Individual at Ranby

Investigation into the circumstances surrounding the death
of a prisoner on 30 June 2005 at HMP Ranby
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2006
This is the report of an investigation into the circumstances surrounding the death of
a prisoner, on 30 June 2005 at HMP Ranby. The prisoner, who was 34, was found
dead in bed in his cell when prisoners were unlocked for breakfast.
My colleagues and I would like to extend our condolences to his family and friends
for their sad loss.
The post mortem toxicology report confirmed that the cause of death was an
overdose of co-codamol. Although he had been prescribed co-codamol and
solpadol to treat back pain, traces of other medications, not prescribed for him, were
also present in his blood. The post mortem findings have raised serious concerns
regarding the prescribing of codeine-based medications in Ranby and the
management of medication prescribed for prisoners to hold in their own possession.
The prisoner had a long standing history of drug misuse.
One of my investigating officers, conducted the investigation, I am grateful to the
Bassetlaw Primary Care Trust who carried out the clinical review and for the opinion
of an independent expert, who reported on the prescribing of codeine-based
medication. I would also like to thank Ranby prison who ensured that all relevant
information was available to my investigator.
I have found no suggestion that the prisoner intended to kill himself; the suggestion
is very strongly that he engaged in the reckless abuse of whatever drugs he could
chance upon.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2006
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CONTENTS
Summary 4
Investigation Methodology 5
Background 5
The Prisoner 5
Ranby Prison 6
Events leading up to his death 6
Events of 30 June 2005 7
Events following the discovery of the body 7
Contacting the family 8
Clinical Review 8
Findings and Conclusions 9
Recommendations 11
Good Practice 12
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Summary
The prisoner was 34 years old when he died on the 30 June 2005, while in custody
at Ranby. He was serving a six year sentence for robbery, dangerous driving and
driving while disqualified.
Prison staff were alerted to attend to the prisoner by a fellow prisoner, who at
approximately 8.10am summoned staff assistance to his cell. A prison officer arrived
at the cell and immediately called for help from other staff. She then radioed to the
control room calling for urgent medical assistance.
Health care officers attended, but they were unable to save the prisoner as it
appeared he had been dead for some time. His body was in an advanced state of
rigor mortis and therefore they did not attempt cardio pulmonary resuscitation (CPR).
The Bassetlaw Primary Care Trust (PCT) carried out a clinical review. The Area
Drugs Co-ordinator, Prison Service East Midlands Area, carried out a review of the
prescribing procedures for codeine at Ranby. They focus in particular upon the
levels of prescription for codeine-based medication at the time of the prisoner’s
death and management and control of in possession medication generally.
The post mortem toxicology findings confirmed that his death was the result of an
overdose of co-codamol,1 an analgesic medication prescribed to him on 20 June.
This report endorses the recommendations made by the clinical review team from
the Bassetlaw Primary Care Trust and the Area Drugs Co-ordinator and makes three
further recommendations. It also identifies one area of good practice.
1 Co-codamol is one of a number of pharmaceutical products which contain codeine phosphate 30mg
and paracetamol 500mg. These products are ‘prescription only’ medicines.
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Investigation Methodology
From the beginning, the cause of death was suspected to be drug related. Notices
to staff and prisoners were sent to the appointed liaison officer at Ranby, to be
displayed around the prison. These announced the investigation and invited staff
and prisoners to submit to my investigator any concerns or views they wished to
express.
Pending further investigation by the pathologist who undertook the post mortem, my
investigator visited Ranby. He was given a tour of the prison visiting all relevant
areas of J and K wing, talking to staff involved and meeting with the Governor. My
investigator was given access to all the prisoner’s records, including his medical
records and all other relevant documents. This subsequently included gathering a
substantial amount of statistical data which was pertinent to the issues of the
prescribing of codeine-based medication and its ramifications.
The Bassetlaw Primary Care Trust carried out a clinical review of the management of
the prisoner’s health needs while in custody. The Area Drugs Co-ordinator, carried
out a review of the prescribing of codeine-based medication at Ranby.
One of my family liaison officers contacted the prisoner’s sister, who told my liaison
officer that a prisoner at HMP Buckley Hall was considered by the family to be the
prisoner’s partner and nominated next of kin. My liaison officer and investigator
visited HMP Buckley Hall. She said that she did not have any issues she wanted to
raise about the prisoner’s death. However, she did say that she did not believe that
he intended to take his own life, but most likely had overdosed accidentally.
Some changes to what this report says about family liaison were agreed following
comments from the Prison Service on an earlier draft.
