Individual at Whatton

Investigation into the circumstances surrounding the
death of a man at HMP Whatton
in December 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
June 2008
This is the report of an investigation into the death of a man who died in December
2007 at HMP Whatton. The man had a history of heart disease, including angina,
and collapsed whilst carrying out cleaning duties.
A post mortem was held at the request of HM Coroner for Nottingham. It found
that the man’s death was due to natural causes, resulting from coronary
atherosclerosis (hardening of the arteries supplying blood to the heart) and
myocardial fibrosis (scarring of heart muscle). I extend my sincere condolences
to the man’s mother, family and friends.
This investigation was undertaken by my colleague. In addition, a review of the
man’s medical care at Whatton was commissioned by Nottinghamshire Primary Care
Trust and carried out by a doctor. I would like to thank the Governor of Whatton and
his staff for their help and assistance. I am also grateful to the prison’s liaison officer
for her support during the investigation.
The man had been non-compliant with his medication, and had otherwise shown
self-harming tendencies. On various occasions, he had been placed on ACCT
monitoring and support. However, the clinical reviewer judges that the quality of
care he received was entirely appropriate and of a high quality. I entirely concur.
I do not make any recommendations in this report, but have been pleased to formally
recognise the professionalism shown by healthcare staff in their interventions with
the man.
In this final version of my report, the draft report has been seen by the Governor,
Area Manager. They consider it to be fair and are pleased that healthcare staff
provided good care for the man and that it was recognised in the report.
This version of my report, published on my website, has been amended to remove
the name of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2008
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CONTENTS
Summary
The investigation process
HMP Whatton
Key findings
Issues
Good practice
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SUMMARY
The man was remanded to HMP Nottingham in September 2005. His first reception
health screen document noted he was awaiting tests for possible bowel cancer, and
had an outstanding appointment to see a cardiovascular doctor. The man was also
depressed, so arrangements were made for him to see the mental health team. He
later asked to be placed in the prison’s segregation unit for his own protection.
The man was assessed by the registered mental health nurse (RMN). No clinical
symptoms of depression were noted, and it was judged that the man was reacting
appropriately to his situation and missing his family. He was prescribed medication
for hypertension and high cholesterol, and painkillers when needed.
Over the next 12 months, the man remained at Nottingham. He showed a negative
attitude to his health, declining to take responsibility for his well-being, and on many
occasions refusing his medication. Tests indicated that he was not suffering from
bowel cancer, but had haemorrhoids. On two occasions, the man was place on an
ACCT plan (the Prison Service’s system for monitoring and supporting prisoners
believed to be at risk of self harm) for food refusal which lasted for two to three days.
The man was bailed by the court on 5 September 2006. On 10 January 2007, he
was convicted of serious offences and returned to HMP Nottingham to await
sentencing. On arrival at Nottingham an ACCT plan was opened as the man told
reception staff he felt at risk of self-harm. He refused medication and was again
located in the segregation unit at his request. An assessment by a RMN noted that
there was no evidence of depression or paranoia. The man refused food
intermittently.
Following his sentence of six years imprisonment imposed by a Crown Court on 14
February, The man transferred to HMP Lincoln on 23 February 2007. nine days
later, he moved to HMP Whatton. However, he did not settle at Whatton, and
constantly requested a move back to Nottingham. He also refused food from time to
time, and declined to take his medication, and there were two incidents of minor self-
harm. An ACCT plan was opened on several occasions.
In August 2007, the man attended hospital for tests and a diagnosis of mild, yet
stable, angina was made. He was prescribed medication but was regularly non-
compliant.
On 7 December 2007 at about 8.55am, the man was carrying out his duties as a
wing cleaner when he was seen to stagger backwards and fall to the floor. Wing
staff immediately alerted healthcare. Three nurses arrived on the wing within two
minutes and started cardio pulmonary resuscitation (CPR). A defibrillator was used
and three cycles of shocks indicated that the man was in a late phase of heart
failure. As a result, CPR was continued. Paramedics arrived at 9.23am and took
over the resuscitation attempts. At 9.39am, paramedics and healthcare staff
stopped treatment and the man was pronounced dead at 9.40am.
