Individual at North Sea Camp

Investigation into the circumstances surrounding the
death of a prisoner at HMP North Sea Camp
in May 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2007
This is the report of an investigation into the death of a prisoner at HMP North Sea
Camp in May 2007. The man was discovered in his room by an officer after failing to
report for work. No signs of life could be detected and prison staff attempted to
revive him until paramedics arrived. He was pronounced dead by the paramedics,
and the cause of death was subsequently identified as a stroke. He was 56 years
old.
I would like to offer my sincere condolences to the man’s family and friends for their
sad loss.
An investigator from my office, conducted the investigation on my behalf. East
Lincolnshire Primary Care Trust, commissioned a clinical review into the man’s
healthcare at North Sea Camp.
I would like to thank the Governor of North Sea Camp, and his staff for their co-
operation and assistance with the investigation. I am particularly indebted to the
Deputy Governor, and the Head of Healthcare, who ensured the relevant
documentation, was made available to my investigator. Thanks also go to North Sea
Camp’s Family Liaison Officer, who has been most helpful during the investigation
process and was supportive to the man’s family throughout.
The man had worked as a butcher within the prison kitchen and was well known to
staff and fellow prisoners and considered a popular individual. He had been at North
Sea Camp for around 18 months. Medical evidence suggests a history of
hypertension within his family, and he exhibited a number of other risk factors.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2007
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CONTENTS
Summary 4
The Investigation process 6
HMP North Sea Camp 8
Key findings 9
Events following the death 12
Issues considered 13
Clinical review 14
Recommendations 16
Annexes
3
SUMMARY
The man was remanded into custody at HMP Leicester in August 2005. He was
subsequently sentenced to six years imprisonment in September 2005.
On arrival into custody, he was given a medical health screening in which it was
noted that he had a family history of hypertension and was suffering from arthritis.
However, whilst on remand, his only contact with medical services was for
prescribed medication for arthritic pain.
Once sentenced, he was considered suitable for open prison conditions and
transferred to HMP North Sea Camp in October 2005. His medical history was
noted by the healthcare staff at North Sea Camp at reception, but he made little use
of healthcare services during his first six months there. In May 2006, while attending
the healthcare centre on an unrelated matter, a routine check showed that his blood
pressure was raised. Thereafter, his fluctuating blood pressure was monitored
regularly. Of greater concern to him was the discomfort caused by arthritis in his hip
and ongoing knee pain for which he was referred to the Orthopaedic Department of
the local hospital.
During his time at North Sea Camp, he was employed in the kitchen and trained in
butchery. He gained a great deal of satisfaction from his work and was a key
member of the team working in that area. He had also started to drive the prison
vehicle. He took fellow prisoners to and from the local train station for work
placements, as well as other journeys around the community.
The day before the man died, he went to Nottingham to spend the day with friends.
His friends said that they had no concerns about him during the day, but with
hindsight they thought he might have been a little quieter than normal. He had taken
some antacid tablets during the day, but had not expressed any feelings of being
unwell.
He returned to North Sea Camp at around 6.24pm. After a brief conversation with
the gate Officer with whom he exchanged some friendly banter, he returned to
Llewellyn unit. At 10.00pm, the man reported to the unit office for roll check and
spoke briefly with the night officer. In interview, the night officer recalled that during
this brief exchange the man seemed fine and gave no cause for concern. During the
night, the officer checked the rooms at various times, his final check being at
6.00am. Nothing unusual was reported.
At around 8.00am on the following morning, an Officer was on duty on Llewellyn unit,
having taken over from the night staff. He was in the process of issuing licences and
dealing with applications in the unit office when he received a telephone call from the
Kitchen Manager, who said that the man had not arrived for work and asked if he
could check on his whereabouts. The Officer went to the man’s room and found him
slumped on his bed. No response could be gained. The Officer tried to contact the
healthcare unit via his radio. There was no response so he contacted the Orderly
Officer, asking him to telephone immediately. The Officer explained the situation to
the Orderly Officer who went to the unit immediately, along with a number of other
officers who had become aware of what was happening.
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Efforts to revive the man using CPR continued until the arrival of the paramedics,
who had been requested by the Orderly Officer, with staff taking turns to ensure that
efforts were continuous. On arrival, the paramedics took over from the staff. They
continued to try and revive him for a further ten minutes, but at 8.47am declared that
he was dead.
