Individual at Maidstone

Investigation into the circumstances surrounding the
death of a man at HMP Maidstone
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2008
This is the report of an investigation into the circumstances surrounding the death of
a man at HMP Maidstone. The man had been recalled to prison in 2004 and was
transferred to Maidstone a year later. A few days before he died, he spoke to his
family and complained of chest pains. He did not seek advice from healthcare. On
the morning of his death, he was found collapsed on the floor of his cell and
pronounced dead by a prison doctor shortly afterwards. He was 58 years old.
The loss of any family member is distressing, but especially so whilst they are in
custody. I offer my sincere condolences to the man’s family and friends.
The investigation was undertaken by one of my investigators. We would like to
extend our thanks to the Governor of Maidstone, and his staff, for their cooperation
during the investigation. Particular thanks go to the prison’s liaison officer, for
gathering all relevant documentation and ensuring it was made available. We would
also like to extend our thanks to the prison’s family liaison officer, for her assistance.
A representative from West Kent Primary Care Trust carried out a clinical review into
the care and treatment the man received whilst in Maidstone. I am indebted to the
clinical reviewer and include her review as an annex to this report.
The main focus of my investigation has been in relation to the way staff at Maidstone
reacted to the man’s collapse. They did so with great professionalism and
compassion. Of particular note was the work of the family liaison officer which was
of the highest order.
My report does highlight two areas where more attention to detail could be paid.
That said, in neither of these areas did the lack of information have an impact on
what happened to the man. A further matter was raised with the Governor at the
investigation stage and all issues have been fed back more formally since. For this
reason my report makes no recommendations. The clinical reviewer makes one
recommendation which I endorse, and commends the Head of Healthcare and her
staff for their record keeping.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2008
2
CONTENTS
Summary 4
The Investigation Process 5
HMP Maidstone 7
Key Findings 9
Issues 18
Recommendation 20
3
SUMMARY
The man was recalled to prison in 2004 following breach of his licence conditions.
He was sent to HMP Maidstone in March 2005 to serve the remainder of his six
year sentence and settled well at the prison. Following his arrival, he was located
on Thanet Wing and allocated a personal officer. He applied for parole and, with
the help of his personal officer, also applied for a place on the Enhanced Thinking
Skills class. He expressed an interest in pursuing an Open University course.
The reception healthcare screening recorded a history of alcohol misuse,
smoking and anxiety. He was referred to a drug counselling service but refused
to attend. He was also offered advice from the smoking cessation clinic but
declined the offer. The doctor who first saw him checked his blood pressure and
asked staff to monitor it for any increase. The doctor also referred him to
Maidstone’s mental health In-reach team. The man attended some support
sessions but not others. Maidstone’s healthcare came to regard him as a
reluctant patient.
For the next few months, the man continued to resist healthcare involvement. In
October 2005, following a high blood pressure reading, he had an electro-cardio
graph (ECG) to determine the source of his high blood pressure. The ECG was
normal, but the doctor prescribed medication to reduce his condition. The
following year, in January 2006, the man was also advised that he increased his
risk of a stroke or heart disease if he did not take his medication. He continued to
resist the medical help he was offered and, reportedly, forgot to collect his
prescriptions.
When the man was not working in the laundry, he spent much of his time playing
guitar, painting and attending a Christian church group. He kept himself to
himself mostly but did interact with his personal officer on a regular basis. His
personal officer changed half way through the year and again in January 2007.
Both personal officers noticed that his church involvement and religious beliefs
had increased. He declined to attend courses as part of his resettlement plan on
the basis that they went against his religion.
The man had a further mental health assessment between November 2006 and
January 2007. This was the last time he accessed the health services at
Maidstone. Ongoing weekly support was offered to help manage his anxiety but
he failed to attend his appointment on 29 January, and no more were made.
On 18 July 2007, the man went to his church group meeting at approximately
6.15pm. When he came back at 7.45pm, he went straight to his cell. A Principal
Officer (PO) carried out the evening lock up at 8.15pm and the Night Duty Officer,
finished his roll check at 9.15pm. The numbers tallied.
At 7.45am on 19 July, during early morning roll check, the officer looked through
the man’s observation panel in his cell door, and noticed he was on the floor.