Background
The prisoner
The prisoner was born in Sheffield on 6 September 1970. He was 34 years old
when he died on 30 June 2005 at HMP Ranby while serving a six-year sentence for
robbery, dangerous driving and driving while disqualified. He was divorced from his
wife of ten years with whom he had two children.
He was taken into custody on 14 October 2004 and initially held at HMP Doncaster.
He was convicted and sentenced on 16 December 2004 and on 8 February 2005 he
was transferred to Ranby. His partner, who was his co-defendant, was also
imprisoned and at the time of his death she was in Buckley Hall.
While at Ranby, he was treated for various medical problems including
sciatica, lower back pain and a bleeding peptic ulcer.
He was a self confessed drug user, regularly taking crack cocaine and heroin, often
by intravenous injection. It is probable that he was still actively involved in taking
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drugs while in custody, given the anecdotal evidence from his partner. At Doncaster,
he had a positive drug test result and due to his involvement in illicit substances was
subject to closed (non-contact) visits. He remained on closed visits until his transfer
to Ranby.
Ranby Prison
Ranby is a category C male adult training prison, near Retford in Nottinghamshire. It
was converted in the early 1970s from its original use as an army camp. While some
old billets remain, purpose built accommodation has since been added. It has an
operational capacity (maximum crowded capacity) of 1,038, a certified normal
accommodation of 912 and a typical daily population of 950 prisoners.
At the end of March 2005, Ranby was given a Prison Service performance rating of
level three - “meeting the majority of targets, experiencing no significant problems in
doing so, delivering a reasonable and decent regime”.
Ranby was last inspected by Her Majesty’s Inspectorate of Prisons on 29 – 31 March
2005 when it was subject to an unannounced visit. In her subsequent report, the
Chief Inspector, commented that Ranby had made considerable progress since the
last full inspection in 2002. However, it is of relevance to my investigation that she
added:-
“Overall, there were better systems for ensuring the safety of prisoners.
The major area of continued concern was healthcare, particularly the
pharmacy. Healthcare lacked effective clinical leadership, and some
pharmacy systems, which we had described as unsafe and possibly illegal at
the time of the last inspection, were still in place.”
Events leading up to the prisoner’s death
The prisoner was on remand at HMP Doncaster from 14 October 2004 until 16
December 2004. He was then convicted and sentenced to six years imprisonment
and returned to Doncaster. During his time at Doncaster, he was assessed in
relation to his drug habit and offered a detoxification programme. However, he
refused the medication offered with the exception of symptomatic relief for gastro-
intestinal discomfort. He was transferred to Ranby on 8 February 2005.
He had been receiving co-codamol on a weekly basis since 14 April 2005 for chronic
lower back pain and arthritic toes.
On 20 June, he was prescribed a 14 day course of co-codamol in possession. He
saw the doctor on 29 June, and said he had taken the medication all at once. The
doctor doubted this was the case, and believed he might have sold the drugs. He
instead prescribed solpadol2 on a weekly basis. He asked the healthcare officer to
issue this daily. He indicated this on the top of the prescription record, but not in the
medical record.
2 Solpadol are effervescent tablets containing phosphate and paracetamol 500mg. Solpadol and co-
codamol are pharmacologically identical but only solpadol tablets are effervescent.
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The doctor said the prisoner was put on sleep watch, as he was asking for sleeping
tablets and the doctor wanted to see if they were needed.
Later that day, an Officer issued him with a week’s supply of solpadol despite the
annotation on the prescription chart by the doctor.
Events of 30 June 2005
On the morning of 30 June, an officer was unlocking the cell doors on the third
landing on J and K wings. At approximately 8.10am, she was alerted to cell K329 by
a prisoner who said that the prisoner was frothing at the mouth. She opened the cell
door and could see him lying on his back in his bed and that he was indeed frothing
at the mouth. The officer called to another officer, who was out on the landing, who
in turn alerted the senior officer.
At 8.11am, the first officer called a code red on her prison radio. A code red is a
term used over the radio at Ranby to alert healthcare staff that there is a medical
emergency taking place and that their help is required. The senior officer and the
second officer arrived at the cell and checked for a response from the prisoner, while
the first officer escorted the other prisoner back to his cell and arranged for him to be
comforted by a friend. She then returned to the ground floor where she met
healthcare officers as they arrived on the wing. They went straight to the cell.
The healthcare officers found that the prisoner had no pulse and was not breathing.
His body was cold and his pupils were fixed and dilated. Rigor mortis was in an
advanced state. In his incident report, one of the healthcare officers said that he
thought the prisoner had been dead for some hours and advised that a doctor should
be called to certify the death.
