Individual at Wormwood Scrubs

Investigation into the circumstances surrounding the death of
a male prisoner at HMP Wormwood Scrubs,
who died in May 2005
Report by the Prisons and Probation Ombudsman for England and
Wales
December 2006
This is the report of an investigation into the circumstances of the death of a
prisoner at HMP Wormwood Scrubs who died on 28 May 2005. The man had
been suffering from severe coronary disease and died from coronary failure.
I extend my sincere condolences to the man’s family and friends for their loss.
The man was on remand for a charge of intimidating a witness and had never
been in prison before.
I would like to thank the Governor of Wormwood Scrubs at the time of our
investigation, and the members of his staff who assisted us. I am particularly
grateful to the prison’s Liaison Officer.
It is not possible to say whether the man’s death could have been prevented.
However, his family has raised several questions about the standard of
healthcare he received. I have benefited from two separate reviews of clinical
matters and the findings have been incorporated into this report.
I make seven recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman December 2006
2
Contents
Summary 4
Investigation Process 6
The man who died 7
HMP Wormwood Scrubs 8
The events leading up to the man’s death 9
Discussion of the issues 15
Findings and Conclusions 22
List of Recommendations 27
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Summary
1. The man who died was born in Pakistan in 1951. He had, however, spent
the majority of his life in Britain and had semi­retired around five years ago.
He spent much of his time with his family and was a devout Muslim.
2. The man was remanded into the custody of Wormwood Scrubs on 7
February 2005, charged with intimidating a witness. He had never
been in prison before and found it difficult to be away from his family.
He was located in a single cell on E wing at Wormwood Scrubs, a
large wing with three landings. Staff described him as polite and
respectful and he was well liked amongst prisoners on his wing.
3. The man underwent a first reception health screen when he arrived in
custody on 7 February. He reported that he sometimes had chest
pain when he was breathless. The man was seen again by a doctor
on five separate occasions between then and the day of his death.
4. On his fifth consultation with a doctor on 26 May, he described
experiencing pain in his chest, shoulders and upper arms. It is
recorded on the man’s medical record that he should have an ECG
and a chest x­ray. However, there is no documentary evidence of
when these investigations were to be carried out.
5. On the morning of Saturday 28 May, the man’s cell door was unlocked
at approximately 8.40am as he was due to receive a visit. He told the
landing officer that he was feeling very unwell, could not lie down or
walk, and had pains in his stomach. The officer asked a healthcare
officer (HCO) to come and see him. The HCO gave the man a dose
of medication to ease his pain and advised him that he would ask the
doctor to come and see him.
6. At approximately 9.50am, the landing officer went to see the man with
the wing senior officer (SO). They arranged for a soft chair to be
brought for him to make him more comfortable. The HCO who had
seen the man earlier that morning went to the Healthcare Centre and
spoke to the doctor on duty. He agreed that he would bring the man
to see the doctor in the Healthcare Centre in order for him to be
assessed. He then took a wheelchair to E wing to collect him.
7. Tragically, the man collapsed whilst he was being helped to walk
down the flight of stairs from the second landing to the first landing.
He was taken to the doctor’s room on the first landing where
healthcare staff and then paramedics attempted to resuscitate him.
The man could not be resuscitated and was pronounced dead at
11.32am.
8. The duty governor and a senior officer visited the man’s family on the
afternoon of 28 May to inform them of his death.
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9. The clinical reviews into the man’s medical care drew attention to
some shortcomings and made a number of recommendations for
improving practice.
10. This report includes seven recommendations.
11. Prior to the finalisation of this report, an inquest was held into the
man’s death. The jury returned a verdict of ‘natural causes to which
neglect contributed’.
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Investigation process
12. Two of my investigators visited Wormwood Scrubs and met with a
member of the Independent Monitoring Board and a representative of
the Prison Officers’ Association (POA). They also visited the wing
where the man had lived. The investigator leading the investigation
issued notices to staff and prisoners informing them of the investigation
and inviting comment.
13. The man’s prison records, including his medical records, were provided
to the investigator during their visit to Wormwood Scrubs. The
Metropolitan Police kindly provided the investigators with statements
taken by them.