After two attempts to attract his attention, the officer called his colleague over and
both officers pushed the cell door open. The officer entered first and found the
man face down on the floor and motionless. The officer radioed for emergency
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help. When healthcare staff arrived at 8.00am, the nurse carried out a series of
checks to determine signs of life. The nurse found no pulse or heart beat and
noticed that rigor mortis had set in.
Healthcare staff decided not to attempt to resuscitate the man, but to wait for
paramedics to arrive. The paramedics confirmed that resuscitation should not be
attempted and the prison doctor pronounced his death at 9.10am that morning.
5
THE INVESTIGATION PROCESS
1. On 23 July 2007, my investigator opened the investigation and was briefed
about the circumstances leading to the man’s death. My investigator
requested all prison and medical files in advance of a visit to Maidstone on 3
August. At the prison, she met with the liaison officer, and visited the man’s
cell. The documents were provided. My investigator began the process of
identifying the key issues and the staff who had interacted with the man
during his time at Maidstone.
2. My investigator visited Maidstone again on 15 October 2007 and interviewed
a number of prison staff. The clinical reviewer, visited Maidstone separately
and interviewed nursing staff and the Head of Healthcare. My investigator
provided her with a number of questions to raise with healthcare staff, and I
am grateful to her for incorporating these into her own enquiries. The clinical
review into the care the man received whilst at Maidstone was sent to my
office on 15 October. The review and recommendations are attached as an
annex to this report.
3. The Coroner was informed of the Ombudsman’s investigation. The post
mortem report concluded that the man’s cause of death was as follows:
1a. haemopericardium
1b. ruptured myocardial infarction
4. The inquest took place on 29 August 2007 and the jury returned a verdict of
natural causes. The Coroner will receive a copy of this report when it is
completed for his information.
5. One of my Family Liaison Officers (FLOs), contacted the man’s next of kin
shortly after the investigation was opened. My FLO explained her role and
that of my office, and provided information about the investigation process.
She also offered his family the opportunity to meet her and my investigator to
discuss any issues or concerns. The man’s family did not wish for a visit but
raised one concern about the monitoring of his blood pressure, and whether
he saw a member of healthcare staff about this. I address this issue in the
appropriate section and hope his family find this report helpful.
6. At the draft report stage, the man’s family raised concern over monitoring of
his high blood pressure. His family also asked whether his death was
unexpected.
6
HMP MAIDSTONE
7. HMP Maidstone is a category C training prison holding around 482 convicted
adult males serving long term sentences (four years or more). Built in 1819,
three of the original buildings are grade II listed and are still in use. Maidstone
has undergone, and was still undergoing, major refurbishment at the time of
my investigation.
8. There are four residential units known as Thanet, Kent, Medway and Weald
wings, and each houses a different type of prisoner. The man was located on
Thanet wing, a vulnerable prisoner wing, which has 174 cells on three levels.
He had a ground floor cell and remained there for the duration of his time at
Maidstone.
9. In 2003, Maidstone was re-roled from a category B to a Category C training
prison. This change in prisoner population led to a shift in focus for staff. It
also resulted in reduced staffing levels. The current population is generally
younger, where prisoners serve shorter sentences and are less settled.
10. Maidstone has been inspected by Her Majesty’s Chief Inspector of Prisons
three times in the last five years. The most recent inspection, conducted in
February 2007 and published in April that year, was the second since
Maidstone’s re-role and drew comparisons with the inspection published in
January 2005. The Chief Inspector of Prisons, said that Maidstone had been
seeking to adjust to its new role since the re-role and was struggling to
provide purposeful activity to prisoners, within its aging buildings.
Healthcare
11. Maidstone has been complimented for its healthcare centre. In 2002, the
Chief Inspector of Prisons found evidence that the centre formed an integral
part of the prison and was not operating as a wholly separate facility. This
integration was demonstrated at both practitioner and management levels.
Healthcare staff made contributions to the prisoner induction programme.
The effectiveness of this was shown in the prisoner questionnaire where most
prisoners said they found it easy to see a doctor or nurse. In 2007, Inspectors
also found that clinical governance meetings were chaired by the Governor,
and that these levels of representation reflected the importance given to
healthcare. The 2007 report also said that healthcare staff were committed to
providing good quality care, and used some innovative approaches.
