Individual at Manchester

INVESTIGATION INTO THE DEATH OF A MAN AT HMP MANCHESTER,
ON 9 MARCH 2005
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
JUNE 2005
This is the report of an investigation into the death of a man who died from
natural causes in North Manchester General Hospital on 9 March 2005,
having been taken ill two days earlier.
The man had been convicted on 25 March 2003 and sentenced to six years
imprisonment. It was his first conviction and his first experience of prison life.
He was held at HMP Manchester and it was there that he was taken ill on 7
March 2005.
This investigation has been undertaken by one of my investigators. I would
like to thank the Governor of Manchester Prison, and his staff for their
participation in the investigation. A doctor of North Manchester Primary Care
Trust was commissioned to undertake a review of the man’s medical care,
and I appreciate his assistance.
The man’s clinical care was found to be appropriate and his transfer to
hospital timely. However, I do have concerns about the failure to notify the
man’s family of his admission to hospital in a timely manner. I have made a
specific recommendation to HMP Manchester on this matter, but this is an
issue that could sensibly be the subject of further guidance from the National
Offender Management Service (NOMS) Safer Custody Unit.
The loss of a loved one is always distressing. I would like to add my
condolences to those already expressed to the man’s family by my Family
Liaison Officer.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2005
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CONTENTS
Summary 4
Background 5
HMP Manchester 6
Conduct of the investigation 7
Key Findings 8
Recommendations 11
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Summary
1. The man was born in 1934 and was 70 years old when he died from
natural causes on Wednesday 9 March 2005.
2. The man arrived at HMP Manchester on 25 March 2003. At his First
Reception health screen it was noted that he had a number of health
problems including diabetes.
3. On 3 March 2005, the man complained of feeling unwell. He was feeling
hot and cold, and suffering from dizziness and nausea. He was examined
by a prison doctor who requested further tests to be carried out. During
the afternoon of Monday 7 March, he remained unwell and it was decided
that he should be transferred to North Manchester General Hospital.
4. Whilst he was an in­patient at the hospital, a bedwatch was carried out by
prison officers. Due to the nature of his offences he was initially
handcuffed, but when his condition deteriorated, a closeting (escort) chain
was used until shortly before his death. The man died in hospital two days
later.
5. The clinical review carried out by the reviewer concludes that the man’s
care whilst in prison was appropriate and of a good standard. The
reviewer also considers that the man’s referral to North Manchester
General Hospital was appropriate and timely following a thorough
examination.
6. On 3 May 2005, one of my Family Liaison Officers contacted the man’s
family. They expressed their concern about the failure of the prison to
notify them when he was first admitted to hospital and also about the care
and treatment given to him by the prison.
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Background
7. The Probation Service prepared a comprehensive assessment on the man
before he was sentenced, which described him as having poor health
including diabetes which was controlled by diet.
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HMP Manchester
8. HMP Manchester was first opened in 1868. It was comprehensively re­
modelled following the serious disturbance of 1990. There are nine wings
and a supporting infrastructure including kitchens, extensive workshops
and a healthcare centre. There is a weekly GP clinic for men in the
vulnerable prisoners unit, but there are no clinics for chronic disease
management.
9. Her Majesty’s Chief Inspectorate of Prisons (HMCIP) carried out an
unannounced inspection of Manchester in July 2004. The inspectors
described a safer prison than when they had last visited three years
earlier. However, the report did state that the quality of healthcare had
deteriorated since the previous inspection and that although ‘individual
staff were motivated, this was undermined by chronic nursing shortages
and the lack of infrastructure and robust systems’.
10.The prison responded to the findings of the inspection report and has
taken positive steps to improve its healthcare provision.
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Conduct of the investigation
11.My investigator studied all relevant prison records relating to the man.
These included his main prison record, Inmate Medical Record and the
Bedwatch Logs covering the period spent at North Manchester General
Hospital between 7 and 9 March. My investigator also studied instructions
at Manchester on the arrangements to be followed when prisoners are
escorted outside the prison, including the use of restraints.
12.A Clinical Review was commissioned from North Manchester Primary Care
Trust. I am very grateful to the PEC Chair for undertaking this review in a
prompt and timely manner.
13.My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner to
assist him in his enquiries into the man’s death.
14.One of my Family Liaison Officers contacted the man’s family and was told
their concerns about his care at HMP Manchester. The families’ concerns
included the use of mechanical restraints, the delay in notification of the
man’s transfer to hospital and questions about whether his previous
medical care had impacted upon his health.
15.My investigator visited Manchester and discussed aspects of the man’s
treatment with staff and discussed the issues raised by his family. I hope
this report provides them with answers to their concerns. The Primary
Care Trust found that the man’s clinical care was appropriate and his
transfer to hospital was timely. However, I do have concerns about the
timeliness of informing the next of kin of admission to hospital and have
made a recommendation concerning this.