14. My investigator returned to Wormwood Scrubs with my Deputy
Ombudsman and conducted interviews with a number of prison officers
and healthcare staff. The investigator also met with some of the
prisoners who knew the man, and with the senior officer on E wing.
15. One of my family liaison officers contacted the man’s family. One of my
family liaison officers and the investigator went to visit the man’s family
to explain the purpose of the Ombudsman's investigation and to discuss
any questions or concerns the family might have. The man’s family had
several concerns about the standard of care he received whilst he was
at Wormwood Scrubs and were particularly worried about his medical
treatment whilst in custody.
16. A review of the man’s medical care whilst he was in prison was carried
out on behalf of Hammersmith & Fulham Primary Care Trust, for which
I am grateful. However, as I felt that there were areas that would
benefit from further exploration (standards of record keeping; the use
of secondary health screening; the appropriateness of intubation within
a secure environment), it was decided that an independent clinical
investigator for the Prisons and Probation Office, would lead a clinical
panel review. In order to prevent the man’s family waiting any longer
than they already had, an interim draft report was issued in November
of 2005. The report was then amended to reflect the results of the
clinical panel review and a second draft report was issued in July of
2006. Both the man’s family and the Prison Service received a copy of
my interim draft report and the second draft report and both have had
the opportunity to comment on the reports. Their comments are
included in the text where relevant.
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The man who died
17. The man was born in Pakistan in 1951 and was 54 years old when he died.
Part of a large family, he had ten children and 15 grandchildren. He had spent
the majority of his life in Britain and for much of that time worked in the grocery
trade. The man semi­retired around five years ago and was enjoying
spending time with his wife, children and grandchildren. He was a devout
Muslim and spent much of his time praying.
18. The man was remanded into the custody of Wormwood Scrubs on 7
February 2005, charged with intimidating a witness. His trial date had
been set for 1 June 2005. He had no previous convictions and was
surprised and distressed when he was remanded into custody. He had
never been in prison before and found it difficult to be away from his
family.
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HMP Wormwood Scrubs
19. Wormwood Scrubs is a large local prison, situated in West London and
predominantly serving the London Courts. In common with many local
prisons, Wormwood Scrubs receives and discharges a high number of
prisoners each day. It has an operational capacity (maximumcapacity
with overcrowding) of 1,167.
20. In her 2003 inspection report, HM Chief Inspector of Prisons described
Wormwood Scrubs as a prison with a troubled recent history and
reputation. The report went on to describe an establishment that is
improving, with attitudes of staff becoming more positive and 75 per
cent of prisoners reporting that they were treated with respect by most
staff.
21. The prison has a Prison Service star rating of three (with four being the
highest and one being the lowest). The rating is based upon several factors
including performance against area targets, Prison Service National
Standards, and the outcome of independent inspections by HM Chief
Inspector of Prisons.
22. Healthcare at Wormwood Scrubs was not under the management of
the Primary Care Trust at the time of this man’s death. The PCT took
over commissioning responsibility in April 2006.
23. The prison does not offer a personal officer scheme but assigns
support officers to prisoners who appear to be vulnerable or who have
specific needs.
24. This man is the fourth prisoner to die at Wormwood Scrubs since 1
April 2004. Each of the other deaths at the prison during that period
has apparently been self inflicted.
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The events leading up to the man’s death
25. Despite his shock at being remanded into custody, the man appeared
to prison staff to be coping with life in prison. He was located on E
wing at Wormwood Scrubs, a large wing with three landings. He had a
single cell and was located on the second landing. He was described
by staff as a pleasant, respectful and polite man. During his time in
custody, he became friends with many of the other prisoners on his
landing, frequently joining in with an informal study group and playing
pool.
26. On the man’s first day in custody (7 February 2005), he underwent a
first reception health screen. During the screen the healthcare officer
(HCO) noted that the man described sometimes experiencing chest
pains when breathless. It was also noted that he was a smoker. The
health screen was not comprehensively completed and seven sections
were left completely blank.
27. On 22 March, the man visited Healthcare and complained to a doctor
(whose name is not printed in the records) that he was experiencing
abdominal pains. He was prescribed 20mg Losec daily for 28 days.
