Individual at Maidstone

INVESTIGATION INTO THE CIRCUMSTANCES OF
THE DEATH OF A MAN
IN NOVEMBER 2004
WHILST IN THE CUSTODY OF HMP MAIDSTONE
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2005
This is the report of an investigation into the circumstances surrounding the death of
a man on 27 November 2004. The man died from heart disease in his cell at HMP
Maidstone. He was 70 years old.
I would like to extend my sincere condolences to his family and to those touched by
his death.
I am sorry for the length of time it has taken to complete this report. The
investigation was initially opened by one of my Assistant Ombudsmen. Following
her retirement, the investigation was taken over and led by one of my other
colleagues. An independent review of the man’s medical care in prison was carried
out as part of the investigation.
We would like to thank the management and staff at HMP Maidstone for their
assistance and co­operation during the course of this investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2005
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Contents
Summary
The investigation process
Background
The events leading up to the man’s death
The prison’s response following the death
Findings and Conclusions
Recommendations
Good practice
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Summary
After sentencing, the man was first received into HMP Belmarsh in February 2003.
He transferred to Maidstone in mid March 2003. His First Reception Health Screens
at both Belmarsh and Maidstone showed him to be physically and mentally fit. He
was taking no medication and had no reported past medical history of any
significance. He did not smoke and only occasionally drank alcohol. His vital signs
were not recorded at either Reception Screen. Apart from a bleeding stomach ulcer
in 2002, he had no other significant past medical history.
At 11am on Saturday 27 November 2004, the man was seen in healthcare as he had
vomited and felt unwell. He was also complaining of chest pain, which he said felt
like indigestion and wind. He was pale, had vomited and felt sweaty. His pulse was
recorded as being 98. The nurse gave himsome Gaviscon and told him she would
ask the doctor to see him that afternoon. He was subsequently returned to his cell.
At 12pmthat day, the man was found on the floor of his cell. No pulse could be
found. Cardiopulmonary resuscitation (CPR) was administered until the arrival of the
paramedics who confirmed his death at 12.25pm.
The Post Mortem report indicates that the man died of Ischaemic Heart Disease.
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Investigation Process
All the indications were that the man’s death was fromapparent natural causes. In
these circumstances, I have judged that it may be sufficient for a clinical review to be
carried out by an independent health care professional rather than a full
investigation. My approach in cases of apparent natural cause deaths has been to
conduct an initial review to determine if a full investigation is justified. In this case, I
decided that the circumstances did not require a full investigation, but appointed a
clinician to undertake the review of his care.
My investigator initially opened the investigation and arranged for the relevant
notices to be sent to the prison inviting staff and prisoners to make contact if they felt
they had any information relevant to the investigation. No letters or telephone calls
were received from either staff or prisoners.
Following the retirement of the first investigator, another colleague conducted a
review of the health and social care the man’s received whilst in custody.
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The events leading up to the man’s death
He reported no significant past medical history. In August 2004, he was seen by the
doctor as part of a routine ‘Well Man’ clinic which was run by healthcare at
Maidstone.
During this visit, his blood pressure (BP) was noted to be 190/110 and his weight
had risen from 14st to 15.2st. At this point, he reported to the doctor that he had had
a bleeding ulcer about four years previously, but that he had overcome the problem
and was fit and well. The doctor felt that his raised BP was due to anxiety.
The man was followed­up by a doctor a week later on 3 September 2004. He looked
well and his blood pressure was 180/90. The doctor prescribed diuretics,
Bendrofluazide 2.5mg, in an attempt to reduce his BP. The doctor requested a re­
check of the man’s BP in one week’s time.
On 10 September, he was prescribed Diltiazem 60mg, in a further attempt to reduce
his BP which was then recorded as 170/90 and 190/90. Blood tests were requested
which appear to have been carried out approximately one month later on 3 October
2004. The results were mainly within normal limits with a slightly raised cholesterol
level of 5.4. The man was advised to see healthcare again in two to three weeks
time. Due to his age, he was also given a flu vaccination in accordance with the
Department of Health guidelines.
On 1 November, the man saw another doctor, who re­checked his BP which was
190/90. The doctor carried out some tests to exclude diabetes. The man reported
some side effects to the medication, feeling sick and suffering from mild headaches.
It was decided to continue the prescription for one month and re­check his BP. If
there was no reduction or the side effects continued, his medication would be
changed.
At 11am on 27 November, a nurse received a phone call in healthcare from the wing
saying that the man was feeling unwell and was vomiting. The nurse asked for him
to come up to healthcare. The man told the officer who escorted him that the pain
felt like indigestion. On arrival, he told the nurse he was getting pain in his chest,
and he was rubbing his upper abdomen. He looked pale but said he had no pain in
his arms, and the nurse reports that his arm did not feel clammy. When asked if he
felt sweaty he said he had been. The nurse took his pulse which was recorded as
being 98 and regular but did not check his blood pressure. The man then belched
and said again he thought it was wind. The nurse gave him Gaviscon tablets to treat
his symptoms. The nurse said she would askthe doctor to see him when he came
in later that afternoon. The man started retching, and vomited again. The nurse
asked him what he had eaten. She then asked the officer whether anyone else on
the wing had been sick. He said not. The nurse commented to himthat his colour
was better and he replied it was because he had been sick. The nurse asked the
officer to keep an eye on himand to call her if he got any worse. The nurse told the
doctor over the phone about the man’s pain and that he had been sick. She asked
the doctor whether he would see him when he came in and he said he would be
there between 2.15 and 2.30pm.