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The man’s mother was promptly informed of the sad news of her son’s passing. The
Governor attended the man’s funeral and held a memorial service later the same
day.
I have made no recommendations in this report. However, I have drawn attention to
the professional manner in which healthcare staff dealt with the man during his time
at Whatton and after his collapse.
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THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened on 19 December 2007 when
my investigator visited HMP Whatton. Notices and the Ombudsman’s terms of
reference had been sent to the prison in advance. My investigator met the
Governor, and a member of the Independent Monitoring Board (IMB). However,
representatives of the Prison Officers’ Association (POA) decided there was no
need to meet with my investigator. Later, my investigator visited A wing (the wing
where the man had been housed) and spoke to an officer, the man’s personal
officer.
2. This report is based on records held in the man’s prison file. No formal interviews
have been undertaken.
One of my family liaison officers wrote to the man’s mother, asking if she wished
to raise any concerns regarding her son’s death, or if she would like a visit. At the
time of writing this report, the man’s mother has neither asked to see my liaison
officer nor raised any particular issues regarding her son’s time in prison.
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HMP WHATTON
3. Whatton is a category C prison that currently holds 761 adult male prisoners, all
sex offenders. It first opened as a detention centre for juveniles, but its role
changed in the early 1990s to that of a prison for vulnerable adult offenders.
During this time, the prison developed as a specialist establishment for adult
male sex offenders to enable them to participate in the Sex Offender Treatment
Programme. Whatton has recently undergone a large expansion programme.
4. Whatton was last inspected by HM Chief Inspector of Prisons in February 2004.
The report found that, “Whatton … provided a respectful environment with good
standards and cleanliness, food and healthcare. Staff-prisoner relationships
were excellent which … speaks volumes for the professionalism of the staff.”
5. Healthcare within the prison is provided by Nottinghamshire County Teaching
Primary Care Trust. The prison does not have a 24-hour healthcare service,
therefore no medical staff are on site during the night or weekends. If staff need
a doctor out of hours, this is provided by Nottingham Emergency Medical Service
(NEMS).
6. Medication is administered on a weekly and/or monthly basis to those prisoners
who have been risk assessed as suitable to hold it in their own possession. It is
administered on a daily basis to other prisoners, if they are considered to be at
risk or the medication is considered unsuitable to be held in-possession in the
prison environment.
7. This is the second death from natural causes due to a heart attack investigated
by my colleague at Whatton this year. The previous death occurred during the
night and issues were raised in relation to staff procedures and access to
qualified healthcare staff. Those issues have been addressed through an action
plan submitted by Whatton and not related to the man’s death, which took place
in the morning, and healthcare staff were on the scene within minutes.
8. A section from the summary of the 2007 annual report from the prison’s
Independent Monitoring Board noted:
“The Board considers Whatton, in general, provides a safe environment
where all are treated with respect and given many opportunities to engage in
purposeful activity to improve their lifestyle and reduce their re-offending.
That is not to say that just as in life outside it is not without its exceptions.
The Board would welcome single accommodation for all.”
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KEY FINDINGS
9. On 29 September 2005, the man was received into HMP Nottingham on remand.
A number of health matters were recorded on his first reception health screen,
including a note that he was awaiting the result of a blood test to determine
whether he had bowel cancer. The man had also said he had an outstanding
outpatient appointment for 31 October at hospital. It was noted that the man had
been prescribed aspirin but was not taking it as it upset his stomach, and that he
was depressed.
10. The following day, the man was seen by the prison’s General Practitioner (GP)
who noted The man’s depression and requested that he be seen by a registered
mental health nurse (RMN). On 13 October, the man was seen in healthcare
where it was noted that he had not yet seen the mental health nurse. The GP
requested that this appointment and the man’s medical records from his
community GP be chased up.
11. At the man’s request, he was placed in the segregation unit for his own protection
because of the nature of the offences with which he had been charged. The
man’s appointment at the hospital on 31 October was cancelled due to lack of
escort staff and re-arranged for two months later. On 15 November 2006, he was
seen by a mental health nurse. The nurse noted that he was reacting
appropriately to his current situation, although he was missing his daughter and
was concerned about his elderly mother. There were no clinical symptoms of
depression. Nine days later, the man was seen again by the mental health nurse
and he agreed to their continued support.
