Individual at Norwich

Investigation into the circumstances surrounding the death of
a man in July 2005 at HMP Norwich
Prisons and Probation Ombudsman for England and Wales
March 2006
The man was aged 43 when he died in July 2005, apparently by his own
hand, in his cell at HMP Norwich. This is a report into the circumstances
surrounding his death.
The man had been diagnosed with a terminal illness, and was experiencing a
great deal of pain and discomfort that appears to have been too much for him
to tolerate. My investigator and I offer our sincere condolences to his family
and friends on their loss.
A member of my team carried out the investigation. I wish to thank the
Governor of Norwich for making the necessary facilities available to my
investigator, and for the help and support of the Liaison Officers. Additionally,
I wish to thank the Area Manager and Governor for their close working
relationship with my investigator. This was a model of good practice between
the Prison Service and my independent office.
In the course of the investigation, I asked for a clinical review of the care and
treatment received by the man to be carried out. I am extremely grateful to
Norwich Primary Care Trust (NPCT), for their assistance and report. The
report makes four recommendations - which will be monitored via the Norwich
Prison and NPCT Healthcare structure - and identifies two areas of good
practice.
I am satisfied that the man was given every care following the diagnosis of his
condition and that appropriate support and treatment was available to make
his remaining time as comfortable as possible. I do not believe there were
any grounds for suspecting that he might take his own life.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2006
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Contents
Summary 4
HMP Norwich 6
Conduct of the Investigation 8
Significant Events prior to 28 July 9
HMP Highpoint 9
Addenbrooke’s Hospital 9
HMP Norwich 10
Events of 28 July 12
Events following the mans death 14
Area Manager’s Review 16
Key Findings 17
Recommendations 19
Annexes 20
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Summary
1. The man died in July 2005, having been found hanging in his cell at HMP
Norwich.
2. Whilst at HMP Highpoint, the man had been diagnosed as having a
terminal illness. During a period of treatment at Addenbrooke’s Hospital,
the medical team and the man agreed that, in the event of cardio
pulmonary arrest, he should not be resuscitated. A “do not resuscitate”
(DNR) order was placed in his medical notes.
3. On 29 March 2005, the man was transferred from Highpoint to Norwich
prison. He was initially located in the prison hospital and later transferred
to the elderly prisoner unit, which is a specialised facility offering full time
medical care to its residents. Although he was not elderly, the Governor
and Head of Healthcare decided that he should live in an environment that
was quieter and offered him the medical care that he needed. The
decision taken at Addenbrooke’s Hospital was re-examined by the prison
doctor, Healthcare Manager, Area Manager and Governor. They, in
agreement with the man, decided that the DNR decision was correct and
would be the policy for the management of his condition.
4. On 28 July, between 5:00pm and 5:15pm, a nurse commenced an
observation patrol of the unit. She said that the man was in his cell, sitting
on his chair and had looked up at her when she looked through the cell
door observation hatch. As his actions were not out of the ordinary, she
continued with her patrol duties.
5. At 5:50pm, a Healthcare Officer (HCO) was unlocking patients to allow
them to collect their evening meal. When he arrived at the mans cell he
was unable to see him. He confirmed with another nurse that the man
was meant to be in the cell, and decided to open the door and check on
his whereabouts. As he attempted to open the door, he found that a
locker and table that had been placed behind the door, blocking access
into the cell. He and the nurse pushed the door open and saw the man
suspended at the neck by a ligature made from the edge of a bed sheet,
which had been secured to the in cell television wall bracket.
6. Once the ligature had been removed, the HCO checked for signs of life,
but could not detect any. Even though the decision had been taken that
the man should not be resuscitated, he began to carry out cardio
pulmonary resuscitation (CPR). The nurse left to summon assistance from
unit staff and the emergency services.
7. At 6:10pm, paramedics arrived and after completing their own tests,
stopped any further attempt at resuscitation. The man was pronounced
dead at 6:15pm.
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8. The clinical reviewer examined the DNR decision and concluded that
nursing staff were aware of it. However, as the man had been found
hanging and this was not within the boundaries of the DNR policy, they
ignored it and made every attempt to resuscitate him. The report shows
that nursing staff took the correct decision in attempting to resuscitate the
man and that their actions were in keeping with the policy.
