Individual at Isle of Wight

Circumstances surrounding the death of a man
in August 2005 at hospital,
while a prisoner at HMP Parkhurst
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2006
This is the report of an investigation into the circumstances surrounding the
death of a man in August 2005. At the time of his death, the man was a
prisoner at HMP Parkhurst. He had been admitted to hospital after a collapse,
and was found to have had a heart attack. He did not regain consciousness.
He was a relatively young man, aged 44, who had previously had little need of
healthcare services. I would like to extend my condolences to his family and
friends for their sad and unexpected loss.
The investigation was carried out on my behalf by a colleague. Unfortunately,
the investigator experienced considerable hold-ups before being able to carry
out her interviews, and I must apologise for the consequent delay in producing
this report.
An independent review into the man’s medical care and treatment was
undertaken by Isle of Wight Primary Care Trust. I am most grateful for their
assistance. I am also grateful to the Governor and staff of Parkhurst for their
co-operation with this investigation.
Although one prisoner has alleged that there were delays, I am satisfied that
prison staff responded appropriately to this emergency. Indeed, this is a
report that generally reflects well upon HMP Parkhurst. That said, I include
five recommendations. I also highlight the initiative of two members of staff
who provide first aid training for their colleagues.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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Contents
Summary 4
Investigation process 5
HMP Parkhurst 6
Events leading up to the man's collapse 7
After the man went to hospital 14
Issues considered in the investigation 17
Conclusions 22
Recommendations and good practice 23
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Summary
The man who is the subject of this report, was sentenced to 14 years
imprisonment in September 2003, for an offence of drug importation. This
was his first and only period of imprisonment. He appealed against both
his conviction and his sentence and successfully had his sentence reduced
to 12 years.
After a period of time at HMP Wandsworth, the man was transferred to
HMP Parkhurst. He soon made some close friends there and, after
induction, settled onto C wing.
It was the man’s custom on a Saturday, along with his two friends, to cook
a West Indian meal. They would spend the morning preparing, and later in
the afternoon would meet in one of their cells to eat whilst watching a film.
On a Saturday in early August, the man and his friend went to the kitchen
and cooked their meal. They then returned to his younger friend’s cell to
serve it. Suddenly, the man collapsed and slumped against the back wall
of the cell.
His older friend started to fan the man with a towel while his younger friend
called from help. He then pressed the emergency cell bell. Within two
minutes, seven members of staff were in attendance and had started
Cardio Pulmonary Resuscitation (CPR). Healthcare staff then arrived and
took over, while an ambulance arrived soon afterwards. The man was
taken to a local hospital but, sadly, did not regain consciousness.
The clinical review, carried out as part of this investigation, does not identify
any specific issues relating to the clinical care the man received. It says
that he received nursing and medical care comparable to that which would
have been available in the community. However, this report does raise
some important issues relating to the management of the news of the
man’s illness and death.
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Investigation process
1. The investigation was opened in September 2005, by my investigator.
She issued notices announcing the investigation to staff and prisoners
at Parkhurst and inviting anyone who wished to see her to make
themselves known. As a result, a friend of the man wrote to the
investigator. He was subsequently interviewed together with another of
the man’s friends.
2. My Investigator visited HMP Parkhurst in November 2005, when she
was provided with the man’s prison record and copies of the notices,
reports and other documents associated with his death.
3. Four additional visits were necessary in order to complete the
interviews. This report is based on those interviews, a thorough review
of all relevant records, and consideration of the findings of the clinical
review.
4. As part of her enquiries, my investigator also spoke to the Isle of Wight
Police who had carried out their own investigation into the man’s death.
She made contact with the Coroner’s office to inform him of our
investigation. Isle of Wight Primary Care Trust conducted a clinical
review of the man’s care while in custody.
5. The investigator also gathered details of the man's next of kin and one
of my Family Liaison Officers contacted the man’s family. Their only
concern was that the man had not been attended to quickly when he
was taken ill. They also asked to be informed when the draft report was
completed.
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HMP Parkhurst
6. HMP Parkhurst is a category B training prison for sentenced adult male
prisoners, situated outside Newport on the Isle of Wight. It also holds
unconvicted adult male prisoners awaiting trail at court on the Isle of
Wight. At the time of the man’s death, it held just over 500 prisoners.
7. Vulnerable prisoners are held on A and D wings. B and G wings hold
prisoners on basic and standard regimes, while C wing is an enhanced
regime. F wing holds remand prisoners and non-vulnerable prisoners
on induction. There is also a segregation unit, a protected witness
programme and an in-patients healthcare unit.