12. The man made regular visits to healthcare for various medical complaints. His
general health, medication and baseline observations were monitored and
appropriate treatment offered. His blood pressure was higher than the normal
range and was checked on a regular basis. He was prescribed medication for
hypertension and high cholesterol, and painkillers when appropriate. On 5
January 2006, it was noted in the man’s medical records that he was non-
compliant with the medication statin (for reducing high cholesterol) as it made him
nauseous.
13. The man refused to attend his outpatient appointment at the hospital vascular
clinic on 9 January 2006 as he had a legal visit that day and considered it a
priority. When he saw the mental health nurse on 26 January, it was noted that
he was still struggling with his current situation. In February, following a court
appearance, it was noted that the man was feeling suicidal with thoughts of self-
harm. Four days later, he was again seen by the mental health nurse and was in
a brighter mood. On 27 February, the man attended an outpatient appointment
at hospital. He was seen by a surgeon for vascular disease and advised to take
exercise and aspirin.
14. On 6 March, the GP wrote a referral letter for the man to see a consultant
surgeon at hospital as had been complaining of haemorrhoids and a sore anus.
Six days later, the man saw a RMN who noted that he was not keen to attend the
gymnasium as suggested by the surgeon during his appointment at hospital. On
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15. On 24 April 2006, the man told a nurse that he would take no further medication
until he had seen the mental health nurse. He was advised that he could see
someone else, but refused this offer. On 1 May, the man was seen by an
occupational therapist. The therapist noted that he seemed more annoyed than
depressed.
16. The man attended hospital on 15 May for an appointment with a consultant
surgeon. Following an examination, it was concluded that the man had
haemorrhoids and nothing more sinister. He was prescribed a soothing ointment.
17. On 5 June, the healthcare centre received a call from the vascular clinic at
hospital. The clinic had received a letter from the man requesting an
appointment and complaining about the lack of care from the prison’s healthcare
centre. A nurse saw him that day and discussed with him his negative approach
to his well-being. Two days later, the man was seen by the GP who noted the
man had an immature attitude to his health and was unwilling to take any
responsibility for his own well-being. The man’s medical records show that on 12
July he was continuing to refuse medication but appeared to be mentally stable.
18. The man saw the mental health nurse on 4 August who recorded that he was
worried about his daughter being in care and being adopted against his will. He
was also anxious abut his forthcoming trial, but seemed to be coping. On 25
August, it was recorded that he was refusing medication because he was not
being treated as well as other prisoners. The nurse asked the man to sign a
disclaimer form for medication refusal, but he replied that he was busy and would
do it when he felt like it. He then became verbally aggressive and agitated. Two
days later, the man again refused to sign a medication refusal disclaimer.
19. On 30 August, wing staff informed healthcare that the man was on hunger strike
and had not eaten for three days. He had further said he would not take fluids,
but requested paracetamol for leg pain. An Assessment, Care in Custody and
Teamwork (ACCT) plan was opened. The next day, the man was seen to have
taken food and a drink.
20. On 1 September 2006, he requested a single cell but was told this would not be
practicable whilst he was on an ACCT plan. He also said he would assault an
officer and stop eating so he could be located in either the segregation unit or
healthcare centre when he returned from court the following day. The man and
the nurse discussed more appropriate ways of dealing with his feelings rather
than making threats. Three days later, when the man returned from court he
asked to be located in the healthcare centre. At that time healthcare was full, so
he returned to E wing and the medical staff based there were made aware of the
situation. The man accepted his return to E wing and was told to let wing and
medical staff know if he needed extra support. In September, the man attended
a court appearance and was granted bail.
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21. In January 2007, the man was convicted of serious offences and returned to
HMP Nottingham to await sentencing. His medical notes record that he had been
discharged from the hospital the previous day having suffered chest pain. The
man said he felt at risk of self-harm and an ACCT plan was opened. He was also
referred to the GP and the mental health nurse. The next day, the man refused
to see the GP or take his medication. He handed a member of the healthcare
staff all his medication, including his Glyceryl Trinitrate (GTN) spray for his heart.