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HMP Norwich
9. HMP Norwich is located within the city boundaries and holds convicted
and remand prisoners, including adults and young offenders. It is
designated as a local prison and serves the courts of East Anglia. The
certified normal accommodation is 591 and the prison has an operational
capacity (maximum crowded capacity) of 823.
10. A car park and road divides the prison. One section of the prison
accommodates young offenders and the Healthcare Centre, which also
includes an elderly prisoner unit. The remainder of the population is
accommodated in the main prison complex. In December 2004 a new
governor was appointed to the prison.
11. In March 2005, Her Majesty’s Chief Inspector of Prisons (HMCIP) carried
out a full announced inspection of the prison. In the introduction to her
subsequent report, she said that there were unacceptable deficits in safety
and recommendations from seven recent deaths in custody had not been
implemented. She also identified that the management of prisoners who
were at risk of self-harm was poor. Additionally, HMCIP said that key
functions within the prison were inadequate and had been poorly
managed. Support plans for prisoners at risk were poor, access to the
Samaritans restricted, and prisoners’ cell alarm bells regularly muted.
However, the report also said that, since the appointment of the new
Governor, performance improvement was under way.
12. All prisons undergo an audit by the Prison Service Standards Audit Unit
(SAU). The SAU examines the establishment’s compliance when
measured against national standards and awards overall scores for,
Standards, General Standards (Critical Baselines) and Security. Following
an audit, the Governor is issued with an action plan which identifies areas
where improvement is required in order to bring the performance level up
to the required standard. The Governor is required to comment against
each area identified and explain how and when the action will be
completed.
13. In October 2004, the prison was audited and it was identified that six
critical baselines, which included suicide and self-harm, were non-
compliant. On 19 May, an internal re-assessment of the six baselines
identified that they were still not being met.
14. The executive summary noted the score for the subjects under the safety
banner is the lowest at 76 per cent and attention was needed in the areas
of Segregation, Use of Force and Suicide and Self-Harm.
15. Each prison has an Independent Monitoring Board (IMB) and their role is
to monitor the prison and to report any concerns that they have regarding
the prison, or how prisoners are treated. They feedback in the first
instance to the Governor, but also have a direct link to Home Office
Ministers. Board members are able to visit any area of the prison at any
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time and have access to any prisoner they wish to see, or who requests to
see them. The Board holds regular meetings in the prison, with the
Governor attending for part of the meeting. The Chair of the Board
produces an annual report for the Home Secretary.
16. The IMB’s Annual Report 1 March 2004 to 28 February 2005 raised a
number of concerns, one of which related directly to an area that my
investigation would consider. Their recommendation was that suicide
prevention should have a higher profile and that lessons must be learnt
from the past.
17. The IMB included the following comment in their report: “… we also feel
that the inquests are taking far too long to get to court, so the urgency to
implement change is lost.”
18. The Governor has a Service Level Agreement, which he has agreed with
the Area Manager, and which sets out the priorities for the prison. Priority
two of the agreement refers to suicide prevention and is the second of the
concerns raised by the IMB.
19. In common with other jails, Norwich has a number of prisoners who have
been trained by the Samaritans in how to help and support any prisoner
feeling vulnerable or considering suicide or self-harm. They are known as
Listeners and their work is carried out on a confidential basis, overseen by
a member of the Samaritans team. The Governor has recently appointed
a Principal Officer as the manager with responsibility for the Listener
scheme. His role is to raise the profile of the Listener scheme, which sadly
had been neglected.
20. The Prison Service has an established suicide and self-harm prevention
policy, and training is prioritised locally by the Governor. Training includes
the use of the Self-Harm at Risk Form, which is normally referred to as
F2052SH. The F2052SH document is a form that can be opened by any
member of staff who has concern about the safety of a prisoner. Prison
staff are required to report on the prisoner’s mood and behaviour at least
daily. The level of observation is decided on a case by case basis
determined by the level of risk of suicide or self harm. Once the document
has been opened, the prisoner is invited to meet a multi disciplinary team,
who assess the reasons behind the raised concern and jointly agree an
action plan with the prisoner. The team has a wide range of support
interventions available and design a plan to fit the individual needs. The
plan is reviewed regularly and only closed when the team agrees that the
risk of self-harm has been reduced.