8. Healthcare is commissioned by the Isle of Wight Primary Care Trust.
The healthcare centre provides 24 hours cover and has 12 in patient
beds. The most recent inspection report by Her Majesty’s Chief
Inspector of Prisons in August 2005, noted that the healthcare service
at Parkhurst was “fragmented and understaffed”. However, healthcare
provision had improved from the previous inspection in 2002.
9. I have investigated two other deaths from natural causes at Parkhurst. I
have found no similarities between those deaths and this case.
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Events leading up to the man’s collapse
10. The man was remanded into custody in December 2002 at HMP
Wandsworth. His ‘First Reception Health Screen’ form reported that he
had no health concerns, either physical or mental, and did not use
drugs, drink or smoke. The clinical reviewer commented that no
significant past medical history or other health risks were recorded. In
September 2003, the man was sentenced to 14 years in prison. This
was later reduced to 12 years, on appeal.
11. The clinical reviewer notes that there are a number of entries in 2003
and 2004, in the man’s medical record, reporting that he was fit and
well.
12. In August 2004, while still at Wandsworth, the man completed an
application form saying he needed to see a doctor urgently, stating that
he had already completed a medical application. The next entry in the
man’s medical record is later that month, and reads, “did not attend sick
parade, out on exercise”. The next entry, nearly a month later, shows,
“did not attend”. The clinical reviewer notes that it is not apparent what
concerned the man at this time.
13. The following year, in February 2005, the man was transferred to HMP
Parkhurst and his medical notes record that he was “fit for transfer”.
The entry on the next day, states that he was transferred from HMP
Wandsworth as an enhanced prisoner with no medical problems, and
who described himself as fit and well. There are no further entries in
the man’s medical file until the day he collapsed.
14. The man’s personal record shows that he completed an induction
interview and was allocated to B2 landing in cell 7. A further entry in
this record advises that regular entries should be made by the man’s
personal officer. There are then several entries in this file each month.
The comments are general, for example describing him as a “quiet man
who keeps himself to himself”, “does not mix a lot on the wing” and
“attends work regularly”.
15. A fellow prisoner said that he had known the man for quite a few
months since he moved to Parkhurst from Wandsworth. He explained
that they first got talking as he was showing him how to use the washing
machine. He subsequently helped the man get to grips with the prison’s
rules to help him settle in. They spent some time together when they
were both on B wing, but then the man moved to G wing and they did
not see each other very often. Some weeks later, they both moved to C
wing and became good friends, even though he was a lot younger that
the man who died. They were joined about six weeks later by a friend
of the man’s from a previous wing.
16. The three men became very close. The younger friend said they “talked
about everything” and looked out for each other. He said the man spent
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a lot of time talking about his legal case. They soon developed a
routine of cooking together on a Saturday when they would pool their
canteen supplies and make carrot juice, a cake and an evening meal.
The younger friend explained that each Saturday morning, after
breakfast, the man would come to his cell to start their preparations.
17. On the Saturday the man collapsed, he left his cell on the first landing
as usual after breakfast and went to his younger friend’s cell on the ‘3s’
landing. His younger friend said that he seemed his normal self, and
they prepared the juice and cake. They had also prepared a dish which
they intended to eat later that day. At lunchtime, about 12 noon, all
three had their lunch from the servery and said they would see each
other later. When they were unlocked later that afternoon, the man and
his younger friend went to the kitchen to cook their evening meal.
18. The younger friend explained that, between 4.00pm and 5.00pm, he
and the man returned to the kitchen, collected their food and took it
back to his cell to share out and eat with their other friend. When they
arrived back at the cell, their friend was already there. At this time the
servery was serving the evening meal and, although they were going to
eat their own food, the older friend asked if anyone wanted a juice or
dessert from the servery. The others declined and the older friend went
down to fetch a drink for himself.
19. As he started to serve their meal, the younger friend said the man
spoke about how stressed he was and suddenly said that he could not
take any more. At this point, the younger friend said he looked up and
saw them man fall backwards. He tried to grab his waist and his arms
but could not, and the man’s glasses came off as he fell to the ground.
The younger friend said he did not know what was happening. He
could see the man’s eyes roll back and he was gasping for breath. He
described how the man appeared to grab for his glasses, but in
hindsight thought that perhaps he was grabbing his heart as he thought
he was fainting.
