Individual at Wandsworth

Investigation into the circumstances surrounding the
death of a man at HMP Wandsworth
in February 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This is the report of an investigation into the death of a man who died from natural
causes on 18 February 2008 in his cell in HMP Wandsworth. He was 35 years old.
I would like to add my personal condolences to those already expressed to the
man’s family on behalf of my office, by one of my Family Liaison Officers.
The investigation was undertaken by one of my investigators. Both he and I would
like to thank the Governor and his staff for their participation and assistance.
Wandsworth Primary Care Trust were asked to undertake a review of the man’s
clinical care, and I also appreciate this. I must apologise for the delay in issuing this
report and for any additional distress caused to the man’s family.
The man was the 17th prisoner to have died in HMP Wandsworth since I was
entrusted with responsibility for investigating all deaths in prison custody. I do not
believe there are any significant common features between this investigation and
those into any of the previous deaths.
I make one recommendation to the Governor. I am pleased to see that the
recommendation has been partially accepted and that the prison are arranging heart
start training and refresher training for staff who have contact with prisoners. My
report also draws attention to a number of other matters that the Governor will wish
to take forward by way of renewed advice and guidance to his staff. In particular, I
note that those staff ‘first on scene’ did not commence resuscitation as they did not
feel confident of their ability to do so.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2009
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CONTENTS
Summary 4
The Investigation Process 5
HMP Wandsworth 6
Key Findings 7
Issues 12
Recommendations 14
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SUMMARY
The man was 35 years old and nearing the end of a two year prison sentence in
HMP Wandsworth. He had not encountered any problems during his sentence, and
was noted as a good worker who got on well with both staff and fellow prisoners.
On 18 February 2008, the man and his cellmate were taking an afternoon sleep in
their cell. When the cellmate awoke, he immediately became concerned about the
man’s wellbeing. He was not breathing and would not respond, so the cellmate
alerted staff. Officers came to the cell and could see that there was a problem.
They called for a nurse. The officers did not attempt to resuscitate the man.
A nurse attended very quickly, and efforts to resuscitate the man began. Although
he was on the top bunk bed and staff had to stand on furniture to reach him, my
investigator was told that this did not hamper the attempts to revive the man. Other
staff arrived quickly to assist with the resuscitation and an ambulance was called.
Other prisoners were taken away from the area and back to their cells, and the
man’s cellmate was relocated and given support.
The prison’s medical emergency responder was called. After initially being sent to
the wrong location, she joined colleagues in the man’s cell as they continued to try to
resuscitate him. Ambulance staff arrived and took over, but sadly were
unsuccessful.
The post mortem found that the man died as a result of a problem with his heart.
The clinical reviewer has likewise concluded that the man died from natural causes.
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THE INVESTIGATION PROCESS
1. My investigator visited HMP Wandsworth and spoke to staff who had dealings
with the man during his imprisonment and prisoners who knew him. He
interviewed eight members of staff and two prisoners. Eight of these interviews
were recorded and transcripts are annexed to this report. Copies of these
transcripts were sent to the interviewees to check and agree that they were
accurate. (Four signed copies were returned.) The other two interviews were
not recorded but notes of the meetings were taken and forwarded to the
interviewees to confirm the content. Neither of these interviewees returned
signed copies.
2. Notices were posted to staff and prisoners about the investigation. There was
one response from a prisoner. In addition, my investigator studied all relevant
prison records relating to the man. These included his main prison record,
medical records and statements made by staff. My investigator also visited the
wing where the man lived, including his cell and the staff office.
3. Wandsworth Primary Care Trust identified a clinical reviewer to carry out a
review, which was received on 1 September 2008. I am most grateful for the
review. My investigator discussed aspects of the response to the man’s collapse
with both healthcare staff at Wandsworth and with the clinical reviewer.
4. The investigator also contacted HM Coroner to inform him of the nature and
scope of my investigation and request a copy of the Post Mortem report. Upon
completion, this report will be sent to the Coroner to assist his enquiries into the
man’s death.