12. West Kent Primary Care Trust took over commissioning responsibility for
providing healthcare services in 2004. In the same year, the management
structure changed with the appointment of a Head of Healthcare. The
healthcare centre has no in-patient facility and currently provides clinic based
and triage provision, similar to a GP surgery in the community.
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Personal Officer Scheme
13. Maidstone operates a personal officer scheme for all prisoners. In 2002, the
Chief Inspector of Prisons was critical of the lack of guidance and training
given to officers to prepare them for the role. The report made a
recommendation for the introduction of personal officer training. It also found
that the level of interaction between personal officers and prisoners could vary
greatly from regular, positive contact to little contact. Despite the lack of
training, there were many examples of well written contributions and good use
of wing history records from some personal officers.
14. The follow up inspection found that the recommendation had not been
achieved. A training booklet was available and had been incorporated into
the induction programme for new members of staff, but there had been no
personal officer training since April 2004. In January 2007, the scheme had
been relaunched and improvements made. However, the Chief Inspector of
Prisons recommended ongoing management checks to assess the quality of
the scheme.
Faith and Religious Activity
15. There is a multi-faith chaplaincy team at Maidstone and the man was a
regular attendee. In 2002, the Chief Inspector of Prisons said that prisoners
should be encouraged to attend religious group activities, and that
unnecessary clashes with other activities should be rescheduled. On her
return in 2004, the chief Inspector of Prisons said “… changes to the core day
had not produced the anticipated clashes between early evening activities.
Prisoners were still able to attend the chapel between 6.15pm and 7.30pm
and the new free-flow system of prisoner movement meant that they were not
delayed in getting there.” In 2007, the Chief Inspector of Prisons reported that
the chapel continued to be used by all faiths and that the Chaplaincy team
was engaged in wider prison work, including deaths in custody procedures.
8
KEY FINDINGS
The man’s arrival at HMP Maidstone
16. When the man arrived at Maidstone, his medical record from HMP Lewes
said he had no outstanding medical appointments. His reception healthcare
screening assessed him as medically fit and made a note of his history of
chronic alcohol use. He was referred to the drug counselling service. His
smoking habit was also recorded but he refused help with smoking cessation.
His blood pressure was taken. A note was made for healthcare staff to take it
again in one week and, if raised, to consider treatment for the condition.
17. Within two days of the man’s arrival on Thanet House, he was allocated a
personal officer. The officer introduced herself and commented that he had
settled in well. He completed his induction week and told staff on the wing
that he thought it was good.
18. It is not clear whether the man’s blood pressure was taken the following
week. The next continuous entry in his medical records was made by a
prison doctor on 14 April. His blood pressure was recorded as normal
(110/80) and the doctor requested another check up in six months time.
19. For the next few months, the man had no contact with healthcare. He
appeared to respond well to his licence recall and completed an application
form to make an appointment to see one of the education tutors. He told his
personal officer that he was keen to continue studying towards a degree. His
record was updated to reflect his positive approach. He joined the church
group and began working in the laundry.
20. A prison doctor saw the man again on 11 August. The doctor made a note of
his history of anxiety and hallucinogenic episodes. He told the doctor that his
mind went blank at times and that he had thought about taking his own life
whilst in HMP Lewes. The doctor wrote a plan in his medical record for an
F2052SH (now ACCT) self harm file to be opened. The doctor also referred
him to the Mental Health In-reach team.
21. The man saw the In-reach team the following day. He spoke openly about
his anxiety and the difficulty he had in relaxing and finding coping
mechanisms. He described symptoms of panicking and cold sweats. The
Registered Mental Health Nurse (RMN) who assessed him arranged to
contact his Community Psychiatric Nurse (CPN) and offered weekly support
meetings.
22. The man’s first support session took place on 24 August. He kept another
appointment on 5 September and spoke openly again. He said that he had
not had further thoughts of self harm and was coping well. He kept himself to
himself on the wing and was happy to be medication free.
23. Over the next few months, the man’s personal officer made a number of
entries relating to his attitude in his wing history. The personal officer also
9
told him that his parole application had been unsuccessful. They agreed to
discuss the application but he appeared uninterested when the time came.