20. The younger friend said that his first reaction was to get some water
and fan the man with a towel. He explained that at this point the man’s
older friend returned to the cell and began to ask what had happened.
The younger friend told him that he did not know, and asked him to
continue fanning the man whilst he called an officer to help.
21. The older friend said that he was in the man’s younger friend’s cell,
talking while the cooking was finished. He decided to go to the servery
to get some drinks. When he returned, he saw the man was on the
floor and asked the younger friend what had happened. He said that he
was told that the man had just collapsed, and went on to say that he
thought that the younger friend seemed afraid and did not give him a
clear explanation about what had happened. He had urged the older
friend to fan him and put some water on the back of his head, while he
started calling for an officer.
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22. When the younger friend put his head out of the cell, he said he saw an
officer at the end of the landing, about 10 to 15 cells away, and called
him to his cell. He said that the officer did not respond, and he did not
know if he had heard him or not. It was nearly time for the prisoners to
be locked up, and the younger friend explained that there were lots of
prisoners running about and so it was very noisy.
23. As the officer did not respond, he decided to press the call bell to make
him react faster and realise something was going on in the cell. The
officer then started to run towards the cell, and he told him that his
friend had collapsed. The officer opened the door and saw that the man
was slumped against the back wall. He asked the younger prisoner
what he had been doing and he described how the man had collapsed
and that he and the older friend had fanned him with a towel and
sprinkled some cold water on him.
24. The older friend reiterated that he did not get a good description about
what had happened. The younger friend had just told him that the man
had collapsed and he went to the landing, called the officer and
returned to the cell. The older friend described the younger friend as
very upset, saying the officer was taking too much time as he was
walking when he should be running. Eventually, the younger friend
rang the call bell and the officer came into the cell.
25. The landing officer said he was on the 3’s landing at about 4.50pm
when the younger friend shouted and beckoned him to his cell, number
98, on the third landing. The landing officer did not think that the
younger prisoner seemed unduly worried, and had not called out that he
needed help or that it was an emergency. He said that he had called
“Gov” twice and pointed to his cell, which the landing officer thought
was because the cell doors frequently slammed shut in the wind and
staff are often asked to unlock them. As he approached, the younger
prisoner then rang the cell bell and that was when he thought that
“something serious” was going on and began to sprint. When the
landing officer entered the cell, he saw the man collapsed on the floor
and the older prisoner told him that they could not get a response from
him.
26. The older prisoner said that when the officer entered the cell he saw the
man on the floor and used his radio to call an alarm. He then said two
other officers rushed into the cell followed by the senior officer. He said
that the way the man had fallen made it difficult for him to breathe. He
described his head as resting on the heating pipe that runs along the
wall, about ten inches from the floor, with the rest of his body on the
floor.
27. The landing officer explained that the 2’s landing officer arrived at the
cell soon after him and they both tried to get a response from the man
by calling his name. The younger friend said that the second officer
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arrived within one and a half to two minutes of the call bell. He asked
him not to let anyone else into the cell, as by then all the prisoners had
heard the emergency call bell and were gathering around the door.
Other officers had also heard the call bell and began to arrive at the cell.
28. The 2’s landing officer said he was patrolling his landing on C wing,
when he heard the alarm bell sound and immediately made his way to
the 3’s landing. He said that, as he approached the cell, there seemed
to be an incident of some kind. When he went in, he found the younger
prisoner, the older prisoner and the landing officer. He described the
man as slumped against the back wall of the cell in a sitting position.
The younger prisoner told him that the man had collapsed.
29. The younger prison said that by then the senior officer had entered the
cell, been told what had happened and called for medical assistance.
According to the younger prisoner, they then waited for a doctor to
arrive. He said he was getting angry at what seemed to be a delay. He
also said that he and the older prisoner were upset, but did not want to
leave the cell as they wanted to know what had happened to their
friend. The younger prisoner said the senior officer looked at him, saw
his reaction and asked what he should do. He said he was angry, but
knew that first aid should be started and began to administer mouth to
mouth resuscitation himself.
30. When the senior officer and a female officer arrived, all four members of
staff lifted the man onto the bed and placed him in the recovery position.
The landing officer said he felt for a pulse, but could not find one. At the
same time, he said the female officer moved the man into a position to
enable CPR to be carried out. He explained that she began mouth to
mouth resuscitations, while the senior officer started administering chest
compressions. The younger prisoner said that the senior officer asked
whether any of the officers knew how to do first aid, and the female
officer confirmed that she did, after which the senior officer told him to
get up as the officer would take over.