5. One of my Family Liaison Officers spoke to the man’s mother. She said that she
wanted to know the cause of her son’s death, and to see my report. I hope that
my report answers any questions that the man’s family may have.
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HMP WANDSWORTH
6. Wandsworth is one of the largest prisons in Western Europe. It was first opened
in 1851. It has the capacity to hold over 1,400 prisoners and a recently-opened
refurbished wing has added extra cells.
7. The Onslow Unit is the Vulnerable Prisoners Unit and is separate from the main
accommodation units. It holds up to 300 prisoners.
8. Wandsworth has 24-hour healthcare cover. There is at least one doctor on site
until 10.00pm, and on-call cover out of hours. However, the doctors act as
General Practitioners and do not necessarily expect to respond to emergencies.
Hotel Three is the radio call sign for the emergency response medical officer in
the prison, and this will be taken on rota by medical staff.
Inspectorate report
9. The most recent inspection of Wandsworth by HM Chief Inspector of Prisons
was a full follow-up inspection in July 2006. The subsequent report does not
touch on any of the issues raised in this investigation.
Independent Monitoring Board (IMB)
10. Each prison in England and Wales has an Independent Monitoring Board
responsible for monitoring day-to-day life in the prison and to ensure that proper
standards of care and decency are maintained. The last report published by the
IMB before the man died does not raise any issues of relevance to this
investigation.
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KEY FINDINGS
11. The man was convicted on 30 January 2007, and on 12 March 2007 was
sentenced to two years imprisonment. He was allocated to HMP Wandsworth,
and located in the Onslow Unit. He worked as a cleaner and received good
reports and several commendations for his work.
12. After the initial health screening at reception, the man did not have any proper
contact with healthcare staff until 11 February 2008 when he complained of a
dental abscess. He was prescribed antibiotics and painkillers.
13. A fellow prisoner and the man had been on a cleaning course together, and
knew each other reasonably well. On the Friday before he died (Friday 15
February), the man complained to the other prisoner about pain in his chest.
The prisoner asked him to point to where this pain was, and the man pointed to
his side just above his hip. The prisoner joked that this was not really chest
pain, but advised the man to speak to medical staff if he felt any more pain. It
does not appear that the man took this advice. At interview with my investigator,
the other prisoner wondered whether the man felt a degree of stress about his
imminent release. The man was due to be released within a matter of weeks,
and had expressed some concern as to how he would cope and be received on
his return to society.
14. Because of a staff absence, the office where the man worked as a cleaner was
not open for a time in February. The man therefore did not go to work for a few
days. This was the case on Monday 18 February. The man’s cellmate had only
recently arrived in Wandsworth, he did not yet have a job. The man’s cellmate
told my investigator that the man enjoyed his job, and was a little unsettled by
having nothing to do. They played cards and Scrabble up until lunchtime, which
was approximately midday. They went from their cell on the fourth floor landing
(K4 landing) down to the servery on the second floor, where they collected their
lunch and brought it back to their cell. Once they were back in their cell the door
was locked.
15. After lunch the man said that he was tired, and asked his cellmate if he minded if
he went to sleep. His cellmate said that was fine by him and decided to sleep as
well. The man was in the top bunk bed and his cellmate in the bottom one.
Each retired to his bed, setting a reminder on the television to wake them in time
to listen to the draw for the quarter-finals of the FA Cup at 1.25pm.
16. The two men woke in time to listen to the FA Cup draw, then talked about
football for a time. They then turned the television off so they could sleep some
more. The man’s cellmate told my investigator that the man began to snore very
loudly, so much so that he thought he was putting it on for comic effect. He
kicked the bed to shake it, but the man did not stop snoring. They were friends,
and the cellmate decided to let him enjoy what he assumed was his joke. The
snoring generally subsided, but with an intermittent loud snore every now and
again.
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17. After a while, the man’s cellmate got out of his bed to use the toilet. He noticed
the man’s arm hanging out of his bed, but did not disturb him and went behind
the privacy curtain. When he came back out he saw that the man’s eyes were
open and he was looking towards the ceiling. There was nothing unusual in that:
The man had often silently reflected on things, and his cellmate went back to his
bed.
