Individual at Wakefield

The Death of a man at a hospital in Leeds
in May 2004
Report by the
Prisons and Probation Ombudsman
for England and Wales
November 2005
CONTENTS
Page
Foreword 2
Summary 3
Information about HMP Wakefield 5
Conduct of the investigation 5
The events of 3 May 2004 6
Contact with the man’s family on 3 May 2004 8
Follow­up to the man’s death 9
The questions asked by the man’s family 10
Night­time medical cover 13
Conclusions 15
Recommendations 17
Family Response to my Report 18
1
Foreword
This is the report of an investigation into the circumstances surrounding the
death of a man on 3 May 2004. The man was taken unwell in his cell at HMP
Wakefield shortly after midnight on that date. He was transferred first to a
hospital in Wakefield then shortly afterwards to a hospital in Leeds where he died
a few hours after admission.
All deaths of prisoners in custody are investigated, including those due to natural
causes. The responsibility for carrying out these investigations traditionally fell to
the Prison Service but has now been passed to the Prisons and Probation
Ombudsman to bring independence and greater consistency to the task. In this
case a member of the Prisons and Probation Ombudsman's staff carried out the
investigation.
My colleagues and I would like to extend our condolences to the man’s family
and friends at their sad loss. I would like to thank the Governor in charge of HMP
Wakefield at the time of the man’s death, and other members of his staff for the
assistance they have given to my investigation over many months. I am
extremely grateful to Wakefield West Primary Care Trust for leading a wide­
ranging clinical review which has obtained information from a significant number
of sources.
I hope that the man’s family will feel that the questions they asked have been
answered as comprehensively as possible. At the end of this report there are
some important learning points, both for HMP Wakefield and for the Prison
Service generally.
This version of my report, published on my website, has been amended to
remove the name of the deceased and the names of staff and prisoners who
were involved in my investigation.
Stephen Shaw
Prisons and Probation Ombudsman November 2005
2
SUMMARY
1. The man was sentenced to life imprisonment at Liverpool Crown Court in
December 1996 and he transferred to HMP Wakefield in May 1997. He
remained at Wakefield until 3 May 2004, the date of his death.
2. The man was 37 years old and his prison medical record indicates that
he complained of migrainous headaches on a number of occasions.
3. At 12:30am on 3 May 2004 he was the sole occupant of cell B1­36. He
rang his cell bell and the officer who was patrolling on C wing at the time,
answered the bell. The man told the officer that he had a very violent
headache and that he had lost vision in his left eye.
4. The officer rang the prison's Health Care Centre (HCC) and at 12:50am
the man’s cell door was unlocked so that the Health Care Officer (HCO)
could examine him. HMP Wakefield is a high security prison and only the
Night Orderly Officer, the senior officer in charge of the prison at the
time, had the keys that enabled the HCO to make the journey to the
man’s cell on B wing.
5. When staff entered the cell at 12:50am the man was found lying under
his bed. There was a considerable amount of vomit on his shirt and on
the cell floor. He was placed in the recovery position but he began to fit.
The HCO decided that an ambulance should be summoned immediately.
6. An ambulance was called by the prison's control room at 12:55am and it
reached the front gate of the prison at 1:05am. The ambulance crew
arrived at the man’s cell at 1:15am. He was unconscious but the
ambulance crew wished to stabilise his condition before transferring him
to outside hospital. He was placed in the ambulance at 1:40am and the
ambulance left HMP Wakefield just before 1:58am.
7. He was taken first to a hospital in Wakefield and then later in the night he
was transferred to a hospital in Leeds General Infirmary.
8. Although the man’s prison record contained no next of kin information,
enquiries were made at HMP Wakefield around 8:00am on the morning
of 3 May, as a result of which contact was made with the man’s family in
Merseyside. His parents, sister and brother were able to reach his
bedside by 11:00am and he was pronounced dead at 12:40pm.
9. A post­mortem examination was conducted on the coroner's behalf by a
Professor and his report shows the cause of death to be subarachnoid
haemorrhage and ruptured aneurysm of the Circle of Willis.
