Individual at Wakefield

Investigation into the circumstances surrounding the death
of a prisoner on 19 April 2005 at HMP Wakefield
Report by the Prisons and Probation Ombudsman for England
and Wales
September 2005
This is the report of an investigation into the circumstances of the death of
a prisoner on 19 April 2005 at HMP Wakefield.
One of my investigating officers conducted the investigation. West Yorkshire
Primary Care Trust carried out the clinical review.
My colleagues and I would like to extend our condolences to the prisoner’s family
for their loss. I would like to thank Wakefield who ensured that all relevant
information was available to my investigator.
I endorse the three recommendations made by the clinical review.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2005
CONTENTS
Page
Summary 4
Investigation Methodology 5
Background 6
The prisoner 6
Wakefield prison 6
The prisoner’s time at Wakefield 7
Events of 19 April 2005 7
Levels of Compliance 9
Clinical Review 9
Findings and Conclusions 10
Recommendations 10
Good Practice 10
Summary
The prisoner died on 19 April 2005 at the age of 73, while in custody at
Wakefield. He had been sentenced to life imprisonment for sexual offences
against children. He was to serve a minimum sentence of nine years.
Prison staff discovered the prisoner in his cell, following the afternoon movement
of prisoners to workshops and education. Immediate assistance was called for,
but staff were unable to save him.
A clinical review was carried out on behalf of the Wakefield West Primary Care
Trust.
The prisoner’s death was not connected to the fact that he was in prison or to the
level of care that he received there. The prisoner died in his cell of natural
causes as a result of: -
• Haemopericardium
• Ruptured myocardial infarction
• Occlusive coronary artery atheroma (blocked arteries)
This report endorses the three recommendations made by the clinical review,
and identifies one example of best practice.
Investigation Methodology
All the indications were that this was a death from natural causes.
When someone dies in prison from an apparently natural cause, I judge that the
public interest may be served simply by a clinical review carried out by an
independent healthcare professional, rather than by my conducting a full
investigation. My approach in cases of apparent natural cause death, therefore,
has been to conduct an initial review to determine if a full investigation is justified.
In this prisoner’s case, my investigator decided that the circumstances did not
require a full investigation. He did so after a review of the available
documentation.
My investigator was given access to all the prisoner’s prison records, including
his medical records, and was given copies of everything that was required. The
documents were well presented, with an index, which was a considerable help to
the investigation.
Notices to staff and prisoners were sent to the prison’s liaison officer, 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.
I received two letters from prisoners. My investigator visited Wakefield on 21
July 2005 and met with the two men concerned. The first man, had concerns
regarding the prisoner’s treatment by other prisoners while working in the prison
kitchen. It transpired that this treatment had no bearing on the prisoner’s death.
The second man, had no relevant information for my investigator with regard to
the prisoner.
The West Yorkshire Primary Care Trust carried out a clinical review of the
management of the prisoner’s health needs while in custody.
One of my family liaison officers has contacted both Wakefield prison and West
Yorkshire Police, but has not been able to locate any members of the prisoner’s
family. It is believed that the prisoner’s wife and two children were killed in a
road traffic accident some years ago.
Background
The prisoner
The prisoner was born on 19 November 1932. He was 73 years old when he
died on 19 April 2005 in custody at Wakefield.
The prisoner was sentenced to life imprisonment on 7 October 1996 for sexual
offences against children. He had 21 previous convictions dating back to 1941.
Alcohol had played a part in the prisoner’s offending. During his sentence, he
attended alcohol awareness courses. He is reported to have played an active
part in all sessions, receiving a better understanding of the effects of his
behaviour on others while under the influence of alcohol.
In July 1994, during an earlier sentence, the prisoner did not return to HMP
Wymott following a period of home leave. He was rearrested on 15 December
1995. During the period he was unlawfully at large, he committed the offences
which resulted in the sentence of life imprisonment in 1996. He was to serve a
minimum of nine years, a period which expired in February 2005. When the
prisoner was rearrested he was taken to HMP Belmarsh and then, in May 1997,
to HMP Wakefield.
At a recent Parole Board hearing, the prisoner was not granted release on life
licence or a move to open conditions in a lower category prison as he was still
considered a risk to children. His next review was not due until February 2007.
Wakefield Prison
Wakefield is a prison for men who are serving sentences of four years or more
and life sentences. It also specialises in the treatment of serious sex offenders.
The prison provides workshops and an education department offering both full
and part time education. The programmes department offers a range of offending
behaviour courses including FOCUS (anti-drug taking programme), the Sex
Offender Treatment Programme (SOTP) and the Enhanced Thinking Skills
programme (ETS)
Wakefield was last subject to a Security and Standards audit in June 2004. It
received a good rating.
