Individual at Isle of Wight

The death of a man, who was a prisoner at HMP Parkhurst,
In 16 March 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2006
This is the report of an investigation into the death of a man who was a
prisoner at HMP Parkhurst. The man died on 16 March 2006 at a hospital
close to the prison. The cause of death was recorded as a spontaneous
intracerebral haemorrhage.
Unfortunately, the man was estranged from his family, and none of his
relatives has been traced. Nevertheless, I wish to take this opportunity to
offer my sincere condolences to the man’s friends and all of those touched by
his loss.
The investigation was carried out on my behalf by one of my investigators. An
independent review of the man’s medical care in prison was carried out by the
Isle of Wight Primary Care Trust. I am most grateful to the clinical reviewer for
his assistance.
I would also like to thank the Governor and staff of HM Prison Parkhurst for
their full and ready co-operation during the course of the investigation.
The investigation has revealed a number of shortcomings in the delivery of
healthcare at Parkhurst and at Dorchester (where the man was first held). I
make six recommendations and highlight three examples of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2006
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Contents
Summary
Investigation methodology
HMP Parkhurst
Events prior to and immediately following the man’s death
Consideration of issues arising from the investigation
Recommendations and good practice
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Summary
The man who died was initially remanded into custody at HM Prison
Dorchester on 3 March 2003, before being convicted and sentenced to life
imprisonment later that year. He spent time at HM Prison Winchester before
transferring to HM Prison Parkhurst on 25 April 2005. He was described by
staff there as a quiet man who kept himself to himself.
On 16 March 2004, whilst at Winchester, the man complained of headaches
and was prescribed Ibuprofen by the Medical Officer. He continued to
complain of headaches intermittently over the next six months, which he
linked to hunger. When he was subsequently found to have lost weight on 29
July, the man was commenced on a nutritional supplement and, following a
review on 6 September, reported that all was okay.
On 27 July 2005, following his transfer to Parkhurst, the man was seen by a
prison doctor who noted that he had had “what sounds like gastro-enteritis”.
Two days later, he was seen by a nurse when he complained of a headache
and tiredness. The man’s condition deteriorated and he was admitted to a
local hospital. He remained in hospital overnight, and was diagnosed with
high blood pressure and prescribed Amlodipine 5mg. The man disclosed at
this time that he had suffered a stroke or stroke-like episode in 1998.
The man was reviewed at Parkhurst on 3 August by a locum GP. The GP
instructed that his blood pressure should be checked every two weeks in
future. However, this instruction was not passed onto healthcare staff and the
checks never took place.
The locum GP also instructed the man to continue to take Amlodipine for his
blood pressure. Sometime in August, however, he stopped taking this
medication. The reason for this is not recorded, and it was not picked up by
healthcare staff.
On 15 March 2006, at around 9.50am, the man collapsed whilst in the weights
room of the gymnasium. He was attended to by an officer, who recalled that
the man was semi-conscious and complaining of a “blinding headache”. At
the same time, another officer radioed for medical assistance. The call was
responded to by a nurse who was in the segregation unit at the time. Before
attending, the nurse telephoned the gymnasium for further details and to
ascertain what equipment he would need. He then went to healthcare to
collect the equipment.
The man was taken by ambulance to a local hospital at 10.20am. His
condition deteriorated rapidly and he was pronounced dead at 2.35am on 16
March. The cause of death was recorded as a spontaneous intracerebral
haemorrhage.
This report includes six recommendations and draws attention to three
examples of good practice.
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Investigation methodology
The investigation was opened on 17 March 2006 when my investigator issued
notices announcing the investigation to staff and to prisoners. The notices
included an invitation to those who wished to submit information relating to the
man’s death to make themselves known to my investigator. No prisoners
came forward as a result. My investigator interviewed three members of staff
during the course of the investigation.
My investigator visited Parkhurst on 8 May 2006, and met with the Governor
and toured the prison. He was therefore able to familiarise himself with the
gymnasium area in which the man had collapsed. He was also given access
to the man’s prison files including the Medical Record.
An independent clinical review of the man’s health needs whilst he was in
custody was carried out by the Isle of Wight Primary Care Trust.
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HMP Parkhurst
Parkhurst, situated outside Newport on the Isle of Wight, was originally built
as a military hospital in 1805 before becoming a prison in 1835. It has served
as a male prison since 1869 and in 1968 became one of the first dispersal
prisons. Parkhurst remained a high security prison until the mid-1990s, when
it became an establishment for category B prisoners (the second highest
security category) serving sentences of over four years. The prison also takes
remandees from the Isle of Wight.
Healthcare is commissioned by the Isle of Wight Primary Care Trust. The
healthcare centre provides 24 hour cover and has inpatient capacity of 12
beds in single cells. The most recent report by HM Inspector of Prisons,
dated August 2005, notes that the healthcare service at Parkhurst was
fragmented and understaffed. However, healthcare provision had improved
from the previous inspection in 2002.