3
10. A detailed clinical review has been conducted by Wakefield West
Primary Care Trust (PCT). A doctor and manager from the Trust made
formal contact with the Clinical Director at HMP Wakefield, West
Yorkshire Metropolitan Ambulance Service (WYMAS), the Assistant
Director Medicines Management at Wakefield West PCT and the Health
Care Manager at HMP Wakefield.
11. This report makes a number of recommendations. The recommendations
at the end of the PCT’s clinical review are endorsed. Additional
recommendations are made in relation to the excellent conduct by an
officer at HMP Wakefield, the need for reviews at least annually of next
of kin details to be used in an emergency and the possibility of
introducing a target time for responses by health care staff at Wakefield
to night­time emergencies.
4
INFORMATION ABOUT HMP WAKEFIELD
12. HMP Wakefield is a high security dispersal prison for prisoners convicted
of serious offences, most of them sex offences. It was most recently
inspected by the HM Chief Inspector of Prisons (HMCIP), between 13­17
October 2003. The introduction to HMCIP's report states:
"Many of those it holds would pose significant risks to society if released,
and it is the prison's task to hold them securely and try to work with them
to reduce those risks."
13. HMP Wakefield is a main lifer centre, which means that it accepts men
as soon as possible after they have been sentenced to life imprisonment.
There has been a prison on the site since 1595. The prison in its current
form dates back to 1845 and the wings are arranged in the Victorian style
radial system. The prison's certified normal accommodation is 567 and it
has an operational (maximum) capacity of 571.
CONDUCT OF THE INVESTIGATION
14. My investigator visited HMP Wakefield on 5 May when he was given a
detailed briefing by the Deputy Governor, the Clinical Director and the
Health Care Manager.
15. I commissioned a clinical review from Wakefield West PCT. I am most
grateful to the Trust for their thorough and professional response to my
request.
16. My investigator met with the man’s mother, father and sister at the family
home. At that meeting the family asked many questions, several of
which were of a medical nature and were therefore conveyed to
Wakefield West PCT when the clinical review was commissioned on 1
June.
17. My investigator interviewed the three members of staff at HMP Wakefield
who were significantly involved in dealing with the emergency very early
in the morning of 3 May. These were the Night Orderly Officer, the HCO
and the C Wing Night Patrol Officer.
5
THE EVENTS OF 3 MAY 2004
18. The man occupied a single cell on B wing at Wakefield. Through the
night of 2­3 May there was a Night Patrol Officer on B Wing and a Night
Patrol Officer on C Wing. The Night Patrol Officer on C Wing heard the
man ring his cell bell at approximately half past midnight and since the B
Wing Officer was elsewhere at the time the C Wing Officer walked onto B
Wing after about 10 or 15 seconds and proceeded to the man’s cell on
the bottom level of the wing. In interview the C wing Officer explained
that the noise of the cell bell was "pretty strident" and carried clearly to
him at that time in the morning. The C Wing Officer was confident about
the time. His routine, which he again observed this particular night, is to
check his watch if such a call is made. In his experience these calls
generally signify a medical problem.
19. The C Wing Officer’s timing of half past midnight is confirmed by entries
in the Wing Occurrence Book (by the B Wing Night Patrol Officer), in the
Governor’s Journal (entry made by the assistant Night Orderly Officer)
and in the HCO memorandum to the Governor of 3 May.
20. When the C Wing Officer reached cell B1­36 (the man’s) he opened the
observation flap on the cell door and could see that the man was
standing at the front of the cell with his face up against the observation
flap. The man told the officer that he had a very violent headache and
that he had lost vision in his left eye. The two men knew each other, as
the C Wing Officer has been an officer at Wakefield for nearly 13 years.
21. After being told the man’s symptoms the C Wing Officer rang the prison’s
HCC and spoke to the HCO who said that he would attend.
22. Wakefield is a high security prison and the HCC is approximately 250
yards from the man’s cell. The HCC is double locked at night­time so the
HCO had to be collected by the Night Orderly Officer (the most senior
officer on duty in the prison).