18. About 30 minutes later the cell door was unlocked. This was not a prison roll
check and the officer unlocking would not be expected to look into the cell. The
man’s cellmate saw that the man’s arm was still hanging out of his bed, but now
it had changed to a purple colour. The man’s cellmate immediately suspected
that something was not right and got out of bed. He looked at the man, and
noticed that he had no colour in his skin and his veins were protruding. He
called the man’s name a few times but, getting no response, ran out of the cell to
get help.
19. An officer was patrolling on K wing, and was only a few doors along the corridor
when the man’s cellmate came out of the cell. This was at approximately
2.20pm. He was the nearest member of staff and the cellmate told him that the
man was not breathing. The officer went into the cell and noted that the man’s
skin was discoloured, and that he did not appear to be breathing. The officer
had not received any first aid training beyond that which he received as part of
his initial prison officer training, and told my investigator that he did not feel
confident that he could resuscitate the man. He also thought it important to alert
other staff rather than commencing resuscitation and not being able to summon
help. He came out of the cell and called to a colleague on the second landing,
telling him to get a nurse. The officer then ran down the stairs to the second
landing to alert other members of staff and get medical assistance from
someone in the treatment room on the second floor landing. On the way there
he passed a second officer on the stairs and told him what was happening.
While the officer went to the treatment room, the second officer ran back up to
the fourth landing and into the cell.
20. Like the first officer, the second officer had received no first aid training beyond
his initial prison officer training. He saw the man, and was taken aback by how
he looked. He stepped back out of the cell. Only certain staff in each area of
the prison carry radios. On that day another officer was one of the staff on
Onslow Wing who had a radio. The second officer called over the balcony to the
third officer on the second landing that there was a Code Three situation. (Code
Three is a radio call sign used to indicate that someone is not breathing, and is
understood by staff throughout the prison.) The third officer immediately notified
the control centre over the radio, and then went to the fourth floor landing so a
member of staff with a radio was available if required. This was at 2.25pm.
21. Two nurses were in the treatment room on the second floor landing when the
first officer came in and said that a nurse was needed on the fourth floor landing.
The first nurse saw from the first officer’s manner that it was urgent and ran up to
the cell. On arrival he checked the man for signs of life but could not find any.
He called out that someone should ensure that Hotel Three was on the way.
The man was still lying on the top bunk bed, so the first nurse stood on a chair to
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allow him to begin cardiopulmonary resuscitation (CPR). The first nurse told my
investigator that he was not hampered in performing CPR by having to do it
while standing on a chair.
22. A crowd of prisoners had gathered around the door to the cell, and one prisoner
said he thought the man was dead. The first officer and colleagues cleared the
crowd and escorted prisoners on the landing back to their own cells. At this
point the man’s cell mate collapsed. The second officer helped him to the
medical room and a doctor briefly checked him before the second officer showed
him into an office and took a statement from him. The man’s cell mate was quite
distressed, and was taken into a Listeners suite. (Listeners are prisoners who
have been trained by the Samaritans to provide support for other prisoners). A
member of the chaplaincy team, a Reverend, came and spoke to him and he
was allowed to make a telephone call. He spoke further with Listeners in the
Listeners suite and, after he had changed his clothing, he was taken to another
cell to share with another prisoner with whom he was friendly. The second
officer opened an ACCT document (Assessment, Care in Custody and
Teamwork: support for prisoners who may be vulnerable or at risk of self-harm)
for the man’s cellmate. He also made sure he spoke informally to the man’s
cellmate in the following days.
23. The senior officer of staff on Onslow Unit on 18 February was briefed as to what
was happening. He arrived at the cell at the same time as the third officer.
Neither the senior officer nor the third officer had received any first aid training
since their initial basic training. The senior officer told the third officer to assist
the first nurse. The third officer took over performing chest compressions,
balancing himself with one foot on the chair and one foot on the bed. Again, the
third officer told my investigator that he was not hampered by having to perform
CPR with the man still on the top bunk bed. The senior officer asked the first
nurse if he needed an ambulance, and checked with the control centre to ensure
one was on its way. An ambulance was called by the control centre at 2.33pm.