His personal officer attempted to speak to him again on 12 October. He said
he was fine and seemed to draw comfort from his religious beliefs. The
personal officer became worried about his behaviour and preoccupation with
his beliefs. His wing history was updated. His personal officer spoke to a
member of healthcare about his preoccupation and they confirmed they knew
about it.
24. Between October 2005 and December 2005, the man’s blood pressure and
anxiety levels were monitored. He underwent a number of medical
examinations to determine the cause of his increasingly high blood pressure,
including an electro-cardio graph (ECG). The result of this was normal but he
was still prescribed medication (bendrofluraside) to control his blood pressure.
He refused to take medication for anxiety and, on a number of occasions, said
that he forgot to collect the medication.
25. On the wing, the man’s personal officer continued to monitor his behaviour.
The officer spoke to him at length about his parole and a hearing planned for
January 2006. In December, she produced a parole assessment for the
security department. The man’s hearing was postponed until 2 May 2006 and
his personal officer continued to work with him on his application throughout
the months leading up to the re-arranged date. When his application for
parole was rejected, the she spoke to him again at length. This time, she
found the conversation unsettling and spoke to healthcare. An appointment
was made for him to see a member of healthcare staff the following day.
26. The man’s non-compliance with healthcare advice continued. From October
2006 to January 2007, his medical records documented a further mental
health assessment, this time at his own request. Regular support sessions
were arranged as before but the CPN found no evidence of anxiety,
depression or psychosis. On Thanet House, he was allocated a new personal
officer. His new personal officer made regular entries in his wing history
which described him as “in a world of his own”. The officer’s last entry on 27
December explained that the man had decided not to attend courses because
it went against his beliefs.
27. The man turned up for one of the In-reach support sessions on 8 January
2007 but decided not to attend the one planned for 29 January. No further
appointments were made for him. During this time, his wing history remained
empty.
28. On 9 February, another officer introduced himself as the man’s new personal
officer. He remained in contact with him for two months until, on 7 April, he
said that he was no longer in the role. Unfortunately, the man was not
allocated a replacement personal officer and his wing history contained no
entries for the next three months. The last entry was made on 4 July by
another Thanet House officer and simply recorded a routine cell search.
10
Evening of 18 July
29. On 18 July 2007, an officer saw the man go to his church group as usual.
This was at approximately 6.15pm. He returned at 7.45pm for evening lock
up. He went into his cell for the night and a PO carried out the evening roll
check. The PO recorded the number on the appropriate sheet, signed for it,
and passed it to the Night Orderly Officer, a Senior Officer (SO), for counter-
signing.
30. The night duty officer, an Operational Support Grade (OSG), came on duty at
8.45pm. He tested the alarm bell and began his own roll check which finished
at approximately 9.15pm. One of the officers told my investigator that he
stayed on as ‘late stop’ until 9.00pm to help out with any remaining jobs. The
OSG recorded the numbers which were the same as the PO’s, and signed for
them. The police asked the OSG whether he remembered seeing the man
when he did his check. His statement said that he did not specifically
remember seeing him, but if he had seen anyone in a collapsed state when
he looked through the observation panel he would have remembered that.
31. At approximately 11.45pm, another prisoner who was located in a cell directly
above the man said that he heard a crash “like a cupboard falling over”. He
did not press his cell bell. The OSG carried out his ‘pegging’ (meaning that he
patrolled the wing and recorded his movements with a pegging gun) as
normal, informing the SO that he was patrolling at regular intervals. The OSG
made no mention of any further activity during the night.
Morning of 19 July
32. The following morning, the same OSG’s shift officially finished at 7.30am. An
officer from another wing was detailed to carry out the early morning roll
check in order for the OSG to go home. One of the officers on Thanet House,
who was on early morning duty, made her way to the wing for 7.30am. The
officer started the roll check on the third landing in her colleague’s absence.
This delayed the OSG who was not permitted to leave the wing until the roll
check numbers were confirmed. Two other officers started work at 7.45am.
When they arrived, both officers began checking cells on the ground floor to
help out the officer. The officer detailed to carry out the role check arrived
some time between 7.30 and 7.45am, and went straight to the second floor
landing to check cells.
33. Two of the officers started checking cells on the left and right hand side of the
ground floor. When one of the officers got to the man’s cell, he looked
through the observation panel and saw him, from the waist down, on the floor.
