Individual at Liverpool

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE DEATH
OF A MAN IN HOSPITAL, IN MARCH 2005 WHILST IN THE CUSTODY OF
HMP LIVERPOOL
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
MARCH 2005
The man died aged 45 in hospital in March 2005. He had been a prisoner at
HMP Liverpool. The man had sustained a head injury in his cell four days earlier.
The man was undergoing detoxification from alcohol, and I believe that his injury
was the result of him falling over. Owing to his medical condition, arrangements
were made for him to be granted bail on 18 March.
I offer my sincere sympathy and condolences to the man’s family and friends for
their loss. I know that the staff at Liverpool who knew him share those
sentiments.
I am indebted to the investigating officers from my office for undertaking the
investigation. My family liaison officer has maintained contact with the family
throughout the investigation.
I wish to extend my thanks to the Governor and staff at Liverpool for their help
and cooperation during this investigation.
This report has been anonymised for publication on the PPO website.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2008
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Contents
Summary
Conduct of the Investigation
HMP Liverpool
Events prior to the man’s death
Events after the man’s death
Family liaison
Clinical review
Observations
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Summary
1. The man was a 45 year old man from Liverpool. He died in Hospital in
March 2005, following a head injury he sustained on 16 March whilst a
prisoner at HMP Liverpool. At the time of his death, he had been granted
bail.
2. The police arrested the man on 11 March after he made threats to kill
using a knife. He appeared at Magistrates’ Court on 12 March and was
remanded in custody. He was taken to Liverpool where during the
reception process he was lucid. He was identified as suffering from
alcoholism, given medication and placed on H wing - the drug and alcohol
detoxification wing.
3. It is reported that, within two hours of being on H wing, the man was seen
by a nurse who assessed that he was withdrawing from alcohol and could
be better cared for in the healthcare centre. The man was relocated to a
gated cell, M1 05, for better observation within the healthcare centre.
There he was monitored by staff.
4. The man went under escort to Magistrates’ Court on 14 March. He
returned to prison at 9:30pm and was relocated back in cell M1 05. The
man was again monitored in the healthcare centre, whilst continuing to
withdraw from alcohol.
5. An officer, and a registered mental nurse (RMN), saw the man when he
came on duty at 8:30pm on 15 March. He had met him the previous night
when he was on duty. He saw him in his cell and says the man was still
suffering from alcohol withdrawal. He described him as having visual and
auditory hallucinations, and having conversations with people who were
not there. The man was wandering around his cell, in and out of the
recess area. The officers say they checked him regularly throughout the
night.
6. At 2:10am on 16 March, an officer found the man lying in the recess area
of his cell with a head wound. It appeared to staff that he had fallen and
banged his head in his cell. Owing to the seriousness of the injury, an
ambulance was called at 2:15am and the wound was bandaged by an
officer. The man was placed in an ambulance chair and pushed to the
ambulance. He was placed on a stretcher bed in the ambulance and
subsequently wheeled into the local Hospital casualty department under
prison escort. He was wearing prisoner escort cuffs, which were removed
later that morning.
7. The escort staff say that a nurse saw the man upon their arrival, and again
briefly after half an hour. The man was not seen again by the hospital
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staff for one and half hours, after they were alerted by the prison staff.
The man was then treated with some urgency, as it appeared that he was
bleeding from his nose and ear.
8. The man was transferred to hospital later that day as they had intensive
care facilities. His condition worsened and he died on Sunday 20 March.
9. Merseyside Police were notified of the man’s death and examined his cell
and spoke with staff. The police are treating the man’s death as non-
suspicious.
10. A post mortem was held on 22 March and the cause of death was given
as:
1A widespread bronchopneumonia
1B Blunt force head injuries
2 Alcoholic liver disease
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Conduct of the Investigation
11. The investigation was opened at the prison on 23 March 2005 by two of
my investigators. The Governor and staff produced the man’s core file
and a number of other documents for examination. Notices were issued
to staff and prisoners informing them of my investigation.
12. Representatives of the Prisoners Officers’ Association (POA) and the
Independent Monitoring Board (IMB) also met the investigators to be
informed of the investigation. Both bodies gave their full co-operation.
Contact was made with Merseyside police.
13. Documents relating to the man’s time in custody were examined and staff
were interviewed. My investigators contacted the Coroner’s Officer at
Liverpool, to brief him on the nature and scope of my investigation and
request a copy of the post mortem report.
14. North Liverpool Primary Care Trust conducted a clinical review of the
man’s care whilst in prison custody.
