Individual at Nottingham

Investigation into the death of a man in hospital on 20 December 2005
whilst in the custody of HMP Nottingham
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2006
This is the report of an investigation into the circumstances of the death of a
man in hospital on 20 December 2005. The man was a prisoner at HMP
Nottingham. He was 48 years old at the time of his death.
The post mortem report states that the man died of a heart attack. I extend
my sincere condolences to the man's family and friends for their loss.
The man had been in custody for two and a half weeks and this was his first
custodial sentence. On his reception into HMP Nottingham, it had been
recorded that he had several serious medical conditions. He spent his first
two nights in the Healthcare Unit followed by six days on E Wing, on a landing
for those finding it difficult coping in prison. Two days before he was admitted
to outside hospital for tests and observation, he was transferred back to the
Healthcare Unit. The man died seven days later in hospital.
A colleague carried out this investigation. I would like to thank the Governor
of Nottingham, and her staff for their help.
I also thank my colleague from the Nottingham City Primary Care Trust for the
Clinical Review she carried out, to assess the medical care the man received
during his time in custody.
I make four recommendations and highlight two points of good practice. One
of the recommendations concerns cell sharing. Despite being a non-smoker
and despite his heart condition, the man shared his cell with a heavy smoker.
Although I understand the practical difficulties in guaranteeing separate
accommodation for non-smokers, the risks associated with not doing so
speak for themselves.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2006
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Contents
Summary……………………………………………………………..4
Investigation process………………………………………………..5
HMP Nottingham…………………………………………………….6
The man……….……………………………………………………..7
Events leading up to the man’s death …………………….….8
Clinical Review…………………..……………………..…………..11
Issues raised by the man’s cellmate 12
Issues raised by the man’s
family……….…………………………………………………….….14
Recommendations and Good Practice…...................................15
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Summary
The man died on 20 December 2005 in hospital. A post mortem was held the
following day and the cause of death was found to be natural causes through:
1a Acute Myocardial infarction
1b Coronary atheroma.
The man was serving an eight-year sentence, having been convicted at
Crown Court on 2 December 2005. He had been in custody at HMP
Nottingham for 17 days before his death.
The man had been in poor health prior to his reception into Nottingham. He
had a serious heart condition and type two diabetes. On reception into prison,
the man spent two days in the Healthcare Unit for observation and
assessment purposes and then six days on E Wing. He was transferred back
to the Healthcare Unit for two days on 12 December, because he was having
difficulties passing urine and had told staff he was vomiting. He was admitted
to hospital on 13 December for tests and observation associated with these
symptoms. He died there seven days later.
Whilst the man was on E Wing, he was visited several times a day for health
care checks and observations. On admission to hospital, his health
deteriorated very quickly and he was placed on a life support system following
a heart attack on 13 December. He remained on the life support system until
20 December when two doctors confirmed there was no brain stem activity
and the system was switched off.
The man was visited on numerous occasions by his family whilst in hospital.
His wife, who is also a serving prisoner, was escorted to the hospital on 13
and 18 December.
The care the man received in HMP Nottingham was generally satisfactory.
On reception into Nottingham, it was indicated that he was in a poor state of
health. His medication was properly administered and he received regular
visits whilst on E wing from Healthcare staff. However, I raise two concerns
regarding his location on E wing.
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Investigation Process
The investigation was opened on 21 December 2005 when my colleague met
with two governors at Nottingham, along with a Senior Officer , the prison's
Family Liaison Officer. My colleague received the man’s Medical Record and
other relevant documentation. Notices were issued to staff and prisoners
notifying them of the investigation.
A governor outlined the facts of the man's death. Neither a representative of
the Prison Officers’ Association (POA) nor a member of the Independent
Monitoring Board (IMB) wished to see my investigator.
One of my Family Liaison Officers contacted the man's brother in early
January 2006 by telephone and post. On 9 March 2006, my Family Liaison
Officer and colleague visited the man’s brother at his home address. Also
present at this meeting were the man’s sister in law and sister.
