Individual at Stocken

The investigation into the circumstances
surrounding the death of a man from HMP Stocken
at Grantham Hospital
on 25 September 2004
Report by the
Prisons and Probation Ombudsman
for England and Wales
April 2005
The man, who had been a prisoner at HMP Stocken, died at Grantham Hospital on 25
September 2004. This is a report into the circumstances surrounding his death. The loss of
any family member is distressing, but especially so whilst they are in custody and I offer my
sincere condolences to the man’s family and friends.
The investigation was carried out by an investigator from my office. I would like to thank the
Governor of Stocken for making the necessary facilities available to my investigator. I also
pay particular thanks for the help and support of the Liaison Officer who, I am aware, has
recently had to deal with his own tragic loss.
In the course of the investigation, I asked the Melton, Rutland and Harborough Primary Care
Trust (PCT) to undertake a Clinical Review of the care and treatment received by the man
from both HMP Stocken and Grantham Hospital. I am most grateful for the report written by
the Director of Public Health, Melton Rutland and Harborough PCT. The Clinical Review
raises concern at the failure of Grantham Hospital to ensure that it communicated the man’s
suspected TB diagnosis appropriately. I also find this disturbing.
The report makes seven recommendations for the prison. Additionally, the Clinical Review
makes six recommendations for HMP Stocken, four for Grantham Hospital and one for the
hospital and the prison jointly.
STEPHEN SHAW CBE
Prisons and Probation Ombudsman
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CONTENTS
Page
SUMMARY 3
BACKGROUND 4
HMP STOCKEN 6
FINDINGS 7
RECOMMENDATIONS 8
CLINICAL REVIEW RECOMMENDATIONS FOR
HMP STOCKEN & GRANTHAM HOSPITAL 9
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SUMMARY
1. The man died whilst in the care of Grantham Hospital on 25 September 2004. The
cause of death is suspected as tuberculosis. However, as there was no post­mortem
carried out, it has not been possible to offer a definitive explanation. He had been
admitted to the hospital on 20 September after suffering from chest pains whilst at
HMP Stocken.
2. The Clinical Review carried out by the Melton, Rutland and Harborough PCT
highlights a number of areas of concern that will need addressing by both the
hospital and the prison. These are identified in the findings and recommendations
section of this report.
3. The family have no questions or concerns regarding his care and are content to
leave the investigation team to assess the level of care and treatment. The Liaison
Officer, who was able to offer immediate initial assistance to the family, met with them
at the hospital. Additionally, the family was invited to meet with the Governor at the
prison, which they did. They described the prison as being supportive both at the
time of the death and following.
4. A collection was carried out within the prison, which the family intend to forward to
the Children in Need Appeal. The family will also write to the establishment to thank
the prisoners for their gift.
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BACKGROUND
5. The man was born on 30 November 1960 in India, and aged 43 when he died at
Grantham Hospital on 25 September 2004. The cause of death was not fully
established due to the lack of a post­mortem. However, medical opinion is that he
died of tuberculosis.
6. On 14 February 2003, he was sentenced by Leicester Crown Court to five and a half
years imprisonment for an offence of Grievous Bodily Harm. This was his first
custodial sentence. Following sentencing he was transferred to HMP Leicester and
then to HMP Stocken, which is a category C establishment located in Rutland.
7. Throughout his time in custody, he presented a number of medical ailments which
were treated by prison medical staff. He was prescribed medication and supplied
with equipment to help relieve his symptoms. The Clinical Review identifies the
treatment and medication. Following his death a large quantity of medication and
equipment were removed from his room, which appeared to have accumulated over a
period of months. The items were on open view in the room and appear to have
remained in place without being challenged by prison staff during cell searching and
inspections. The cell searching programme was up to date, which means that his
room would have been checked frequently. The checks seem to have been
ineffective as apparently the medication was not questioned or checked to see if it
was permitted, whether it posed a hazard to other prisoners, and ­ most importantly ­
whether he was actually taking what was prescribed for him.
8. Although this was his first custodial sentence, the man settled well into the prison
routines and gained “enhanced status”, which is the highest status level available for
prisoners and recognition that he was dealing with the sentence and demonstrating
good behaviour. The wing reports were good, with one describing him as a model
enhanced prisoner. He made good use of his time by attending educational classes,
as he wanted to improve his literacy and numeracy skills.
