Individual at Rye Hill

Investigation into the circumstances surrounding the death of
a prisoner at HMP Rye Hill on 9 May 2004
Prisons and Probation Ombudsman for England and Wales
May 2005
This is the report of an investigation into the circumstances surrounding the
death of a prisoner at HMP Rye Hill on 9 May 2004. At the time of his death, he
was serving a sentence of seven and a half years. A post­mortem was
performed and concluded that his death was due to a chronic coronary disease.
Since 1 April 2004, the Prison and Probation Ombudsman's office has been
responsible for investigating all deaths of prisoners in custody, including those
due to natural causes. I must apologise for the long delay in completing this
report.
I offer my condolences to the family of the man who died. I would like to thank
the Director of Rye Hill and his staff for their co­operation with the investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman
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CONTENTS
Summary
Investigative Process
The deceased
HMP Rye Hill
The deceased’s health whilst at HMP Rye Hill
Events leading to the death of the subject of the report
Post Mortem and Inquest
Clinical review
Responses from prisoners at Rye Hill
Conclusion and Recommendation
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Summary
The subject of this report was 48 years old when he died on 9 May 2004. At the
time of his death, he was serving a seven and a half year sentence at HMP Rye
Hill. Rye Hill is a privately managed medium security prison in Warwickshire,
and was opened in 2001.
Before his death, the man appeared to be in reasonable health, although it had
been noted that he was overweight, breathless and showed signs of early heart
disease. He complained of chest pains the day before he died, was given
medication for suspected angina and a referral was made for a cardiology
appointment at his local hospital. Unfortunately, he was found dead in his cell
before the appointment could be arranged.
The report makes one recommendation in relation to healthcare services at HMP
Rye Hill and two in relation to the complaints process.
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Investigative Process
My investigators visited Rye Hill on 13 May 2004. They spoke to the Senior
Controller. The Senior Controller is a Home Office official whose role is to
monitor the performance of Global Solutions, who run Rye Hill, and to impose
penalties if the contract is breached. They also spoke to, the Deputy Controller,
Head of Health Care, Head of Tactical Service, and to two prisoners.
A Notice of Investigation, Notice to Staff and Notice to Prisoners were issued
explaining the purpose of the investigation and inviting contributions. Six
prisoners contacted us to express their views about health care at Rye Hill. No
responses were received from staff.
A clinical review of the man who died’s health care whilst in prison was carried
out by Daventry and South Northants Primary Care Trust and forms part of this
report as an annex.
No formal interviews with staff were conducted. This report is based on a review
of the relevant documentation, including the man’s clinical records.
One of the man’s daughters and his mother were contacted as part of the
investigation. They chose not to respond to an offer to be involved in the
investigation process.
The inquest into the man’s death took place on 13 October 2004. A finding of
death by natural causes was recorded.
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The deceased
He was 48 years old when he died on 9 May 2004. He had five children and was
divorced. He was imprisoned on 3 March 2000 for sexual offences, but had
already been in prison since September 1999 having been remanded in custody
on other charges. He was serving a sentence of seven and a half years. He
went first to HMP Nottingham then, on conviction, to HMP Blakenhurst. He was
moved to HMP Birmingham in September 2000 and to Rye Hill on 28 February
2002. He remained at Rye Hill until his death. According to his friends at Rye
Hill he was an affable, likeable, placid person.
HMP Rye Hill
Rye Hill is a privately managed medium security prison in Warwickshire. It was
opened in 2001.
The health of the man who died
On reception to Nottingham, he was assessed as having a history of depression,
anxiety and panic attacks but no history of significant past physical health
problems. He did not have a history of illegal drug use but his Inmate Medical
Record (IMR) does record heavy alcohol intake before he was imprisoned and he
had taken an overdose just before entering custody. His IMR states he admitted
to feeling suicidal and that he had suffered breakdowns in 1967 and 1995. His
father had had a triple heart by­pass in 1995 and died in 2002, shortly after the
subject of the report arrived at Rye Hill on 28 February 2002.