According to the clinical review, the man died of a massive haemorrhagic stroke,
likely to have been caused by hypertension. He had other risk factors including
smoking, obesity, and family history.
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THE INVESTIGATION PROCESS
The investigation was opened at HMP North Sea Camp three days after the man’s
death. Notices were issued, informing staff and prisoners of the investigation and
inviting anyone who had relevant information to come forward. There were no
responses to the notices.
The investigator visited the prison a few days later. He met with the Deputy
Governor, as well as the Head of Healthcare. The investigator liaised regularly with
the prison to clarify information about the man’s healthcare needs and his prison life.
He also obtained relevant documentation, including the man’s medical record.
One of my Family Liaison Officers (FLOs), contacted a very close friend of the man’s
who was authorised to act on behalf of the family. She discussed the role of the
Ombudsman and asked about any concerns the family had about the man’s care.
His family and friends had been very shocked by his death, but told the Family
Liaison officer that they were very pleased with the way the prison had dealt with
them. They singled out, the prison FLO, for particular praise.
I am grateful to Her Majesty’s Coroner for providing the post mortem report. The
report records the cause of death as ‘left intracerebral haemorrhage’ and
‘hypertension’. A copy of my report will be sent to the Coroner to assist with the
inquest process.
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HMP NORTH SEA CAMP
HMP North Sea Camp is located in the Lincolnshire fens. It is a category D open
prison that holds up to 314 prisoners.
Built using prison labour from Stafford prison, it opened in 1935 as a Borstal and
became an open male establishment in 1988. Most of the accommodation is in the
original buildings, but two new units, Llewellyn and Harrison, were built in 2002 to
accommodate up to 40 prisoners on the resettlement regime.
As an open prison, North Sea Camp has good links with the local community, with
some prisoners working for local businesses as part of their resettlement.
Ms Anne Owers, HM Chief Inspector of Prisons, conducted an announced inspection
in April 2004. The Inspection team said of North Sea Camp:
“Overall, it was a safe place. However, the inspection found clear evidence of
the need to bolster systems to monitor, support and sustain this safe
environment, in order to manage a growing and changing population.”
Ms Owers further commented on the need to strengthen systems for monitoring
bullying and substance abuse, but highlighted good relations between staff and
prisoners.
Healthcare at North Sea Camp has been provided by East Lincolnshire Primary Care
Trust since April 2005. The inspectorate considered the quality of healthcare to be
good to very good. Ms Owers recommended construction of a new building to house
the healthcare department and this has since been achieved.
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KEY FINDINGS
On 16 August 2005, the man was charged with the unlawful importation of cigarettes
and remanded into custody at HMP Leicester. During health screening on reception
at Leicester, he informed medical staff of a family history of hypertension (a condition
that occurs when blood is forced through the arteries at an increased pressure). He
also complained of pain in his left hip caused by rheumatoid arthritis that limited his
mobility. It was recorded that he was a smoker with a habit of around 25g of tobacco
per day who had “no desire” to give up.
The man had little contact with healthcare services while on remand. He was seen
in September 2005 for the arthritic pain in his hip for which he was given pain relief
medication. He also started on a remedial gymnasium programme to build up a
thigh muscle that had been adversely affected by the arthritis.
On 30 September 2005, he was sentenced to six years imprisonment at Nottingham
Crown Court. The sentence came as a shock to him. He had maintained his
innocence throughout, as he did not consider the nature of his offences as ‘criminal’.
During the man’s initial sentence planning interview, he made clear his intention to
appeal against his sentence.
After he was sentenced, he was classified as a category D prisoner and transferred
to North Sea Camp on 11 October 2005. On reception, his medical history was
noted, but the clinical record suggests he had little contact with healthcare services
in his first six months. The man spent intermittent spells in Nottingham prison when
attending court for ongoing matters related to his case.
On 10 May 2006, while attending the healthcare centre on an unrelated matter, his
blood pressure was taken and a reading of 150 over 100 was recorded. (A normal
blood pressure reading for a man of his age is considered to be around 120 over 80.)
The man was advised to return for a follow-up check within a week. This took place
on 16 May, when his blood pressure was recorded as 180 over 100. He was
therefore referred to the doctor.