This was at approximately 7.50am. The officer told my investigator that he
could not see the man’s head and upper body because he was positioned
with his head closest to the door. The officer tried to attract his attention by
kicking the door and calling his name. When he did not get a response, the
officer called his colleague, who was on the opposite side of the landing. This
officer also attempted to get a response from the man, but when he heard
nothing he decided to enter the cell. The officer who first discovered the man,
11
told my investigator that he knew from his basic training that it was usual for
three officers to go in. He added that he knew the man was not a problematic
prisoner, and that he was in a single cell, so they decided to go in together.
34. The officer described the difficulty they had in getting into the cell because
the man had fallen with his head and upper body directly behind the door.
The other officer unlocked the door but it took both men to open it sufficiently
for the officer to squeeze through and go in. By this time approximately two
minutes had passed and it was 7.52am. The officer checked the man’s pulse
and ‘felt it was too late’ according to the recollection of his colleague. The
officer who checked the man, got on his radio and called the control room for
emergency assistance. The other officer also went into the cell and helped
his colleague turn the man over in order to make it easier for healthcare to
work. The officer told my investigator that he remembered how ‘squashed’ his
face and hand was when he and his colleague turned him. He said that this
was due to the man’s body weight bearing down on them.
35. When an SO from the healthcare centre and a Registered General Nurse
(RGN), heard the emergency call, they grabbed the emergency bag and
oxygen and immediately made their way to Thanet House. The log said that
they arrived at 8.00am, which was approximately 10 minutes after the first
officer found the man. On arrival, they both went into the cell and the officers
left. Extensive entries were made in his medical records to record what they
found. The nurse checked to see if he was breathing and said he was
motionless. The man did not respond to pain stimuli, and the nurse did not
detect a pulse or heart beat. His pupils were also fixed and dilated and, in the
nurse’s opinion, haemostasis had set in. Neither the SO nor the nurse felt it
was appropriate to administer Cardio Pulmonary Resuscitation (CPR). The
nurse asked one of the officers to call an ambulance.
36. Another Thanet House officer came on duty at 8.00am and saw one of his
colleagues in the lobby area of the wing. He told my investigator that he knew
something was wrong. The wing manager from Medway House, an SO, had
already made his way to Thanet House to co-ordinate a response to the
emergency. The SO asked the officer to act as log keeper and briefed him as
to what had happened. The officer went to the man’s cell and positioned
himself outside. The cell door was already shut and security sealed with
healthcare staff inside. The officer began his log at approximately 8.10 am
and proceeded to record who entered and left the cell and at what time.
37. Paramedics arrived on the wing at approximately 8.20am. They went into the
man’s cell and checked for signs of life. Approximately five minutes later, the
paramedics left the cell. According to the incident log, his death was
pronounced at 8.20am.
38. The morning regime on Thanet House was inevitably disrupted. Prisoners on
Thanet House were due to be unlocked at 8.15am to go to work or education
but this was delayed.
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39. A PO, who is also a trained family liaison officer (FLO), was contacted by the
deputy governor who told her that the man had died. The PO immediately
made her way to his wing to check the computer system for further
information about his next of kin. The system showed that his sister lived a
long way from Maidstone, in the south west of England. On seeing this, the
PO contacted the nearest prisons to his sister’s home and spoke with their
respective FLOs. The PO arranged with the FLOs at two other prisons, for
the news to be broken in person. The PO followed up in writing what had
been agreed and provided the FLO’s with further information about the man’s
collapse. The PO also arranged for a police liaison officer to be on stand by
in case the prison FLOs ran into any difficulties.
40. At 8.35am, the man’s cell was secured with a security lock supplied by the
wing manager. The officer keeping a log was also placed in charge of the
key. He continued to keep a log outside the cell door until approximately
9.05am when he was instructed by the wing manager to hand over log
keeping duties to another officer. The officer who kept a log, told my
investigator this was because he was better deployed as a wing officer to help
return the wing to as normal a regime as possible. He handed the security
lock key over to his colleague and then began to unlock prisoners. The officer
told my investigator that no prisoners approached him about the man’s
collapse. They just seemed to want to return to normal.
