Individual at Littlehey

The Death in Custody of a man at
HMP Littlehey – September 2004
Report by the Prisons and Probation Ombudsman for
England and Wales
November 2005
This is the report of an investigation into the circumstances of the death of a man a
HM Prison Littlehey on 29 September 2004. The man, who was 46 years old, died
as a result of asphyxia following an epileptic fit. He had suffered from epilepsy for a
number of years. This followed a road traffic accident in 1981 during which he
suffered head injuries needing surgery to replace a piece of his skull with a plastic
plate. He was under medication for his epilepsy until his death.
I would like to extend my condolences to his mother, and to the rest of his family and
to all those touched by his death. I regret that this report has taken so long to
complete.
The investigation was led by one of my Fatal Incident Investigators. An independent
review of the prisoner’s medical care in prison was commissioned by the local
Primary Care Trust and Prison Health Regional Development Team. On all their
behalves, I would like to thank the management and staff at HMP Littlehey for their
assistance and co­operation during the course of this investigation.
The death of this man was from natural causes but, whilst it was apparently
straightforward, the circumstances were not documented by clinical staff as fully as
would be expected. I make two recommendations in respect of this. Furthermore,
as he was not fully compliant with his prescribed treatment I recommend that
systems are developed to manage non­compliant patients.
I note the way in which the news of her son’s death was broken to the mother and
commend the practice adopted by the Governor. This sad duty was handled in an
entirely appropriate and sensitive manner.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2005
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Contents
Foreword 2
Summary 4
The investigation process 5
Littlehey Prison 6
The deceased 7
Events leading up to 29 September 9
The day he died 10
The prison’s response following the death 12
Issues considered during the investigation 13
Medical record keeping at Littlehey . 13
Staff statements and action sheets 13
Conclusions and Recommendations 14
Annexes
Annex A – Notice of Investigation
Annex B – Terms of Reference
Annex C – Clinical Review
Annex D – Post Mortem Report
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Summary
The man was a 46 year old man serving a mandatory life sentence at HMP Littlehey.
He was located on B wing, designated as a Lifer wing. He lived here from his
reception into Littlehey on 23 December 2003 until the time of his death.
Following a serious road traffic accident in 1981, he suffered head injuries resulting
in an operation to replace a section of skull with a plastic implant. The injuries
suffered resulted in long term epilepsy and a degree of personality change and some
facial disfigurement. He was given a life sentence in May 1985.
The man died on 29 September 2004 from asphyxia as a consequence of epilepsy.
His death was not connected to his imprisonment or to the level of care he received
whilst in prison. Death due to natural causes was recorded at the inquest on 20 April
2005.
The post mortem report was prepared by, a consultant pathologist at Hinchingbrook
Hospital Huntingdon, for Huntingdon South and West Cambridgeshire Coroner. The
report indicates that he died as a result of asphyxia as a consequence of epilepsy.
The conclusion that the Coroner’s Inquest came to on 20 April 2005 was death due
to natural causes.
The clinical review was carried out in response to a request made by Huntingdon
Primary Care Trust and the Prison Health Regional Development Team. No major
concerns were raised by the clinical review regarding the medical care that the man
received during his time in prison. However, a number of recommendations are
made by the clinical reviewer regarding the levels of compliance for clinical record
keeping by HMP Littlehey. The clinical reviewer also mentions that throughout his
sentence, the prisoner was documented as being non compliant with the taking of
his prescribed anti­epileptic medication.
The reviewer recommends that health care staff should be reminded of the
requirement for accurate and contemporaneous record keeping in accordance with
General Medical Council guidelines. She also recommends that a policy should be
implemented for the management of prisoners who refuse to comply with prescribed
treatment. I make a separate recommendation designed to ensure that all staff
involved in an incident, including medical staff, should write and sign a statement as
soon as possible after the event and before they leave the prison at the end of their
shift.
I also conclude that the actions taken by Littlehey in the aftermath of this death were
examples of very good practice.
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Investigation Process
My practice in investigations into a death from apparently natural causes is to
conduct an initial review to determine the extent of investigation required.
My colleague, visited Littlehey following the death. She was given a full briefing
about the circumstances surrounding his death and the situation regarding family
contact and actions instigated by the establishment. A notice to staff and a notice to
prisoners were published in the prison, inviting anyone who might have information
relating to this death to make themselves known to the inquiry team. Three
prisoners who knew himcame forward and spoke to my investigator.
My investigator took away with her files and records relating to the prisoner. A
clinical review was later commissioned. A post mortemreport and information about
the inquest were requested from HM Coroner for South and West Cambridgeshire.
The mother of the deceased, was informed that her son had died by way of a
personal visit from the Governor, and the prison chaplain. They visited her home on
the day that he died. The mother expressed her thanks for the support offered by
them and appreciated their visit. The Governor followed her visit with a letter of
condolence and support.