15. My investigator and family liaison officer met the man’s wife and sister in
law on 18 April. Their concerns were centred on the treatment the man
received once at the hospital. The man’s wife had concerns as to whether
he had really fallen and bumped his head. The main points they raised
were:
• The man waited for two hours to be seen at the hospital, and was
only seen after he was coughing blood;
• As he had arrived in an ambulance and had a head injury, he
should have been assessed immediately;
• Who carried out the initial assessment at the hospital?
• What state was the man in when he arrived at the hospital as the
family had been told he walked in and was unresponsive?
• Why was the man transferred to local hospital instead of a bed
being found at a specialist hospital?
As most of the family’s concerns were outside my terms of reference, my
investigator, wrote to the Liverpool Coroner, informing him of the family concerns.
The wife has also made a complaint to the hospital authorities about her
husband’s care and this is currently being investigated. My investigator and
family liaison officer visited the family again on 21 June. The family had read the
post mortem report and was concerned about the bruising to the man’s body.
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They were concerned that he had not fallen and hit his head on the sink, as the
bruising in her opinion was not consistent with a fall, particularly that on his inner
thigh. They believed that the man had been assaulted within the prison.
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HMP Liverpool
16. Liverpool was constructed in 1855 to replace a much older establishment
in the centre of Liverpool. It covers some 22 acres. Most of the original
hospital and cellular accommodation remains, though it has been
extended over the years. There are eight wings, all refurbished and
equipped with integral sanitation systems. The prison holds both
sentenced and remand prisoners and serves the whole of the Merseyside
area.
17. The healthcare centre at Liverpool has 30 clinical beds as well as looking
after eight prisoners who work as cleaners. The healthcare has the
following staffing levels:
Inpatient manager
Two deputy inpatient managers
15 nursing staff
It provides 24 hour nursing coverage with five qualified nurses working
throughout the day, three working on a late shift and two on night shift.
18. There is General Practitioner cover Mondays to Fridays between the
hours of 9:00am and 8:00pm, Saturday 9:00am to 3:00pm and Sunday
9:00am to 1:00pm. At all other times there is a General Practitioner on
call service. In cases of emergency, an ambulance is summoned.
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Events prior to the man’s death
19. The police arrested the man on 11 March for an offence of threats to kill
using a knife. He was charged with the offence and appeared at the
Magistrates’ Court on 12 March. He was remanded in custody to HMP
Liverpool until 14 March.
20. Upon arrival at Liverpool, the man went through the reception procedure.
A healthcare officer commenced a clinical record for the man in the
reception area by asking him a number of set questions. The man was
lucid and informed the officer that he drank cider daily. He gave him
details of his home address and the offence for which he was in custody.
The officer asked him if he had received any physical injuries over the
past few days, to which the man replied no. He informed the officer that
he was asthmatic and that he had concerns for his physical health. The
man also told the officer that he was an alcoholic and had been for five
years, and that he was not taking drugs. The man said that he did not
have any mental health problems. He had never tried to harm himself the
officer referred the man to the doctor for detoxification treatment.
21. In the officers’ presence, the prison doctor saw the man and prescribed
him 20 milligrams of Librium which he gave him at 2:00pm. The reception
officer who was working in the reception area remembers speaking with
the man and completing his cell sharing risk assessment form.
22. After the reception process, the man was located on H wing - the
detoxification wing – where the staff nurse saw him. The man was
apparently feeling unwell and light-headed. She assessed that his needs
were best met in the healthcare centre, as he had chronic alcoholic
withdrawal. The man was relocated in the healthcare centre to cell M1 05.
23. An entry was made on the man’s medical record at 6:30pm on 12 March
which stated: “Inmate states he had two fits. Feeling very cold
temperature 36.8. Blankets given reassured and encouraged fluids. Fully
conscious to time place.”
24. The man was seen in his gated cell by the duty nurse, who completed an
Initial Care Plan covering alcohol detoxification and safety by asking a
number of pre set questions. The man had no problem communicating or
hearing, or with his sight or speech. He reported that he suffered with
asthma. He had no problems with eating, drinking or going to the toilet.
The nurse completed a care plan. The problem was identified as alcohol
withdrawal; the intervention was to be medication and a detox regime.
The man was to be observed for signs and symptoms of alcohol
withdrawal, but no times for the observations were specified. He was
referred to the drugs Dual Diagnosis Unit, and encouraged to take oral
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fluids: the goal was to alleviate withdrawal symptoms and maintain patient
safety.
25. The following entries were made on the man’s clinical record:
13:03:05 3:22pm No evidence of any seizure at time of report.
Spent most of the day resting on bed.
