Individual at Rye Hill

Investigation in the circumstances surrounding the death of
a man at St Cross Hospital, Rugby, on 11 September 2004
while a serving prisoner at HMP Rye Hill
Prisons and Probation Ombudsman for England and Wales
June 2005
This is a report into the death of a prisoner at HMP Rye Hill. On 11 September 2004,
the man was found in his cell, struggling to breathe. He was rushed to St Cross
Hospital for emergency treatment, but died later that night. The subsequent post-
mortem examination established that the cause of death was an overdose of heroin.
There was evidence that the drug had been taken intravenously.
I offer my sincere condolences to the man’s family and friends for their loss.
I should also like to thank the Director, staff and prisoners of HMP Rye Hill, the Coroner
and the local police for the co-operation throughout the investigation.
This report covers the man’s time in prison prior to his death, the events on the day that
he died and the actions of all the people involved in the incident. I understand the
police investigation found that illegal drugs were readily available in the prison but
concluded that there were no other unusual or suspicious circumstances surrounding
the death.
A significant part of the investigation was devoted to a clinical review of the man’s
treatment and care.
The investigation was conducted on my behalf by one of my call-off contractors.
However, I personally visited Rye Hill at the start of the investigation, spoke with the
then Director and chair of the Independent Monitoring Board, and formed my own
impressions, some of which are reflected in this report. In particular, I was struck by the
inexperience of many staff, the level of staff turnover, and the consequences for good
order and safety.
The man at the centre of this report died as a result of taking heroin. He was not the
first, and will not be the last, prisoner to lose his life because of drug-taking. Nor is Rye
Hill unique as a prison with a drugs problem. However, the current Director will need to
look closely at the way drugs are entering the establishment and more generally at the
experience, confidence and competence of his staff.
Although one cannot be certain, there are indications in this report that staff may have
been ‘conditioned’ by prisoners with the consequence that the cause of the man’s
drowsiness and failure to respond was not identified earlier.
This report was first submitted in July 2005. This published version is identical save for
the anonymisation of the main parties and some very minor changes to improve the
clarity of the text.
Stephen Shaw CBE
Prisons and Probation Ombudsman
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Contents
Summary 4
Conduct of the Investigation 5
The man who died 7
Details and history of HMP Rye Hill 8
Chronology of events 9
Findings and conclusions 12
Recommendations 14
3
Summary
The man who died was 35 years old. He was serving an 11-year sentence for armed
robbery. He arrived at Rye Hill prison on 22 June 2004. He had a history of asthma but
this was not troubling him significantly and he was considered to be healthy, well-
behaved and friendly and gave no cause for concern. Although he had a former history
of drug-taking there was no indication that he had been using drugs whilst in prison.
On Saturday 11 September 2004, the man did not attend as required for work in the
kitchen. Officers went to his cell several times during the day to speak to him but he did
not wake up properly. However, he did make noises which suggested that he was
aware that he had been spoken to and staff assumed he was simply having a weekend
lie-in, as is normal for many prisoners. He did not attend for breakfast or lunch.
At about 2.00pm, two prisoners went to his cell and found him struggling to breathe.
They raised the alarm and wing staff responded. Resuscitation attempts were made by
the officers and then by Healthcare nurses who managed to maintain life signs. A
paramedic team continued the treatment and the man was eventually taken to an
outside hospital. Throughout the evening, the man had several cardiac arrests and the
doctors at the hospital eventually concluded that his condition was irretrievable.
Emergency support equipment was switched off and the man died at 9.05pm.
The subsequent post-mortem revealed that the man had died of an overdose of heroin.
Other prisoners in the wing informed staff that he had been taking illegal drugs and,
possibly, alcohol on the night before he died. There were no signs of drug-taking
equipment in the cell, but it is believed that any such evidence might have been
removed by other prisoners prior to the alarm being raised.
The investigation concludes that there was no serious neglect or misbehaviour by any
member of staff. There are, however, several recommendations regarding the need to
be more alert to unusual situations and improvements to record-keeping and follow-up
action to clinical matters. One example of good practice was also noted in the clinical
review.
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Conduct of the investigation
Following the man’s death, the prison authorities contacted the local police, the Coroner
and the Prisons and Probation Ombudsman’s Office. The woman named as the man’s
next-of-kin was also contacted, but it later became clear that his long-time partner and
mother of his children was more properly his next-of-kin. She subsequently visited the
prison to collect all his property, and there was regular contact between her and the
Ombudsman’s Office during the investigation.
The investigation was carried out by a Senior Investigating Officer from amongst my
call-off contractors. The man’s family were informed and invited to meet with the
investigating team if they wished. Notices were also posted inviting any prisoners or
members of staff who might have information to contact the investigative team. The
Coroner and the local police were informed.