23. In interview the Night Orderly Officer explained that he was the only
person during the night who had access to the major areas of the prison
which were double locked so he made his way to the HCC, collected the
HCO and the two men returned to the centre of the prison. The HCO
indicated that there were nine sets of locks to negotiate on both the
outward and return legs of the journey.
24. In interview the HCO explained that the complement of staff in the HCC
during the night was himself and an agency nurse. Whilst waiting to be
collected by the Night Orderly, the HCO had time to check the man’s
medical records but he discovered no recent entries of significance.
6
25. At 00:50am (timing in both the HCO’s memo and the Night Patrol
Officer’s Wing Occurrence Book), an officer who was assisting the Night
Orderly Officer, unlocked the man’s cell door and the C Wing Patrol
Officer and the HCO went inside.
26. The man was found to be lying on the cell floor with his upper body, from
his waist upwards, under the bed. The C Wing Officer said there was a
lot of vomit on the floor and when he spoke to the man he received no
response whatsoever. The C Wing Officer and the HCO pulled the man
from under his bed onto an open piece of cell floor and discovered vomit
all down the front of his T­shirt and around his mouth.
27. In interview the C Wing Officer said that the man’s speech seemed fairly
normal when the two men spoke at half past midnight and his estimate
was that the vomiting began after he had left the man. He could see no
vomit on the man’s shirt at 00:30am but there was so much at 00:50am
that the two officers removed his shirt.
28. The two officers tried to put the man into the recovery position but he
started to fit and it was difficult to hold him in the recovery position. When
the HCO observed the first fit he decided that an ambulance must be
called. The log maintained by Control Room staff at the prison indicates
that an ambulance was called by them on the HCO’s instructions at
00:55am. This time is confirmed in a letter written to the PCT by the
Acting Chief Executive of West Yorkshire Metropolitan Ambulance
Service (WYMAS). The WYMAS letter establishes that the ambulance
crew arrived at the outer gates of the prison at 1.05 am. They reached
the man’s cell at 1.15am.
29. While the HCO and the C Wing Officer were waiting for the ambulance to
arrive, they observed the man fit on a significant number of occasions
(between six and 12 according to the HCO). The two men did their
utmost to maintain an airway and to maintain the man in a safe
environment where he could not cause himself injury. The C Wing Officer
explained how they made the man as comfortable as possible by putting
a pillow under his head and covering him with a blanket. The HCO
constantly tried to talk to him but received no response. The man was
moaning a lot but was unconscious.
30. According to the C Wing Officer the paramedics who attended wanted to
get a cannula (thin tube) into the back of one of the man’s hands so that
they could administer a sedative to calm him down because he was
continuing to fit. This was achieved but then the man had another fit and
inadvertently ripped the cannula out. The memorandum submitted by the
HCO states that the man was stabilized at 1:40am and the ambulance
left for Pinderfields Hospital, Wakefield 15 minutes later. The Control
7
Room log times the man’s removal to Pinderfields as being at 1:58am.
The WYMAS timing is identical.
31. During the night the man was transferred from Pinderfields to Ward 6,
the Neurology Unit at a hospital in Leeds. At the request of the hospital
the prison supplied a contact telephone number for the man’s parents
and family members who were able to make their way from their home to
be at the man’s bedside before he passed away at 12:40pm on 3 May.
CONTACT WITH THE MAN’S FAMILY ON 3 MAY 2004
32. When the man first came into HMP Liverpool on 17 August 1996 he gave
his home address. He was asked for the name and address of his next
of kin and the answer given was "states none". He was also asked for the
name and address of any other person to be notified in an emergency
and again the answer was "states none". There is no evidence that the
man was asked at any stage during the next seven and a half years
whether he wished to supply such information.