Staff felt that the man had been very arrogant in his attitude, and he said he was
happy to take the consequences of having no medication. He was located in the
segregation unit at his own request.
22. Five days later, the man was still refusing his medication, but was considered fit
and well. The next day, he told medical staff that he was neither eating nor
taking his medication. On 17 January, the man was assessed by a RMN. The
nurse noted that he was still refusing medication and they had discussed the
consequences. The man said he was aware of the implications of refusing his
medication and accepted responsibility for his actions. The RMN could find no
evidence of depression, paranoia or other psychotic phenomena, and there was
good eye contact. The man presented as lucid and rational in his speech and its
context. The RMN noted that he would discuss the man’s assessment with the
GP. The next day, the GP noted that it was the man’s decision to decline his
medication.
23. On 19 January 2007, it was noted that the man was still declining medication and
meals but appeared fit and well. The wing senior officer expressed his concerns
to medical staff. He told them that the man had said he had not eaten for five
days. The next day, a nurse saw him lying on his bed and recorded that he
seemed fit and well. He told the nurse he was ‘living on coffee’. He said he had
asked to see a psychologist and was not happy with the service being provided.
The nurse offered the man some encouragement and reassurance. A urine test
showed no abnormalities. The ACCT plan was continued.
24. The man approached a member of healthcare on 23 January and complained
that nobody had been to see him regarding his hunger strike. He told the nurse
that he had not eaten for eight days. The nurse examined the man and noted
that he looked well, was well hydrated and showed no physical signs of any
health problems. There was good eye contact, a reasonable standard of self-
care and no evidence of any other acute mental health issues. Two days later,
the man’s weight was noted to have dropped four kilograms since his reception
into Nottingham.
25. On 27 January, the man was still refusing his medication, but was eating small
amounts of food and taking fluids. He appeared cheerful, with good eye contact
and his cellmate had been encouraging him to eat. The next day, he was
weighed and it was noted he had lost one kilogram in the previous three days.
The man was still eating small meals but not taking his medication. By 4
February, his weight had increased by a kilogram. He was seen by a RMN and
they discussed his life and present situation. The RMN advised the man to think
positively.
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26. The man refused breakfast, lunch and medication on 12 February. He said he
had thrown away his GTN spray. He further instructed staff that he did not want
any intervention if he fell ill. The next day, the man had an assessment with a
RMN who noted that he seemed low in mood with a general sense of apathy and
hopelessness. The nurse suggested that an anti-depressant medication might
help and other therapeutic interventions could be explored. The man told the
nurse that he had no immediate thoughts of self-harm or suicide, but did get
bothered by others. The nurse noted that he required ongoing support and
reassurance and his current ACCT plan was to continue.
27. The next day, the RMN saw the man again. He still appeared low in mood and
negative in his thought processes, but there were no thoughts of self-harm or
suicide. The ACCT plan was to be continued.
28. Three days later, the nurse told the man he needed to start taking control of his
life and they discussed how he could do this. The nurse noted that he was in
need of support and encouragement. An anti-depressant drug was prescribed to
help lift his mood. The following day, the man appeared more relaxed; he was
taking plenty of fluids, although his weight had dropped by three kilograms.
29. The man transferred to HMP Lincoln on 23 February 2007. The next day he told
medical staff he would ‘cut up’ if he did not see anyone from the mental health
team. He remained on an ACCT plan and was located in the healthcare centre.
Nine days later, the man transferred to HMP Whatton.
30. The man attended the healthcare centre for a health check on 9 March. It was
noted he was feeling low in mood and did not want to take his medication. He felt
that there had been a lack of response to his health problems and said, “I don’t
believe in drugs”. The nurse discussed the importance of maintaining his blood
pressure within the recommended limits. The man was aware of the implications
as his brother and father had both had strokes, and his mother had suffered three
heart attacks. He said he had no suicidal or self-harm thoughts. The nurse
made a note to check with the hospital find out if the man had an outstanding
appointment with the vascular department and referred him to the RMN.