41. The officer who relieved his colleague of log keeping duty, had arrived on
Thanet House just before 9.00am. He told my investigator that he worked in
the Education Department and had arrived that morning to find his classes
cancelled. He was told to make his way over to the man’s wing to help with
the contingency plans. When the wing manager asked him to take over log
keeping duties, the officer did as his colleague had done and placed himself
outside the man’s cell. At around 9.20am, the nurse returned, this time with a
prison doctor. The officer unlocked the cell and they entered. The prison
doctor pronounced the man dead at 9.25am.
42. Within 30 minutes, two police officers and the Coroner’s officer arrived at the
man’s cell and the officer keeping log let them in. At 10.10am, all three left
the cell and it was resealed. The man’s cell was not reopened until the
funeral directors arrived at approximately midday. The police officers took a
statement from the officer who found the man. This acted as a combined
statement for both he and his colleague. The OSG, who was still unable to
leave the wing, also spoke to the police and provided a statement. The police
did not take statements from anyone else who responded to the man’s
collapse, including healthcare staff.
43. A hot de-brief took place and all staff involved in responding to the man’s
collapse were offered support by the prison care team. The officers who
found him were told to go home and were offered ongoing support.
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Informing the man’s next of kin and ongoing support
44. At the request of the PO with FLO responsibilities, the FLO’s from the two
prisons closest to where the man’s family lived, visited their home and broke
the news of his death in person. They offered immediate support in their
capacity as FLOs and took with them an information pack with advice and
guidance on sudden death experiences. They explained what type of ongoing
support Maidstone could offer, including help with arranging the funeral.
45. During the visit, the man’s sister said she had spoken to him a few days
before he died. He had complained of feeling unwell and said he was “having
the most violent pain that he had ever experienced”. His sister told him to see
the healthcare staff at Maidstone. The visiting FLO’s informed him sister that,
according to the information they had, he did not approach healthcare.
46. The man’s sister rang the PO at Maidstone in the afternoon. She was
naturally upset and explained that she had not been aware of the reason for
his latest imprisonment. The PO felt that this was not the right time to clarify
why he had returned to custody. They spoke about the post mortem and the
PO explained why this was a mandatory procedure for all deaths in custody.
The man’s sister said that she did not want to discuss funeral arrangements
yet, but did enquire about the inquest procedure. The PO offered her help in
contacting his daughter if other family members felt unable to do so. The
man’s sister agreed to let her know if help would be needed and said she was
happy for the PO to contact her with the post mortem results.
47. For the next few days, the PO updated her colleagues at Maidstone and kept
in contact with the Coroner’s officer for news of the post mortem. On 25 July,
she rang the Coroner’s office again and obtained the post mortem results.
The PO then told her senior management team that the man had a heart
attack and that the inquest would be opened and adjourned the following day.
She then rang his sister. They discussed his death and the inquest
procedure. The PO also explained that a memorial service would take place
at Maidstone, and that his family were welcome to attend.
48. They also discussed the man’s funeral arrangements and his property. The
PO explained that Maidstone could contribute towards the cost of the funeral
and had collated all of his property. The PO offered to travel to the south west
to return the property to his family in person. His sister was grateful for the
offer and said she would discuss a funeral contribution with her solicitor.
49. The PO spent the next day arranging the funeral and rang the man’s sister.
During the conversation she asked if a member of staff from Maidstone’s
chaplaincy could attend, to which his sister had no objections. On 27 July, the
Coroner’s office told the PO that the inquest was scheduled for 29 August.
She telephoned his sister to confirm both the funeral arrangements and the
date of the inquest. The PO also agreed to travel to the south west on 8
August to return his property.
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50. On 31 July, one of the FLOs wrote a summary of the family visit for the PO’s
records. The letter was married up with the PO’s family liaison log. The final
funeral arrangements were also logged, including another telephone call to
the man’s sister to confirm his favorite hymn for the service. The funeral took
place on 6 August. A member of staff from Maidstone’s chaplaincy attended
and flowers were also sent from the prison. The PO returned the man’s
property in person two days later.
15
ISSUES CONSIDERED IN THE INVESTIGATION
51. It is pleasing to issue a report where the investigation has revealed nothing
that should be the subject of my own formal recommendations. Nevertheless,
I have identified two areas where improvement would strengthen Maidstone’s
policies and procedures and deal with these below. The clinical reviewer
makes one recommendation.