33. There is clear evidence in the man’s prison record of regular contact with
his family before his death. A probation officer contributed in January
2004 to the man’s Sentence Planning and Review Board. In the section
headed 'outside contacts with family' the probation officer wrote that the
man "has some good external support from his family. They maintain
contact via the telephone". Two Visiting Orders, issued just weeks before
the man’s death, provide even clearer evidence of the strong relationship
with his family. The Visiting Orders were issued on 4 March and 6 April
2004 with visits paid by two family members (according to the orders) on
18 March and 23 April 2004.
34. On the morning of 3 May 2004 it was clear that the man was very
seriously ill, but making contact with his family was a difficult exercise in
view of the absence of information on the first page of his prison record.
Thanks to the determination of medical staff at Leeds General Infirmary,
a phone call was made to the prison by one of the two prison officers
accompanying the man at the hospital. Records of the man’s phone calls
were studied and the prison was able to give the necessary information
to nurses. At 8:25am a nurse informed one of the escorting officers, that
the man’s next of kin had been contacted. The Escort Record kept by
this officer shows that the man was visited at his bedside by his parents,
brother and sister at 11:00am. The man was pronounced dead less than
two hours later.
8
35. It was thanks to some quick and humane thinking by both prison and
medical staff that the man’s relatives were able to be with him before he
passed away. Contact with the relatives would have been much easier if
next of kin information had been contained in the man’s record. It is not
completely surprising that the man did not wish to supply such
information when he first arrived at HMP Liverpool in August 1996. At
that time he was very unsettled and he had been charged with serious
offences. There are some prisoners who have no next of kin, or who
remain adamant that they do not wish to supply contact information, even
for use in an emergency. The man was a lifer whose progress through
his sentence was reviewed annually.
Recommendation
I recommend that the Prison Service should devise a method of
updating next of kin information on long term prisoners on at least
an annual basis.
FOLLOW UP TO THE MAN’S DEATH
36. The man’s parents, brother and sister were at his bedside when he died.
3 May 2004 was a Bank Holiday and the following day the Governor at
Wakefield published a Notice to Staff and a separate Notice to Prisoners
in which he announced the man’s death with deep regret.
37. Subsequently the family accepted an invitation to visit the prison when
items of the man’s property were handed over and the family had an
opportunity to see the areas where he had lived and worked. They also
spoke with both staff and prisoners who had known the man well.
38. The family were originally advised by the prison to make a claim for a
Social Fund Funeral Payment to help with funeral costs. The family were
not sure how to access such a payment and explained their concern to
my investigator when he visited them on 25 May 2004. My investigator
wrote to the Deputy Governor about this and related matters and the
Governor then made an ex gratia payment to the funeral director towards
the funeral costs which had been incurred. The family are most grateful
to the Governor for his response.
9
THE QUESTIONS ASKED BY THE MAN’S FAMILY
39. During my investigator's meeting with the man’s parents and sister on 25
May 2004, the family asked nine questions. The most detailed responses
that can be given to these questions are as follows:
1) They understood that a doctor was on duty in the prison's HCC throughout
each night and they wondered why a doctor did not attend the man when he
was taken ill in his cell after midnight on 3 May.
Page 4 of the PCT’s clinical review explains that during the night period a doctor
is on­call for advice but he/she is at home, not in the prison. The letter from the
Health Care Manager to the PCT explains that the two staff on duty in the HCC
were the HCO and an RMN. (The RMN had been supplied by a nursing agency.)
2) The family understands that paramedics arrived at the prison at
approximately 1:10am and that the man was removed to Pinderfields Hospital
at approximately 1:40am. They ask why he was not transferred to hospital
sooner.
According to the letter from the Acting Chief Executive of WYMAS, the
ambulance crew arrived at the outer gates of the prison at 1:04am. They arrived
at the man’s cell at 1:15am. The paramedics decided it would be dangerous for
both patient and crew to move him before first administering Diazemuls (this is a
drug to help the patient stop fitting). The crew arrived back at the ambulance at
1:40am.
The third paragraph of the Chief Executive’s letter explains that once back in the
ambulance the crew carried out a full routine baseline examination, taking
approximately two to three minutes. They passed through a number of security
gates and left the prison at 1:57:57am.