31. The female officer said she was on G wing on the 2’s landing when she
heard an alarm bell call from C wing on the radio. She explained that
there is a connecting door from G2 landing which takes you through to
C1 landing. She said that, as she arrived on C2, she was directed by
prisoners onto the 3’s landing and into cell 98. She estimated it had
taken her no more that 60 seconds from hearing the alarm to entering
the cell. She explained that inside the cell were the younger prisoner,
the older prisoner, 3’s landing officer, the wing officer and the 2’s
landing officer. She said that the 3’s landing officer and the 2’s landing
officer were fanning the man, who was slumped against the back wall,
and were trying to get a reaction from him by slapping his face. She
told them to stop in case the man had any neck or head injuries. They
believed he had a gold tooth and they were trying to remove this before
attempting CPR.
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32. The female officer said that together the officers lifted the man onto the
bed. She said the senior officer asked who was a first aider, and she
replied that she was and started to check for a pulse. She said she
called out that no pulse could be detected and shouted for a face mask.
In interview, she said that the staff agreed that they could not wait for a
mask whilst the man was not breathing. She started to move him into
the recovery position and she and the senior officer, who by now had
arrived at the cell, started CPR. She started mouth to mouth without the
mask, with the senior officer giving chest compressions. She said they
went through this process twice and then the healthcare officer relieved
her. She said she stayed in the cell in case the senior officer needed a
break. She said a prison service nurse, also from healthcare, then
arrived and let them know that the defibrillator was on its way.
33. As other officers arrived, the 2’s landing officer said they lifted the man
up onto the bed and, when they failed to locate a pulse, they informed
the principal officer who had just arrived. The 2’s landing officer said
principal officer then contacted the control room by radio, informing
them that an ambulance should be called and that healthcare staff were
required. He explained that, following the first set of chest
compressions, he checked for a pulse again but was unsuccessful.
They continued with CPR until healthcare staff arrived a few minutes
later and took over. The senior officer estimated that it was about five
minutes later when the healthcare staff arrived and took over the
resuscitation. The female said they continued to attempt CPR until the
healthcare officer arrived and took over, she estimated this was at about
4.54pm. At this point, she explained, both she and the landing officer
left the cell and had no further involvement. The 2’s landing officer said
he also left the cell, but later helped the ambulance crew carry the man
onto the landing, and later still helped get him into the ambulance.
34. According to the healthcare officer, the alarm bell for C wing rang at
approximately 4.51pm asking for healthcare staff to attend the wing. He
said he used his radio to ask whether blood or oxygen was required so
he could decide which emergency bag to take. He said that, virtually at
the same time, he heard the senior officer issue the instruction to get
healthcare staff, and so he grabbed both bags and ran. At that time his
colleague, was returning from administering treatments and they went
together to the wing and up onto the 3’s landing.
35. When the healthcare officers arrived at the cell, they found the senior
officer and the female officer administering CPR. The healthcare officer
told them that they would take over and he took over chest
compressions, whilst his colleague used the Ambu bag to administer
oxygen. An ‘Injury to Prisoner’ form was completed when the man
collapsed. This shows that healthcare staff were contacted at 4.54pm
and the duty Governor was contacted at the same time. Also at this
time, an ambulance was called.
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36. The healthcare worker explained that a second senior officer then
arrived with the defibrillator machine which he wired up and instructed
him to administer electric shocks to the man. He said that the
ambulance crew then arrived, by which time the man appeared to have
regained some colour. The ambulance crew moved the man off the bed
and onto the landing floor in order to have more space to work. The
healthcare worker continued CPR while the ambulance crew
administered medications, and continued to shock the man.
37. The healthcare worker explained the weekend healthcare arrangements
at Parkhurst. There are two workers on the clinics which are the
outpatients department for the whole prison. There is also an in-
patients department with an additional three or four members of staff.
There is no doctor on site on Saturday but they are called in to attend,
when necessary.
38. The second senior officer said he arrived on C wing at 4.57pm. He was
told by a prison service nurse that a prisoner had no pulse and was not
breathing. On the way he collected the defibrillator from E3. He
pointed out that he had not been carrying a radio that day and so only
heard about the alarm through another member of staff (I return to this
issue later). When he came into the cell he saw the man on the bed.
The healthcare worker was administering chest compressions while his
colleague was giving breaths. He said a prison service nurse was also
there, having brought oxygen from E3.
