Individual at Whatton

Circumstances surrounding the death of a man who was
a prisoner at HMP Whatton in September 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
March 2007
This is the report of an investigation into the death of a man. The man, a prisoner at
HMP Whatton, died from apparently natural causes on 5 September 2006 in outside
hospital. He was 77 years old.
I would like to add my personal condolences to those already expressed to the
man’s family on behalf of this office by one of my Family Liaison Officers.
This investigation has been undertaken by one of my investigators. He and I would
like to thank the Governor of HMP Whatton and his staff for their assistance.
Nottinghamshire County Teaching Primary Care Trust identified a doctor and Public
Health Assistant to undertake a review of the man’s clinical care, and we also much
appreciate their help.
As is the case in many of my investigations following a death from natural causes, I
am much influenced by the findings of the clinical review. I have noted the issues
highlighted by the clinical reviewers and there are clearly lessons to be learned in
terms of the clinical management of patients in prison. I endorse the
recommendations made in the clinical review and urge the prison health partnership
to develop an action plan to address these in a timely manner.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in the
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2007
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CONTENTS
Summary 3
The investigation process 4
HMP Whatton 5
Key findings 6
Clinical review 7
Conclusion 10
Recommendations 11
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SUMMARY
The man was born in 1929. He was 77 years old when he died on 5 September
2006 in a hospital in Nottinghamshire.
The man was received into custody after being sentenced on 14 December 2005 to
18 months imprisonment. He was initially held at HMP High Down and HMP Lewes
before being transferred to HMP Whatton on 6 June 2006. During his first health
screen, it was noted that the man had an abdominal hernia (protrusion of organs
through the abdominal wall) and had also previously undergone heart surgery for an
aortic graft to improve the blood flow to his heart. The man was due to be released
from prison on 13 September 2006.
During the early afternoon on 5 September 2006, the man complained that he was
feeling unwell. He was taken to Whatton’s healthcare centre for observation and,
after he had been assessed, an ambulance was called. Paramedics took the man to
hospital where doctors diagnosed a bleed from his aorta (the large vessel which
opens out of the heart and carries blood to the rest of the body) which would require
an operation. The man’s family were advised of his condition and he was allowed to
speak with them.
Whilst he was in hospital, a bedwatch was carried out by prison staff. The security
risk assessment was that handcuffs were to be used. However, due to the man’s
deteriorating condition and the impending operation, the restraints were removed at
5:40pm and not reapplied.
At 7:30pm, the man was taken into the operating theatre. Prison staff waited in an
adjacent room while the operation was performed. At around 10:40pm, doctors
informed the prison staff that the man had not survived the operation.
The clinical review identifies areas for improvement and makes five
recommendations that I support.
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THE INVESTIGATION PROCESS
1. My investigator studied all relevant prison records relating to the man. These
included his main prison record, medical records and statements made by
prisoners and staff.
2. The Nottinghamshire County Teaching Primary Care Trust identified a doctor
and a Public Health Assistant to carry out a review of the man’s clinical care. I
am grateful for this review being undertaken in a most timely manner.
3. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the Post Mortem report.
Upon completion, this report will be sent to the Coroner to assist him in his
enquiries into the man’s death.
4. One of my Family Liaison Officers contacted the man’s family. This gave them
the opportunity to meet with the investigator to discuss the purpose of the
investigation, and to raise any concerns or questions that they would like
explored and addressed. In the event, the family raised no specific matters of
concern about the man’s care and treatment whilst he was in custody.
5. My investigator discussed aspects of the man’s treatment with staff and
prisoners at Whatton and with the clinical reviewer.
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HMP WHATTON
6. Whatton is a category C prison which currently holds 761 adult male prisoners,
primarily 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 Offenders
Treatment Programme. Whatton has recently undergone a large expansion
programme that saw the prison more than double in capacity.
7. Whatton was last inspected by Her Majesty’s Chief Inspector of Prisons
(HMCIP), Ms Anne Owers, in February 2004. Ms Owers 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.”
8. Due to the offending histories of prisoners held at Whatton, a protocol exists
between the prison and local hospitals, which specifies the security measures
that must be in place before a prisoner will be accepted for treatment. No
prisoner would be left alone in hospital even if released on temporary licence.
9. Healthcare within the prison is commissioned and provided by Nottinghamshire
County Teaching Primary Care Trust. The Primary Care Trust provides a
range of primary care services including General Practitioner (GP) clinics. It
contracts out of hours GP services to a private provider.
10. Medication is administered on a weekly and/or monthly basis to those prisoners
who have been risk assessed as suitable for holding it in their own possession.
It is administered on a daily basis to other prisoners, when either they are
considered to be at risk or the medication is considered unsuitable to be held in
their possession.
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KEY FINDINGS
11. On 11 January 2006, the man was transferred from High Down to Lewes and,
after induction, it was decided that he should be given Vulnerable Prisoner
status because of his age and the nature of his offence.