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The man was found collapsed on his cell floor at approximately 12.05pm. An
emergency ambulance was requested. An officer phoned healthcare for medical
assistance but there was no response. He heard over the radio that an ambulance
had been called. Cardio­pulmonary resuscitation was commenced by discipline
officers. On arrival, the paramedics took over the resuscitation. Sadly, this was
unsuccessful and the man was pronounced dead.
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The prison’s response following the death
Staff followed contingency plans following the death in custody. The man’s next of
kin were contacted by the Head of Security. A notice was drafted and issued to
every prisoner on the wing where the man had resided.
A hot debrief was held for staff by the head of security at 5.15pm on 27 November,
the afternoon of the man’s death.
The man’s family (Brother in Law and Sister), visited the prison the next day and met
with the Governors. Advice and support was offered to them and it was agreed that
a memorial service would take place.
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Findings and Conclusions
During the man’s First Reception Health Screen there were no baseline observations
of height, blood pressure, pulse or respirations recorded. The man’s weight was
however recorded to be 14st.
The First Reception Health Screen forms should be fully completed and
include base line observations of blood pressure, pulse, respirations,
temperature, height, weight and urinalysis.
The man was seen as a matter of routine by the doctor in the over 65’s clinic on 27
August 2004, approximately 18 months after admission to prison. It was noted at
this stage that his blood pressure was a little above normal levels at 190/110 and his
weight had risen to 15.2st.
He was followed­up by the doctor a week later on 3 September. The man looked well
and his blood pressure was 180/90. The doctor prescribed appropriate medication in
an attempt to reduce his BP.
On 10 September, the man was prescribed further appropriate medication in an
attempt to reduce his BP. His BP was recorded as 190/90. Blood tests were
requested which do not appear to have been carried out until approximately one
month later on 3 October 2004. The results were mainly within normal limits with a
slightly raised cholesterol level of 5.4. There is no reference to the raised cholesterol
level or steps that could be taken to help himreduce his cholesterol intake and level.
Requested blood tests should be carried out promptly and results documented
in the medical record and acted upon if required in a timely and appropriate
manner.
The man’s BP was checked weekly for three weeks until 10 September when it was
not checked again until 1 November 2004. At this time it was recorded as 190/90. It
was decided to continue the same medication and to review himagain in one
month’s time.
The regular monitoring of vital signs (particularly BP) for a patient with
hypertension should be carried out and documented on a regular and frequent
basis in accordance with the National Service Framework.
When the man attended healthcare on 27 November complaining of chest pain, the
nurse on duty was a registered mental health nurse (RMN). She appeared to make
an attempt to rule out cardiac involvement, noting whether he felt cold and clammy,
sweaty or had pain in his arms. However, the fact that the man was rubbing his
upper abdomen and told her that it felt like wind may have confused her attempt to
diagnose the problem. The man had told the officer escorting him over to healthcare
that his chest pain felt like indigestion. Despite his raised pulse rate and history of
hypertension, the nurse appears not to have taken his BP. The nurse missed the
classic symptoms associated with Myocardial Infarction (MI) of which the man was
complaining. He was pale and sweaty, had vomited and complained of chest pain.
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If an ambulance had been called at this stage, it might have improved the chances of
the man’s survival.
The nurse states that she reported his symptoms to the doctor over the telephone
and asked him to see him when he came into healthcare. There is no
documentation regarding the content of the discussion, but it appears that the doctor
thought several hours later would be soon enough to assess the man.
All conversations between healthcare professionals in which a patient’s
condition is discussed should be clearly documented in the medical record.
The man was found collapsed in his cell at approximately 12.05pm. Resuscitation
was administered by two discipline officers and continued until the paramedics
arrived. An officer phoned healthcare for medical assistance but there was no
response. He heard over the radio that an ambulance had been called.
The arrangements for contacting healthcare in the event of an emergency
should be reviewed to ensure that staff respond promptly.
The post mortem concluded that the man died from Ischaemic Heart Disease.
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Recommendations
Health
1. The First Reception Health Screen forms should be fully completed and
include base line observations of blood pressure, pulse, respirations,
temperature, height, weight and urinalysis.
2. Requested blood tests should be carried out promptly and results
documented in the medical record and acted upon if required in a timely and
appropriate manner.
3. The regular monitoring of vital signs (particularly BP) for a patient with
hypertension should be carried out and documented on a regular and frequent
basis in accordance with the National Service Framework.
4. All conversations between healthcare professionals in which a patient’s
condition is discussed, should be clearly documented in the medical record.
5. The arrangements for contacting healthcare in the event of an emergency
should be reviewed to ensure that staff respond promptly.
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Good Practice
1. Maidstone’s routine well­man check of persons over 65 is good practice and
in this case picked up a previously unknown case of hypertension.
2. The officers involved when the man first became ill, and when he was
subsequently found collapsed in his cell on 27 November, acted quickly,
appropriately and professionally.
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