Individual at Liverpool

Investigation into the circumstances surrounding the
death of a man in July 2004
at Fazakerley Hospital
whilst a prisoner at HMP Liverpool
Report by the Prisons and Probation Ombudsman for
England and Wales
December 2004
CONTENTS
Introduction by the Ombudsman, Stephen Shaw CBE
Summary
Investigation methodology
The deceased
HMP Liverpool
Events prior to the man's death
Discovery of the man's death
Clinical review
Observations and conclusions
Recommendations
Introduction
This is the report of an investigation into the circumstances of the death of a
man at Fazakerley Hospital in the summer of 2004 whilst a prisoner at HMP
Liverpool.
Since 1 April 2004,as the Prisons and Probation Ombudsman I have had the
responsibility of investigating the deaths of people in prisons, probation
hostels and immigration holding centres.
I wish to extend my thanks to the Governor and staff at Liverpool for their help
and co-operation during this investigation. I am also grateful to the Liverpool
Primary Care Trust for preparing a clinical review of the man's care.
This published version does not include the original annexes. This material
was extensive and included the original SIO report.
Stephen Shaw CBE
Prisons and Probation Ombudsman
Summary
The man was remanded in custody by Liverpool Magistrates Court a week
before his death in July 2004 for an alleged assault on his partner. He had
been excluded from an Approved Premises for infringing the rules concerning
alcohol and could not provide a suitable alternative bail address.
During the reception process, he made a telephone call to his partner during
which she made it clear that she had had enough. He did not make any
further calls.
Over the next few days, he was aware that prison staff were trying to locate a
hostel place for him. His cellmate told my investigator that the man did not
give any indication that he intended to harm himself.
On the morning of the incident, his cellmate was taken from the cell to attend
a video court link between 10:00 and 10:30 am. The evidence indicates that
the cellmate was the last person to see him before he was found hanging.
The cellmate returned to his cell, which was locked. He could not see the
man through the flap in the cell door and went to speak with a friend in
another cell. He returned a few minutes later and, still not able to see the man
in the main cell area, looked into the toilet area. He saw the man's back; it
appeared as though he was looking out of the window. After obtaining no
response to banging on the door, the cellmate became concerned and alerted
staff on the landing.
An Officer entered the cell at approximately 11:40 am and found the man
hanging from a ligature attached to the toilet area window. With the help of
other staff he was cut down and CPR was commenced. Paramedics arrived
and a pulse was eventually found, after which the man was taken to
Fazakerley Hospital. He was pronounced dead at 5.45 pm four days later
having never regained consciousness.
Investigation Methodology
1. The investigation was conducted under the terms of the transitional
arrangements agreed between my office and the Prison Service, which came
into effect on 1 April 2004. In keeping with that agreement a Senior
Investigating Officer (SIO) was appointed to carry out the bulk of the
investigative work on my behalf. He was supported by one of my own
investigators.
2. The investigation was opened at Liverpool shortly after the man's death.
The Governor and her 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.
3. Representatives of the Prison Officers' Association (POA) and the
Independent Monitoring Board were also informed about the investigation.
4. Documents relating to the man's time in custody were examined and a
number of prison staff and prisoners were interviewed.
5. My investigator 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.
6. A meeting was held with the family during which a number of concerns
were raised.
The Deceased
7. The man was 46 years old at the time of his death. He had three siblings, a
brother and two sisters. He was not married but had been in a relationship
with his partner for 17 years. They had three children, two boys and a girl, and
the man had a son from a previous relationship. He was unemployed at the
time of his death.
8. Thirteen years ago his father died, and the man's family believe that it was
his reaction to the death that started him drinking to excess. Upon reception at
Liverpool he told staff that he drank up to 8 litres of cider a day. His drinking
caused arguments and occasionally violence within his relationship, both of
which were factors in his remand to Liverpool.
9. The man had written two letters whilst in Liverpool, probably on his first
night, one to his mother and one to his partner. In the latter he refers to the
latest argument which appears to have been on his mind.
HMP Liverpool
10. HMP Liverpool was opened in 1855 to replace a much older and more
cramped establishment in the centre of Liverpool. It covers some 22 acres.
There are eight wings, all of which are in use having been refurbished and
equipped with integral sanitation. The prison is a category B establishment
and serves the whole of the Merseyside area. The man was located on B
wing, which primarily houses remand and trial prisoners. Prison records show
that in July 2004 there were 172 prisoners on B wing.
Events prior to the man's death
11. The man was remanded into custody by Liverpool magistrates for an
alleged assault on his partner. Prior to that hearing he had been living in an
Approved Premises. It appears that he had been excluded from the premises
after infringing the rules concerning alcohol.
12. The man went through the reception process at HMP Liverpool during
which he denied any thoughts of, or intention to, self-harm. He saw a
healthcare nurse and was recommended for detoxification from alcohol. A
doctor prescribed Librium for 13 days and Thiamine 300mg for 28 days.
13. The man made a telephone call to his partner from reception. That call
lasted a little over 30 seconds and after making it clear that she had had
enough, his partner terminated the call. The man made no other calls during
his time in custody.
14. In reception, he spoke with a Listener. A Listener is a prisoner who has
volunteered to undergo training by the Samaritans and who is available to
carry out a similar role as that organisation does in the community. Without
breaking his promise of confidentiality, the Listener has said that the man was
not contemplating self-harm.
15. After the reception process, the man was located in a cell on B wing,
sharing with another prisoner. The following day the induction process
continued, and an Officer made enquiries at Approved Premises on the man's
behalf to find one willing to accept him, thereby allowing him to be released
from prison. The officer had some initial positive results and had informed the
man about them.