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Events prior to and immediately following the man’s death
When he was first remanded into custody at Dorchester on 3 March 2003, the
man reported that he had poor eyesight but spoke of no other outstanding
issues at his reception health screening. He said that he was a former drug
user but had been clean for a period of 12 months. Over the course of the
next year, the man reported a couple of minor complaints but his health was
generally good in this period.
On 16 March 2004, the man was seen by a Medical Officer at Winchester and
complained of a headache, for which he was prescribed Ibuprofen. He was
seen again on 31 March, when he complained that his headaches were
getting worse, especially at night. He was therefore prescribed a stronger
painkiller.
On 21 April, the man was seen by a different Medical Officer. On this
occasion he specifically requested Tramadol for his headaches. The Medical
Officer said, however, that they did not consider it appropriate to use
Tramadol on a regular basis for headaches and therefore prescribed Nefopam
as an alternative. The man only took Nefopam for one week before returning
his supply. He gave reasons for returning his supply at a review on 5 May,
but this particular entry in the clinical record is illegible.
At the review, the man said that the headaches had only been occurring for a
period of six months since his arrival at Winchester. He said that they did not
occur every day, perhaps four days out of five, that they did not make him
nauseous but did sometimes affect his appetite. The Medical Officer therefore
prescribed a further course of Ibuprofen.
The man again complained of headaches on 22 July, which he now said were
due to hunger. Two weeks previously, on 7 July, he had requested food
supplements due to a problem with basil in his food which he said upset his
gut and appetite. The man was therefore scheduled for weekly weighing and
on 29 July, when he was found to have lost weight, he was commenced on
Fortisip (a nutritional supplement). His weight subsequently stabilised and, at
a review on 6 September, the Medical Officer reported that “all was ok”.
The man reported no further medical problems prior to his transfer to
Parkhurst on 25 April 2005. On 27 July, he was seen by a locum GP, who
noted that the man had “had what sounds like viral gastro-enteritis”, but that
he was better now. None of the man’s symptoms were recorded at the time.
On 29 July, the man was seen by a nurse. He complained of a headache and
tiredness. The nurse recorded that all of the man’s observations were within
normal limits and advised him to see the doctor the following week if his
symptoms persisted.
The man was seen again by the same nurse on 30 July. The nurse recorded
that he appeared to have deteriorated overnight, was now unable to walk
properly and appeared dehydrated. The nurse therefore arranged for the man
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to be admitted to a local hospital. He remained in hospital overnight, and was
diagnosed with hypertension (persistently high blood pressure) and prescribed
Amlodipine 5mg to be taken once a day. Whilst in hospital, the man disclosed
that he had had a cerebro-vascular accident (a stroke or stroke-like episode)
in 1998.
The man returned to Parkhurst on 31 July and, at a review at 12.15pm, all of
his observations were recorded as normal. He was, however, reported as
being very weak and was offered a cell on the ground floor which he refused.
He therefore stayed on his landing and was permitted to have his food
brought up to him for one week.
The man was subsequently reviewed by a different locum GP on 3 August.
He was now complaining of a persistent headache which the doctor noted as
probably being due to dehydration. The doctor instructed that the man should
continue with Amlodipine as per the hospital’s request, and that his blood
pressure be checked every two weeks in future. It does not appear that these
checks took place. The doctor also prescribed paracetamol for the man’s
headaches and requested a urea and electrolytes check (a measure of how
the kidney is functioning) in two weeks. There is no documented evidence to
support that these tests were carried out.
Three days later, on 6 August, the man was seen on the wing by a healthcare
officer. He was again complaining of headaches, which the HCO said
appeared to be due to dehydration. The man was advised to drink plenty of
water, to take paracetamol for the headaches, and to apply to see the doctor if
his headaches continued. The HCO asked the wing staff to remind the man
to drink plenty.
On 17 August, the man was seen by a doctor and complained of persistent
constipation and overflow incontinence for a period of two weeks, which he
said was since he started taking Movicol (a treatment for constipation). The
entry on 17 August also states that the man had attended hospital in the last
week and was awaiting blood results. There is no entry regarding this
appointment in his medical record, other than a printout from a local hospital
stating that a full blood count had been taken on 11 August. The doctor
subsequently stopped the man’s course of Movicol and started him on Senna
instead. The doctor noted that he should return for a review in two weeks if
still constipated.
No further request was received from the man to see a doctor or healthcare
staff throughout the rest of his time at Parkhurst. It would also appear that
healthcare staff made no effort to follow the man up for his headaches, blood
pressure or constipation. At some time in August 2005, he stopped taking his
medication for hypertension. The reason for this is not recorded and it was
not picked up by healthcare staff.