31. A RMN who saw the man on15 March recorded that he was not taking his
medication, but not actively planning any self-harm. Later that day, medical staff
made contact with the vascular department at the hospital. In response to their
enquiries, the hospital confirmed the following day that there were no outstanding
appointments in respect of the man. However, if he needed to see the vascular
surgeon he should be referred.
32. On 22 March, the GP wrote a referral letter to the consultant vascular surgeon at
hospital. The GP informed the consultant that the man felt he had not been
receiving appropriate treatment and had declined to take his medication. During
a health check the following day, the man told the nurse that he had been
unhappy with his treatment at Nottingham. The nurse explained to him that he
could have in-possession medication if he took responsibility for his health. The
man agreed and took his medication. However, four days later, he saw the RMN
who noted that he was angry and frustrated and had started another ‘hunger
11
33. On 27 March, the man was again seen by a RMN. It was noted that he was no
longer on an ACCT plan, had no current thoughts of self-harm and no evidence
of mental illness. The nurse recorded that his mood was subjectively low, but
there were no symptoms of depression. Two days later, the man attended the
healthcare centre for a pre-planned electrocardiogram (EGC), to measure his
heart rate, and for a blood pressure check. The tests did not take place as he
presented as angry and stressed. The man then returned all his in-possession
medication to medical staff.
34. The next day, the man attended healthcare for blood tests. He had flatly refused
to fast for the tests, and said he was not eating. The man fainted after the blood
test and was given some time to recover. He also accepted a cup of sweet tea
and a biscuit. Later, the nurse rang wing staff and was told that the man had
taken food and drink on the previous days, and was no longer refusing food.
35. When he attended a healthcare sick parade on 4 April, the man said he was
feeling anxious, not sleeping, had a headache and chest pain. The man refused
any medication and said he wanted to be frustrated. He further said he would
harm himself or anybody that got in his way. The nurse was advised to complete
a security information report to inform the security department of the man’s threat
to hurt someone.
36. A week later, the man attended healthcare saying he felt unwell. The nurse
discussed the symptoms with a senior nurse who thought that his refusal to take
his medications, especially those for high blood pressure, could be the cause.
Both nurses explained to him the potential consequences of not taking his
medication and his high risk of having a stroke. He was insistent that he did not
want to be at Whatton and blamed his non-compliance on the stress and issues
he had with the prison. The man was advised that, if he continued not to take his
medication against healthcare advice, he would need to sign a disclaimer. He
remained unwilling to accept the advice.
37. Two days later, the man attended healthcare complaining of chest pain. He was
still not taking any medication. The man had been told he was moving from A to
B wing. He did not want to move and claimed this was making him feel stressed.
When the nurse told him this move could not be overruled by medical staff, he
said, “Well I’ll kill myself then”. The nurse opened an ACCT plan. The nurse
later visited the man on A wing, the ACCT plan was closed and he agreed to take
his medication.
38. On 24 April, the man stopped eating and drinking. He had also cut himself during
the night because he had been moved to B wing. Several superficial cuts to his
arms had been dressed. The man told staff he had stopped taking his
medication and on return to his cell would smash it up. In view of this, an ACCT
plan was opened. Later that day, he went to the pharmacy and asked for
paracetamol. The nurse went to the wing and spoke to the officers there
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39. Healthcare staff were called to B wing on 30 April. The man had told discipline
staff he was agoraphobic and could not get his meals from the servery or go to
healthcare to collect his medication. He had been eating sandwiches brought to
him in his cell. The medical notes show that he had been to the visits hall earlier
that day for a legal visit, and there was no record of him having agoraphobia.
Additionally, the man had previously been socialising with other prisoners and
using the phone. Wing staff were advised not to collect food for him and he was
taken off the food refusal register. The medical notes for this day record that the
man had not attended healthcare for a blood pressure check.
40. An ACCT review was held on 2 May, attended by a RMN. There had been no
change in the man’s attitude: he presented as angry and claimed to be
agoraphobic. He said he would harm himself if his demands were not met. Nine
days later, he again attended healthcare. He reported two angina attacks, but
said he did not use his GTN spray as he did not like the side effects. He had
been moved back to A wing and had resumed collecting his meals. It was
agreed that he could collect his meals from reception if he felt that would keep
him away from large numbers of people. He was still non-compliant with his
medication.