The man suffered from obesity, high cholesterol, hypertension and depression.
He continued be treated for depression whilst in custody. He first reported a
problem of chest tightness in September 1999 which was treated as indigestion.
On 8 March 2002, health care staff were called to his unit after he experienced
pain in his chest. He was not observed to be short of breath or clammy and said
he had had a similar pain before which resolved itself. He was advised to
contact the Health Care Centre again if his condition did not improve. During the
rest of 2002 and 2003, he suffered intermittently from chest pains and
breathlessness. His chest pain was attributed to panic, and breathing problems
attributed to stress. In October 2003, he reported chest pain attributed to a panic
attack. In December 2003, he again reported chest pain. He was prescribed a
number of medications including Ibuprofen, Gaviscon, Transxasin, Atenolol,
Statins and Beta Blockers.
On 20 March 2004, he underwent a mental health assessment. It was noted that
he was experiencing weight problems, high blood pressure and high cholesterol.
A follow up psychiatric review on 22 April referred to the man as suffering from
panic attacks but said that these were under control.
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Events leading up to the man’s death
On 8 May 2004 at about 11:15 in the morning, Health Care staff were asked to
see the man on Andrews wing. An entry in his IMR afterwards stated that hes
had complained of a "constant and dull" pain in his chest but, although he said he
could not take a breath in, he did not appear to be struggling with his breathing.
The man said that he had experienced similar episodes over the previous weeks
but he had not mentioned them to staff as they had resolved themselves. He
was taken from Andrews wing to the Health Care Centre in a wheelchair for
observation. He was seen by a doctor who diagnosed angina and prescribed the
man with GTN spray to have in his possession and use when he felt the
symptoms returning. The doctor drafted a letter to be sent to the local hospital,
requesting an appointment with a cardiologist as he felt that the man’s health
warranted further investigation.
The man returned to Andrews wing and spoke to a fellow prisoner on the wing
about how he was feeling. According to that prisoner, the man said that he was
feeling some "niggling" pains down his left arm and was holding his chest shortly
before they were locked in their respective cells at 8:30pm. They continued to
talk in their adjacent cells through the ventilation pipes. The prisoner on his wing
was concerned that the man should seek help if he continued to feel ill, but the
man did not want to draw attention to himself and thought it was too much bother
to ring his cell bell. He did agree that he would ask to see the doctor again if he
still felt unwell.
The cell of the man who is the subject of this report was unlocked by a residential
unit officer at 8:30am. My investigators were told by Rye Hill that it is not the
practice for staff to enter prisoners' cells after the door is unlocked, particularly on
weekends, so that prisoners may sleep until lunchtime if they wish. A prisoner on
the same unit, said that the man was usually up and out of his cell shortly after
being unlocked. When the man did not appear, the prisoner went into his cell at
8:40am and found the man dead in bed. He said that from the man’s
appearance, he seemed to have been dead for several hours. The prisoner who
had been concerned about the man told the unit staff who then alerted the Health
Care Centre at 08:45 am. A doctor arrived at 10:05 and pronounced the man
dead at 10:10am.
Post Mortem and Inquest
A post­mortem was performed on 11 May 2004. It described evidence of heart
disease including very severe atherosclerosis of the coronary arteries and gave
the cause of death as acute chronic myocardial ischaemia, haemorrhage into
atheromatous plaque left main coronary artery, coronary artery atheroma and old
myocardial infarction of left ventricle. The inquest into the man’s death took place
on 13 October 2004. The jury returned a finding of death by natural causes.
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Clinical Review
A clinical review into the health care the man received was carried out by a
Clinical Governor from Daventry and South Northants NHS Primary Care Trust.
He noted that the man had been experiencing possible symptoms of heart
disease periodically since September 1999 but concluded:
" …this 48 year old died following a number of indications that he could have
been developing Coronary Heart Disease. There were attempts to treat his risk
factors, but these were not followed up in systematic fashion. In the 6 months
leading up to his death, in retrospect, there were further indications that he may
have had episodes of angina.