The other healthcare officer gave a similar account in his report, but he also noticed
that the prisoner had a small amount of white foam on his lips, and that there were
six empty single dose solpadol sachets on the prisoner’s bedside cabinet.
Events following the discovery of the prisoner’s body
At 8.25am, all the staff left the cell and the cell door was locked and sealed with an
officer remaining outside the cell door as log keeper. His responsibility was to keep
a record of anyone entering the cell and to keep the area sterile and secure.
A sergeant and a police constable from Retford police arrived and entered the cell at
approximately 9.40am and left a few minutes later. At 9.50am, the doctor and
healthcare principal officer arrived and the doctor confirmed that the prisoner was
dead. A police inspector and a sergeant arrived and entered the cell at 10.08am
leaving a few minutes later. At 12.04pm, the scenes of crime officer and police
doctor arrived at the cell to check for forensic details, leaving at 12.26pm. The
funeral directors arrived at 3.20pm and removed the prisoner’s body from the prison.
Prison Service Order 2710 sets out what action must be taken following a death in
custody. Chapter 5 sections 3 and 4 both state that an immediate post incident
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debrief or (hot de-brief) should be carried out before the staff involved go off duty.
On this occasion this was not carried out. However, support for the staff has since
been offered by the Head of Programmes/Psychology, and this was continuing
during my investigation.
Within the local contingency plans it states that all persons involved should complete
an incident report. Individual incident reports were not completed until my
investigator alerted the Governor to the omission.
A post mortem examination was carried out at the University of Leicester on 30
June. Although initially unable to establish the cause of death, the pathologist
suspected it was drug related and asked for a toxicology report. It was received on
21 September and led the pathologist to conclude that the cause of death was an
overdose of co-codamol.
Contacting the prisoner’s family
Following the death of the prisoner, the decision was taken by the Governor that
because the prison’s family liaison officer was not on duty, the prisoner’s sister,
would be contacted and informed by South Yorkshire Police. She informed the
prison that a serving prisoner at Buckley Hall, was the prisoner’s partner, and
considered by his family to be his nominated next of kin.
Prison staff at Buckley Hall, informed his partner of his sad death, and prompt
arrangements were made for her to attend his funeral. She was given access to the
prison chaplaincy team when she felt she needed to speak to them.
Clinical Review
Bassetlaw Primary Care Trust completed a clinical review into the care of the
prisoner at Ranby. During the course of the review, they interviewed the prison
doctor and healthcare officers who were involved. They also reviewed all the
available medical documentation.
Their report concludes that there was a poor standard of clinical record keeping.
The patient’s excess taking of co-codamol, the changing of his medication and the
dosage had not been recorded. The report stated that this was unacceptable and
suggested that the medical records could be computerised to allow all notes to be
read and completed to an acceptable standard.
The reviewers criticised the manner in which medication was dispensed and the
forms used to record the information. They concluded that for some reason the
instruction to dispense solpadol daily was not carried out. The dispensing forms do
not include a section indicating that a drug should be issued daily. They concluded
the form required amendment and the prescribing system should be computerised.
The term sleep watch used at Ranby is not a medical observation and appears an
inappropriate way of gauging whether sleeping tablets should be prescribed or not.
However, the reviewers stated that this issue did not appear to have had an impact
in this case.
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Independent of the clinical review, the area drugs co-ordinator for the Prison Service
in the East Midlands, examined the prescribing of codeine- based medication at
Ranby. Following a routine monitoring visit in May, the area Manager’s staff officer
had brought to her attention that there was a high level of prescribing of codeine-
based preparations. 15% of Ranby’s population were being prescribed a codeine-
based preparation which was a cause for concern. Staff suspected that prisoners
were trying to mask their heroin use by obtaining a prescription for codeine-based
medication. It is not always possible for mandatory drug testing (MDT) or voluntary
drug testing (VDT) to differentiate between heroin and codeine. Codeine could also
be traded to other prisoners.
The area drugs co-ordinator made a number of detailed recommendations to
improve the management of medication at Ranby.
Findings and Conclusions
The clinical reviewers found that the prisoner appeared to have received medical
care of the standard they expected. However, they concluded that the quality of the
continuous medical record was poor.