3) The family enquired whether the man suffered an epileptic fit in his cell which
induced a brain haemorrhage or whether a haemorrhage led to a subsequent fit.
4) The man’s father asked if it was thought that his son had banged his head as
he fell in his cell and whether such a fall could have induced a brain
haemorrhage.
No information has been made available which supplies definitive answers to
these questions.
5) He also asked whether his son was receiving medication at the prison prior to
his death.
10
The Continuous Medical Record section of the man’s Inmate Medical Record
(IMR) shows that medication reviews were held at regular intervals. The last such
review is recorded as taking place on 14 April 2004 when the man was again
prescribed paracetamol to have in his own possession. The amount to be taken
was one or two tablets 3 times a day.
6) The man’s father asked if his son had had bad headaches before going into
prison and receiving his life sentence. He asked whether the prison had arranged
for any examinations of his son's headache problem and whether the response to
the presenting problem(s) had been sufficiently thorough.
7) The man’s father said that his son had complained often in phone calls home
from the prison about bad headaches and blurred vision in one eye.
The clinical review submitted by the PCT includes notes from a meeting that was
held on 10 August 2004 between the Medical Director at Wakefield West PCT,
and the Clinical Director at HMP Wakefield. The meeting noted that the man’s
IMR recorded evidence of a history of migrainous headaches but there was little
evidence in the IMR of medical neurological examinations having taken place.
There were also scant records of examinations by clinicians in the prison. The
last two notes made at the meeting between the two doctors were as follows:
· from the medical record it seems that the man had been
appropriately managed and treated at the prison
· The man had been referred to, and seen by, a consultant
neurologist with another referral pending.
In relation to clinical management, the relevant section of the clinical review
states that there is no evidence to indicate that the clinical management of the
man’s case was flawed or mismanaged during his custody at HMP Wakefield.
Evidence­based guidance for clinicians is that it is not appropriate for a patient to
undergo imaging without specific neurological clinical indicators, which were not
present in the man’s case. In his case there had not been any specific or clinical
indicators, other than migrainous headaches, that would have led a clinician
(whether a prison doctor or consultant neurologist) to carry out imaging on this
patient. Imaging is a medical procedure for scanning or x­raying the part of a
patient’s body under scrutiny.
8) The family stated that a nurse at the hospital in Leeds had complained to them
on the morning of 3 May about the man’s remaining in handcuffs.
Wakefield is a high security prison and the prison has local security instructions
which indicate that in a medical emergency, where there is no time for a risk
assessment, restraints must be applied until a risk assessment is completed.
The Prisoner Escort Record, maintained by staff who escorted the man to
hospital, shows that one of the officers who accompanied the man to hospital
11
rang the prison from a hospital in Leeds at 7:51am on 3 May. He reported that
the doctor caring for the man had made a request that the prison staff
accompanying him go into a side room so as not to upset other patients on the
ward. The request was denied at that time by the Deputy Governor. At that stage
he had relatively limited information about the man’s medical condition.
The Deputy Governor made two important and humane decisions when he came
on duty on the morning of 3 May 2004. Firstly, he made the final decision on a
form entitled Risk Assessment for Hospital Escort/Bed Watch about the level of
security that was required for the man. He ordered that the handcuffs should be
removed and that the man should remain uncuffed while he was unconscious
and attached to a life support machine. Secondly, he discussed the case with the
Duty Governor at the prison on that Bank Holiday Monday. The Duty Governor
was dispatched to a hospital in Leeds with authority from the Deputy Governor to
withdraw the staff if he considered that appropriate.
The Prisoner Escort Record shows that a Duty Governor visit was made to the
man at a hospital in Leeds at 10:25am. My investigator spoke to the Duty
Governor about the visit and he could remember the circumstances clearly. He
recalled that the man had been cared for in a small ward at the infirmary and that
at the time he arrived there, mid morning, the man was neither handcuffed nor
restrained in any way. The Duty Governor was aware that nurses were
concerned about the impact of the two prison officers accompanying the man on
the remaining patients in the ward. The Duty Governor remembered that the
doctor on the ward was very busy indeed, but he discussed the situation with the
ward sister and doctor as soon as the doctor was free. The Duty Governor
agreed that both the officers who accompanied the man should withdraw from
the ward to a small ante­room outside, where they still had sight of the man but
were able to give more privacy to his family and the other patients on the ward.
