Individual at Rye Hill

A death in custody at
HMP Rye Hill in September 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2005
This is the report of an investigation into the circumstances of the death in
September 2004 of a life sentence prisoner at HMP Rye Hill. The man
died as a result of a blockage in a coronary artery.
I would like to extend our condolences to the man’s family for their
loss. I would like to thank the Director in charge of HMP Rye Hill,
and his staff for their help.
Stephen Shaw CBE April 2005
Prisons and Probation Ombudsman
2
INDEX
Summary
Investigation process
HMP Rye Hill
The Events Leading up to the Man’s Death
Interviews with Prisoners and Staff
After the Man’s Death
Level of Compliance with Prison Service Requirement
Findings
Conclusion
Recommendations
3
Summary
The man had suffered from anxiety and depression for many years
for which he received a great deal of attention in the early years of
his imprisonment. Although he smoked, his clinical records give no
indication that he had any problems with his physical health.
In the early hours of the morning on 2 September 2004, the man
rang his cell call bell and asked the night officer for some
paracetamol as he had stomach pain. He did not ask to see a nurse.
Later that morning, he was found to be dead.
The man’s cause of death, as determined at post mortem, was acute
thrombotic and atheromatous coronary artery occlusion (blockage in
a coronary artery). His death could not have been anticipated and
was not connected to the fact that he was in prison or to the level of
care that he received there.
This report makes two recommendations in relation to Healthcare
services. These are in relation to the issuing of medication by non­
clinicians and to the provision of age related medical check­ups for
long term prisoners.
4
Investigation process
My practice in cases of deaths from apparently natural causes is to
conduct an initial review to determine the extent of investigation
required.
My investigator visited Rye Hill on 6 September 2004 when he spoke
informally with the Duty Director and other staff. He also spoke to
four prisoners. The investigator was given copies of all relevant
records including medical records. The investigator subsequently
spoke by telephone to one of the prison’s night officers.
The investigator met a representative of the Independent Monitoring
Board (IMB), who said that the IMB had been informed promptly
and appropriately about the man’s death and she had no concerns
to bring to the PPO’s attention.
We contacted the man’s mother by telephone and letter. She
replied by letter and explained that she had kept in touch with her
son by visiting him at prison each fortnight. She had visited her son
on 1 September, the day before his death. He had been extremely
tired that day, although he had not complained about being in any
pain. The man’s mother added that she understood that at some
point after her visit her son had reported to staff that he was feeling
unwell. She asked the PPO to investigate whether there had been
any failure or delay in treating her son.
Another of my staff, a trained nurse, carried out a clinical review of
the man’s care and treatment. No formal interviews with staff were
conducted. This report is based upon a thorough review of all
relevant paperwork and upon the clinical review.
5
HMP Rye Hill
HMP Rye Hill was opened in early 2001 as a purpose built category B
training prison. It has a 660­bed capacity, predominantly made up
of single cells. Rye Hill is a privately managed prison which is run
by Global Solutions Ltd (GSL).
GSL’s stated aims include the creation of a constructive prison
regime through the provision of education, work and other
programmes to best prepare people for re­integration into
mainstream society.
The prison regime is based on a minimum of 35 hours per week
purposeful activity including work, training and education (including
physical education) and offending behaviour programmes, all of
which are linked to a system of earned incentives and privileges.
Healthcare services at Rye Hill are provided by Primecare Forensic
Medical, which is a private healthcare provider. The Healthcare Centre is
staffed 24 hours per day by qualified nurses and healthcare assistants
who are supported by visiting specialists, including doctors, dentists and
psychiatrists. The Healthcare unit has eight in­patient beds.
6
The Events Leading up to the Man’s Death
The man’s medical records from the time of his imprisonment show
that during health screening on various occasions he reported
experiencing feelings of anxiety dating back many years and taking
medication for the condition, also for many years. The man was a
regular user of Healthcare services. The majority of these
consultations related to his anxiety state. Other consultations were
to report minor complaints such as headaches, colds and muscle
injuries. The man’s last consultation with a Healthcare doctor before
his death was in June 2004 when his complaint was about a minor
eye injury, possibly caused by a foreign body in the eye.
The man’s mother visited him on 1 September 2004 and, in a letter
to the PPO, she wrote to say that her son was feeling extremely
tired that day, although he had not been in any pain. The man did
not mention any concerns to Healthcare staff.
At around 3.30am on the morning of 2 September, the man pressed
his cell call button. When the night duty officer responded to the
call, the man said that he had stomach pain and wanted some
paracetamol. He did not report being in severe pain, nor did he ask
to see a nurse. The night duty officer gave the man two
paracetamol tablets and she watched him take the tablets with a
cup of water.
Following standard practice at Rye Hill, cell doors were unlocked at
7.20am on the morning of 2 September. Again in keeping with the
prison’s standard practice, prisoners were not roused at that point in
time; instead prison officers merely satisfied themselves that each
cell was occupied. A little after 8.30am, another prisoner, a friend
of the man’s, visited his cell and found him lying in bed and
seemingly dead. The prisoner alerted staff at about 8.40am and
they went immediately to the man’s cell when, on checking for
presence of a pulse, found none. Healthcare staff then arrived at
the scene and confirmed that there were no detectable signs of life.