52. The man’s death was sudden and unexpected. As I mention in the foreword
to this report, staff at Maidstone responded well. From the moment he was
found, the local emergency contingency plans were put to the test and staff
followed them efficiently and effectively. I also mentioned the strength of
family liaison support that his family received after his death. There is much
in this report of which Maidstone can feel justly proud.
53. The man had high blood pressure and displayed symptoms of anxiety at
Maidstone. On the whole he chose not to comply with the treatment he was
offered. This did not go unrecognised. He was monitored by healthcare staff
and the mental health In-reach team regularly and his non-compliance with
prescribed medication was always recorded. These were interventions that
the clinical reviewer feels were equitable to and consistent with those offered
within the wider community.
54. Throughout his time at Maidstone, the man’s history of alcoholism, high blood
pressure and anxiety was documented by healthcare staff. Regular
monitoring was evidenced and appropriate interventions were offered but he
was reluctant to take the advice. The clinical reviewer did not feel that his
healthcare was anything other than what he would have received in the
community. As with a patient in the community, medical professionals cannot
force someone to comply. What they can do is record any non-compliance
that a patient displays. Healthcare staff at Maidstone did exactly that.
55. Prison was not a barrier to the care the man received before his death. In
fact, the communication between his personal officer, and healthcare staff in
relation to his behaviour demonstrated a holistic approach to working with
him. His personal officer’s approach to the personal officer role brought two
sides of the prison together and reduced the likelihood of any concerns being
missed. I am disappointed that staffing changes in Thanet House broke the
consistency of this work. However, it did not have any bearing on the
outcome for the man.
Personal officer scheme
56. The personal officer scheme generally works well at Maidstone. Within two
days of arrival, the man was allocated his personal officer and he settled in
well. From then on, he interacted with his personal officer regularly. His
prison records were updated after each discussion, development or concern
that either the man or his personal officer had, and any action to take as a
result of discussions was carried out in a timely and effective way. I am in no
doubt that his personal officer’s approach to the scheme and her record
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keeping gave her colleagues all the information they needed about him.
There are obvious benefits to prisoners when the personal officer scheme
works well. There are also prison wide benefits in providing both positive and
negative information about individual prisoners. In addition, his personal
officer’s records have helped to tell the man’s story in this report.
57. The man’s personal officer changed on two occasions during his last year in
prison. The level of interaction remained consistent enough. One of the
officer’s told my investigator that changes in personal officer were usually due
to staff shortages or movement, and could not always be avoided. I accept
the need to redeploy staff. I also accept that promotions and transfers are an
inevitable development affecting staffing. However, I am saddened that, for
whatever reason, the man did not get another personal officer after the last
conversation recorded on 7 April 2007. The man’s wing history was left blank
for three months and it does not appear that management checks were
carried out to pick up on the lengthy gap in recording. I do not suggest that
the personal officer scheme needs to be reviewed. However, I know the
Governor will wish to reflect upon what happened on this occasion to ensure
that the high standards of the personal officer scheme do not lapse.
58. The Chief Inspector of Prisons made a recommendation for personal officer
training in her 2002 and 2004 inspections. The most recent report in 2007
recommended ongoing management checks. I make no recommendation of
my own, but I do urge the Governor to consider the benefits of training. I also
bring to his attention the absence of entries and management checks in the
last few months of the man’s life.
Roll check 18 July
59. The night OSG came on duty at 8.45pm. He carried out a roll check,
according to Maidstone’s local instructions, and this was recorded
appropriately. When interviewed by the police, the OSG could not remember
specifically seeing the man between 8.45pm and 9.15pm when the roll check
was complete. However, he did say that he would have remembered seeing
a prisoner on the floor. A night duty OSG’s role is fairly specific and he or she
is not expected to look through observation panels to check on prisoners
throughout the night. An OSG is expected to physically observe prisoners
who are subject to ACCT checks, but the man was not one of them. An OSG
is also expected to respond to cell bells, but again there is no evidence to
suggest that he used his cell bell during the night. The OSG carried out his
patrols and did not record any significant events.
Roll check 19 July
60. During the investigation, the Governor was made aware that officers not
strictly detailed to carry out the morning roll check on Thanet House had done
so. This was in the absence of the officer who had been allocated the duty.