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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 1985 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.
As noted, B wing is one of the original wings at Littlehey and holds around 40 life
sentence prisoners. The other lifers are dispersed throughout the rest of the prison.
The regime is relaxed and informal. Each prisoner can work in one of the workshops
or attend education classes. Association is available every weekday evening and at
weekends.
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. At the time of this man’s death,
medical cover was provided by a locum doctor. Secondary care was available
through out­patient services in the community. Appointments to see a doctor are
triggered by wing application.
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The man
The man was born on 21 October 1958 at Thatcham in Berkshire. He was an
unmarried man living in a hostel when he committed the crime for which he received
a life sentence in 1985.
He had been in prison before, but none of his previous offences had involved
violence.
During 1981, he suffered head injuries as a result of a serious road traffic accident
which necessitated the insertion of a plastic plate to rectify damage done to his skull
during the accident. The accident left him with some brain damage and a diagnosis
of “post­traumatic epilepsy”. He received a substantial sum in compensation for the
injuries he suffered. He bore the scars of his facial injuries, had very poor vision in
his right eye and was deaf in the left ear. Medical reports have suggested that his
personality changed following the accident and that he began drinking more heavily.
Psychiatric reports also indicate that he suffered from a personality disorder, flew
into rages, and became very difficult, with a number of complex mental health
problems. He was on constant medication for his condition but was erratic in taking
the prescribed medicines.
He had regularly abused alcohol, indeed most of his criminality was related to drink
including the crime for which he received his life sentence. He was aware that
alcohol played a large part in his offending behaviour and had made several
attempts to address the problem.
In 1984, he was a manual worker with the Reading Industrial Therapy Organisation
where he was described as the “best worker they had had in years”. This had been
his first regular employment since he was 17 years old.
He was convicted at Reading Crown Court on 10 May 1985 for murder. He was
serving a life sentence with a tariff of 15 years. He began his sentence at HMP
Winchester, following a period of some eight months on remand. He was transferred
on a number of occasions to various prison establishments including Maidstone,
Kingston and Parkhurst. He transferred from Parkhurst to Littlehey on 23 December
2003. He remained there until his death on 29 September 2004.
During his sentence and whilst at other establishments, he had not always reacted
well to stressful or confrontational situations. He was prone to outbursts of temper,
violence and other inappropriate behaviour. However, to his credit, he had shown
none of this type of behaviour whilst at Littlehey. Indeed, he had not been reported
for any misbehaviour since February 2001.
Whilst at Littlehey, he lived on B wing (as note earlier, the wing caters primarily for
life sentence prisoners). His friends ­ mainlyother lifers ­ described him as being
liked and respected. He was also described by another prisoner who had known him
since 1987 as “a last minute kind of person in the mornings” and was known to
respond robustly to being roused by staff in the morning. During an annual review in
March 2004, one staff member wrote of himthat he was not a problem and related
well to staff and was comfortable with them. The member of staff who employed him
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in workshop 6 described him as a quiet but not withdrawn man, polite and who would
apologise for his absence if for health reasons he could not attend work. He
described himas a very steady and reliable worker who always did his best.
The man was actively participating in his Life Sentence Plan in order to reduce the
risk of re­offending. He had commenced the Enhanced Thinking Skills course. Prior
to his death, he was on the enhanced regime at Littlehey. His cell, 2­6 on B wing,
was a single occupancy cell.
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Events leading up to 29 September 2004.
The man was remanded in custody on 1 September 1984. He was convicted of murder
and sentenced to life imprisonment on 10 May 1985. He first came into prison custody at
Reading. During the following 18 years he was transferred on several occasions to and
from various establishments. He was transferred from Parkhurst to Littlehey on 23
December 2003.
At Parkhurst, the man’s medical records show the seizures from which he was suffering
to be getting more frequent. He was prescribed Tegretol 600mgs twice daily and
Valporate 1gm twice daily to try to control the epilepsy.
On reception into Littlehey, he told staff that he had no thoughts of self harm and his
blood pressure and pulse rate were within normal bounds. His previous medical history
was noted.
On 3 January 2004, the man suffered an epileptic fit in another prisoner’s cell. Nursing
staff attended, he was reassured and helped back to his own cell. Nothing of significance
is noted between then and 4 March 2004 when he suffered another seizure from which he
recovered spontaneously. There was then a series of similar entries in his medical record
with increasing clinical involvement, mainly due to the minor injuries he sustained during
the seizures. His prescribed medication was also changed.