41. On 4 June, the man complained of four angina attacks over the weekend. He
had used his GTN spray, but it had left him with a headache for which
paracetamol was prescribed. Four days later, it was noted that he had wax in his
ears and was given some olive oil to soften it. On 15 June, the man had an
appointment with the GP who referred him to the cardiology department at the
hospital. Three weeks later, he saw a nurse about a mark on his left leg and
some pain when walking. The appointment at the hospital was subsequently
postponed until August.
42. Following a minor self-harm incident during the night of 16/17 July 2007, the man
refused to attend the healthcare centre. On 6 August, he saw the GP who noted
the man was unhappy at Whatton and was confused over his medication. He
was not taking his medication for angina. The GP explained his medication
regime, and made an appointment for the man to see the pharmacist to discuss
the possible side effects of an increased dosage of a beta-blocker.
43. The man attended hospital on 9 August for an exercise test. The results of the
tests were received two weeks later. On 22 August, the man saw a nurse with
whom he discussed his medication regime. The man told the nurse he would
only take aspirin, bisoprolol (the beta blocker) and statin, although he often failed
to take statin. He was warned of the consequences of not taking his medication
regularly, but did not seemed concerned. He also missed healthcare
appointments and blamed it on wing staff not unlocking him in time. The man
insisted that he wanted a transfer out of Whatton and was not interested in taking
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44. On 5 September, the man attended an out patient appointment at hospital to see
the cardiology surgeon. Following an examination and analysis of the man’s
previous exercise test, it was noted that he had mild chronic stable angina. The
surgeon also said that, if his symptoms persisted despite good anti-angina
medication, a coronary angiography (a procedure where dye is passed through
the heart and x-rayed) would be considered. A follow up appointment was made
for March 2008.
45. The man attended healthcare on 18 September. He was taking paracetamol for
his headaches, aspirin, bisoprolol and lansoprazole, but was refusing to take
amlodipine and statin. The nurse reiterated the importance of taking all his
medication. Two days later, the man saw the GP for a review. He was next seen
in healthcare on 4 October as he was feeling dizzy. Both ears had wax and olive
oil was prescribed. Two weeks later, he returned to healthcare. The man told
the nurse he was not sleeping and wanted a transfer from Whatton. She advised
about relaxation techniques.
46. On 12 November, the man saw the nurse and agreed to try amlodipine again for
his angina. On 5 December, he complained to staff in healthcare that he had
been lacking sleep for 12 weeks and felt his temper was increasing. He was
refusing to take his GTN spray due to headaches. The man also felt fellow
prisoners and staff were laughing at him. An appointment was made for him to
see a nurse on 10 December and a GP on 18 December.
47. However, in early December 2007 at about 8.55am while, the man was carrying
out his duties as a cleaner on A wing, he was seen to stagger backwards and fall
to the floor outside the wing office. Immediately, an officer rang healthcare for
staff to attend urgently. The man was placed in the recovery position. Three
nurses arrived at the wing within two minutes. A nurse examined the man. She
established that he was not breathing properly and there was no palpable pulse.
The nurse asked wing staff to call a code blue alert. (A code blue indicates a
medical emergency.) An ambulance was requested.
48. The nurse began resuscitation using a mask and oxygen, assisted by the other
two nurses. She called for the wing defibrillator machine (this delivers an electric
shock to the heart to re-start a rhythm) and began cardio pulmonary resuscitation
(CPR). An airway was inserted into the man’s throat. Three cycles of shocks
suggested that he was in a late phase of heart failure. Following those initial
shocks, the defibrillator advised that a shock was not appropriate, so the nurses
followed the non-shockable side of the defibrillator algorhythm and CPR was re-
started. The man’s throat was suctioned several times due to vomiting.