The Duty Governor signed a detailed Management Visits Checklist in relation to
his visit.
9) The man’s sister expressed surprise that her brother had gained so much
weight. She enquired as to whether he had gone to the prison gym regularly and
asked whether the weight gain had contributed to his death.
My investigator made enquiries at Wakefield as to whether the man had attended
the gymnasium regularly, now and then or not at all. A Senior Officer from the
Physical Education Department at Wakefield sent an e­mail response stating that
as far as is possible he could say that the man did not use the gymnasium at the
prison. The clinical review has provided no information as to whether the man’s
weight gain contributed to his death.
12
NIGHT­TIME MEDICAL COVER AT HMP WAKEFIELD
40. During the night of 2­3 May 2004 there were two members of staff on
duty in the prison's HCC. They were the HCO and a trained nurse
supplied by an agency. The HCO received the telephone call from the C
Wing Officer at approximately 12:30am and it was he who entered the
man’s cell, at 12:50am. The letter from the Health Care Manager at HMP
Wakefield to the PCT states that the HCO has no formal health care or
medical qualifications. The Healthcare Manager also reported that the
HCO had not undertaken any formal training or Continuous Professional
Development in terms of Emergency Aid, CPR (cardiopulmonary
resuscitation) or First Aid.
41. The PCT’s clinical review makes it clear that the HCO carried out the
appropriate interventions to save life: "This involved maintaining the
patient's safe environment, maintaining a clear airway, placing the patient
in the recovery position, managing the patient's seizures and taking
clinical observations of the vital signs prior to either the doctor or
paramedics arriving." The PCT’s professional endorsement of the HCO’s
actions is reassuring, but the Protocol and Training Issues section of the
Clinical Review also expresses concerns about the HCO’s level of
current competence. The PCT has included a most important
recommendation about health care staff training which reads as follows:
"The HCO and all members of the prison health care team should
receive regular training, particularly life­saving/emergency aid type
training, if they are to competently fulfil the role of being responsible for
the health care of the prisoners during the night­time period and
competently manage health emergencies. We also recommended that
any health care staff at the prison without a professional qualification
achieve a minimum of NVQ Care at Level 3."
Recommendation
I agree wholeheartedly with this recommendation in the clinical
review and draw this matter formally to the attention of the
Governor and Clinical Director at HMP Wakefield. I believe this may
not be an issue confined to Wakefield and I therefore draw the
matter additionally to the attention of the Acting Director of Prison
Health, Department of Health.
42. It is of concern to me that 20 minutes passed between the phone call
from the C Wing Officer to the HCO and the entry to the man’s cell at
12:50am. I am aware that Wakefield holds prisoners of the highest
security category and that correct security procedures must be observed
13
when health care staff are required to see prisoners in the middle of the
night. The C Wing Officer estimated that the distance from the HCC to
the man’s cell was about 250 yards. The Night Orderly Officer stated that
he and the HCO had to negotiate nine locked gates when they made that
journey. The PCT’s clinical review concludes that the time taken for the
HCO to reach the man was "within the normal time parameters and
without any undue delay".
43. It seems unlikely that the eventual outcome would have been any
different even if the HCO had arrived at the man’s cell more rapidly.
However I do not take the view that a 20 minute time lag before a
prisoner (or member of staff) receives emergency assessment or
treatment from a member of health care staff should be accepted as
being within normal time parameters.
Recommendation
I recommend that the Governor should review his existing
procedures for emergency access by healthcare personnel to cells
during the night with a view to providing medical assistance much
more quickly than in the case of the man.
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CONCLUSIONS
44. The Clinical Management Section of the PCT’s clinical review notes that
"there is no evidence to indicate that the clinical management of the
man’s case was flawed or mismanaged during his custody at HMP
Wakefield".