"The above comments have to be made in the context of a man who had anxiety
problems and panic attacks, which can closely mimic the symptoms of angina.
"My recommendations would be, that risk factor data should be collected,
recorded in the medical record and followed up in a more systematic way, that a
formal tool for risk assessment should have been used at some stage and that a
database with chronic diseases should be kept."
The clinical reviewer’s comments were put to PrimeCare Forensic Medical, the
health care provider at Rye Hill. Their Health Care Manager responded that the
man was followed up systematically but accepted that the system needed to be
developed and improved. The man had been on their Chronic Disease Register
and had been reviewed at the Coronary Heart Disease clinic a month before his
death.
Responses from prisoners at Rye Hill
After the man’s death, a number of prisoners telephoned my office or wrote to my
investigators as a result of the notices about the investigation into his death being
displayed. One prisoner wrote that the man told him before his death that Health
Care would not listen to him when he complained about his health problems, but
"he did not want to cause any hassle" so would not put in a complaint. The
prisoner said that he himself felt that Vulnerable Prisoners were treated poorly by
Health Care and that he had no confidence in the nurses at Rye Hill. Two
distressed­sounding prisoners telephoned to say they were concerned at the
quality of care they had received after harming themselves. Worryingly, there
was a consistent theme from almost all the respondents that they were
concerned about the consequences of complaining. They said they had
experienced pressure from staff not to make complaints, or perceived that they
had been treated adversely for doing so. Several prisoners expressed concerns
about a named Senior Medical Officer, whom I understand has since left Rye Hill.
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Conclusion and Recommendation
Standards of clinical care in prison are intended to mirror those available in the
outside community. The records of the subject of this report indicate that he was
prescribed medication according to his symptoms. He suffered from anxiety
problems, panic attacks and may have had episodes of angina. The deceased’s
family might well ask whether his coronary heart disease could reasonably have
been diagnosed at an earlier stage. The man had been seen by a doctor several
times whilst he was in custody, he had a family history of heart disease and he
was on the register of patients with chronic disease, so Rye Hill were aware of
the possibility that he had the potential to become seriously ill.
It is possible that the man might have sought treatment earlier but, as the
prisoners who responded have said, he did not want to draw attention to himself.
Indeed, the man who died told the health care worker who had seen him the day
before his death that he had not said anything to staff about the discomfort he
had been suffering because his symptoms had eased.
The NHS National Service Framework for the management of Coronary Heart
Disease contains 12 standards for the prevention, diagnosis and treatment of
coronary heart disease. Whilst not all of these are relevant to the man’s
circumstances, it is clear from the man’s IMR and from the clinical review that his
risk factors were not followed up systematically. By the time an appointment with
a cardiologist was requested, it was too late for the subject of this report.
I recommend that policies are drawn up and implemented for the
systematic management of Chronic Diseases in accordance with the
National Service Frameworks, when prisoners present with associated
clinical risk factors.
In October 2004, two recommendations were made by my office and accepted,
by Rye Hill regarding a full review of the Complaints System at Rye Hill being
undertaken and the handling of prisoners complaints. During the course of this
investigation, it has become apparent that prisoners still have concerns about the
Complaints System. I therefore repeat these recommendations and ask that they
are addressed as a matter of urgency by Rye Hill's new management team.
Steps should be taken to ensure that staff members and management are
receiving appropriate levels of training in the handling of prisoners'
complaints.
A full review of the Complaints System at Rye Hill be carried out with a
view to ensuring that all complaints are collected, logged and answered to
an acceptable standard within approved timescales.
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Annexes
1. Mr Phillips' Inmate Medical Record
2. Rye Hill Staff Statements
3. Post mortem report
4. Clinical Review
5. Response to Clinical Review from PrimeCare Forensic Medical
6. NHS National Service Framework for Coronary Heart Disease:
Executive Summary.
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