At 9.15 am on 17 June, he suffered a prolonged fit and was found unconscious and
unresponsive. Twenty­seven Epilim tablets were found in his locker. An entry in his
medical record stated he did not appear to be compliant in taking his Epilim. His
medication was to be provided on a ‘see to take’ basis thereafter. At 10.20 am a further
entry reads “reported to have continuous fits, refer to hospital”. A blood test to establish
the levels of anti­epileptic medication in the blood stream was taken on 28 June. The
results of that test are not available. There then followed a number of interventions by
both medical and nursing staff mainly related to reports of seizures and appropriate
treatments both during and after each episode. Most of these interventions occurred
during July of 2004 and then nil of note until 8 September. On that date, an entry in his
medical record noted that he had “collapsed” whilst at work, but that this collapse might
have been due to postural hypertension (a condition which results in the sudden drop of
blood pressure when the individual stands up, made worse if they stand up quickly).
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The day he died
At around 8.10 pmon 28 September 2004, an Officer spoke to the man because he had
some concerns over his canteen [purchases from the prison shop]. Following this,
nothing out of the ordinary was noted by the Officer.
At or just before 9 pm, another prisoner, heard someone who he believed to be the man
(in whose company he had been earlier in the evening) calling out that he needed a
doctor. He thought the man was speaking to a member of staff and did nothing further
about it. At 4 amon the morning of 29 September, he says that he was writing a letter
and again heard the voice saying “I need a doctor. I am having difficulty breathing”. Again
he thought the man was talking to a staff member and did nothing about it.
At around 4.40 am, the duty Night Patrol Officer, responded to a cell buzzer at B2­6, the
man’s cell. He reported that when he arrived at the cell the man had returned to bed and
was apparently asleep. He tried to obtain a verbal response by asking the man if he was
alright, but there was no answer. He said he saw himturn over in bed and pull his cover
over him. He stated that he appeared to be comfortable and that he was satisfied there
was no medical emergency. The Night Patrol Officer left the cell area and carried on with
his normal duties for the remainder of the night, reporting nothing unusual.
Two other prisoners living opposite and next door to the man respectively reported
hearing a loud banging around 5 am followed by heavy snoring. They both presumed that
the noise was the man having an epileptic fit followed by loud snoring, which was not
unusual for him. They said he would normally come through the fit unscathed. They both
then went back to sleep.
At about 7.30 am, another Officer was on duty on B2 landing performing the early
morning count of prisoners. He opened the observation panel at cell B2­6 and saw the
man laying on his stomach on the floor, with his feet towards the door and his head
turned to the right. The Officer knocked on the cell door but got no response and saw
that the man was not moving. A prisoner confirmed that he heard a prison officer
checking and asking the man if he was okay and that there was no reply from him. He
said this was followed by a commotion outside the cell.
At 7.36 am, an Officer says he then ran to the Senior Officer’s office and requested that,
the duty Senior Officer, return to the cell with himbecause the man was lying motionless
on the floor of his cell. The two staff returned to the cell, entered and tried to wake him.
There was no response from him, and he was not conscious or breathing. The SO then
instructed an Officer to telephone the Orderly Officer, Principal Officer, and tell her that
there was a problem and to call an ambulance. On the way to telephone the Orderly
Officer an Officer met and told the PO of the incident in the man’s cell. The PO went
directly to cell B2­6. The Officer contacted PO and informed her of what had happened
on B wing and that an ambulance was required urgently. She then instructed him to
return to the cell and assist the SO and report back. On returning to the cell the Officer,
PO and SO checked for a pulse and for breathing. They turned the man on to his back
and attempted to resuscitate him using Cardiopulmonary Resuscitation (CPR)
techniques. The Officer states that this proved difficult because of the stiffness of the
man’s body and the previous injuries from the car accident. At around 7.45 am they were
joined by a Nurse and another Officer. The Nurse took over chest compressions. The
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staff trying to resuscitate the man periodically checked for vital signs during CPR but at no
stage did they find any. CPR was continued until paramedics from the local ambulance
service arrived at 7.56 am and took over the attempts to resuscitate him. An
Electrocardiogram (ECG) was attached and showed no activity. A paramedic noted that
rigor mortis and post mortem lividity were present, that there were no breath sounds and
that the man’s pupils were fixed and dilated. Resuscitation attempts were halted and he
was pronounced dead at 8.04 am.
A prisoner states that, at about 8 am, a PO opened his cell door and requested a blanket
from him which he supplied. A short time later, the wing was unlocked and prisoners
were asked to assemble in the wing television room where they were told of a fellow
prisoner’s death.
At 10.40 am, the police surgeon certified the death.
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The prison’s response following the death.
At 8.10 on 29 September, following the pronouncement of the death by paramedics,
cell B2­6 was closed and isolated. The names of potential witnesses at the scene,
both staff and prisoners were noted.