21. Since taking over, the Governor has raised the profile of suicide prevention
and on a daily basis, either he, or the Deputy Governor reviews all
F2052SH documents that are open and quality check the entries and
decisions made.
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Conduct of the Investigation
22. The investigation opened at the prison on 2 July. My investigator met the
Governor, Liaison Officer, a member of the PCT, Prison Healthcare
Manager, and received a briefing about the circumstances of the mans
death. He then visited the cell where the man had been found.
23. A number of prison documents were made available by the Governor
which the investigator read. The prison records and reports identified
which members of staff the investigator would seek to interview and, in the
majority of cases; the interviews were carried out using recording
equipment.
24. A clinical review was commissioned from Norwich PCT and they were
asked to review the care and treatment received by the man during his
period in custody.
25. Throughout the investigation, the Governor made himself available on a
daily basis to receive any feedback that my investigator had to share with
him. Following the meetings, the Governor addressed any findings that he
was able to deal with immediately. Additionally, the Area Manager made
time available to meet with my investigator and discuss his findings and
likely recommendations. I am very grateful to them both.
26. I have as part of my office team, staff who are employed as Family Liaison
Officers (FLOs). Their role is to contact the family and, should they wish to
speak to the FLO, invite any comments that they have in relation to the
care and treatment of the person who has died.
27. On 26 August, the FLO contacted the mans brother. He told her that his
main concern was the delay in informing the family of the mans death.
The concern he raised will be addressed later in report.
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Significant events prior to 28 July 2005
HMP Highpoint
28. On 24 January 2005, the man complained to medical staff of headaches
and dizziness.
29. Five days later, on 29 January 2005, he lacerated his left wrist with a razor
blade and told staff that he had done it in order to relieve his headache
pain. Although the man told staff that he did not have any suicidal intent,
he was correctly monitored under the F2052SH procedure.
30. Following the opening of the F2052SH, a case review was carried out and
on 19 February a decision was taken to close the document. My
investigator reviewed this decision. In light of the fact that monitoring
followed an isolated event, he concluded that the document was closed
appropriately.
31. The Clinical Review shows that between 31 January and 3 February, the
man saw a doctor on four further occasions due to headache, dizziness
and nausea. On 3 February, he was referred and admitted to the West
Suffolk Hospital for further investigation. After being given an intravenous
injection during a CT scan, he had a seizure and became unresponsive.
32. On 11 February, following a deterioration in his condition, he was
transferred to the Neuro Clinical Care Unit at Addenbrooke’s Hospital,
where he was diagnosed and treated for Gliobastoma Multiforme WHO
grade IV of posterior fossa, which is a terminal cancer. The man
underwent a variety of treatments and investigations which are well
documented in the Clinical Review. Additionally, and with the agreement
of the man, a decision was taken that in the event of cardio pulmonary
arrest he should not be resuscitated and a “do not resuscitate” (DNR)
order was placed in his medical record. He was admitted into intensive
care, where his condition was stabilised. The scan showed a large
cerebella mass and gross hydrocephalus. This is a brain tumour,
surrounded by liquid that is unable to drain away due to its size.
33. On 28 February, the man was granted temporary release from prison on
compassionate grounds to enable him to receive medical treatment at
Addenbrooke’s Hospital. Following treatment, he returned to the prison.
Addenbrooke’s Hospital
34. On 22 March, an entry was made in the clinical notes confirming that
radiotherapy would be completed on 24 March and that the tumour would
grow again and produce similar symptoms in one to two months. It goes
on to say that the survival rate was 120 days.
35. Following the diagnosis, the Healthcare Manager at Highpoint contacted
the Healthcare Manager at Norwich to discuss transferring the man to
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Norwich, which could offer 24 hour medical cover, should his condition
deteriorate. The Healthcare Manager at Norwich agreed to the transfer.