Initially, a full review of all the documentary evidence was undertaken to ascertain
whether there were any procedural failures or errors on the part of any member of staff.
Since the police were also conducting an investigation, no interviews or further inquiries
were made by the investigator in order to ensure that the police investigation was not
compromised.
The post-mortem examination subsequently established that the man had died of a
heroin overdose and, since such drugs must have been illegally obtained, the police
were obliged to carry out a detailed and protracted inquiry to ascertain whether there
were any suspicious circumstances to the death, or any evidence that might lead to
prosecution for any criminal activity. Additionally, two SIM cards for mobile phones
were found in the man’s cell, indicating that some smuggling of unauthorised items had
taken place. This meant that the investigation by the Ombudsman’s Office was delayed
by several months.
In January 2005, the police completed their investigation. They were satisfied that there
were no suspicious circumstances to the death and insufficient evidence to justify formal
action of any kind. Copies of all the interview transcripts were passed to the
investigator, as agreed by the Coroner.
Further visits were then made to the prison to speak to the people involved and obtain
additional information regarding the circumstances of the man’s death and the actions
of prison staff.
Because illegal drugs had been used, the investigation also reviewed the prison’s Drugs
Strategy. This is a comprehensive and well-established plan for deterring drug use and
supporting and helping those prisoners seeking assistance in avoiding future abuse.
The investigation established that the authorities make considerable efforts to identify
and prevent the entry of drugs into the prison. How far this is successful remains a
matter of controversy.
5
A clinical review of procedures and treatment was undertaken by an experienced
clinician appointed by the Ombudsman. There were no serious shortcomings or
criticisms of the Healthcare staff or their practices and procedures. It was recognised,
however, that the man might have had a better chance of survival if emergency
treatment had been administered earlier.
6
The man who died
The man who died was aged 35. He had been born on 10 May 1969. He was initially
remanded into Norwich Prison on 26 February 2004, before being sentenced to 11
years imprisonment by Norwich Crown Court on 7 June 2004 for offences of armed
robbery. He was transferred to HMP Rye Hill on 22 June 2004.
The man had a long history of offending dating back to 1985, mainly for theft, burglary,
taking vehicles and many associated Road Traffic Act offences. Several of his later
offences were drink-related and there was one minor offence of violence and one drugs
offence for which he was cautioned.
On reception into Rye Hill, the man was seen by members of staff during the Induction
process and the usual assessments were made. There were no concerns expressed by
the man himself or by Healthcare and Induction staff with regard to his health, general
well-being or his mental state. He was placed on location with other category B
prisoners.
During his time at Rye Hill, there were no recorded problems with the man. He
appeared to get on well with other prisoners, and members of staff commented
favourably on his good humour, his work effort and his relationships with others. Similar
comments had been made at HMP Norwich.
An entry in the man’s history sheets at Norwich is representative:
“Still part of a team. However, not sure if it is on the servery, or with the circus.”
It is clear that the man was well liked by staff and prisoners alike.
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Details and history of HMP Rye Hill
HMP Rye Hill is a purpose-built category B adult training prison, opened in 2001 and run
by a private company, Global Solutions Ltd, on a contract with the Home Office. The
certified normal accommodation (CNA) is 600 but this can be increased to a maximum
operating capacity (Op. Cap.) of 664, if needed. All the prisoners are male, serving over
4 years and there is capacity to hold up to 120 life sentence prisoners.
In the first four years after the prison opened, there were a total of 14 deaths in custody.
There were no deaths in 2001, four in 2002, three in 2003 and three others in 2004 prior
to this one. The earlier investigations found no serious neglect or shortcomings and
made only minor recommendations regarding procedures.
The last Standards Audit report was satisfied with the procedures and plans for dealing
with prisoners at risk and for handling deaths in custody. A few minor improvements to
the F2052SH system were suggested and these were agreed by the prison authorities
and carried out.
A full announced inspection of HM Prison Rye Hill was carried out by HM Chief
Inspector of Prisons in June 2003. The report concluded that the prison’s “open and
relaxed approach” could carry risks: “Most officers were fairly new and young, often with
far less experience of prison than the long-term prisoners in their care; and there were
relatively few of them. We were not clear, on all wings, that the appropriate boundaries
had been drawn and were being maintained.”
Anxieties about Rye Hill have continued. During my own visit to Rye Hill at the
beginning of this investigation, I was conscious that many staff and prisoners spoke
openly about the availability of drugs. However, this contrasted with the formal
Mandatory Drug Testing statistics which were at a low level.