39. The prison service nurse explained that she was Radio Call Sign Hotel
1 that day. This meant she was the nurse designated to respond to any
emergency situation. She said she received the call asking for hospital
staff to attend an unconscious person on the wing. She heard on the
radio that the person had stopped breathing, so she picked up the
oxygen. When she arrived at the cell she said the healthcare worker
was already there doing chest compressions and someone else was
giving breaths. She said the ambulance had already been called. She
explained that, by the time the paramedics arrived, the defibrillator had
already been connected and had directed them to shock the man twice
- which they had done.
40. The second senior officer to attend the cell said he applied the
defibrillator pads and the machine advised him to shock the man, which
he did. He said CPR was restarted, until the machine advised that
another shock should be given. Again CPR was continued until the
paramedics arrived. They then took control of the man’s care and
instructed the healthcare worker to continue giving rescue breaths.
They directed the healthcare worker and the second senior officer to
alternate giving external cardiac compressions. The second senior
officer said that three doses of drugs were administered and the
paramedics shocked the man two or three more times.
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41. The younger friend said he remained angry with the situation and
eventually he got up and stood by the door to allow the other officers to
get inside. He and the older prisoner then left and did not see what else
happened in the cell. Whilst waiting outside, he said that the female
officer came out and was upset. By this time, the younger prisoner said
that he and the older prisoner were extremely upset, and he asked the
officers to tell them whether the man was still breathing. He said that
the officers could not tell them anything, but brought chairs for them to
sit down and then encouraged them to go to the older prisoners’ cell
together. The older prisoner estimated that the ambulance arrived
about five or six minutes later.
42. The Prison Service nurse remembered that the ambulance arrived very
quickly. She said the man was breathing with oxygen when he left in
the ambulance. Before he left, she went to get his medical record to
see if he had a treatment card, which he did not.
43. Records show that another senior officer arranged for all the prison
gates to be opened to allow the ambulance clear access. The
ambulance arrived at the prison gate at 4.57pm and the paramedics
were on C wing at 4.59pm. The doctor was called to the prison at
5.14pm. Records also show that the security department, reception and
the hospital were contacted at 5.25pm to make arrangements for the
man to be moved there. The ambulance left the prison at 5.30pm.
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After the man went to hospital
44. At 6.20pm, a member of the care team, a support service for staff, was
asked to come into the prison. The Independent Monitoring Board
(IMB) were notified at 6:32pm. The man’s family were also contacted
that evening and told that he had been taken to hospital. Some of them
travelled to see him that night.
45. Later that evening, the younger prisoner said that a member of staff
whom he did not know approached him and the older prisoner and said
that the hospital had informed them that the man had overdosed.
According to the younger, he asked whether the man had taken any
drugs or alcohol. The younger prison said that both he and the older
prisoner were certain that the man had not taken either and they told
the officer this.
46. The officer said he would relay that information to the hospital. The
younger prisoner said throughout the night other officers spoke to them
saying that the man was recovering, was pulling through, but was “on a
machine”. The younger prisoner said at this time he knew from a
secret source that the man had had another heart attack, and had not
been informed by prison staff even though he was a close friend. After
getting the information, the younger prisoner said he approached a
member of staff to ask why he had not been told, and was informed that
staff were also unaware of it.
47. About two days later, the younger prisoner said that another member of
staff approached him to ask if he wanted to see the chaplain or speak to
a Listener. The younger prisoner said that for three nights he and the
older prisoner stayed together in his cell on the 2’s landing. On the first
night, he said that an officer left their door open and stayed with them
for three hours to see how they were.
48. He then was moved over to F wing and found it even more difficult to
obtain information about the man. When he did make enquiries of the
staff, he said they said that nothing had changed and he learnt of the
man’s death through his secret contact. He commented that he had not
found the officers very caring, and compared them with others he had
met in other prisons. The older prisoner said he was not told about the
man’s death, but saw a notice on the board announcing his death. He
said he was very upset and went to the senior officer to say so. He said
the senior officer replied that everyone had the right to know at the
same time, but the older prisoner said that he and the younger prisoner
were not the same as other prisoners, but were like a family.
49. The older prisoner said he and the younger prisoner planned a
memorial service together. He described the man as a great friend -
one who would put his own worries aside and take care of someone
else and was like a father to him.