14:03:05 At Court
14:03:05 Return from court 9:30pm
15:03:05 07:00am Awake for periods during the night asking for
the door to be opened and allowed home. Alcohol withdrawals.
Fluids encouraged and reassurance given.
15:03:05 Continues to appear to be withdrawing from alcohol
requesting an ambulance taxi to go home, accepted Librium as per
detox regime. Fluids encouraged accepted, diet accepted.
Reassurances given with good effect.
26. The man was observed in cell M1 05 by the staff going about their daily
business. At 7:00pm on 15 March, the acting inpatient manager spoke to
the man enquiring about his health and gave him a cup of tea. He
described the man as reasonably orientated at the time. However, over a
period of time while the manager questioned him, the man became
confused as to time, place and location. The inpatient manager described
the man as not appearing unsettled or agitated by his situation. He
observed him standing at the cell door on other occasions and did not
notice any injuries on him.
27. The duty nurse remembers last speaking to the man at approximately
8:50pm on 15 March before she finished work at 9:00pm. The man was
experiencing hallucinations but was not distressed.
28. A registered mental nurse(RMN), started duty as the hospital officer in
charge of the healthcare centre at 8:30pm on 15 March together with the
Operational Support Grade Officer (OSG) and the duty senior officer (SO),
who was carrying out a one to one watch outside cell M1 02. The RMN
visually checked all the patients in the healthcare centre. He saw the man
located in cell M1 05, a gated cell. He had met the man the previous night
when he was returned from court at 9:30pm.
29. The RMN noticed that the man was still withdrawing from alcohol. He was
suffering with visual and auditory hallucinations, having conversations with
people who were not there, pacing and wandering around his cell, in and
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out of the cell recess area. The RMN and the OSG checked the man
regularly throughout the night. The RMN says that the man’s presentation
did not change.
30. At 2:10am on 16 March, the RMN could not see the man in his cell but
could hear him muttering and groaning in the cell’s recess area. He called
to him to attract his attention but without success. The RMN - in
accordance with his instructions - telephoned the main prison centre and
requested that the orderly officer attend so that entry could be made to the
cell to examine the man.
31. The orderly officer arrived approximately five minutes later at 2:15am and
entered the cell with the RMN. The man was lying on the floor in the
recess area. His head was under the sink and his feet pointing towards
the window. The man had a head injury, which had been bleeding. He
was incoherent and moving his limbs. The man appeared unaware of his
injuries. The RMN and the orderly officer assisted him to his feet and he
walked with their assistance to the treatment room.
32. On examination of the man’s injuries, the RMN could see that he had
sustained a one and half to two inch laceration to the left side of his head
above the ear and had a swelling to his jaw line on the left side. An
ambulance was called at 2:15am. The RMN cleaned the wound and
applied a dry dressing and a bandage. The man was described as
conscious throughout, talking incoherently and trying to move.
33. The ambulance arrived at 2:25am and left the prison at 2:45am. The man
was wheeled into the ambulance in an ambulance chair, and is described
as being wheeled into a local hospital on the ambulance stretcher. The
reception officer and two wing officers went with the man in the ambulance
as part of the prisoner bedwatch escort. Three officers accompanied him
as a precautionary measure.
34. The escorting officers have stated that, on arrival at the hospital, a nurse
told the ambulance staff to place the man in a cubicle in the Accident and
Emergency Department. The officers stayed with him and the man wore
escort cuffs. After approximately half an hour, a nurse checked the man’s
mouth. The officers describe him as lying on his side and going in and out
of consciousness. After a further hour and a half, the reception officer
drew the attention of nursing staff to blood from the man’s nose and, he
believed, from his ear. The man’s wife has made a complaint to the
hospital authorities who have acknowledged that there was a delay before
her husband was medically assessed. This is the subject of a hospital
investigation.
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35. After the reception officer’s intervention, the man was seen by a number of
hospital staff. The officer removed the cuffs from the man at 6:55am to
facilitate treatment. The man was transferred to the Hospital Intensive
Care Unit at 3:30pm. He never regained consciousness.
36. Two days later, on 18 March, the hospital manager arranged with the
court to have the man released on bail. The request for unconditional bail
was granted and the man was released from the custody of the prison,
remaining in the care of the hospital. The duty officer, who was an officer
on bedwatch at the time, told the man’s family that he had been granted
bail and because of this he was entitled to have any property which was
still at the prison. He asked them to contact the governor to arrange to
collect it. He also informed them that the prison would continue to supply
taxis for their visits to the man in hospital. The prison chaplain maintained
contact and made himself available to the man’s family.