The turnover of staff, and their relative lack of experience, was also striking and my
contemporaneous notes cite staff concern about the availability of hooch, the potential
for a major incident, and a shortage of staff affecting appointments with Healthcare. On
the other hand, Rye Hill’s activity hours were good (albeit below target) and the Units
and grounds were clean and tidy.
The IMB Report on Rye Hill refers to the “continuing level of staff turnover”:
“The lack of experience and confidence amongst officers results in issues that
should be dealt with at Unit level being referred to an unnecessarily higher level
of management.”
In pursuit of my complaints remit, this has been my experience personally and of the
Ombudsman’s Office as a whole.
8
Chronology of Events
Following his conviction and sentence, the man arrived at HMP Rye Hill on 22 June
2004. Throughout his time at Rye Hill,he was cheerful and well-behaved and got on
well with staff and other prisoners, never giving cause for concern or alarm. He
admitted to a drug problem in the past but stated that he had been ‘clean’ for several
years prior to coming to prison. During his stay at Rye Hill he was given three drug
tests, all of which proved negative. He was eventually given a job working in the
kitchen.
At about 8.30am on Saturday 11 September, a prison custody officer (PCO) went into
the man’s cell to remind him that he was due to work that morning. The man was in
bed, apparently asleep, but gave a groan, as if in acknowledgement, when the officer
spoke to him. He made no attempt to get up and the PCO left. He told a fellow PCO
that he did not think the man intended to go to work.
At about 9.20am, the kitchen phoned the wing and asked why the man had not attended
and said that he should be told that he might lose his job if he did not attend, as
required. The second PCO went to the man’s cell and found him still in bed. She spoke
to him but received no response. The man was lying on his side, facing the wall. The
PCO went into the cell and touched him on the shoulder, but did not shake him. She
gave the man the message from the kitchen. He gave a groan in response, but did not
wake up. The PCO was satisfied that the man was simply sleeping. She returned to
the office and informed the kitchen.
During the course of the morning, several prisoners made comments to the PCO about
the man, saying that he was fine, just ‘out of it’. The PCO, who was new to the wing,
did not have any concern at this time accepting that, like a number of prisoners at
weekend, he was just sleeping late. It is normal practice at Rye Hill, to allow prisoners
to spend their weekend leisure time as they choose and many prisoners enjoy a late lie-
in, often missing breakfast in order to do so. Staff are encouraged to allow this,
provided there are no security or control implications for doing so.
The man was still sleeping at 11.30am when a roll-check was made. At 1.30pm, the
first PCO commented that the man, along with several other prisoners, had not
collected their lunchtime meal. The second PCO checked again and found the man still
in bed, in a different position, but breathing deeply and normally as if asleep. She
asked him about his meal and he again made a moaning noise in response.
At about 2.20pm, two prisoners went into the man’s cell to borrow a newspaper. They
noted that the man was having difficulty breathing and shouted to the officer to get help.
The second PCO was talking to another prisoner at the time and both of them ran
upstairs to the cell along with a third PCO. The first PCO went to the office and
telephoned the Healthcare department to warn them that there might be an emergency.
9
When the second PCO got to the cell, she found the man lying on his back struggling to
breathe. His eyes were wide open and he was taking short, rapid breaths. His
forehead felt cold and the PCO could not detect a pulse in his wrist. She ran out of the
cell and called down to a fourth PCO that this was a ‘code 2’ emergency. (This
identifies the second level of emergency and includes someone with serious breathing
difficulties.) Assisted by the prisoner to whom she had been talking, the PCO tried to
turn the man onto his side to make his breathing easier, but he was too heavy and they
could not move him. She spoke to him but he did not respond. The prisoner started to
try to give the man mouth-to-mouth resuscitation. The man seemed to be breathing
more deeply, therefore the third PCO told the prisoner to stop. She then felt his wrist
and was able to detect a pulse.
A few seconds later, three nurses arrived with emergency equipment and took over. An
emergency ambulance was called. The nurses gave the man oxygen but his breathing
stopped and there was no pulse. The nurses commenced Cardio Pulmonary
Resuscitation (CPR) and inserted an airway to assist his breathing. Staff continued to
work on him until the emergency ambulance crew arrived about 20 minutes later and
took over his treatment, assisted by the Healthcare nurses. At 3.30pm, the man’s
condition was stabilised and he was taken to St Cross Hospital in Rugby. Resuscitation
measures were continued throughout the evening, but the man died at 9.05pm.
Comments made by prisoners suggested that the man had been taking illegal drugs or
alcohol on the evening before his death. No drugs paraphernalia was found in the cell
by the police, although two SIM cards for mobile phones were retrieved. The post-
mortem examination established that the man died of a heroin overdose, suggesting
that the speculation about his activities the night before may have been true. Several
prisoners went into the cell during the morning and it is possible that any evidence of
drug use was removed, either in a misguided attempt to protect the man or to be
secreted for further use by others.