9. He was described by one prisoner as quiet, but always looking ill and frail. This
prisoner had befriended the man and would sit with him during the evening
association periods. He commented that he had noticed medication building up in
the man’s room and would ask him if he was taking it. He would confirm that he was,
but the prisoner said that he was not convinced by his answer. He also asked if he
was seeing the doctor and the man would say that he sometimes found it difficult to
see the medical staff. I could find no evidence to suggest that access to the
Healthcare Centre was unnecessarily restricted or difficult. The prisoner also said
that the man had developed a bad cough and would spend a great deal of time in
bed, shivering, and he was surprised that no one in the wing appeared to notice how
ill he was. He did say that at one stage the man was transferred from the top floor to
the ground floor, as he was experiencing difficulty in walking. I could find no record
to show that his condition had been referred to the Healthcare Department by the
wing staff. Finally, the prisoner wanted me to know that, despite the man’s
difficulties, he would attend the Sikh service on Thursday mornings and enjoyed the
opportunity to follow his religion.
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10. When asked to describe Stocken Prison, this prisoner said that prisoners were dealt
with fairly by the majority of staff, but that there were the odd exceptions. He also
said that he felt safe in the establishment.
11. On 20 September, the man was admitted to Grantham Hospital suffering from a chest
complaint. Two Prison Officers accompanied him to the hospital in accordance with
the security manual and local policy for handcuffing. I can confirm that he was not
handcuffed at the time of his death, as instructions had been given two days prior to
his death to remove the restraints following a review of his medical condition. This is
to be welcomed. The Officers remained with himat all times. He was initially located
on the ground floor of the hospital and then moved to a single room on the second
floor. Given his condition, and the height of the room above ground level, it would
have been reasonable to have reviewed his risk at an earlier stage. I could find no
evidence to suggest that consideration had been given to Release on Temporary
Licence (ROTL).
12. On 24 September, escort staff raised concern with the prison that the hospital
doctors suspected the man had developed infectious tuberculosis (TB). The Duty
Governor authorised the immediate withdrawal of the prison staff from the room in
which he was located. The Clinical Review has confirmed that tests for suspected
TB had commenced as early as 23 September and it is therefore a matter of concern
that the hospital management did not contact the prison and advise them. It was only
when the tests were confirmed as positive on 24 September that the escort staff were
provided with protective clothing. The Clinical Review comments on this issue.
13. The Health Protection Agency has subsequently made arrangements for staff and
prisoners at the prison to undergo testing for TB and for recently released prisoners
to be contacted and advised to attend their own GP. A number of prisoners and at
least one member of staff have been recalled for chest X rays following the test
results. The TB incident has been reported in the local and national newspapers and
the case taken up by the Prison Reform Trust in a letter to the prison’s Independent
Monitoring Board (IMB).
14. At approximately 8:10 pm on 25 September, nurses attended the man’s room and
reported to the prison staff that they believed he had passed away. The doctor
confirmed death at 8:45. The Duty Governor was informed and he actioned the local
contingency plans for dealing with a death in custody. The plans were not up to
date, however, with a number of telephone numbers incorrectly recorded. I was
unable to establish when the last prison exercise for dealing with a death in custody
had taken place.
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HMP STOCKEN
15. The prison was built in 1985 and opened as a Category C closed training
establishment for Young Offenders. An additional wing was added in 1990 and a
further two wings in 1998 and 2002. The establishment now operates as an Adult
Male Category C Training Prison. The Certified Nominal Accommodation (CNA) is
595, with an Operational Capacity of 622.
16. The latest Standards Audit Report June 2003 rated the prison at 80 per cent, with
Security at 75 per cent. The Healthcare Traffic Light Assessment was rated as
Green. The latest Chief Inspector of Prisons (HMCIP) Report dated October 2002,
which was an unannounced inspection, highlighted the following:
· A mutually respectful relationship between staff and prisoners.
· An effective personal officer and Incentives and Earned Privileges (IEP)
scheme.
· An excellent visitor’s centre.
· A can do attitude with a pronounced focus on resettlement.
· An influential Education Department supporting prisoners and staff
throughout the prison.
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FINDINGS
17. The Clinical Review raises no serious concerns regarding the care of the man.
However, it does level criticism at Grantham Hospital for failing to alert the prison to
a potentially serious health issue. He was undergoing tests for suspected TB from at
least 23 September, and this information should have been passed to the prison
management.
18. It would seem that his health had been deteriorating for some time while at Stocken.
This ought to have been noticed and acted upon by the prison officers and
Healthcare staff earlier. Additionally, a large amount of medication was allowed to
accumulate in the room, with no evidence that anyone challenged the quantity or
discussed whether he was taking the prescribed treatment. This raises the question
as to the effectiveness of the cell searching/inspection process.
19. The establishment offered a good level of support to the family and contributed to the
final funeral expenses. The fact that the Liaison Officer was available to the family at
the hospital was well received by them.