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Key Findings
16.When the man first arrived in Manchester, it was decided that he should be
given Vulnerable Prisoner status because of his age and the nature of his
offence. The First Reception health screen was carried out on 25 March
2003 and this stated that he had a number of health problems including
diabetes.
17.On 18 November, the man was admitted to Manchester Royal Infirmary for
knee replacement surgery. Just over a year later, he was admitted to
Manchester Royal Infirmary for an operation to replace an aortic valve in
his heart.
18.On 3 March 2005, the man complained of feeling unwell as he had a
temperature, dizziness and nausea. He told the prison doctor that he had
suffered from dizzy spells since the previous week, when he had fallen and
hit his head. The prison doctor examined him and asked for further tests
to be carried out. Blood samples were taken for testing the following day.
19.During the afternoon of 7 March, the man was still feeling unwell. He
attended the GP clinic and was seen again by the prison doctor. The
doctor thought that there was a possibility of endocarditis (the inflammation
of the lining, valves and muscle of the heart), and he decided to refer him
to North Manchester General Hospital. The man was escorted in
handcuffs from the prison to the hospital.
20.Once he was settled on the ward in the hospital, the nursing staff
requested that a closeting (escort) chain be used instead of handcuffs.
This enabled the nursing staff to have easier access to the man when they
carried out their duties. The request was granted.
21.On 8 March, the nursing staff carried out further tests and administered
medication. During the evening of the same day the doctor attending the
man told the officers that he had an infection and would be unwell until the
medication started to have an effect. The doctor also told the officers that
he expected himto be in hospital for about a week.
22.At 8:30am on 9 March, The man was taken for an electrocardiogram
(ECG). While the nurse attempted to carry out the ECG, the needle, which
was administering drugs intravenously, came out of his arm. The officer
escorting the man removed the closeting chain to facilitate the re­
attachment of the needle. The chain was replaced, but a little later it was
removed again to enable him to have a shower following the earlier blood
spillage.
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23.At 1:05pm, after the man was seen by the doctor, hospital staff were asked
by a Senior Officer to telephone his next of kin to inform them that he was
in hospital and tell them to contact the prison about visiting arrangements.
The man’s sister had been visiting the hospital since 7 March to see her
daughter, who was also an in­patient, but was not informed about her
brother’s situation until the evening on 9 March. The man’s sister was able
to visit him immediately after she was informed, but by this time he had
already passed away.
24.At 4:15pm, the man was moved to the Intensive Care Unit (ICU) and at
6:10pmthe ICU Consultant, informed the Senior Officer that the man’s
condition had deteriorated to such an extent that it necessitated the
removal of the closeting chain. This was to enable nursing staff to have
instant access for defibrillation and on health and safety grounds. The
doctors prognosis was poor, as he had found that the man had suffered
heart failure. Permission was given by the Governor to remove the
closeting chain.
25.At 6:20pm, the man’s condition deteriorated and the officers on bedwatch
duty withdrew to enable clinical staff to carry out the necessary medical
interventions. At 7:00pm, the doctor informed the Senior Officer that the
man had died.
26.The duty governor was immediately informed of the man’s death. A
member of the prison chaplaincy, maintained contact with the family and
assisted with the funeral arrangements. The prison also provided financial
assistance with the funeral costs and the Governor represented the prison
at the man’s funeral.
27.The post mortem report states that the cause of death was due to natural
causes as a consequence of endocarditis of the aortic valve and tight
aortic stenosis (the narrowing of the aortic valve).
28.The Clinical Reviewer concluded that the man’s care while he was in
prison was of a good standard and that medical issues were dealt with in a
timely manner.
29.I share the concern of the man’s next of kin that they were not informed in
a timely manner of his admission to hospital. In his comments on the
bedwatch logs, the Senior Officer stated that he asked the hospital to
inform the man’s next of kin about his admission to the hospital and to tell
them to contact the prison to arrange when they could visit him.
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30.In my view, the prison itself should have informed the man’s family about
his admission to hospital as soon as it occurred. This was especially
important because of his age and his medical condition, and it would have
enabled his family to visit him at an earlier stage. It is particularly sad that
the man’s sister, who visited another patient on the Monday, Tuesday and
Wednesday, could have seen her brother when he was still alive, if she
had been notified in a timely manner.
31.My investigator considered the use of mechanical restraints and I am
satisfied that the decision to remove the man’s restraints was taken at the
earliest opportunity.
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Recommendations
Operational
The Governor should remind staff that next of kin should be informed when a
prisoner is admitted as an in­patient to hospital at the earliest opportunity.
Should a prisoner be insistent that their next of kin is not informed, this should
be appropriately recorded in the bedwatch log.
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