Following the conclusion of the police investigation, a review of the man’s medical care
was carried out by an experienced clinician. The review noted that the man was in
generally good health on first admission to prison on 26 February 2004 although he was
having a little difficulty sleeping, probably from the stress of being in prison. He was
prescribed medication for this.
He was subsequently transferred to Rye Hill on 22 June 2004 and was once again
considered quite fit for all activities. It was not until 21 July 2004 that the man
mentioned a history of asthma. Although he seemed well at the time, he was
prescribed an inhaler and arrangements were made for him to attend an asthma clinic.
On 2 August, he was seen again by the Medical Officer and it was suggested that
information should be sought from the man’s GP regarding his asthma. However, there
is no indication that the man attended an asthma clinic or that a letter was sent to his
GP.
10
The review also notes the drug (naloxone) administered to the man by the paramedic
team when they arrived and says that, “earlier administration of this drug … may have
improved his chances of survival.”
There are two recommendations and one example of good practice made in the clinical
review.
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Findings and conclusions
The man was serving a lengthy prison sentence for robbery offences. Although he had
a history of drug-taking, there was no indication that he had been involved in using illicit
drugs prior to his death. His behaviour in prison was very good, he responded
positively to the regime at HMP Rye Hill and seemed to get on well with all staff and
prisoners.
The man was a kitchen worker and was supposed to be on weekend duty in the kitchen
on the day that he died. One of the wing officers went to his cell to remind him he
should be at work. He was still lying in bed, apparently asleep, but gave a moan in
response when the officer spoke to him. A second officer went to his cell about an hour
later and received a similar response.
Throughout the morning several more people, staff and prisoners, went to his cell. He
did not wake up but gave some indication that he was aware that he was being spoken
to. No-one felt any serious concern, believing that the man was simply having a long
lie-in as many Rye Hill prisoners do at weekend.
At about 2.30pm, two more prisoners went into his cell and recognised that he was in
serious distress and was struggling to breathe. They raised the alarm and two wing
officers responded. They were unable to wake the man or turn him over. An
emergency call was made to the prison Healthcare department and nurses responded
immediately.
A prisoner who had also entered the cell tried to give mouth-to-mouth resuscitation.
The man appeared to breathe more easily and an officer told the prisoner to stop and
allow him to breathe unaided. The nurses then took over and continued to treat him
until an ambulance team from St Cross Hospital arrived.
After about 40 minutes, the man was stable enough to move to the outside hospital,
accompanied by two Prisoner Custody Officers. The medical staff at the hospital
continued to give emergency treatment for several hours during which time the man had
several cardiac arrests. Eventually it became clear that he could not survive and the life
support systems were switched off. The man died at about 9.00pm.
Subsequently, several prisoners volunteered the information that the man might have
taken drugs or alcohol the night before. No mention was made of this to staff until after
the man’s serious condition became known. It is possible that prisoners knew this and
believed that the man was sleeping off a drug-induced condition. There would have
been a reluctance to inform the officers of this until it became clear that his life was in
danger. The absence of any drug-taking equipment in the cell may also be the result of
prisoners removing such incriminating evidence before staff became aware of the man’s
situation.
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It seems clear from the clinical review that the man would have had a better chance of
survival if his condition had been discovered earlier and appropriate treatment given.
The reluctance of staff to rouse him properly and ascertain his state of health
contributed to this delay. Given the ethos of the establishment, the actions of the staff
involved are understandable but, in this case, they had tragic consequences. It is
possible that staff were unduly influenced by the comments of other prisoners that the
man was ‘fine’.
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Recommendations
1. All staff should be reminded of the need to be alert to any unusual circumstances
with regard to prisoners and to recognise their duty of care. In particular, they
should not be distracted or influenced by comments made by other prisoners.
2. All staff should be reminded that prisoners should not be allowed to give
emergency assistance to other prisoners. It is the responsibility of properly-
trained staff to take appropriate action, as laid down in the establishment’s
emergency procedures.
3. The Director of Rye Hill should review security and searching practices to
maximise searching and reduce the availability of drugs, alcohol and mobile
phone SIM cards.
Clinical Review Recommendations
1. The Healthcare Manager should ensure audits of records and record-keeping are
carried out on a regular basis to ensure appropriate standards of record-keeping
are achieved and maintained.
2. Healthcare staff should be trained in the administration of naloxone in emergency
situations and a locally agreed policy developed to ensure safe and appropriate
administration.
Good Practice
The use of the locally developed Risk Assessment tool is considered an example of
good practice to provide appropriate and timely information for the development of
effective pathways of care.
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