37. Sadly, the man died on Sunday 20 March.
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Events after the man’s death
38. Merseyside Police were notified of the man’s death and conducted an
investigation into the circumstances. They visited the prison and cell M1
05 and spoke with staff. The police are treating the man’s death as non-
suspicious.
39. A pathologist carried out a post mortem on Tuesday 22 March and
concluded:
“[The man] was in a double occupancy cell when on 12 March he
suffered a fit probably an alcohol withdrawal fit and was taken to
the Health Care Unit and placed in a cell on his own.
“At 2:15am on 16 March he was found collapsed near to the sink
and had sustained a head injury with underlying brain damage and
bleeding around the brain and he was subsequently admitted to the
Intensive Care Unit where he died at 10:05am on 20 March 2005.
“My autopsy examination revealed the presence of a pale fatty liver
consistent with chronic alcohol abuse and the man has died
ultimately of widespread pneumonic consolidation of the lungs, This
is not an unusual complication of severe head injury and the lung
damage would have resulted in terminal right ventricular failure
leading to the chronic venous congestion of the liver.
“I did not identify any evidence to suggest that the man had been
assaulted prior to his death and of particular note was that on the
16 March he was found close to the sink in his single occupancy
cell with a head injury and blood was present on the sink.
“The laceration to the scalp above the left ear would be entirely
consistent with a primary impact of his head against the sink and
this had resulted in a left temporal skull fracture, centre-coup brain
damage and subarachnoid bleeding.
“The bleeding around the brain beneath the dura and damage to
the brain has resulted in considerable brain swelling which would
have further reduced vascular perfusion of the brain and resulted in
secondary infarction as described.
“It is my opinion that the man has sustained these head injuries
after his head struck the sink and this may be due to a simple fall
but could also be a further fit related to alcohol withdrawal.
“Taking in account all of the above I find the cause of death to be:
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1A Widespread bronchopneumonia
1B Blunt force head injuries
2 Alcoholic liver diseases”
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Family Liaison
40. A chaplain from HMP Liverpool has maintained family contact. My
investigator and one of my family liaison officers have met and maintained
a good working relationship with the wife. The wife has been offered the
opportunity to visit the prison, but she has not yet taken up the offer.
41. Unfortunately, some of the man’s belongings have not yet been returned
to his wife and the prison is continuing to try to locate them.
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Clinical Review
42. North Liverpool Primary Care Trust was contacted and has commissioned
a clinical review of the man’s care whilst in prison custody. That review is
still awaited and will be subject of a further supplementary report if
considered necessary.
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Observations
43. The man had been correctly identified as suffering from alcoholism during
the reception process at Liverpool on 12 March. He was placed on a
detoxification programme and located on H wing the Drug and Alcohol
Detoxification Unit. Within hours of being placed on H wing, he was
relocated to the healthcare centre and placed in a gated cell for increased
observation. A full care plan was completed and staff also observed him
as they passed by his cell, which was about every 15 minutes although
the timings were not specified.
44. An entry in his medical record at 3:22pm on 13 March shows that there
was no evidence of any seizure at that time. The man was observed most
of the day resting on his bed, accepting diet and fluids.
45. The man went to court on 14 March returning to the healthcare centre at
9:30pm. The officer in charge of the healthcare made an entry in the
medical record at 9:30pm showing the man had returned. He made
another entry at 7:00am on 15 March, indicating that the man had been
awake for periods during the night asking for the door to be open and to
be allowed home. The man was offered reassurance and encouraged to
take fluids.
46. The officer in charge of healthcare observed the man when he came on
duty at 8:30pm on 15 March. He says the man was still suffering alcohol
withdrawal. He describes him as having visual and auditory
hallucinations, having conversations with people who were not there. The
man was wandering around his cell, in and out of the recess area. The
officer, together with a colleague, continued to observe him periodically
through the night. Subsequently, he heard him groaning from the recess
area of the cell and found him with a head injury. The man was treated
and taken by ambulance under prison escort to a local hospital.
47. I conclude that the head injury sustained by the man on the morning of 16
March was caused by him falling over in his cell. I have found no
evidence to suggest that he was assaulted whilst at the prison.
48. I do not believe that the findings from this investigation justify formal
recommendations. However, accordingly my investigator was concerned
by the safety of the gated cells in the healthcare centre and felt they would
benefit from a Health and Safety check. In addition, the investigation
team had difficulty identifying the names of staff making entries in the
man’s medical record and the governor may wish to draw to the attention
of healthcare staff the need to ensure that entries are signed, with the date
and time and the signature is also printed.
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