The man’s brother raised some issues in relation to his brother’s care whilst in
HMP Nottingham. He asked for confirmation that his brother was able to have
his medication whilst in custody. He also asked for clarification on the order
of events for 13 December, as he felt they had received different accounts
from different people. The family wished to point out that, during the first
telephone call to the man’s sister in law received from the prison, it was stated
that the man had been taken to hospital and he had arrested in his cell. A
second telephone call made a little later asked them to attend the hospital
quickly as he was extremely poorly. Whilst at the hospital on the afternoon of
20 December, they were told the man had not arrested in his cell and had
walked to the ambulance. Lastly, they wanted to know if the prison knew of
the man’s medical history and issues around his disability. The man’s brother
and his sister both agreed that the prison had been very supportive during
their brother’s stay in hospital, and subsequently after his death.
On 9 January 2006, my colleague returned to HMP Nottingham and spoke to
an Officer and a member of staff from the Healthcare Unit. She sought
clarification on the complex medication regime for the man. My colleague
also spoke to one of the man's cellmates.
This report is based upon a review of all relevant paperwork, including the
man's clinical records and the discussions mentioned earlier.
A doctor, from Nottingham City Primary Healthcare Trust, carried out an
investigation into the man's medical care.
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HMP Nottingham
HMP Nottingham is a Category B local prison, three miles from the city centre.
It first opened in 1891 and has capacity for 550 prisoners. Two new
cellblocks were opened in 1996 and further cellblocks are under construction
at the present time. A Vulnerable Prison Unit (VPU) is located on E Wing.
The Healthcare Unit provides 24 hour nursing care. A report by Her Majesty's
Chief Inspector of Prisons (HMCIP) of an inspection at Nottingham in
February 2005 states, ‘Prisoners were offered a wide range of clinical
services including nurse-led clinics and visiting clinical specialists'. It also
says, 'The Nottingham City Primary Care Trust (PCT) had seconded one of
the community managers to lead healthcare services, and there was evidence
of dynamic and effective managerial leadership and robust plans for the
development of healthcare services.'
On healthcare the report reads, 'Prisoners with chronic or long term illness
receive good care, although the systems were all manually based as the
registers were not computerised. Prisoners with one or more chronic
illnesses were seen at least monthly or more frequently if required. Individual
nurses were responsible for the specific prisoners identified as suffering from
diabetes, chronic heart disease or asthma.’
The HMCIP report was generally positive about the medical services provided
at Nottingham.
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The man
The man had not been in prison before and had no previous criminal record.
He was sentenced to eight years imprisonment at Crown Court on 2
December 2005. His wife was also sentenced to four years imprisonment.
The man had serious medical problems including angina, type two diabetes,
hypothyroidism, a pancreatic disorder and an amputation of his right arm. He
had undergone a triple heart bypass operation in 1998. A total of 13 different
medications were recorded on his repeat prescription certificate.
The man's family visited him regularly whilst he was in hospital. Staff from
another prison escorted the man’s wife on 13 and 18 December to visit him in
the hospital.
During the man’s short time in prison he seemed calm and relaxed. There
were no issues raised by prison staff in terms of his behaviour or attitude.
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The events leading up to the man’s death
On reception into HMP Nottingham on 2 December 2005, Healthcare staff
assessed the man and his observations and medical history were recorded.
Because of his complex medical conditions, he was admitted to the
Healthcare Unit for observation and assessment.
The man's medical record was opened and all his various medications were
recorded. A first reception health screen was completed, including a test of
his blood sugar levels. A secondary health screen took place the following
day, including a request for baseline blood tests. The man settled well into
the Healthcare Unit over the next two days.
On 5 December, he was transferred from the Healthcare Unit to E Wing on
landing four. This wing is specifically for those prisoners who are described
(in a term I dislike) as 'poor copers'. The man was moved to E Wing as no
serious medical concerns had been identified during his observation period in
the Healthcare Unit. He was allocated a shared cell.
On 8 December, the man complained to wing staff of diarrhoea and vomiting.