The senior officer alerted the duty governor and also ensured that a member of
staff was taking a log of what was happening, and that the Orderly Officer (the
senior member of staff scheduled that day with responsibility for the prison’s
operations) was aware of the situation.
24. A sister was the designated Hotel Three medical emergency responder on 18
February. When the control centre had been informed that there was a Code
Three emergency, they radioed the sister and told her to go to A4 landing. This
was at 2.26pm. The sister was being shadowed by another nurse on that day,
so she instructed the nurse to collect an emergency bag and she went straight to
A4. On arrival there was no sign of any emergency, and staff there were
unaware of one. The sister radioed the control centre and asked for
confirmation. The control centre checked, and then informed sister that the
emergency was on K4 landing. It took the sister a further few minutes to make
her way to the Onslow Unit, where she and the nurse were directed by staff to
the man’s cell.
25. The duty governor on being alerted by the senior officer, immediately made his
way to the man’s cell. He ensured that an ambulance had been called and that
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a log was being taken, and informed the Governor and Deputy Governor what
was happening. He then relieved the third officer in performing CPR. As more
medical staff arrived, the third officer left the cell. The duty governor continued
performing CPR until he in turn was relieved by the first nurse. The duty
governor told my investigator that it was a deliberate decision to carry on
performing CPR with the man on the top bunk bed, and to take further advice
from paramedics when they arrived.
26. When the first nurse had left the treatment room and gone to the fourth floor
landing, the second nurse secured the room and followed on with an emergency
bag. He remained outside the cell and passed equipment in to colleagues as
required.
27. When the sister arrived at the man’s cell, the first nurse was performing CPR.
He briefed the sister on what had happened, and the sister checked the man for
signs of life. She found none. While first nurse continued with chest
compressions, the sister told the nurse to manage the man’s airway and provide
oxygen. The sister applied a defibrillator (a machine that applies electrical
impulses to the heart) to the man’s chest. The machine indicated that there was
no rhythm. They continued to check the man’s heart for traces of rhythm every
two or three minutes whilst still performing CPR, but no rhythm was found. The
man vomited due to the pressure of the chest compressions. (It is a possible
effect of CPR and did not indicate that he was still alive at the time.)
28. The ambulance arrived at 2.45pm. Paramedics went to the man’s cell, which
non-medical staff had now left. With prison medical staff continuing CPR, the
paramedics went through their system of checks on the man. No signs of life
were found. They administered drugs to the man to assist the resuscitation
effort, but to no avail. Shortly after 3.00pm it was agreed that life was extinct,
and that the man had died. The paramedics left the prison and, after medical
staff had cleaned the man, the cell was sealed.
29. A hot debrief was held by a principal officer. Members of the Post Incident Care
Team attended to offer support to any staff who felt that they needed it, and to
let them know that ongoing support would be available afterwards. Uniformed
staff told my investigator that they were happy with the support offered. The first
officer told my investigator that the principal officer spoke to him in the days
afterwards to ensure he was not suffering any delayed anxiety or problems. A
round-up meeting was also held the following day (Tuesday 19 February),
chaired by a governor.
30. When they had left the man’s cell, the sister had asked medical staff to make
written statements. She checked that the staff were all okay and asked if
anybody had any issues they wanted to raise. There were none. Medical staff
were also invited to the hot debrief, but by the time they had completed their
statements none actually attended.
31. Prisoners were locked in their cells after lunch. Rumours spread through the
wing that this was because a prisoner had taken his own life. Later that
afternoon, the other prisoner was in the queue to collect his evening meal when
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another prisoner said he had heard that it was the man who had taken his own
life. A member of staff confirmed that it was the man who had died, but had
collapsed rather than taken his own life. The other prisoner was rather shocked
by this news and the way he had found out. He does not recall any official
notification being made to prisoners. The other prisoner was aware of the
methods of support that were available to him both at the time and subsequently,
but does not remember being specifically offered support should he have
needed it. Staff told my investigator that all prisoners with an open ACCT
document were reviewed within 24 hours.