16. On the morning he was found, the man and his cellmate woke about
07:00 am and watched the news on TV until they were given hot water to
make a drink about 08:00 am. About 08:30 am the man was unlocked to
enable him to collect his medication from the dispensary on B wing. He
returned a short while later.
17. About 10:15 am, an officer unlocked the cell to collect the cellmate for a
court video link. He does not recall seeing the man who died. The evidence
points to the cellmate being the last person to see the man before he was
found hanging. The cell was locked again.
Discovery of the man's death
18. Sometime after 11:00 am the cellmate was returned to B wing and
allowed to make his own way back to his cell. He looked into the cell through
the observation window but did not see the man. The cellmate then walked to
the level 5 landing to speak with a friend. About 11:40 am the cellmate
returned to level 3 and looked through the toilet observation window. He saw
the man apparently looking out of the window with his back to him. The
cellmate banged on the door to attract his attention. When he had no
response he alerted nearby staff.
19. An officer entered the cell and found the man hanging by a torn sheet
ligature around his neck attached to the window. His feet were still on the
floor. With the assistance of other officers, the man was cut down and laid on
the floor. Healthcare and an ambulance were called. Healthcare staff arrived,
assessed the situation and commenced CPR. A defibrillator was attached to
the man and an airway inserted into his mouth. CPR continued until about
11:52 am when the paramedics arrived.
20. The paramedics attached their defibrillator, which showed no cardiac
output. Prison staff continued CPR whilst the paramedics administered drugs
intravenously on two occasions. After the second injection a cardiac output
was detected. About 12:27 pm the man was taken by ambulance to the
accident and emergency department of Fazakerley hospital. He was treated
there for about an hour before being transferred to the Intensive Therapy Unit
(ITU).
21. At 12.45 pm, the prison Chaplain, together with a Senior Officer, went to
inform the man’s mother, and then the Chaplain accompanied her to the
hospital.
22. The man's condition deteriorated over the next few days. On the day
before the man died, a doctor spoke to the man's family having decided that
the man should not be resuscitated should he arrest again. He noted that
discussion on the medical notes. On the day the man died a doctor told the
family that the prognosis was exceptionally poor and that he was quite likely
to die soon. At 17:45 pm the man was dead. He was not on 'life support' on
the day of his death. Although his partner was at the hospital, it was the
man's mother who was notified by telephone of his death, as his nominated
next of kin.
Clinical review
23. The North Liverpool Primary Care Trust were asked to prepare a clinical
review of the medical care that the man received whilst at HMP Liverpool and
Fazakerley hospital.
24. The reviewer found that the initial health screen of the man appeared
appropriate and sufficiently comprehensive and the diagnosis and treatment
for his potential alcoholic abuse was also appropriate.
25. The clinical response when the man was found hanging was appropriate
and the quality of the resuscitation adequate. The review made comment on
the initial radio call being made to the wrong person and not stating the
urgency of the situation.
26. The man's care in the Intensive Therapy Unit at Fazakerley hospital was
of a very high standard. The review found that there was adequate
communication between the medical and nursing teams and the man's family.
27. Although it is a matter for the Coroner to determine the cause of death,
the review postulates the causes to be hypoxic brain injury, cardio-pulmonary
arrest and hanging.
Observations and conclusions
28. When the man arrived at Liverpool he did not give any indication of
thoughts of or an intention to take his own life. He was appropriately
medicated for alcohol detoxification and efforts were made to find him a
suitable bail address. His cellmate said that even a short time before the man
hanged himself he had not noticed any change in his behaviour.
29. I conclude that no act or omission by the Governor or staff at HMP
Liverpool contributed to the death. I also believe that staff acted appropriately
and with due care upon finding the man hanging.
30. Both the clinical review and the SIO (SIO report not published) draw
attention to the fact that the initial call for help upon finding the man hanging
went to the wrong person. This failure meant that the healthcare staff and the
control room were not immediately aware of the urgency of the situation. In
fact, upon hearing the call, the correct member of staff had contacted the
control room to ascertain if he was required and was told no.
31. Conclusion - Some staff were unclear regarding whom to contact in a
medical emergency and that could have led to a response delay. However in
this case there is no evidence to suggest that the man's medical care was
adversely affected by the confusion.
32. The SIO highlights in his report that the prison contingency plans for
attempted suicide and death in custody were in place and adhered to.
However, he also notes that the plans used were variously dated May 2000,
September 2000 and September 2003.
33. Conclusion - Having more than one version of contingency plans in
circulation could lead to confusion but did not on this occasion.
34. When the man arrived at Liverpool he was allowed to make a telephone
call. The calls made in reception are recorded but no record of which prisoner
made which call is logged. The investigation team was only able to trace the
call the man made after speaking to his partner and obtaining the number he
rang.
35. Conclusion - Not having the ability to correlate the telephone number
called, the name of the recipient, and the name of the prisoner making the call
could have serious implications. The prison currently collects this information
via the PIN telephone system once the prisoner is on a wing.
Recommendations
36. Local radio procedure in respect of medical responses should be re-
examined and a code system for identifying the nature of the emergency
considered.
37. Operational staff should be trained to ensure that they are fully conversant
with how to summon appropriate medical assistance.
38. The Governor should ensure that only current copies of contingency plans
are in circulation.
39. A system should be introduced to allow details of the telephone numbers
and the person contacted by prisoners in Reception to be logged in their
records.
40. The Governor should issue commendations to the staff who responded to
the medical emergency and those who administered CPR, and to a Senior
Officer and the Chaplain for their liaison with the man's family.
Stephen Shaw CBE
Prisons and Probation Ombudsman