49. At 9.23am, a fast car paramedic and full ambulance crew arrived on the wing.
The nurses carried on with CPR whilst the paramedics connected the man to
their defibrillator machine. This machine also indicated that the man was in a
non-shockable rhythm. Nurses continued with CPR whilst the paramedics
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50. By 9.39am, there was still no response to treatment so it was agreed to stop the
resuscitation. The man was pronounced dead by the paramedics at 9.40am. He
was then moved back to his cell to maintain his dignity and show respect.
51. Later that morning, the prison’s Family Liaison Officer and the chaplain went to
inform the man’s mother of her son’s death. In the evening, the chaplain
telephoned the man’s mother to ensure she was receiving support from her
friends and family.
52. The Governor attended the man’s funeral in December 2007. Later that
afternoon, a memorial service was held in the prison’s chapel for the man’s
friends. The family accepted the prison’s offer of a contribution towards the costs
of the funeral.
15
ISSUES
Clinical Review
53. Nottinghamshire Primary Care Trust (PCT) was commissioned to carry out a
review of the man’s medical care. A doctor, carried out this review on behalf of
the PCT. The doctor’s summary is reproduced below:
“The man suffered from significant arterial disease affecting the heart and lower
limbs and he was suffering increasing attacks of angina leading up to his death.
Unfortunately as his angina got worse, either through lost confidence or just
belligerence, he took even less medication. In addition, the side effects from
some of the medication he had to take seemed to put him off from taking other
medication. His death in December 2007 whilst unexpected was not totally
surprising considering his medical history, poor compliance with medication and
attitudes to a healthy lifestyle.
“The man’s exercise capacity would have been much reduced with his angina
problem. He did complain of angina pains, and stated that these would occur
at rest. This would imply an element of instability. However, his recent
cardiology review at hospital stated he had mild chronic stable angina. With a
diagnosis of mild chronic stable angina he would have been advised not to
over-exert himself. However, aerobic exercise, where he could exercise and
talk at the same time would have been encouraged.
“The man made frequent complaints directed against prison healthcare. He
repeatedly stated that he wanted help but unfortunately, he either did not listen
to advice, or felt patronised whenever he was having a consultation. He
missed follow up appointments due to indifference, or his own sense of priority.
When he did miss appointments that were not of his doing, this all reinforced
his negative perceptions of prison healthcare.”
54. The doctor comments that the medical and mental health care of the man at
Nottingham and at Whatton was entirely appropriate. Staff always offered
support, encouraged compliance with medication and promoted positive lifestyle
choices. The attempts at resuscitation when the man collapsed in December
were also appropriate. The doctor concludes that there were no significant
shortcomings in the management of the man’s medical care at Whatton.
Healthcare
55. The man’s medical records contained legible, precise and well documented
entries whilst he was a Whatton. Members of healthcare appear to have been
understanding and very professional throughout their interventions with the man.
Following his collapse, the resuscitation and use of the defibrillator was also
appropriate. Although the man did not survive the heart attack, healthcare acted
promptly and competently.
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I note the professional manner in which healthcare staff cared for the man
as a patient and how they attended to him following his collapse on the
wing.
The man’s employment as a wing cleaner
56. The man was employed as a wing cleaner. His duties included the collection and
delivery of laundry from the wing. Shortly before he collapsed in December 2007,
the man had been collecting laundry on the wing and pushing a trolley. Although
he suffered from angina, I cannot find any evidence from the man’s medical notes
that this type of work would have been inappropriate given his medical condition.
In his clinical review, the doctor comments that, whilst the man would have been
advised not to over-exert himself, aerobic exercise would have been encouraged.
Conclusion
57. The man had a number of serious medical conditions, including heart disease
and mental health problems. The investigation has shown that medical
interventions were appropriate and staff referred him to outside hospital when
necessary. In spite of the man’s negative attitude towards the treatment of his
ailments, staff encouraged him to adopt a more constructive approach to his
health. The man’s collapse and subsequent death could not have been foreseen
and I have found nothing untoward in his management and treatment. Staff are
to be commended for their professionalism in caring for him. I have formally
recognised this as good practice in my report, and trust that my sentiments can
be shared with the staff concerned and their employer.
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GOOD PRACTICE
I note the professional manner in which healthcare staff cared for the man as a
patient and how they attended to him following his collapse on the wing.
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