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50. While the man was in hospital, a Release on Temporary Licence
(ROTL) Board was convened at Parkhurst. This was attended by a
governor and the Head of Resettlement. It was decided that, following
a risk assessment under the terms of Governor’s Instruction 36/1995,
the man was eligible for temporary release on compassionate grounds.
This meant that the man would not require the supervision of staff and
would not be handcuffed during his stay in hospital. It was decided that
the man’s situation would be reviewed by the head of security on a daily
basis. A week later, the ROTL conditions were reviewed and it was
decided to continue with the agreed arrangements.
51. The man did not regain consciousness and died in mid August. At
9.00pm, the duty governor was informed by the control room at
Parkhurst that the man had died at 8.45pm. At 9.10pm, he confirmed
the death with the night sister at the hospital. At 9.15pm, he contacted
the man’s mother and brother to inform them of the death. The control
room then contacted the police and requested that they inform the
Coroner.
52. At 10.00am the next day, the family were contacted again and it was
arranged that the man’s brother, would travel that day to identify the
body. The bed manager at the hospital was also contacted and asked
to meet the man’s brother.
53. The then Governor, wrote to the Coroner’s office, formally notifying him
of the man’s death. He said that the man had had a heart attack and
had been taken to the local hospital by ambulance. He had been
treated in the Intensive Care Unit. The governor confirmed that he had
released the man on temporary licence. He also mentioned that
security information had been received to indicate that the man might
have been assaulted before his death. He said this information had
been passed to both the hospital and the police. He confirmed that he
had secured all of the man’s records should they be required. This is
another issue to which I shall return.
54. Later that month, the governor wrote to the man’s mother properly
offering condolences following the death of her son. He explained the
procedures that would follow, including an inquest and my investigation.
He also invited the family to visit the prison if they wished and confirmed
they would keep the man’s possessions safe until they were ready to
receive them. He provided the man’s mother with the contact details of
the Family Liaison Officer (FLO) and confirmed that the family could
contact him or the FLO at any time.
55. I have considered these actions in the light of Prison Service Order
2710: Follow up to deaths in custody, which provides detailed
instructions of the actions required following any death in custody. I
consider that all the instructions were followed appropriately in this
case.
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56. The same day, a post mortem was conducted. The pathologist
concluded that the man had suffered a heart attack. He reported that
the man’s heart had stopped beating for a period of time and his brain
suffered severe and irreversible damage due to oxygen starvation.
Despite resuscitation and other continuing supportive measures, there
was no improvement in his condition and he subsequently died. There
was no autopsy evidence to suggest that he had suffered violence prior
to his death. For recording purposes the cause of death was given as:
1a Hypoxia brain injury (brain injury as a result of a lack of
oxygen)
1b Myocardial infarction (heart attack)
1c Coronary artery thrombosis (fatty narrowing of the arteries
supplying the heart muscle).
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Issues considered during the investigation
The man’s clinical care
57. The clinical reviewer says that the man had little contact with medical
services in prison, having been found fit and well on reception at
Wandsworth. He was also found to be fit and well when he transferred
to Parkhurst. The clinical reviewer observes that it is not clear why the
man completed a healthcare application form in 2004. It seems that he
did not complete any subsequent applications and did not raise any
issues when he was transferred to Parkhurst, where he would have had
the opportunity to see a member of staff - usually a nurse, on a first
night health screen. He would also have had the opportunity to see a
doctor if he needed to do so.
58. In the opinion of the clinical reviewer, the man’s medical care was
equivalent to that he was likely to have received in the community and
he appears to have received urgent attention when he was found
collapsed. His only comment is that, in the long term, prison medical
services should be undertaking more Well Man clinics including the
recording of individual’s smoking status, offering stop smoking advice
and recording blood pressure.
Healthcare at Parkhurst should consider undertaking more Well
Man clinics.
The prison’s response to the man’s collapse
59. The man collapsed suddenly and unexpectedly. My investigator has
spoken at length to his friends, and to several members of staff. From
these interviews, it is clear that there was a certain level of panic in the
cell. Not surprisingly, the man’s close friends were both upset and
troubled.
60. CPR was first attempted whilst the man was lying on a bed. This
contravenes the instructions in PSO 2700 (annex c) which say that CPR
should be administered on a hard surface such as a floor. The clinical
reviewer makes no comment and I am satisfied that it did not affect the
outcome for the man. However, staff should be reminded of the terms
of the PSO.
Staff should be reminded that it is best practice for CPR to be
administered on a hard surface and not a bed.