His medical record shows an entry stating that a nurse came to the wing and
checked his observations. His blood pressure was significantly lower than at
his reception screening, but he told the nurse this was normal for him because
of his history of hypertension. He was given medication to counteract the
vomiting and a sugar concentrate to ease any diabetic symptoms. It was
recorded that the man would see the triage nurse the following morning.
On 9 December, the first entry on his medical record for that day states, ' No
problem this morning'. At 11.30am, an entry records the man saying he was
unable to eat or drink and that he had vomited recently. His weight showed a
drop of five kilos from his reception into the prison. He was given a blood
sugar test and a bottle to provide a urine sample to test for ketones. The
entry also states, 'repeat of blood glucose levels pm'. At 7pm, his medical
record indicates he was unable to provide a urine sample. The man said he
was not in any discomfort and was seen socialising on the Wing.
The man's blood sugar levels were tested on 10 December at 8am. He said
he was still unable to urinate. The nurse thought he appeared physically well.
At 10am, he was seen again by healthcare staff as he had informed an officer
he had vomited and that he had angina. The nurse records that the man had
used his GTN spray for his angina and that he felt fine apart from his nausea.
The nurse tested a small amount of urine for ketones and recorded the result
as being negative. Later that day, the man's blood sugar was tested and he
was given medication to relieve his nausea symptoms.
At 8pm, a member of healthcare staff carried out a review of the man's
condition on the wing. Although he said he had not passed urine for two and
a half days, he did not appear clinically dehydrated. The man was still
complaining of sickness and not eating or drinking. His blood sugar was
tested. The man was advised to take sips of water overnight and told that he
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would be reviewed again in the morning. He told medical staff he did not
have any chest pain.
On the morning of 11 December, the man said he still had diarrhoea and
vomiting. He was not eating, only taking sips of water and not passing water.
His blood sugars and temperature were recorded, but not his blood pressure
or other observations. The man’s cellmate confirmed that the man had
diarrhoea and vomiting. An entry on the medical record indicated that the
man should see the Medical Officer or be admitted to the Healthcare Unit, if
appropriate. At 2.45pm, he was again visited on the wing and his blood
sugars were tested. The man's bladder did not feel full to the touch of the
Healthcare staff member. He was taking fluid but no food. At 7.45pm, he was
noted to be asleep in his bed.
On 12 December, after a visit by healthcare staff to the man on E Wing, he
was admitted to the Healthcare Unit. His treatment plan is recorded on his
medical record. At 7pm, an entry records that he was settled into the
Healthcare Unit. The sweet,” fruity” smelling breath, indicated he might have
an accumulation of ketones in the body. He was advised by staff to take
fluids. (The smell of ketones on breath can indicate that there may be signs
of dehydration or abnormal blood sugars in a diabetic.) Some medication was
administered to help with any dehydration.
On 13 December, in the early morning, a strong smell of ketones was
detected on his breath. His observations were recorded. Later in the
morning, the doctor saw the man and arrangements were made for him to be
transferred to hospital. An Officer recalled that the man was well enough at
this stage to dress himself for the transfer to hospital. He walked, with
assistance, out of his cell.
The Prison Escort Record for the man records departure time from HMP
Nottingham at 10.50am by ambulance to hospital. Arrival time is recorded at
11am.
A full bed watch log was created. Two officers were assigned to the man's
bedside. Restraints were removed on reception into the accident and
emergency unit at the request of medical staff, as he was clearly unwell and
requiring intensive medical support. One of the escort Officers, has confirmed
the removal of restraints on arrival at the unit. Formal approval for the
removal of restraints was subsequently given by the duty governor at 1 pm.
After the removal of restraints, the man had a cardiac arrest and medical staff
had to perform cardiac massage.
The man was placed on a life support machine and transferred to the High
Dependency Unit (HDU) of the hospital. The prison chaplain was contacted
and went to the hospital at 3.23pm. The man's relatives were also contacted
and attended the hospital. The chaplain took the relatives to the family room
for prayers. At 6pm, the man's wife was brought to the hospital under escort
from prison to visit her husband. It was noted in the bed watch log that the
man was very ill.