The post mortem report concluded that the cause of death was an overdose of co-
codamol. The analysis of the post mortem blood samples showed not only the
presence of a codeine level above the quoted lethal range but also the presence of
other therapeutic medications not prescribed to the prisoner. These were
amitriptyline, a tricyclic antidepressant, and carbamazepine, an anti-epileptic agent,
both of which were present below the therapeutic range. Mirtazepine, another
antidepressant drug, was present at a level within the therapeutic range. In addition,
traces of ibruprofen, mefanamic acid and diclofenac which the prisoner had been
prescribed at some time previously were detected as well as olanzepine, tramadol
and metoclopromide which he had never been prescribed. The picture which
emerges from these findings is one of someone who would take medication
indiscriminately.
Examination of statistics, performance data and security reports from Ranby showed
that, in the quarter ending in June 2005, the rate of positive mandatory drug tests
(MDT) was running at 12.75 %. This was more than double the annual performance
target of 6 %. Subsequent action taken by the management of the prison caused the
prescribing of codeine- based medication by the doctors to be significantly curtailed.
In July and August, the rate of positive MDT was 5.88 % and 4 % respectively. The
prison report on the results for August 2005 concluded that:-
“The decision to reduce the amount of codeine-based medication issued from
health care has had a great impact on the amount of positive opiate results.”
There was evidence in the performance reports examined by my investigator that
there was a trade in prescribed medication with associated bullying, intimidation and
theft. The potential for these behaviours to occur is escalated when in-possession
medication procedures are unmanaged. In the prisoner’s case, the latest instruction
was to issue his medication daily but this was not followed. The Chief Inspector of
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Prisons reported earlier this year that the health care service at Ranby, particularly
the pharmacy, gave her great cause for concern. Recommendations about
pharmacy services made in 2002 had not been fully acted upon.
South Yorkshire police delivered the news of the prisoner’s death to his sister in the
first instance. I do not generally consider it appropriate to use the police to inform
family members of the death of a loved one. The Prison Service’s newly revised
guidance, Liaison with Bereaved Families Following a Death in Custody (Prison
Service Order 2710), explores the issues to be considered when taking the decision
on how news of a death in custody is to be delivered. The Prison Service Order
(PSO) recommends that the news is broken to a family as soon as possible after the
death, face to face, by a dedicated family liaison officer along with the chaplain,
Governor or most senior individual available. The use of police officers to break the
sad news is not encouraged as they may not be trained in breaking the news of a
death and may have no knowledge of how prisons work. This can leave the family
with lots of unanswered questions and with an impression that the Prison Service is
not taking the death seriously. The new policy did not come into force until 4
January 2006, and so was not in operation at the time of the prisoner’s death. I hope
that management at Ranby will consider the new policy and develop local guidance
in line with the approach it recommends.
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Recommendations
I support the recommendations of the clinical reviewers from the Bassetlaw Primary
Care Trust (PCT), which can be summarised as:
1. To improve the standards of medical records and record keeping.
2. To amend and improve the dispensing forms and computerise the prescribing
system.
3. Although it did not appear to have an impact on the prisoner’s case, the use of
the procedure known as ‘sleep watch’ appeared to be an inappropriate way of
gauging whether sleeping pills should be prescribed.
4. There should be procedures to minimise the sharing of prescription
medications.
In company with the clinical reviewers, I support the detailed recommendations of
the area drugs co-ordinator, which were in summary:
1. For the Governor, Director of Bassetlaw PCT, Healthcare Manager and
representative from Prison Health Development team to address the issue of
prescribing codeine-based medications.
2. For the healthcare manager to secure the co-operation of the doctors and
provide ongoing support to them in implementing changes in prescribing.
3. For healthcare to provide a regular report at monthly Drug Strategy meetings
on numbers of prisoners being prescribed opiate-based medications.
4. To reduce trade in prescribed medications.
5. To consider the option of stopping all in-possession opiate-based medication.
6. To require prisoners to sign a medication compact and carry out audits to
ensure compliance, i.e. they have the correct amount of medication in
possession.
I recommend that the PCT in partnership with the Governor and head of healthcare
should consider the early implementation of these recommendations.
I recommend that the local contingency plan for handling a death in custody be
reviewed to ensure that the requirement for incident reports be made more
prominent, thereby raising the likelihood of timely compliance.
I further recommend that the post incident de-brief procedure in the local
contingency plan be placed within the section labelled Support for Staff and
Prisoners on the front page of the document. This should ensure that incident
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commanders are aware that this is an important part of the support system designed
to care for those involved in a death in custody.
Finally, I recommend that the prison reviews its arrangements for breaking the news
of a death in custody to bereaved relatives, to ensure that this is normally done face
to face by prison staff.
Good Practice
The use of the term Code Red to summon help to serious medical emergencies is
good practice, as everyone carrying a radio and those within hearing distance of a
radio will know what help is needed.
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