61. The man’s younger friend said that he was both angry and upset at the
delay in the landing officer’s response to his request for help. However,
he also conceded that at the time the wing was busy and noisy and it
would have been difficult for the landing officer to have heard his calling
above the noise. Moreover, within two minutes of him pressing his call
bell there were eight members of staff in and outside the cell.
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62. Both the landing officers were in the cell when the female officer arrived
but had not started to administer CPR. When questioned why this had
happened, the female officer explained that when she arrived they were
fanning the man with a towel. They believed he had a gold tooth and
they were trying to remove this before attempting CPR.
63. In an ideal situation, if the landing officer had heard the younger
prisoner’s call he might have attended the cell slightly earlier. Perhaps
if the cell call bell had been used earlier again the officer might have
attended sooner. However, I am satisfied that staff attended promptly
when the bell was rung and that there was no delay in their response. I
am equally reassured that CPR was started as soon as was possible,
whilst ensuring that the man’s care and safety was preserved. I do not
share the younger prisoner’s claim that staff “did not seem to care”.
Did the younger prisoner attempt CPR?
64. In his discussion with the investigator, the younger prisoner said that he
instigated the CPR proceedings as staff did not seem to be taking any
action. However, the senior officer is adamant that this did not happen.
Additionally, he is definite that the comments attributed to him by the
younger prisoner were not said. He is clear that, as soon as staff
assessed the situation and moved the man up onto the bed, he and the
female officer began CPR. He is unambiguous about the fact that this
was the first attempt at CPR.
65. The landing officer and the other staff members who attended the man’s
cell agreed with the senior officer’s account. I have found no further
evidence to support the younger prisoner’s description of events.
Was the man attacked?
66. There was some concern expressed by the staff interviewed during this
investigation that the man had been attacked. From the documents
reviewed, it is clear that management at Parkhurst had been made
aware of these concerns and acted appropriately in passing on the
information. Hospital staff were informed, but subsequent checks found
no evidence that the man had been attacked or had been involved in a
struggle. This information was also passed to the police who conducted
their own enquiries and again found nothing to support this assertion.
67. I am satisfied that no evidence has come to light to support the concern
expressed by staff.
Bedwatch arrangements
68. I am pleased to say that the man’s ROTL arrangements were well
handled. The decision not to use restraints was entirely appropriate
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given the circumstances. I believe the Governor made a correct and
timely decision, and commend him for it.
How staff and prisoners were informed of the man’s death
69. As this investigation unfolded, it became clear that one area of concern
for staff and prisoners alike was that they were not kept up to date
about the man’s condition, and felt they were not informed of his death
appropriately when he died. It was particularly upsetting for the man’s
friends, who quite rightly felt that they deserved to be told in a more
sensitive way and certainly not by way of a general notice.
70. Equally, for staff involved in the man’s resuscitation I do not think a
personal telephone call or visit from a governor is too much to ask. I
know some of the staff involved visited the man in hospital of their own
volition to check on his progress. Others volunteered for bed watch
duties in order that they could visit him. It appears that staff members
found out from colleagues or notices placed around the prison. The
majority of staff felt this was rather a wretched way to learn of the man’s
death, in addition to not receiving any updates on his prognosis. I agree
with the views of the staff and prisoners involved and believe a review
of the arrangements should be undertaken.
The Governor should take steps to ensure that the local Death in
Custody policy is reviewed, in particular ensuring there is sensitive and
appropriate communication of such news with staff and prisoners.
Contact with the man’s family
71. The man’s family were informed quickly after he collapsed and
subsequently several members of the family were able to visit him at
hospital.
72. Although no members of prison staff attended the funeral, a memorial
service did take place at Parkhurst and several members of the family
were able to attend. The family were happy that they had been treated
properly by the prison and particularly mentioned the chaplain as
someone who had been helpful.
First Aid & CPR Training
73. Although not pertinent to the man’s death, this investigation did identify
an area of concern regarding training in first aid and the use of the
defibrillator, and the deployment of those trained staff.
74. The second senior officer who responded to the alarm and the
healthcare nurse had been trained by the St. John’s Ambulance
Brigade. They are both first aid and Use of Defibrillator trainers, which
means they train other staff within the prison as well as prisoners. At
the time of the man’s collapse, they were the only two members of staff
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in the prison trained to use the machine. The senior officer pointed out
that, despite his qualification, his duties that day did not require him to
carry a radio and so he did not hear the emergency call. He was
informed of the man’s collapse by another staff member who happened
to pass him as she was on her way to the cell.