20. Given the fact that the man was considered low risk, located above ground level and
clearly ill, it is unfortunate that consideration to removal of restraints was not taken at
an earlier stage. I could also find no evidence to show that ROTL was considered as
an option at any stage.
21. The prison’s local contingency plan worked well in the main. However, the telephone
numbers contained in the documents were in need of updating. Additionally, I was
unable to establish when the last death in custody exercise had taken place. Such
an exercise should have highlighted the errors over the telephone numbers.
22. The Clinical Review criticises Grantham Hospital management for its failure to alert
the prison to a potential communicable disease. This meant prison staff were at risk.
23. The Clinical Review commends the care and support offered to the man by an F
Grade RGN of Stocken Prison.
24. The level of medical record keeping at Stocken requires attention as identified in the
Clinical Review. This has been identified previously in the Standards and Security
Audit Action Plan 2003.
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RECOMMENDATIONS
1. The Governor of Stocken should remind staff undertaking cell checks searching or
inspections, of the need to be vigilant to the contents of the area, as well as physical
security.
2. The Governor should review systems to ensure that prescribed medication is taken
and not allowed to be stored.
3. The Governor should review her policy on the use of restraints for prisoners in
hospital.
4. The Governor should review the use of Release on Temporary Licence for prisoners
in hospital.
5. The Governor should initiate a review of contingency plans for dealing with a death in
custody and a desk top exercise should be carried out.
6. In conjunction with the NHS, the contingency plans for dealing with a potential
communicable disease should be reviewed with clear protocols established between
the Hospital, Health Protection Agency, PCT and HMP Stocken.
7. An F Grade RGN should be commended for her support and care.
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CLINICAL REVIEW RECOMMENDATIONS FOR
HMP STOCKEN & GRANTHAM HOSPITAL
Director of Public Health
Melton Rutland and Harborough Primary Care Trust
HMP Stocken (referred to as the Prison)
1. There is a need to recruit permanently to nursing and Prison Medical Officer posts.
The Prison should work closely with the local PCT to achieve this, considering
innovative approaches, including posts split between the Prison and the PCT, posts
involving rotations between different locations and ensuring all staff receive
adequate support and supervision.
2. Detailed, informative, contemporaneous and legible records are essential to support
communication between staff and improve patient care. There is a need to reiterate
this to all Healthcare staff and stress that the Inmate Medical Records are legal
documents and all entries must be dated and signed.
3. Within the Prison Healthcare Service, there needs to be a robust system in place to
ensure follow­up of letters from hospital clinicians and investigation results, with clear
responsibilities identified to ensure that action is taken where required.
4. The policy on searching of prisoners’ cells needs to be reviewed, including
appropriate frequency. In this case, poor compliance with treatment would have
been detected.
5. There is a need for a medicines management clinic within the prison. Such a clinic,
which could be run by a pharmacy technician based on an appointment system,
would provide confidentiality, improve patient understanding and confidence
concerning medication and thus lead to better compliance with treatment.
6. All existing National Service Frameworks (NSFs) need to be implemented within the
Prison, as in the NHS. As part of the NSF for Coronary Heart Disease and the NSF
for Diabetes, chronic disease management registers need to be established, to
facilitate regular review and improved care of patients. Clinical IT systems are an
essential requirement for the effective implementation of such registers.
Grantham Hospital, United Lincolnshire Hospitals NHS Trust
7. In cases of unexpected death or complex clinical circumstances, wherever possible
the agreement of relatives to the carrying out of post­mortem examinations should be
sought. Full explanations as to the value and purpose of the examination should be
provided.
8. Action is required to raise awareness of TB among junior medical staff and nursing
staff. This should include information covering risk factors for TB, presentation of the
disease and its management and public health consequences. The incidence of TB
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in England is increasing and in his most recent Annual Report, the Chief Medical
Officer has highlighted TB as the issue of concern for the East Midlands Region.
9. There is a need to raise awareness of and update training in infection control policies
and procedures among nursing staff. If not already in place, a system of regular
infection control update training should be implemented.
10. Effective communication between staff and with relevant others, both verbal and
written, is essential to ensure optimum patient care. There is a need to ensure all
clinical staff, particularly nursing staff in this instance, understand this requirement
and that systems are in place to audit the quality of such communication.
Joint Action between the Prison and Grantham Hospital
11. Grantham Hospital is the main provider of specialist inpatient and outpatient services
to HMP Stocken. In order to improve liaison and understanding between the Prison
and Grantham Hospital at all levels, including at the ward level, the development of a
joint communication plan should be considered. This should include the
identification of prison­hospital link managers in both establishments.
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