The man continued to have his blood pressure monitored on a regular basis for
several months, with no cause for concern. During this time, he continued to work in
the kitchen and never missed a day as a result of illness. On 9 December 2006, he
reported to the healthcare centre that he had felt dizzy when standing up and
described feeling ‘fuzzy’ headed. His blood pressure was taken and a reading of
140 over 104 was recorded. The man said that he otherwise felt generally well and
was instructed to return in the afternoon for another test after he had taken his
medication. He did not return for the second test and there was no follow up by
healthcare staff. (At North Sea Camp, which operates an open regime, it is
apparently common for prisoners to choose not to attend pre-arranged appointments
- as often happens in the community.)
The man’s next visit to healthcare was on 13 December when he attended the
chronic disease clinic. His blood pressure was recorded as 148 over 97. He said
that he had recently had ‘palpitations’ but no real chest pain. Arrangements were
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made for him to be seen by the doctor and for a blood test. His blood pressure
continued to be monitored, but he did not experience further significant problems.
As well as working in the kitchens as a butcher, he also worked as a driver. This
entailed driving one of the prison vans to take fellow prisoners to work placements or
medical appointments in the local community. He had only been driving for a short
while and it helped towards his resettlement plans. The last time that he drove the
van was two days before his death. He did not mention feeling unwell to anyone.
The following day, the man went on a home visit to Nottingham to spend the day with
friends. He left at the prison at 8.20am. His friends said they had no concerns at the
time, but with hindsight he might have been a little quieter than normal. He had
asked for some antacid tablets during the day, but his friends simply assumed that
he had indigestion as he did not say that he was feeling unwell or display any
outward signs.
He returned to the prison at 6.24pm. The man spoke to an Officer who was working
on the gate and had known him since his arrival at the prison. The Officer recalls
having a “bit of banter” with him, which he often did. In his opinion, the man was his
usual chatty, happy self. He said that he had no concerns about his wellbeing either
during the conversation or on the other occasions he saw him during his shift.
The open regime at North Sea Camp requires the prisoners to be responsible for
reporting their presence to the Officer on duty so that a full roll check can be
completed. At approximately 10.00pm, the man reported to the office on Llewellyn
unit to give his room number to the Officer on night duty. The Operational Support
Grade (OSG) said that he exchanged ‘pleasantries’ with the man who appeared well
and gave him no cause for concern. As part of his duties the OSG checked all the
rooms on the unit, on an ad hoc basis, throughout the night. There was no indication
of a problem when he checked the man’s room. The OSG recalled that, during his
final roll check at around 6.00am, the man’s leg was slightly out of bed but he felt
that there was nothing unusual or of concern. At the end of his shift, the OSG
handed over to the day Officer.
The day Officer had only recently started to work in the resettlement unit. He was in
the unit office issuing work licences and taking prisoner applications (the normal
morning routine) when he received a call from the Catering Manager. He told the
Officer that the man had not arrived for work. The Officer checked the man’s
whereabouts on the roll board and confirmed that he had two work placements,
kitchen and CSV driver. He told the Kitchen Manager that he would check on the
man to clarify the situation after he had finished issuing the licences.
At 8.15am, the Officer went to the man’s room. On entering the room, he found him
sitting on the edge of the bed ‘slumped’ to one side, with his chin on his chest. The
Officer touched the man’s shoulder, but there was no response and he felt cold to
the touch. The Officer attempted to contact healthcare using his radio. He did not
receive an immediate verbal response, so contacted the Principal Officer (PO) who
was the Orderly Officer, requesting that he telephone him at Llewellyn unit. The
Officer then returned to the unit office to collect the first aid equipment. In the office
he spoke with the PO on the telephone and told him that he had found the man in his
9
room and that he did not appear to be breathing. The PO immediately made his way
to Llewellyn unit and directed other staff to contact the healthcare team. The
healthcare team were already on their way after hearing the call for assistance over
the radio net.
When the PO arrived, he went straight to the man’s room to meet the Officer. They
moved the man onto the bed so that he was on his back. The PO said that the
man’s face and extremities were blue and that he could find no signs of life. Another
Officer arrived on the unit and assisted the PO with cardio pulmonary resuscitation
(CPR). An ambulance had been requested. Other members of staff arrived,
including two nurses from the healthcare centre, and they took it in turns to
administer continuous CPR until the paramedics arrived.