On 15 March 2006, at approximately 9.50am, the man collapsed in the
weights room of the gym at Parkhurst. He was attended to by a physical
education officer. In his statement to the Governor, the officer said that the
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man was semi-conscious when he first spoke to him, and complained of
having a “blinding headache”. The man then began to vomit and the officer
therefore placed him in the recovery position.
At the same time, another officer radioed for assistance. At interview, he said
that he made the call to the control room and asked for medical assistance to
the gymnasium. The response nurse responded to the call, but first
telephoned the gym for further details as the radio call gave no indication of
the type of incident.
On arrival at the gym, the response nurse applied oxygen to the man and
commenced an initial assessment. In his statement to the Governor, the
response nurse noted that the man was able to speak but was incoherent,
and that his left pupil was sluggish in response to light. He also noted that the
man was again vomiting and therefore asked for an ambulance to be called.
The ambulance left Parkhurst at approximately 10.20am to take the man to
Accident and Emergency at a local hospital. On arrival at hospital, the man’s
condition deteriorated rapidly and he lost consciousness. His condition
continued to deteriorate through the course of the day and he was
pronounced dead at 2.35am on the morning of 16 March. The cause of death
was recorded as a spontaneous intracerebral haemorrhage (a stroke resulting
from the bursting of a blood vessel in his brain).
Sadly, none of the man’s relatives has been traced. His funeral was held on
18 April 2006. A former cellmate of the man was traced through his visits
record and attended the funeral along with prison staff. A memorial service
was held at the prison on the same day.
Following the man’s death, the healthcare manager reviewed his treatment
and produced a summary report and action plan. This plan included a
number of learning points for healthcare staff and subsequent corrective
actions and targets.
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6. Consideration of issues arising from the investigation
The man’s reception health screening
During his one night stay as an inpatient at hospital on 30 July 2005, the man
was diagnosed with hypertension (persistently high blood pressure). The
clinical review, conducted by the Isle of Wight Primary Care Trust, expresses
reservations that his high blood pressure was not diagnosed prior to this
occasion.
On his first reception at Dorchester on 3 March 2003, the man was
interviewed by healthcare staff as part of the reception process. A ‘First
Reception Health Screen’ form was completed. This form contains a box of
standard observations that are required to be completed within 24 hours of a
prisoner’s arrival at the establishment. In the man’s case, a number of these
observations, including his blood pressure, were not taken.
The clinical review also expresses reservations that prison healthcare did not
know that the man had suffered a stroke or stroke-like episode in 1998. It is
true that he did not disclose this episode when questioned about his medical
history at his reception health screening. Furthermore, the man said that he
was not registered with a GP. However, it was known that the man had
previously been in prison, having been released on life licence in 1998. No
efforts were apparently made to obtain his previous prison medical records.
A copy of this report will be sent to the Governor at Dorchester and he
should remind staff of the importance of completing the ‘First Reception
Health Screen’ thoroughly.
Quality of healthcare provided at Parkhurst
On balance, the clinical review concludes that the man received equivalent
healthcare to that which he would have received in the community. As noted
above, however, the review expresses reservations that his high blood
pressure was not diagnosed prior to 30 July 2005. It notes that his blood
pressure was not taken on a number of occasions when he saw the prison
medical services complaining of headache.
At interview, the Team Leader of Primary Healthcare at Parkhurst, said that all
prisoners who report to healthcare now have their blood pressure taken as
standard. All those who are found to have raised blood pressure are now
referred to the prison’s Hypertensive Clinic. An action plan produced following
the man’s death states that it is required that all notes are audited to ensure
that no patients with high blood pressure have “fallen out of the loop”. I
consider this to be good practice.
The healthcare manager should continue to ensure that blood pressure
checks occur before each healthcare appointment, and that the clinical
audit results are shared amongst the clinical team.
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On 3 August 2005, the man was seen by a locum GP and complained of a
persistent headache. The GP produced a four-part action plan for the man’s
treatment which included the request that his blood pressure be checked
every two weeks. These checks did not take place. At interview, the Team
Leader of Primary Healthcare said that the checks did not take place because
the instruction was not passed onto anyone in healthcare by the locum GP.
In the light of this communication failure, GPs at Parkhurst have now been
asked to pass on explicit instructions to a nominated member of healthcare
staff each day. Staff have also been reminded to check GP entries on Vision
(a computerised medical recording system) by the end of each surgery.
The healthcare manager should ensure that systems for passing GP’s
instructions onto nursing staff are regularly audited, and the results of
such audits published for evidence and compliance.
At his review on 3 August, the locum GP also requested that the man continue
to take Amlodipine 5mg for his hypertension. However, the man did not apply
for a renewal of his prescription later that month and therefore stopped taking
the medication. It is not known why he failed to repeat his prescription, and
this failure was not picked up by healthcare staff.