The prisoner’s time at Wakefield
Following his arrival at Wakefield prison, the prisoner settled into the regime of
the establishment. He attended the workshops and made use of the educational
opportunities offered to him.
In March 2004, the prisoner took part in the Sex Offender Treatment Programme,
and he successfully completed the course in September 2004. He then returned
to work in the workshops for a short period of time, before moving to the kitchen.
Events of 19 April 2005
At approximately 1.40pm, an officer started checking the landing after prisoners
had returned to work. At 1.45pm, he arrived at the cell occupied by the prisoner,
and noticed that the door was closed but not locked.
The officer entered the cell and found the prisoner lying on the floor. His first
impression was that he was dead and had been so for some considerable time.
He immediately raised the alarm by shouting to another officer to fetch a hospital
officer and to tell them that it was a Code Blue emergency. A Code Blue is a
method of raising the alarm in a medical emergency. It will ensure that when
staff hear the radio calls they know what kind of emergency they are attending,
and what equipment might be needed.
The officer remained with the prisoner and tried, unsuccessfully, to find a pulse.
He then covered the prisoner with a blanket and removed other prisoners from
the cell door where they had started to gather.
Another officer ran to an office on the landing and the telephoned the control
room. He asked the control room to call a hospital officer to attend the wing
immediately, and said that it was a Code Blue emergency and that an ambulance
was urgently required. The control room immediately sent out a radio message.
The control room also contacted the duty Orderly Officer and asked him to attend
the wing.
After the officer had called the control room, he returned to the prisoner’s cell and
met a Senior Officer en route. When they arrived at the cell, the Officer
explained that he could not find a pulse. The Senior Officer then transmitted an
urgent radio message for a healthcare officer and the Orderly Officer to attend.
A Hospital Officer attended at 1.46pm followed by a Healthcare Nurse and they
attempted to find a pulse. The prisoner’s pupils were fixed and dilated. He was
incontinent of urine and the pooling of his blood was evident. It was therefore
decided not to commence Cardio Pulmonary Resuscitation (CPR).
At 1.52pm, a Principal Officer who was the duty Orderly Officer arrived. He was
closely followed by the paramedics. The paramedics checked for vital signs and
pronounced life extinct at 2.00pm. At 2.03pm, a Doctor arrived and confirmed
the death of the prisoner.
Officers from the dedicated search team (DST) arrived at 2.05pm and sealed the
cell to preserve any evidence for the police. The police arrived at the prison at
3.15pm, followed by the Coroner’s Officer.
The funeral directors arrived at 5.40pm to remove the prisoner’s body. By
5.54pm, the police, the Coroner’s Officer and the funeral director had all left the
prison.
A Post Mortem was carried out on 20 April. The findings were that the prisoner
died of:
• 1 (a) Haemopericardium due to
• 1 (b) Ruptured myocardial infarction due to
• 1 (c) Occlusive coronary artery atheroma.
Levels of compliance
Prison Service Order 2710 sets out what action must be taken following a death
in custody. Wakefield fully complied with this order.
All necessary documentation was collated for the purposes of this investigation.
Clinical Review
A clinical review was carried out into the care of the prisoner at Wakefield.
During the course of the review, the reviewers interviewed the healthcare
manager at Wakefield, and reviewed all medical records.
Their report concludes that there was a poor standard of clinical record keeping,
and expresses some concerns about the way the prisoner’s healthcare needs
had been met over the years.
In relation to the events of 19 April, the clinical review says that it was most
unlikely that CPR would have been successful given the cause of death.
However, the report concludes that clearer guidance should be given to staff as
to who has the authority to make the decision whether CPR should be started or
not.
The recommendations from the clinical review are: -
• There should be included within the contingency plans at Wakefield a
resuscitation policy, giving clearer guidance regarding decisions to
resuscitate or not to resuscitate and which members of staff should
make that decision.
• Healthcare management are advised to put in place a system of audit
to monitor and improve the quality of clinical record keeping.
• Systems to effectively manage coronary heart disease risk factors
should be established.
Findings and Conclusions
The prisoner received appropriate treatment for his medical needs and died of
natural causes as a result of: -
• Haemopericardium
• Ruptured myocardial infarction
• Occlusive coronary artery atheroma (blocked arteries)
I believe that on the day of the prisoner’s death, the staff acted in a professional
manner, preserving his dignity while summoning help and assistance.
Recommendations
I support the recommendations of the clinical review.
Good Practice
The use of the term Code Blue to summon help to serious medical emergencies
is good practice, as everyone carrying a radio and those within hearing distance
of a radio know what help is needed.