The paramedics arrived at 8.37am and took over the CPR from staff. They
continued efforts to revive the man until 8.47am when they declared that he had
died. At this point all staff in the vicinity, including the paramedics, left the room to
allow the chaplain to enter and offer prayers.
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EVENTS FOLLOWING THE DEATH
After the man’s death, the Governor appointed a prison Family Liaison Officer (FLO).
Along with an Administrative Officer from North Sea Camp, they drove to Nottingham
to inform the man’s girlfriend and next-of-kin. They remained with his family for most
of the day, making arrangements with the Coroner’s officer for the family to see the
man. They escorted the family to the homes of other family members to tell them of
the man’s death. The prison FLO invited the family to a memorial service that was to
be held at North Sea Camp. They also offered the family financial assistance
towards the funeral expenses.
The day after the man’s death, the FLO met the man’s family at North Sea Camp to
accompany them to view his body. After a meeting with the Coroner, the FLO and
the man’s family returned to the prison. They were shown Llewellyn unit and visited
the chapel to meet other prisoners who had been friends with him.
The FLO subsequently returned the man’s property to the family. He also met with
the chaplain who would be conducting the man’s funeral who happened to be at the
family home while he was visiting.
The Deputy Governor, FLO and Kitchen Manager attended the man’s funeral. A
number of serving and ex- prisoners also attended, which was a sign of the man’s
popularity. The family were pleased with the attendance of the prison staff and
picked out the FLO for particular mention during the service for all the help and
assistance he had given.
On 12 June, members of the family attended a memorial service held in the chapel
at North Sea Camp.
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ISSUES CONSIDERED
Healthcare
My investigation has shown that the man’s ongoing hypertension was regularly
monitored. However, it is also apparent that there was no system in place to follow
up patients who failed to attend for scheduled appointments. I fully appreciate that
this is also the case with many GPs when members of the public fail to attend for
routine appointments. However, the prison would benefit from a system to follow-up
prisoners suffering from chronic conditions who fail to attend for their appointments.
The Prison Health Partnership at North Sea Camp may wish to consider
introducing a system to contact prisoners receiving ongoing treatment who
fail to attend for appointments and to record the reasons for their non-
attendance.
Family
The actions of the prison following the man’s death, in particular the prompt and
personal way that the next of kin were informed, was entirely appropriate and
compassionate. At his funeral, the family made particular reference to the
professional way that they had been treated by the prison and singled out the actions
of the prison FLO.
The Governor and staff at North Sea Camp should be commended for their
quick response and the compassionate way in which they dealt with the man’s
next of kin following his death. In particular, the FLO should be recognised for
his wholly professional approach in carrying out his role.
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CLINICAL REVIEW
Lincolnshire Teaching Primary Care Trust conducted the Clinical Review. The
appointed Doctor produced a comprehensive report of the medical care given to the
man whilst in custody and makes four recommendations. The report is attached in
full as an annex, but the main findings are reproduced below:
Key Findings and Conclusions
1. The man had several risk factors for development of an acute cerebrovascular or
cardiac event, namely long term, poorly controlled hypertension; clinical obesity;
smoking; raised cholesterol with a very high Total/HDL ratio and a family history
of hypertension and stroke. His overall risk of cardio- or cerebro-vascular event
in December 2006 would have been assessed as > 20% using a CVD risk
calculator.
2. The standard of documentation in the North Sea Camp prison medical records
was excellent and there is a robust system within the healthcare service for
monitoring patients with chronic conditions such as hypertension and coronary
heart disease.
3. All contacts to healthcare were recorded and there was repeated reference to the
man’s hypertension during individual consultations with nursing staff. Appropriate
investigations were arranged by the healthcare staff and referral to the duty GP
was made on several occasions. He did not attend some of the appointments
that were made for him. Responsibility for attending follow-up appointments lies
with the patient and there is no formal recall system in place for patients that do
not attend.