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The restraints were not replaced during the rest of his time in hospital. He did
not regain consciousness. The prison assessed that release on temporary
licence was not appropriate due to the nature of the offences for which the
man had been convicted.
The man’s wife again visited her husband under escort from prison on 18
December for an hour and a half. The man's relatives visited on numerous
occasions during the seven days he was in the HDU. The Governor, Duty
Governors, Family Liaison Officer and chaplain also visited the man on a
regular basis.
On the morning of 20 December, medical staff at the hospital commenced
procedures to assess brain stem activity. One doctor confirmed stem death at
12.07pm. Another doctor carried out a second procedure at 4.30pm when it
was confirmed that the man was clinically dead and the life support was
switched off.
In line with Prison Service Order 2710, the prison offered financial assistance
towards funeral costs. The man’s funeral was held at the end of December.
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Clinical Review
The clinical review analyses several areas of the man's care whilst in custody.
The man was in prison for just ten days, with an additional seven days as an
in patient at the hospital. His clinical care whilst at HMP Nottingham was
reviewed by the Nottingham City Primary Health Trust. The review
acknowledges the good clinical practice undertaken by the Healthcare Unit.
The reception medical screening process was effective. The man’s physical
health assessment was appropriate. The documentation and record keeping
was of a good standard. The review accepts that the care he received in
prison was comparable to that which would have been expected in the
community from a GP.
The review comments on two points. First, the clinical review indicates that a
blood test for Urea and Electrolytes (U&E) should have been requested as
early as 10 December in the light of the man’s other medical problems and
medications, and particularly because he said he was still drinking. (This
blood test measures the chemicals in the blood relating to kidney function.)
Second, blood pressure readings should have been checked regularly. The
man’s blood pressure showed a low reading at the onset of his illness on E
Wing, which was lower than in his first assessment in healthcare. The man
had previously told staff it was not unusual for his blood pressure to be low.
Nevertheless, a daily check of his blood pressures might have assisted in
providing an overview of his medical condition at the onset of his illness.
The clinical reviewer expresses the opinion that the regular monitoring of
healthcare needs in the prison environment is welcome and appropriate, but
may also delay access to secondary care compared to community GP care.
GPs often admit to hospital to provide the monitoring which prison healthcare
provides. As a consequence, the superior service of prison healthcare to that
provided in the community may affect outcomes in some cases.
The man received regular monitoring by healthcare staff whilst on E Wing.
When his observations began to show symptoms of an illness, not previously
recorded in his medical notes, he was re-admitted to the Healthcare Unit. His
admission into hospital followed when concerns for his medical condition
became more apparent.
There is no record of an individual nurse taking responsibility for the man's
chronic health issues. I note that the report on HMP Nottingham by HM Chief
Inspector of Prisons indicates that individual nurses were allocated to
prisoners with chronic illnesses, but this did not occur in the case of the man
who is the subject of this report.
I recommend the allocation of an individual nurse, with necessary
competences, for prisoners with chronic illness when they are first
received into Nottingham.
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Issues raised by the man’s cellmate
The cellmate of the man whilst he was on E Wing, spoke to my investigating
officer on 9 January 2006. The cellmate said that the man was sick on many
occasions and alleged that his difficulty in passing water did not seem to be
taken seriously enough by healthcare staff when they visited him on the wing.
(The entries on his medical record indicated that he was visited several times
a day to check his condition. His observations were noted and blood sugar
levels checked.)
The cellmate was aware of the man's poor state of health. The cellmate told
my investigator that he is a heavy smoker. Given the man’s heart problems
and the fact that he was a non-smoker, he was concerned that the man was
placed in a shared cell with him. The cellmate said he would smoke near to
the open window to reduce any discomfort for him.