The clinical review states that, “even if [the man] had been maintained on
blood pressure drugs, in view of the abnormality that he had an artery of his
brain, a stroke at some point in time was likely”. Despite this, it concerns me
that, when he chose not to repeat his prescription, the man’s failure to do so
was not noted by staff.
My investigator spoke to the head of healthcare at Parkhurst, on this matter.
She said that, at the time, the responsibility was with the prisoner to request a
repeat prescription, as in the community. However, following the introduction
of the computerised system, a review date should now be automatically
generated for prisoners on repeat prescriptions.
The healthcare manager should ensure that electronic reminders of the
review date for prisoners with repeat prescriptions are regularly
monitored and audited.
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Radio procedures on the morning that the man collapsed
The man collapsed in the gymnasium at around 9.50am on 15 March 2006.
Following his collapse, an officer radioed for assistance to the control room.
At interview, the officer said that his call asked for “medical assistance to the
gymnasium”. The control room log sheet shows that at 9.50am a call was
made which said, “healthcare required in gym”. The officer said that it was an
option for him to ask for ‘urgent’ assistance over the radio. He did not ask for
‘urgent’ assistance, however, as he believed that as he was near to a
telephone he could explain the situation in greater detail over the phone.
There does not appear to have been any consideration given to also
requesting an emergency ambulance at this stage.
The joint Prison Service and Department of Health letter of March 2004
implicitly states that internal procedures should not waste undue time
summoning emergency assistance and there is no requirement for a member
of the healthcare team to attend before such action is taken.
The Governor, Head of Healthcare and PCT should ensure that internal
procedures facilitate prompt requests for emergency ambulances and
that this procedure is communicated to all staff.
The call for assistance was heard by the response nurse who was, at the
time, in the segregation block distributing medication. At interview, the
response nurse said that, as there was no indication of the type of incident in
the radio call, it was necessary for him to telephone the gymnasium so that he
could decide what equipment he needed.
The response nurse was of the opinion that the need to make a telephone call
to the gymnasium did not have a serious effect on the care he was able to
provide on this occasion. However, he expressed concern to my investigator
that, in different circumstances, this may have adversely affected his
timeliness and the quality of care that he could provide. I share this concern.
Given the circumstances of the man’s collapse and the condition that he was
in when found by officers in the gymnasium, I consider that it would have been
justified to call for ‘urgent’ assistance over the radio and request an
emergency ambulance be called.
At interview, the response nurse said that there is a code system in place for
classifying different types of medical emergency. He subsequently provided a
copy for my investigator. The system used is as follows:
1 – Hanging
2 – Bleeding
3 – Unconscious
The response nurse said that this system has not been deemed useful by
healthcare staff and is not therefore generally used. At his interview, the
officer who radioed for assistance was unaware of such a system being in
existence. He did not therefore use a radio emergency code on the morning
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that the man collapsed. The head of security and operations was also
unaware of the existence of such a system. He confirmed that those control
room staff to whom he had spoken were also unaware of such a system.
I consider it essential that healthcare staff are able to respond to a medical
emergency as quickly as possible. Moreover, it is particularly advantageous if
healthcare staff have an idea of the type of emergency that they are facing
prior to their arrival so that they can prepare accordingly.
The Governor should ensure that the system for summoning emergency
medical assistance enables the healthcare team to have some
understanding of the type of emergency they are attending and the likely
emergency equipment needed. This system must be communicated to
all staff.
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7. Recommendations and Good Practice
Recommendations
A copy of this report will be sent to the Governor at Dorchester and he should
remind staff of the importance of completing the ‘First Reception Health
Screen’ thoroughly.
The healthcare manager should continue to ensure that blood pressure
checks occur before each healthcare appointment, and that the clinical audit
results are shared amongst the clinical team.
The healthcare manager should ensure that systems for passing GP’s
instructions onto nursing staff are regularly audited, and the results of such
audits published for evidence and compliance.
The healthcare manager should ensure that electronic reminders of the review
date for prisoners with repeat prescriptions are regularly monitored and
audited.
The Governor, Head of Healthcare and PCT should ensure that internal
procedures facilitate prompt requests for emergency ambulances and that this
procedure is communicated to all staff.
The Governor should ensure that the system for summoning emergency
medical assistance enables the healthcare team to have some understanding
of the type of emergency they are attending and the likely emergency
equipment needed. This system must be communicated to all staff.
Good Practice
A summary report and subsequent action plan was produced by the
healthcare manager following the man’s death.
The man’s funeral was arranged and paid for by the establishment, and a
memorial service was held at the prison.
Staff used the man’s visits record to locate a former cellmate who was
subsequently able to attend his funeral.
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