12. The man arrived at Whatton on 6 June 2006. During the health screening
procedure in reception it was noted that he had a hernia and that he walked
with a stick as he had limited mobility. It was also noted that the man had
previously undergone an aortic graft operation. A range of medications were
prescribed to treat his various conditions and he was allowed to keep these in
his possession for self medication.
13. The man was transferred to Whatton after the wing for vulnerable prisoners at
Lewes was closed for refurbishment. Although the man arrived at Whatton on
6 June, it was not until three days later that a further health screening took
place. The health screen form was completed satisfactorily by a nurse.
However, there were actions present on the form which do not appear to have
been completed. The nurse noted that the man should have a General
Practitioner (GP) appointment. However, the section on the screening form to
be completed by the GP is blank. There is also no record in the man’s medical
history of him having such an appointment. On 20 June, the man had a blood
sample taken and tested. The results showed nothing untoward.
14. On 5 September 2006 at around 1:30pm, a Prison Officer was approached by a
prisoner who told him to look in on the man as he was not feeling very well.
The officer went into the man’s cell and saw him sitting at his desk. The officer
asked the man how he felt. The man told him that he had pains in his stomach
and, although he had taken some ‘Rennie’ (an anti-acid preparation), he did not
feel any better. The officer judged that the man’s colouring and demeanour
suggested that he was in pain and decided that he should be immediately
taken to the prison’s healthcare centre. The officer arranged for his colleague
to take the man to the healthcare centre, and a wheelchair was used to
facilitate the journey.
15. The man was met in the healthcare centre by the Practice Nurse. The nurse
immediately informed the prison doctor that the man had arrived and
commenced her assessment. The man was able to co-operate with the
assessment process and told the nurse that the pains he was experiencing in
his stomach were like “trapped wind”. He said that if he could just “burp” he
would be alright. The nurse completed her assessment and informed the duty
manager she thought that the man was likely to need an ambulance. After the
prison doctor completed a thorough examination of the man, he asked the
nurse to call for an ambulance.
16. An ambulance was called at 3:00pm. While waiting for the ambulance to
arrive, the man was lucid and able to engage in conversation. He discussed
his impending release on 13 September 2006, and said that he came from
Kent.
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17. A support paramedic arrived before the ambulance crew and, after he had
carried out an assessment, the ambulance left the prison around 3:55pm. The
man was taken to hospital, accompanied by two officers.
18. Doctors at the hospital diagnosed a bleed from the man’s aorta which would
require an operation. The man’s family was immediately advised of his
condition and he was allowed to speak with them on the telephone.
19. Whilst the man was at the hospital, a bedwatch was carried out by prison staff.
The initial security risk assessment was that handcuffs were to be used.
However, these were removed at 5:40pm after a further security assessment
when the man’s condition started to deteriorate and also due to his impending
operation.
20. Two new officers relieved their colleagues at 7:00pm and were briefed about
the man’s situation. Around 7:30pm, the man was taken into the operating
theatre. The escort staff waited in an adjacent room while the operation was
performed. At around 10:40pm, a doctor from the hospital informed the staff
that the man had died during the operation.
21. The prison contacted the man’s family to inform them of his death and to offer
condolences and support. A Senior Officer was appointed as the prison’s
family liaison officer. She maintained contact with the family and assisted with
the arrangements for the funeral. The Governor also attended the funeral. The
prison provided financial assistance for the funeral and a memorial service was
also held by the prison chaplain.
22. The post mortem report records the cause of death as due to natural causes,
as a consequence of a massive intra thoracic haemorrhage caused by a
ruptured thoracic aortic aneurysm (dangerous ballooning of the aorta, the main
artery leaving the heart, which is caused by disease in the artery's wall).
Clinical Review
23. As previously noted, the clinical review was undertaken by a doctor and Public
Health Assistant on behalf of Nottinghamshire County Teaching Primary Care
Trust. The reviewers found that the man had suffered from significant long-
term chronic diseases.
24. From the medical records, it was clear that the man was seen regularly by
healthcare staff and, when necessary, referred to secondary care services.
The clinical review concludes that there are no circumstances indicating that
death could have been anticipated or prevented, but makes recommendations
for improvements to clinical practice.
25. The reviewers judge that the prison should develop a system for ensuring that
prisoners with health problems undergo priority screening. The review notes
that the health screening for the man took place three days after his arrival at
Whatton. The reviewers draw attention to the fact that, due to his age and the
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five different medications he was prescribed, the man should have been a
priority for health screening.
The prison health partnership should develop a system for ensuring
priority screening for prisoners with health problems.
26. They also judge that a policy should be developed to ensure the correct and
timely referral of prisoners to the General Practitioner (GP) clinic, disability
office and other relevant services. The reviewers say there must be
documentary evidence in a prisoner’s medical records to support the offer of
the appointment and any subsequent actions or interventions.