HMP Norwich
36. On 29 March, the man was transferred to Norwich. He was admitted to
the Healthcare Inpatient Unit where the Healthcare Manager reviewed the
records and discharge summary. She wrote in his medical record that,
even though a decision had been taken at Addenbrooke’s that the man
was not for resuscitation, until such time as a local decision has been
made and documented, resuscitation must be attempted.
37. Two days later, the man was referred to the Macmillan team which would
provide palliative care.
38. A doctor reviewed the case notes on 4 April, and sought the advice of the
Neuro Oncology Team regarding the mans condition. In agreement with
the man, the doctor and the medical staff agreed that the decision taken at
Addenbrooke’s Hospital for the man not to be resuscitated in the event of
cardio pulmonary arrest was correct. His medical notes were updated to
reflect the decision.
39. On 26 April, the Staff Nurse discussed the diagnosis and prognosis with
the man and explained that the Palliative Care Team would be visiting him
the following day. The nurse also agreed to move the man into the elderly
prisoners unit, as he was becoming increasingly upset by the noise from
the patients in the unit where he was located.
40. A consultant in palliative care wrote to the prison on 4 May explaining that
the prognosis for the mans condition was poor, and asking for
compassionate licence to be considered. My report comments on this
later.
41. An urgent referral for a repeat CT head scan was made on 26 May, as the
man had developed recurrent symptoms suggestive of raised intra cranial
pressure. The mans tumour was not allowing fluid to drain away from the
area, which in turn caused headache due to the pressure. The mans
condition was noted as having improved, but that his mood had changed
and that he was becoming hostile and experiencing difficulty in retaining
information.
42. On 16 June, the man attended Norfolk and Norwich University Hospital,
but the results were not with his medical records.
43. Throughout July, the medical records indicate that the man was
experiencing worsening symptoms which resulted in his medication being
changed. The man was not happy that one of his drugs was being
increased, as the side effects made him feel sick. He decided to remain
on the lower level of 4mg and said that he would discuss it with the
consultant at his next appointment due on 29 July.
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44. On 25 July, the man complained of having dizzy spells, difficulty seeing
and numbness in his mouth. Nursing staff explained that the symptoms
were as a result of his tumour, but the man believed that it was as a result
of his medication.
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Events of 28 July
45. On 28 July, the man had spoken to nursing staff and collected his meals
as normal, giving them no cause for concern. He received his morning
medication and carried on with his usual daily routines, which consisted of
resting in his cell and the occasional walk in the unit corridor.
46. Between 5:00pm and 5:15pm, a nurse carried out an observation round of
the unit. This meant that she would check on certain designated patients
and, although the man was not one of the patients she specifically needed
to check, she looked into his cell. She saw that he was sitting on his chair
and said that he looked up to acknowledge her. She closed the
observation flap and continued with her duties. She was the last person to
see the man alive.
47. At 5:50pm, a Healthcare Officer was unlocking patients to allow them to
collect their evening meal. When he arrived at the mans cell, he was
unable to see him through the observation panel situated in the cell door.
He confirmed with a nurse that the man was meant to be in the cell and
called out his name, but did not receive a response and decided to open
the door and check on his whereabouts. As he attempted to open the
door he found that a locker and table had been placed behind the door,
preventing access into the cell. He and the nurse pushed the door open
and saw the man suspended at the neck by a ligature made from the edge
of a bed sheet, which had been secured to the in cell television wall
bracket.
48. My investigator examined the room and the view through the observation
panel. He found the level of observation to be good, but that there is a
blind spot on the left hand side of the door which is where the TV wall
bracket is located. He discussed the possibility of re-locating the wall
bracket to the opposite end of the room, but this suggestion was not
possible as it would mean the bed would need to be moved. Moving the
bed would restrict the staff view of patients.
49. The HCO lifted the man to release the pressure on his neck, whilst the
nurse removed the ligature from around his neck. They laid the man onto
the floor and began to check for signs of life, but could not detect any. The
HCO commenced Cardio Pulmonary Resuscitation (CPR) at a rate of 15
compressions to two breaths. The nurse left to obtain the assistance of
other nursing staff and collect the emergency bag, which contained an
Ambu bag and oxygen. Ambu bags have a facial mask, which is placed
over the patient’s mouth, and a bag which is then squeezed, supplying air
into the patient.