75. It also became clear during this investigation that several members of
healthcare are not first aid or Defibrillator trained. It must be questioned
why staff members with key skills were not asked to attend the
emergency, and whether healthcare staff are the best people to contact
in such emergencies. I make no judgement either way, save to say it is
an area the Governor should consider, in consultation with both
healthcare and the relevant members of non-medical staff.
The Governor should undertake a review of emergency response
systems within the prison, ensuring the most appropriate staff are
contacted in such emergencies.
76. The landing officer said that he had been first aid trained some four
years ago and had not had the opportunity to undergo a refresher
course since. He believed, as other staff did, that a refresher course
should be available once a year. He was clear that he did not feel
competent in attempting resuscitation without up to date training.
77. The second senior officer and the healthcare nurse have dedicated
much of their own time to undertake courses and gain qualifications in
order to train other staff and prisoners at Parkhurst. At present, there
are 35 members of staff trained in first aid at Work, 37 staff trained in
Emergency Aid and 14 staff who are defibrillator trained. It is important
that such staff are properly supported and resourced to enable them to
continue the work they do.
The prison should undertake a review of the first aid, emergency
aid and defibrillator training to ensure staff have regular access to
refresher training.
Response to the PPO investigation
78. My conclusions about the man’s care at Parkhurst are almost entirely
positive. All those interviewed have impressed as professional and
decent members of staff. However, unusually, I have very real
reservations about how the prison organised its liaison with my
investigation.
79. Initially, my investigator was allocated an officer to act as her point of
liaison. He was frank about his lack of training, but said he was keen to
learn and be as helpful as he could. A few days later, the investigator
was contacted by another member of staff who also believed that he
was to be the liaison officer. This person had been trained as a family
liaison officer and was indeed working with the man’s family as their
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contact. Some days further on, he spoke to the investigator again and
said he had made a mistake and was not to be the liaison. The
investigator then contacted the prison and was told that a governor
would be the liaison, and indeed was so until the investigator made her
first visit. Thereafter, the investigator was told to use a member of the
support staff as her contact.
80. Again, this person tried to be as helpful as possible but she did not have
any training or resources to carry out the role. Additionally, although it
should not be so, she had no authority to release officers from their
duties to attend interviews. As a consequence, my investigator arrived
at the prison on a number of occasions to interview staff only for people
to fail to attend, or to arrive but not be prepared to proceed with the
interviews. The staff members explained that they had not been given
notice of the interviews, and therefore could not arrange representation
to accompany them or indeed prepare themselves to be questioned.
This resulted in the investigator having to return several times to
Parkhurst to compete interviews which would usually have taken a day
or two.
81. Overall, this suggested a lack of management interest in my
investigation, something that was quickly picked up by the staff who
were interviewed.
82. As liaison was given insufficient priority, it contributed in some part to
the delay in the production of this report. However, following the
appointment of a new governing Governor, I am pleased to say the
liaison procedures improved significantly allowing the investigation to be
completed more effectively.
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Conclusions
83. The man’s collapse was sudden and unexpected. He had not reported
any illness to healthcare staff at Parkhurst or complained to staff or
friends of feeling unwell. Staff responded promptly and professionally
when the alarm was raised and did all they could to aid him. The
ambulance was called promptly and arrived swiftly and he was taken
quickly to the local hospital.
84. I am satisfied with the way the man was cared for at Parkhurst. His
family did raise some concerns when initially contacted by my family
liaison officer, and were worried that the man had not been attended to
quickly when was taken ill. I hope that this report has answered their
questions and met their concerns.
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Recommendations
1. Healthcare at Parkhurst should consider undertaking more Well Man
clinics.
2. Staff should be reminded that it is best practice for CPR to be
administered on a hard surface and not a bed.
3. The Governor should take steps to ensure that the local Death in
Custody policy is reviewed, in particular ensuring there is sensitive and
appropriate communication of such news with staff and prisoners.
4. The Governor should undertake a review of emergency response
systems within the prison, ensuring the most appropriate staff are
contacted in such emergencies.
5. The prison should undertake a review of the first aid, emergency aid
and defibrillator training to ensure staff have regular access to refresher
training.
Having read a draft copy of this report the Prison Service have accepted
all of the recommendations made.
Good Practice
(cid:190) The Governor should commend the initiative of the staff members
who have obtained first aid qualifications in their own time and used
them to train colleagues.
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