32. The man’s family were informed of his death by the prison’s family liaison officer,
and the chaplain. They were offered assistance with the funeral costs, and the
prison was represented at the man’s funeral. The family told my family liaison
officer that they were treated well in their contact with the prison.
33. The two nurses told my investigator that no formal support was offered to them.
They would have welcomed this. The first nurse did say, however, that a
governor personally spoke to him and thanked him for his attempts to revive the
man. The sister, his line manager, was also supportive in the following days.
The sister told my investigator that, while she did not recall any support actually
being offered, she was aware of the good support available from colleagues and
from the prison’s care team.
34. A church service for the man was held in the prison chapel. The man’s family
were invited to this service and attended. Prisoners also signed a book of
condolence.
Post mortem report
35. The post mortem report indicates that the man died of a prolapsed mitral valve
and left ventricular hypertrophy, which are both problems with the heart.
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ISSUES
Healthcare
36. The clinical reviewer says that he found nothing significant in the man’s medical
records. His family have said that the man had heart surgery as a child, but medical
notes do not contain any information about this.
37. There is no evidence that there was any infection as a result of the man’s dental
abscess. There was no evidence of any illegal substances in the man’s system, and
the clinical reviewer is of the opinion that the man died from natural causes.
38. The call to the control centre informing them of the emergency was made at
2.25pm. An ambulance was not called until 2.33pm. Prison Service Order 2710
says that “local contingency plans must provide for the summoning of an ambulance
… and state clearly who should do this”. In this case trained medical staff were with
The man in a very short time and it is unlikely that the delay had any effect on the
outcome. However, while I make no formal recommendation, the Governor will wish
to ensure that Wandsworth’s local instructions are clear about summoning an
ambulance when an emergency call has been made.
Staff first aid training
39. Uniformed staff are given first aid training as part of their induction when they
join the Prison Service. Beyond that, there are no further courses or refreshers
unless staff elect to undertake these on their own. The first two members of staff
who entered the cell looked at the man and then went to seek help. Neither felt
confident in attempting CPR. Although I do not believe it likely that their decision not
to commence CPR made a difference on this occasion, it could do so in other
circumstances. The Governor will wish to consider what further advice or training he
should offer his staff about their responsibilities when ‘first on scene’.
40. In that light, the second officer told my investigator that he thought annual
refresher training would be helpful. The duty governor told my investigator that first
aid training is often cancelled through lack of instructors. The clinical reviewer writes
that the prison should consider regular updates on basic life support training for
uniformed staff. This is a view that I share. Indeed, the question of first aid and life
support training arises in very many of my investigation reports.
The Governor should consider refresher first aid training for all staff who come
into contact with prisoners.
41. When staff attended the man’s cell and needed to perform CPR, The man was
lying on the top bunk bed. Rather than moving him before attempting resuscitation,
staff stood on furniture to put themselves at the correct height. The clinical reviewer
notes in his report that staff were carrying out resuscitation in a satisfactory fashion.
I do not underestimate the physical and emotional demands on both uniformed and
healthcare staff when attempting resuscitation and intend no criticism whatsoever of
the staff members concerned. For that reason, I make no further comment save to
note that CPR is best conducted on a firm surface rather than on a bed. Again, this
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is something that the Governor may wish to reinforce in his advice to staff about
dealing with a medical emergency.
42. When the emergency responder, the sister, was told to respond to a Code Three
emergency call she was sent to the wrong location. In this instance medical
assistance was already with the man and it does not appear that this had a material
effect on the final outcome. I do not make a recommendation here, but the Governor
will wish to reinforce to his staff that it is imperative in an emergency that the correct
information is passed on.
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RECOMMENDATION
The Governor should consider refresher first aid training for all staff
who come into contact with prisoners.
The Prison Service have partially accepted this recommendation. They
comment that HMP Wandsworth are in the process of organising a “heart
start” training programme for staff. All staff who have contact with prisoners
will undertake the course and will be regularly refreshed as part of a rolling
programme organised by the training department
.
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