50. A Principal Officer was in the unit at the time assistance was requested.
He responded and assisted with resuscitation and continued with cardiac
massage while the HCO carried out the breathing procedure. The nurse
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returned and an airway was inserted into the mans mouth, with the Ambu
bag being used to supply oxygen via the airway.
51. The Clinical Review has identified that a defibrillator was available to the
healthcare staff attending the man, but that they were not trained in its
use. A recommendation has been made in the Clinical Review to address
this as soon as possible.
52. The Healthcare Manager, who had left work for the day, was contacted by
mobile telephone on her way home and asked to return to the prison. At
6:05pm, she arrived and assisted with the resuscitation attempts. These
continued until the arrival of the paramedics at 6:10pm.
53. Paramedics were briefed about the mans medical condition and the
circumstances in which he had been found. They carried out their own
examination and, after confirming that the cardiac monitors did not show
any sign of life, decided to stop any further attempts to resuscitate the man
and pronounced him dead at 6:15pm.
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Events following the mans death
54. Following the mans death, a Prison Service Operational Manager
attempted to contact the mans family using the information contained in
his prison record. As the address identified was some considerable
distance from Norwich, he telephoned a prison close to the Slough area
but could not obtain a response. He telephoned another prison local to
Slough and spoke to the duty governor to ask him to break the news to the
family. The person he spoke to said that he was unwilling to assist due to
the distance and lack of knowledge of the Slough area. I understand that
The Governor has discussed their response separately with the Governor
of the establishment concerned.
55. The police were then asked to visit the family home to break the news. At
first, the police declined and said that it was the responsibility of the Prison
Service to notify the family. However, following the intervention of a
Sergeant at Norwich Police Control Room, Thames Valley Police agreed
to inform the family. Unfortunately, when they arrived they found that the
address given to them was wrong, as the person named had moved house
and the information in the prison record was out of date.
56. My investigator concluded that the Operational Manager had gone to
extraordinary lengths to ensure that the mans family were made aware of
his death. Despite failing to obtain the support of a colleague and the
initial reluctance of the police, he persisted until the police eventually
agreed to help. It is regrettable that the address given to the Thames
Valley Police was in fact incorrect. The managers actions are
commendable.
57. However, it was not until the following day, once the prison records could
be accessed fully, that a telephone number was obtained from the prison
telephone system and the mans brother was informed of his death.
Unfortunately, the delay meant that the family were not informed until
lunchtime of the mans death the previous evening. This is very regrettable
and, while I have explained the reasons, there are lessons to be learned.
58. The mans brother said that the prison had returned all his property to them
and that the Governor had offered to assist with the cost of the funeral. He
confirmed that the mans family was aware that he had a brain tumour and
that the illness was terminal. He said that he had spoken to the man
about ten days prior to his death and, although the man said that he was
not feeling well, he confirmed that he was not in pain. The man said
nothing to suggest to his brother that he was planning to take his own life.
He said that he did not know what eventually caused him to end his life,
but thought that either the pain became too much for him or that he had
given up on life.
59. On 7 September, The Coroner, wrote to my investigator enclosing a copy
of a letter that had been written by the man which had been forwarded to
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him by the prison. The mans letter was not written in English and the
author of the letter from the prison suggested that it could have been a
suicide note. My investigator had the letter translated and confirmed that it
was a religious greeting, written in Punjabi, and dated in line with the
Hindu calendar.
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Area Manager’s Review
60. Since September 2001, there have been 17 deaths at HMP Norwich plus
two men who died shortly after being released. Of the deaths in custody,
ten appear to be self-inflicted, with five of the prisoners being monitored
under the F2052SH procedure.
61. Prior to April 2004, the Prison Service investigated the circumstances of all
deaths in custody and produced a report containing the investigation
findings and necessary recommendations. (Since that date, my office has
taken over responsibility for investigating all deaths in prison custody.)