Healthcare should develop a policy to ensure the correct and timely
referral of a patient to the General Practitioner (GP) clinic, disability office
and other relevant health and social care services. There should be
documentary evidence in the prisoners’ medical records of attempts to
invite prisoners to appointments. Clear lines of responsibility for those
involved in screening should be in place and actions noted on the
medical records file for the relevant prisoner.
27. The reviewers recommend that a review of health policies should be
undertaken when prisoners fail to turn up for scheduled appointments, or do not
collect their medication. This issue is related to the point that documentary
evidence should be recorded of actions taken in relation to a prisoner’s medical
care. However, the reviewers say that, if a prisoner has been invited to an
appointment, the onus should be on the prisoner to take responsibility to
contact healthcare to re-arrange missed appointments. The policy review may
also include requesting that residential prison staff should be asked by health
professionals to check up on prisoners who fail to attend or miss appointments
and when medication is not collected.
A review of health policies should be undertaken when prisoners fail to
show up for appointments or to collect medication.
28. The clinical reviewers also say there should be a policy on whom and under
which circumstances prison staff can access prisoner medical records.
There should be a clear PCT policy on whom and under what
circumstances prison officers can gain access to the medical records of
prisoners.
29. Looking at the medication prescribed to the man, the review noted that on one
occasion medication had been prescribed to the man without a doctor’s
authorisation. The medicine concerned, Rinatec Nasal Spray, is a type known
as an antimuscarinic or anticholinergic. It is used for many purposes, but when
applied into the nose is used to treat runny noses that are a result of allergic or
non-allergic inflammation in the nose. While in this case the medication was a
nasal spray, in another case a different prisoner could be given an
inappropriate and potentially damaging medicine.
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There must be an appropriate PCT policy in place to ensure medications
are not prescribed without the appropriate authorisation of a prescribing
clinician.
30. Prisoners raised a concern that, since the increase in the size of Whatton and
the influx of new prisoners, there had been a cut back in services. For
example, they said that nurses who had been based on wings had been
withdrawn, and disabled and elderly prisoners were being forced to travel to
reception or healthcare for treatment. The review concluded that these
concerns are unfounded; indeed, that since the number of prisoners has
increased there has been an increase in staffing levels. The reviewer noted
that there had never been a ‘wing based’ service, with the exception of elderly
prisoners. The elderly prisoners are all based on one wing and clinical care is
taken to them.
31. The suggestion that prisoners are experiencing delays in getting appointments
for dental and chiropody services has been investigated as part of a health
needs assessment. The number of dental appointments has been doubled
from the start of 2007 and the chiropody service will be provided directly by the
Primary Care Trust. The reviewers state that, as the prison has expanded
since February 2006, the mix of prisoners has consequently changed. The
Public Health team at Nottinghamshire County Teaching Primary Care Trust is
currently undertaking a Health Care Needs Assessment (HCNA) which is
looking at all aspects of healthcare. This work includes asking prisoners to fill
in a questionnaire on a range of health issues and reviewing their medical
records. From the results of this information and data gathering exercises, the
level of health need will be understood better and this will include dental and
chiropody services. I welcome this initiative.
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CONCLUSION
32. The man moved to Whatton on 19 May 2006. He died of apparently natural
causes in September 2006.
33. The man had arrived in prison with a history of chronic health problems. He
was due to be released from prison the week after his death and it is sad that
he was unable to spend his final days at home with his family.
34. From comments made by staff and prisoners at Whatton, the man was a
respected and well liked prisoner. His popularity was further demonstrated by a
collection by prisoners on his wing which raised £85. This was used to buy a
wreath, with the remainder given to charity.
35. From the bedwatch log, it was clear to my investigator that the staff involved
with the man’s care behaved with sensitivity. The decision to remove
mechanical restraints, following a risk assessment, was entirely appropriate
given the circumstances. The security arrangements at the hospital seem to
have been suitable, and to have struck a good balance between public
protection and respect for the man.
36. The clinical review makes five recommendations designed to improve practice
that I endorse. These should be addressed by the Nottinghamshire County
Teaching Primary Care Trust in partnership with the Governor of Whatton.
37. I commend the good level of communication between prison officers and the
healthcare staff which helped to ensure the man was attended to quickly and
appropriately.
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RECOMMENDATIONS
Medical
Recommendations
1. The prison health partnership should develop a system for ensuring
priority screening for prisoners with health problems.
2. Healthcare should develop a policy to ensure the correct and timely
referral of a patient to the General Practitioner (GP) clinic, disability office
and other relevant health and social care services. There should be
documentary evidence in the prisoners’ medical records of attempts to
invite prisoners to appointments. Clear lines of responsibility for those
involved in screening should be in place and actions noted on the
medical records file for the relevant prisoner.
3. A review of health policies should be undertaken when prisoners fail to
show for appointments or to collect medication.
4. There should be a clear PCT policy on whom and under what
circumstances prison officers can gain access to the medical records of
prisoners.
5. There must be an appropriate PCT policy in place to ensure medications
are not prescribed without the appropriate authorisation of a prescribing
clinician.
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