The Governor told my investigator that he was already aware that one officer
did not read the printed detail and that this delayed the roll check, albeit not in
any significant way. I am grateful to the Governor for his swift action to
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remedy the oversight. He said that he would produce a reminder to staff to
check the printed detail and that this would be circulated in the internal
newsletter issued on a monthly basis.
Administering first aid in cell
61. When both the nurse and the SO entered the man’s cell, the nurse examined
him for signs of life before asking an officer to call an ambulance. He did not
respond and a decision was taken not to perform CPR. The nurse noticed
that rigor mortis was present and said that the decision not to resuscitate was
in line with Maidstone’s death in custody policy. The clinical reviewer spoke
to the nurse and the Head of Healthcare, about the resuscitation policy at
Maidstone. The Head of Healthcare confirmed that Maidstone did not have a
separate resuscitation policy and that healthcare staff took guidance from
PSO 2710 which covers resuscitation, emergency equipment and how to
preserve a cell after a death. The Head of Healthcare stressed that the policy
advises medical staff to administer CPR, if there are no signs of breathing,
unless rigor mortis has set in.
62. Responding to an emergency is a highly stressful and difficult part of the job
for both officers and healthcare staff. The nurse who responded, is fully
trained in advanced life support and, in her professional judgement, the man
presented as someone beyond resuscitation due to the presence of rigor
mortis. The clinical reviewer is satisfied that the healthcare response was
appropriate and in line with local guidance. So am I. The reviewer further
commends the Head of Healthcare and her staff for their record keeping, and
the significant events analysis following the man’s death. This is designed to
identify good practice and how responses can be improved in future. The
clinical reviewer notes that the Head of Healthcare will anonymise his records
and use them as a future training tool. The review makes one
recommendation as follows (I have re-worded this slightly):
The Head of Healthcare should consider reviewing the death in custody
policy to include a format for recording observations and actions such
as the ambulance life extinct form.
Deaths in Custody contingencies
63. I have already said that the staff at Maidstone responded well to the local
instructions governing life threatening situations. All three officers interviewed
by my investigator reflected that the prison handled the man’s death well.
What I have not said is that this was the first experience of a death in custody
for the officer who found him. As newly qualified officers, both officers
checking the ground floor that morning, responded professionally and exactly
as their recent training had prepared them to do. Prison officers never know
what they may be faced with from one shift to the next and must be prepared
to respond to a wide range of situations. I congratulate both officers for their
response to the man’s collapse.
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64. I am also impressed with the way officers on the wing ensured that the
regime went back to normal as soon as possible. This was carried out under
the wing manager’s instructions and with minimum disruption to prisoners.
65. I am surprised that the officers and healthcare staff who responded to the
man’s collapse did not appear to record their individual statements. The wing
manager said in his own incident report that he had asked the two officers
who found him to make incident reports. PSO 2710 lists the need for a record
of events explicitly. However, in interview, the officer who found him told my
investigator that he was not asked to make a prison statement. The only
statement he did make was to the police, jointly with his colleague. The
absence of prison statements in no way suggests that important information
went unreported. Both the nurse and the SO made extensive notes in his
medical record and, as I have already said, the Head of Healthcare produced
a significant events analysis which focused on the healthcare response. That
said, my investigator was not given copies of any prison statements. This did
not come to light until after my investigator’s feedback session with the
Governor. If not already explicit in Maidstone’s local contingency plans, I urge
the Governor to ensure that it is amended to reflect the requirement for
statements as soon as possible.
The prison’s Family Liaison Officer
66. The PO and trained FLO has already been recognised in this report for the
sensitivity and compassion she showed in providing support to the man’s
family. During the investigation, it became clear to my investigator that the
PO’s colleagues had also recognised the contribution she made.
Furthermore, during the feedback session with the Governor, the PO’s role as
FLO was discussed and recognised again. I would like to echo the
commendations she has already received from the Governor and her
colleagues. The family liaison support she offered is a measure of the quality
of the FLO training, and the compassion and commitment that she evidently
brings to the role. I urge other prisons to replicate Maidstone’s approach,
which is one of the best examples of family liaison work I have seen.
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RECOMMENDATIONS
1. The Head of Healthcare should consider reviewing the death in custody policy
to include a format for recording observations and actions such as the
ambulance life extinct form.
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