Prisoners on B wing were asked to assemble in the wing television room where they
were told of the death. The prisoner’s telephone system was closed to ensure that
the next of kin were informed in a dignified manner, not learning of it from a
telephone call.
At 8.12 am, prison contingency plans for a death in custody were implemented. All
necessary people were informed of the death. The prison chaplain arrived at cell
B2­6 at 8.55 am, was allowed into the cell and said a prayer.
A police Sgt and PC attended at 9.20 am and left at 9.23 am. At 9.39, the Police
Liaison Officer notified the Coroner, and at 9.50 a Detective Inspector and Detective
Constable, and scenes of crime officers, examined the scene. At 10.27 am, the
police surgeon arrived on B wing and at 10.40 am formally certified the man’s death.
At 11.10 am, he informed the prison that the death was not suspicious.
Cell B2­6 remained secure and the funeral directors removed the body at 11.42am to
a local chapel of rest.
The mother was his next of kin. She is an elderly lady living in sheltered
accommodation, having the support of her five children and her carers. Immediately
following her son’s death, the Governor, and the Prison Chaplain, travelled to her
home address and informed her of the sad news. The Governor wrote to her
immediately following the visit and included details of organisations offering support
to bereaved families.
Staff debriefings took place and the Care Team were actively involved in supporting
those staff who had been involved. The Governor issued a notice to prisoners
informing them of the man’s death and a memorial service was held for himin the
prison chapel.
A consultant pathologist, carried out the post mortem at Hinchingbrook Hospital,
Huntingdon on 29 September 2004 and confirmed the cause of death as Asphyxia
as a consequence of Epilepsy. A toxicology report was also prepared by, the Chief
Biomedical Scientist for the Sheffield Teaching Hospitals, in which he states that the
results are consistent with the therapeutic use of anti­convulsant drugs.
An inquest into the death of this man was held by HM Coroner for South and West
Cambridgeshire on 20 April 2005. The verdict was death from natural causes.
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Issues considered during the investigation.
Medical record keeping at Littlehey
The man died on 29 September 2004. Unfortunately, there is no written
documentation in the Medical Record relating to the cause or events which led to his
death.
Statements and Action Sheets
My investigator found the Control Room Action sheet for a death in custody was well
completed. All prison staff and prisoners who had been involved made statements
and these were found to carry an appropriate amount of detail. However, the nurse
involved did not make a statement. My investigator made efforts to contact her but
she is retired and now lives in Spain. She has not responded to requests for
interviews or a statement.
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Conclusions and Recommendations
The man was a 46 year old man in poor health, having suffered a serious road traffic
accident in 1981. The accident left him with some brain damage and a diagnosis of
post­traumatic epilepsy. His personality changed following the accident and he
drank heavily. Psychiatric reports indicate that he suffered from a personality
disorder and had number of mental health problems. He was on constant
medication for his epilepsy but was erratic in taking the prescribed medicine.
Littlehey cared for himto the best of their abilities and that care was comparable to
that which he would have received in the community. The management of his health
was sensitive to his needs given his age and medical history.
Having suffered a serious epileptic episode early in the morning of 29 September
2004, He was discovered lying on the floor of his cell and not responding to stimuli.
He was treated in a speedy and professional manner by staff who had the necessary
skills to make a determined attempt to resuscitate him. Unfortunately, that attempt
was unsuccessful. The local ambulance service paramedic attached an ECG
machine, established that no activity was present, saw no vital signs, noted the
condition of his body and concluded that he had died.
Following the death the response by Littlehey was speedy, effective and sensitive.
The manner in which his mother was treated by the Governor and Chaplain was
exemplary. The mother expressed her appreciation of the way they handled the
breaking of the news to her. Within the establishment, the support of prisoners on B
wing and the staff closely involved with himand those involved with the actual event
of his death was good.
The death of this man was one from natural causes. But whilst it was relatively
straightforward, the circumstances were not documented by medical staff as fully as
would have been expected. The retirement and emigration of the nurse who
attended has not made it possible to obtain a statement regarding the death from her
perspective.
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Recommendations
I make the following recommendations.
Health
1. Healthcare staff should be reminded of the requirements of accurate and
contemporaneous record keeping in accordance with the standards required by
their professional bodies.
The prison accepted this recommendation.
2. A local policy should be developed and implemented in partnership with the local
Primary Care Trust for the management of prisoners who refuse to comply with
prescribed treatment.
The prison accepted this recommendation.
Operational
3. The Governor of Littlehey should remind senior colleagues that all staff including
medical staff present at an incident should write and sign a statement.
The prison accepted this recommendation.
Good Practice
4. The decision of the Governor and Chaplain personally to break the news of her
son’s death to the man’s mother was an example of good practice. I also
commend the other local actions taken by the prison in the aftermath of this
man’s death.
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