45. The Medical Director of Wakefield West PCT did however note during his
meeting with the Clinical Director of HMP Wakefield, on 10 August 2004,
that there was little evidence in the man’s IMR of medical neurological
examinations having taken place.
46. The C Wing Officer first became aware that the man was in distress
when he rang his cell bell at approximately 12:30am on 3 May. The C
Wing Officer remembers looking at his watch at the time because it was
unusual for a cell bell to be rung in the middle of the night. The C Wing
Officer was an impressive interviewee and I am confident that he rang
the HCO promptly after speaking to the man at his cell door.
Approximately 20 minutes then passed before the HCO arrived at cell
B1­36 where the man was found lying on the floor of his cell.
47. Once the HCO had entered the cell, and assessed the scale of the
emergency, he asked immediately for an ambulance to be summoned.
48. The timings supplied by WYMAS show that only ten minutes passed
between the call being received and an ambulance arriving at the
prison's main gate, one second before 1:05am. There was no undue
delay in escorting the ambulance staff to the man’s cell but the crew
decided it would be dangerous to transport him to hospital immediately.
They administered Diazemuls, a drug to help a patient stop fitting, to the
man. The evidence given by the C Wing Officer in interview indicates the
difficulty experienced by the ambulance crew before they were able to
administer the necessary sedative to the man.
49. The crew arrived back at the ambulance with the man at 1:40am and
they carried out a full routine baseline examination in the vehicle which
took approximately two/three minutes. The clinical review concludes that
the ambulance response, and the way the man was treated and
managed, was appropriate.
50. The part played during the incident by the C Wing Officer was
noteworthy. He answered the man’s call for assistance at 12:30am,
although he was the patrolling officer on an adjacent wing. He promptly
requested medical assistance from the HCO. He remained in the man’s
cell with the HCO for 25 minutes until the ambulance crew arrived there
at 115 am. During that time he helped to remove the man’s T­shirt which
15
was covered with vomit. He did his best to make the man comfortable
and tried to maintain him in the recovery position. When the paramedics
arrived on the scene he remained in the man’s cell and assisted their
professional efforts.
Recommendation
I recommend that the C Wing Officer be commended for his actions.
They were humane and decent and went well beyond the call of
duty.
51. Once the man had been transferred to a hospital in Leeds there was
some delay before his family could be notified that he was gravely ill.
This complication arose because there was no next of kin information
recorded on his prison record. Prison staff and nursing staff at Leeds
cooperated effectively to find the necessary telephone number and, as a
consequence, the man’s father, mother, brother and sister were able to
join him at his bedside before he died.
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RECOMMENDATIONS
LOCAL
(1) The C Wing Officer on duty that night should be formally
commended in a way selected by the Governor of HMP
Wakefield for conduct that went beyond the call of duty.
(2) The recommendations made at the conclusion of Wakefield
West PCT's Clinical Review are endorsed. The Governor,
Clinical Director and PCT are invited to establish an action
plan for implementation of these recommendations if they
are accepted locally.
(3) I recommend that the Governor should review his existing
procedures for emergency access by healthcare personnel
to cells during the night with a view to providing medical
assistance much more quickly than in the case of the man
who is the subject of this report.
NATIONAL
(4) I recommend that the Prison Service should devise a
method of updating next of kin information on long term
prisoners on at least an annual basis
(5) The Prison Service should arrange for prison health care
staff to receive regular training, particularly life­
saving/emergency aid type training.
17
FAMILY RESPONSE TO MY REPORT
In September 2005 the solicitor acting for the man’s family contacted my
investigator to say that the family considered that doctors at HMP
Wakefield should have paid much greater attention to the man’s persistent
complaints about headaches in view of the serious accident he sustained
in 1995, before coming into prison. The family stated that prison doctors
were aware of this accident, as indicated by the letter of 8 October 1998
from a Medical Officer at the prison to the Consultant Neurologist at
Pinderfields Hospital, Wakefield.
18