62. Following the mans death, the Area Manager commissioned a team of his
own staff to review prisoner care arrangements at the establishment.
Although his report does not form any part of my own, I support and
welcome his review.
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Key Findings
(i) Compassionate Release
63. Under certain circumstances the Governor can release prisoners on
compassionate licence, but this is only done following a risk assessment.
The risk assessment process considers the nature of the offence,
custodial history, and level of compliance with the sentence plan. Any
decision taken is based on the likelihood of failure to comply with the
conditions of the licence and the likely risk to the public.
64. The Governor informed my investigator that he had considered
compassionate licence as an option for the man. However, he said that
the documentation process to consider the licence had not been started.
He said that, in his opinion, it was preferable for the man to be with people
that he knew, rather than in unfamiliar surroundings in an external hospital
setting. I am satisfied that the decision taken to allow the man to remain in
the elderly prisoner unit rather than in an external hospital was
compassionate and correct. Nevertheless, if the Governor is to allow
terminally ill patients to remain in the unit, then a protocol needs to be
developed that allows the relatives of a terminally ill patient to be at the
bedside as with normal NHS practice. The Clinical Review makes a
recommendation on this matter which the Prison Service may wish to
consider and offer guidance nationally.
(ii) Emergency Equipment
65. The emergency bag did not contain a defibrillator, although one was
available within the Healthcare Unit. Nursing staff attending to the man
were not trained it its use and it is therefore not possible to say with any
certainty what the outcome might have been had they been able to use the
equipment. The Clinical Review has identified this and makes a
recommendation to address this, which I support.
The Governor in partnership with Norwich PCT should implement the
recommendations made in the Clinical Review.
(iii) Contacting the family
66. One of the contributory factors in the delay in informing the mans family of
his death was that the next of kin information contained within his prison
record was out of date. Sadly, this is not the first occasion where my office
has found similar problems. My investigator discussed with the Governor
ways of keeping next of kin details up to date, and suggested it could be
carried out at the time lifer reviews and sentence plans were completed.
The Governor was receptive to this idea and said that he would be looking
to introduce it locally into the prison routine. I welcome his approach and
ask the Prison Service as a whole to examine ways of updating prisoner
records and to issue guidance.
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The Prison Service should examine ways to update prisoner next of
kin details and issue guidance.
The Operational Manager should be commended for his efforts to
inform Gurmail’s family of his death.
(iv) Caring for the man
69. I have been impressed by the decisions taken with respect to the mans
care in custody once his terminal illness had been diagnosed. I do not
believe that he gave staff at Norwich any grounds for believing that he
might take his own life.
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Recommendations
For the Prison Service
1. The Prison Service should examine ways to update prisoner next of kin
details and issue guidance.
For the prison
1. The Governor in partnership with Norwich PCT should implement the
recommendations made in the Clinical Review.
2. The Prison Service Operational Manager, should be commended for
his efforts to inform the mans family of his death.
Clinical Review Recommendations
1. A Healthcare reception screening form is completed for all transfers in
to Norwich Prison including direct transfers into the Healthcare
Inpatients Unit.
2. A policy is developed to facilitate visits within the Healthcare Older
Person’s Lifer Unit as appropriate.
3. Healthcare Norwich Prison fully adopts the NPCT Resuscitation Policy.
4. Healthcare Staff receive defibrillator training as soon as possible.
Good Practice
1. Effective partnership working between the Healthcare Staff, Norwich
Prison, Palliative Care Services at Priscilla Bacon Lodge and Oncology
Department at Norfolk and Norwich University Hospital.
2. Negotiation of the implementation of HMP Norwich Cardio-Pulmonary
Resuscitation Decisions Protocol with the Prison Service.
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Annexes
1. Clinical Review
2. Transcript, Healthcare Manager
3. Transcript, Health Care Officer
4. Transcript, Staff Nurse
5. Transcript, Nurse
6. Cardio Pulmonary Resuscitation Policy
7. Letter from Norwich Prison to Coroner, 1 September
8. Letter written by the man, 28/07/2549 (Hindu Calendar)
9. Release on Temporary Licence Form, 28 February 2005
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