4. The man did not receive optimal treatment for hypertension despite regular
readings that were outside the recommended treatment targets. He was taking
enalapril for most of his period in custody. He received a month’s supply of
amlodipine at Nottingham prison, but this was not continued following his return
to North Sea Camp. He appeared to be reasonably compliant with his treatment
as evidenced by regular collection of his medication and regular attendance for
BP measurement. There was, however, no trace of enalapril or simvastatin
found on analysis of his post mortem blood sample.
5. There were several possible reasons for poor BP control, including reduced
patient compliance with medication, co-prescription of a NSAID, which can
elevate BP, and lack of optimisation of anti-hypertensive medication. The
recommended treatment regime would have included the addition of a calcium
channel blocker to the enalapril with consideration to use of a beta or alpha-
blocker if further reduction was required.
6. The man was prescribed simvastatin 10mg daily to lower his cholesterol. This is
lower than the recommended dose of 40mg for primary prevention and there
were no follow up measurements to check the efficiency of this dose in lowering
the Total/HDL ratio.
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7. The man was seen and assessed for his knee problem and he was appropriately
referred for an orthopaedic opinion. It is likely that the Orthopaedic Surgeon
would have requested anaesthetic assessment of his BP, which was 152/96 at
the time of referral.
8. The man died of a massive haemorrhagic stroke, likely to have been caused by
hypertension, with additional contribution from his smoking, obesity, an adverse
lipid profile and family history.
Recommendations
1. The GPs who have been commissioned by the PCT to provide general
medical services to the prisoners at North Sea Camp should review current
guidelines on management of chronic diseases such as hypertension,
coronary heart disease and diabetes. There should be consistency in their
treatment targets.
2. There is a clear need for management protocols, based on National
Guidelines, to be introduced so that the GPs and Healthcare staff are
working to recognised minimum standards of care for all chronic
conditions.
3. Transfer of prisoners is always a risk in terms of continuity of healthcare
and there should be a robust system which outlines the patient’s current,
recent and past health problems, ongoing treatment and monitoring
arrangements, and continuation of therapy as planned following transfer.
There should be a formal clinical handover at the time of transfer with full
documentation of ongoing treatment and monitoring requirements.
4. A Clinical Governance Policy and Plan should be established for North Sea
Camp to ensure that clinical protocols are regularly reviewed and
performance is monitored. Critical incidents should be reviewed in a “no
blame” culture and used as a learning process. The Clinical Governance
process should receive input from the GPs, healthcare staff and nurses, the
PCT, and relevant Chronic Disease Groups to ensure that prisoners with
chronic medical and mental health problems receive appropriate
management.
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RECOMMENDATIONS
1. The Prison Health Partnership at North Sea Camp may wish to consider
introducing a system to contact prisoners receiving ongoing treatment
who fail to attend for appointments and to record the reasons for their
non-attendance.
2. The GPs who have been commissioned by the PCT to provide general
medical services to the prisoners at North Sea Camp should review
current guidelines on management of chronic diseases such as
hypertension, coronary heart disease and diabetes. There should be
consistency in their treatment targets.
3. There is a clear need for management protocols, based on National
Guidelines, to be introduced so that the GPs and Healthcare staff are
working to recognised minimum standards of care for all chronic
conditions.
4. Transfer of prisoners is always a risk in terms of continuity of healthcare
and there should be a robust system which outlines the patient’s
current, recent and past health problems, ongoing treatment and
monitoring arrangements, and continuation of therapy as planned
following transfer. There should be a formal clinical handover at the
time of transfer with full documentation of ongoing treatment and
monitoring requirements.
5. A Clinical Governance Policy and Plan should be established for North
Sea Camp to ensure that clinical protocols are regularly reviewed and
performance is monitored. Critical incidents should be reviewed in a
“no blame” culture and used as a learning process. The Clinical
Governance process should receive input from the GPs, healthcare staff
and nurses, the PCT and relevant Chronic Disease Groups to ensure
that prisoners with chronic medical and mental health problems receive
appropriate management.
GOOD PRACTICE
The Governor and staff involved at North Sea Camp should be
commended for their quick response and the compassionate way in
which they dealt with the next of kin following the man’s death. In
particular, the prison FLO should be recognised for his wholly
professional approach in carrying out the role.
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ANNEXES
1. Clinical review
2. Medical record
3. Wing record (page 16)
4. Statements of staff
5. Roll check report
Incident log
Minutes of debrief
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