleared on the 15 February and his possessions returned to
his wife. His wife said that these were packed neatly and sent by special
delivery. In this, as in other areas explored during this investigation, Littlehey
emerges well.
Documentation was completed by prison staff after the man’s death, including an
incident report, information sheet and certificate of final release. However, the
certificate of final release does not allow for a specific recording of a death
occurring in hospital.
Key Findings and Conclusions
The man who was in poor health before coming in to custody and this continued
throughout his time in prison. The evidence from my investigation indicates that
the healthcare he received whilst in prison compared favourably with that he
could have expected to receive if he was living at home. He had access to
prison health care staff promptly when he complained of feeling unwell, or when
wing staff were concerned about his health. There is good evidence to suggest
that his physical and medical condition was well known to all staff in regular
contact with him, and that appropriate support was given when necessary. He
attended out-patient appointments to specialist services as he would have had
he been living at home.
The man had spent a period in hospital between 30 January 2005 and 8
February 2005. It is uncertain how well or unwell he was when he was
discharged from hospital on 8 February. Unfortunately, the clinical review carried
out by the PCT does not cover this issue.
During the investigation interviews, we discovered there were some cases of
diarrhoea and vomiting in the prison, although not on A wing. We were told at
interview that there was diarrhoea and vomiting in hospital at the time of his
illness. My investigator asked the Clinical Governance lead at the PCT to
investigate that suggestion. She made no report but when pressed she said that
the hospital had confirmed there were diarrhoea and vomiting cases in the
hospital at that time. We asked for this to be confirmed in writing but nothing was
forthcoming.
It appears that his fitness for discharge was dependent on test results and self-
reporting of symptoms. We were unable to ascertain what the tests carried out
were for, however it appeared from interviews with the escort staff that the man
reported to the nurses that he was feeling well. It was evident that he was quite
unwell at the prison on 9 February, the day after his discharge from hospital.
From then until his readmission he was seen by prison healthcare staff, given
medication and monitored. He was readmitted by ambulance on 10 February. I
consider that the healthcare he received at the prison during this period and the
action that was taken when his condition deteriorated was appropriate.
There is no evidence to suggest that, whilst in hospital on 10 February, that he
did not receive the level of care and treatment that would be afforded anyone
else in his condition. The prison carried out a risk assessment that was flexible
enough to allow for the appropriate treatment to be carried out and good records
were kept by prison escort staff during this period.
The post-mortem examination revealed a recent myocardial infarct but when this
may have occurred is uncertain. There is no evidence to suggest that any form
of heart attack was suspected by prison health care or custodial staff during his
time in Littlehey.
The action taken by prison staff following his death was appropriate and in line
with prison policy, even though there was not a specific contingency plan for
deaths occurring in hospital. I do not consider that having a specific plan would
have improved the response to his death, however the current plan does not take
into account recent changes in policy and the role of the Prison and Probation
Ombudsman with regard to the investigation of deaths in custody. Similarly, the
Certificate of Final Release does not allow for the specific recording of a death
occurring in hospital.
Recommendations
1. I recommend that the contingency plan No. 5 for deaths in custody is
reviewed to accommodate changes in policy and the role of the Prison
and Probation Ombudsman with regard to the investigation of deaths in
custody.
2. I recommend that the Certificate of Final Release is reviewed to
accommodate specific recording of removal to an acute hospital. At the
same time, sections referring to the Mental Health Act 1959 should be
replaced by references to the appropriate sections of the Mental Health
Act 1983.
Good practice
I commend the high standards of communication, record keeping and prisoner
care at Littlehey which my investigation revealed.