HMP Nottingham has a smoking policy. An extract from that policy states, ‘…
prisoners have the right to smoke if they wish. Adequate provision within
areas of residence will therefore be made in addition to designated communal
areas. However, HMP Nottingham will also endorse the protection of non
smoking personnel and prisoners.’ A second extract from that policy states,
‘prisoners are only allowed to smoke in their cells, however, wing managers
will provide smoking and non smoking cells where possible.’ Whilst I
appreciate the population pressures, the policy clearly and correctly states
that Nottingham will protect non-smoking prisoners. Yet in the man’s case, he
shared a cell for six days with his cellmate, a heavy smoker. (There is no
evidence to say the man actually requested a non smoking cell.)
I recommend, wherever possible, non smoking prisoners should not be
required to share cells with smokers. Given the evident health hazards
of passive smoking, the Governor will wish to reinforce this message to
all staff.
The VPU is located on the fourth landing on E Wing and food is served on the
ground floor. The man's level of heart disease and the amputation of his right
arm indicate the difficulty he would have using stairs, especially when
collecting food and being unable to steady himself on the handrail whilst
carrying a food tray. The man’s cellmate told my investigator that the man
struggled with the stairs when collecting his food. I am very surprised that he
was located to an area of the prison where the physical layout of the building
would have caused him mobility problems. Whilst taking into account the
location of the VPU and the need for him to be located on the VPU, I would
have expected staff to have arranged for the man’s food to have been brought
to him on the fourth landing.
My investigator visited E Wing to look at the wing observation book and
readily appreciated the difficulties the man would have faced in being
expected to climb so many stairs. His complex medical condition and the
amputation of his arm may well have caused him problems in adjusting to the
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prison regime in Nottingham. A review of prisoners with disabilities should be
carried out, on reception, to ensure they are able to cope with the prison
regime on a day to day basis.
My investigator has been informed that Nottingham is presently reviewing a
disability policy. I welcome this.
I recommend that, on arrival at HMP Nottingham, prisoners with
disabilities should be risk assessed and appropriate packages put in
place to meet their health and social care needs, including location.
Bearing in mind the vulnerable prisoner population is generally older and less
physically able than the rest of the prison population, I question the
appropriateness of having a VPU on the fourth landing of a Victorian prison.
I recommend HMP Nottingham reviews the current location of the VPU.
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Issues raised by the man’s family
Medication whilst in custody
On 9 January, my investigator viewed the man’s medication and prescription
charts. Nurses dispense medication at set times of the day. He had in his
possession his GTN spray which he used to relieve his angina symptoms. I
am satisfied that the man received all his medication at the appropriate times
and in accordance with his prescription.
Did the man suffer a cardiac arrest in his cell?
The first telephone call that the man's sister in law received on the morning of
13 December stated that he was being admitted to hospital and had arrested
in his cell. The notes of the man's medical record show there is no
documented evidence that he suffered a cardiac arrest before being taken to
the hospital. An Officer told my investigator that he was able to dress himself
for the transfer to hospital, and was able to walk out of his cell with some
assistance when the ambulance arrived. The man was then placed in a
wheelchair and taken to the ambulance. I am satisfied that he did not arrest
in his cell before being taken to hospital. Information from the man’s family,
in response to my draft report, suggests that the Chaplain at Nottingham
made the misleading call to the family in good faith. He apologised to the
family at the hospital for the mistake.
Was the man’s medical history known to the prison?
The prison completed a full medical screening of the man’s medical history
and this is reflected in the points highlighted by the doctor’s clinical review.
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Recommendations
(cid:131) I recommend the allocation of an individual nurse with necessary
competences for prisoners with chronic illness when they are first
received into Nottingham.
(cid:131) I recommend, wherever possible, non smoking prisoners should
not be required to share cells with smokers. Given the evident
health hazards of passive smoking, the Governor will wish to
reinforce this message to all staff.
(cid:131) I recommend that, on arrival at HMP Nottingham, prisoners with
disabilities should be risk assessed and appropriate packages put
in place to meet their health and social care needs, including
location.
(cid:131) I recommend HMP Nottingham reviews the current location of the
VPU.
Good Practice
(cid:131) I commend the Senior Officer for the way he conducted himself as
Family Liaison Officer, both in meeting with the family and in
following up this support after the man's death.
(cid:131) The man's custodial records were well presented and
chronologically filed.
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