At about 9.05am, first paramedics and then a doctor arrived. At
9.14am, the man was formally pronounced dead.
7
Interviews with Prisoners and Staff
When my investigator visited Rye Hill, he was told that a prisoner
had reported that the man pressed his cell call button at 6.30am,
but when the night officer went to his cell she told him to wait for
the day staff to come on duty later that morning. My investigator
spoke separately to four prisoners about this report.
The prisoner who made the report that the man had called for
assistance at 6.30am was located in a different prison wing to the
man’s. This prisoner made his report after hearing a rumour that
the man had been told to wait for the day staff to come on duty.
Two of the prisoners, one of whom was in one of the cells adjoining
the man’s, had heard the rumour, but they had not personally
witnessed the incident and they knew nothing about the rumour’s
origin.
The fourth prisoner was in the other cell adjoining the man’s cell.
This prisoner said that he had woken at some point on 2 September
and had overheard a conversation between the man and the night
officer. The night officer asked the man whether he had a
headache, to which the man replied that he did not have a
headache, he had a stomach­ache. The prisoner heard no further
conversation as he fell back to sleep. The prisoner thought that this
conversation might have occurred at around 6.30am, but he could
not say why he thought that.
The Duty Director told the investigator that night officers are
required to respond immediately when call bells are sounded. If the
prisoner wants pain relief for a straightforward ailment, such as a
stomach­ache or headache, the night officer is able to give out
soluble paracetamol. When the ailment requires clinical assessment,
a Healthcare nurse should be summoned. Healthcare is staffed 24
hours a day. No record is kept of call bells being sounded.
The night officer who gave the man paracetamol at 3.30am said that
that was the only call for assistance that he made that night. If he had
sounded his call bell again, for instance at 6.30am, she would have
responded to that call too.
8
After the Man’s Death
On the morning of the man’s death, the prison’s head of residence,
accompanied by one of the prison chaplains, visited the man’s
mother to inform her of her son’s death. The prison staff spent
approximately 30 minutes with the man’s mother and passed to her
as much information as was known at that stage. When they left,
the man’s mother was left in the company of the warden at the
residential care unit where she lived.
Rye Hill notified the Prison Service’s National Operations Unit of the
man’s death and statements were taken from staff involved.
On arrival at the prison by my investigator, all the necessary
information had been gathered together for the purposes of the
investigation. Arrangements were made for the investigator to
speak to relevant members of staff.
9
Level of Compliance with Prison Service Requirements
Standards of clinical care in prison are intended to mirror those
available in the outside community. The clinical aspects of the
man’s care are described in the independent clinical review which
indicates that that the man’s health was not compromised as a
direct consequence of his being in prison.
The post­incident response by Rye Hill was fully compliant with
Prison Service instructions and policies on managing a death in
custody.
10
Findings
The man had been in prison since October 1996. He was a
reasonably frequent user of Healthcare services during his eight
years in custody, the last three years of which he spent at Rye Hill.
Typically, his consultations were for treatment of anxiety, and
otherwise for comparatively minor physical ailments.
At about 3.30am on 2 September 2004, the man rang his call bell
and asked the night officer for paracetamol as he had stomach pain.
The night officer gave him two paracetamol tablets, which she
watched him consume with water. The night officer’s action, in
issuing the man paracetamol, was in accordance with standard
practice at the prison. At around 8.30am the following morning the
man was found dead.
Later that day, a rumour circulated around the prison that the man
had called for assistance on a second occasion that morning, this
time at 6.30am, when he was told to wait for the day staff to come
on duty. Rye Hill keeps no records of call bells being sounded,
however prisoners were interviewed and it was found that there was
no substance to the rumour. What seems to have happened was
that a prisoner in an adjoining cell woke to hear part of the
conversation that occurred at 3.30am. The prisoner did not remain
awake to hear the conclusion of the conversation and he later
wrongly estimated that it had occurred at 6.30am.
While not finding fault with the night officer in giving the man
paracetamol in the early hours of 2 September – the night officer
was, after all, following standard procedures – the clinical review,
has pointed out the potential problem of such a practice. The
problem is that a prisoner might self diagnose and request
analgesia, when the early intervention of a Healthcare nurse might
result in the identification of symptoms indicating a more serious
illness.
There were no early warnings that the man was about to suffer a
heart attack. However, the clinical review has also pointed out that,
as the man had a history of alcohol misuse and benzodiazepine
dependence, he might have benefited from pro­active health
monitoring. The prison will also wish to note the toxicologist’s
findings that the man had used both heroin and cannabis in the
period shortly before his death.
11
Conclusions
The care that the man received at Rye Hill was probably at least as
good as it would have been in the outside community. There were
no early warnings that he was about to suffer a heart attack.
12
Recommendations
Local
HMP Rye Hill should consider reviewing the circumstances under
which non­clinical staff are able to issue paracetamol to prisoners.
National
Consideration should be given to devising a policy for regular
medical checks for long sentenced prisoners with reference to the
checks being age appropriate.
13