This prescription was repeated on 18 April. There is no documented
evidence that investigations to identify the cause of the abdominal
discomfort were either considered or requested.
28. The next entry in the man’s medical record was made on 10 May when
the notes suggest that he may have been presenting with depression.
He was given a prescription of 20mg Prozac for 14 days and another
repeat prescription of 20mg Losec. Again, the name of the doctor is
not printed but the handwriting appears to the same as that of the
doctor who saw the man on 22 March.
29. Notes on the man’s prison records throughout the period of 7 February
to 22 May indicate that he was observed to be quiet, respectful and
compliant with wing rules. There are no references made to the man’s
health until the morning of 28 May.
30. The man’s family spoke to him on the telephone every day and visited
the prison as often as they could. They had been worried that his
health had been declining since he arrived in custody and, at various
times, had communicated these concerns to the man’s solicitor.
Despite my investigator writing to the solicitor and making several
phone calls to him, it has not been possible to establish whether he
passed these concerns on to anyone at the prison.
31. The man’s family told my investigator that he had had been suffering
from toothache and had waited for seven weeks to see a dentist. In the
end the tooth had become so painful that he had removed it himself.
Despite the efforts of my investigator and the staff at the prison, it has
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not been possible to establish if the man was placed on the waiting list
to see the dentist, and if he was, how long he had been waiting. The
prison was able to confirm that he had not ever seen a dentist at the
prison as a dental patient record had never been created for him. Staff
in the prison’s healthcare centre advised by investigator that there was
an emergency dental clinic available on Friday mornings, and that
prisoners urgently needing attention would usually be seen within a
week or two of requesting an appointment. For prisoners needing
routine appointments, it would not be at all unusual to wait up to twelve
weeks to be seen.
The events of 26 and 27 May
32. On 26 May, the man visited Healthcare again. He complained to a
doctor (whose name is not printed in the medical records and whose
signature is not legible) of pains in his chest, both shoulders and upper
arms. Notes in his medical record indicate that the man’s father had
had heart disease. The doctor checked the man’s heart which
sounded normal. He also checked his lungs and found them to be
clear. His blood pressure and pulse were checked and found to be
within normal limits. The doctor advised the man to stop smoking and
a note was made that he should receive a chest x­ray and an ECG. He
was given a repeat prescription of 20mg Prozac for 14 days. There
was no indication of when the ECG or chest x­ray should be carried
out.
33. The staff on E wing were not aware that the man was feeling unwell.
The investigation team asked the wing’s Senior Officer (SO) whether
there is a protocol for communicating this kind of information about a
prisoner. The SO said that, if Healthcare staff had concerns over a
prisoner, she would expect this would be communicated to the wing
staff. They should then make a note in the handover book. No
information about the man’s health was passed to staff on E wing
following his visit to the doctor on 26 May.
34. The man was visited by members of his family on the afternoon of 26
May. He told them he felt very unwell and had lost his appetite. They
thought he seemed to be in low spirits and were concerned. The family
also told the investigation team that, following their visit to see him, the
man’s solicitor had contacted someone at the prison to discuss his
health and the family’s concerns for him. Regrettably, despite efforts
by my investigator, it has not been possible to establish if and when the
solicitor made contact with the prison.
35. My investigator spoke to the prisoner who was located in the next cell
to the man. On 26 May, the man had commented to him that he had
seen the doctor and that he had been having pains. The man had
continued to fetch his meals and to come out onto the landing to play
pool and socialise with the other prisoners.
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36. The investigator spoke to another E wing prisoner, who was a friend of
the man’s and also had a cell on the same landing. He remembered
the man talking about feeling ill a few weeks before his death. He
recalled that he had been feeling unwell at night, one or two nights
before his death. He had advised the man to drink water and keep his
window open to get some air. The prisoner could not remember the
man speaking to a member of staff about his condition.
28 May
37. On the morning of 28 May, the wing cleaners on E wing were the first
to be unlocked to enable them to start their duties. Shortly after that, at
approximately 8.40am, any prisoners due to receive visits were also
unlocked. The man who is the subject of thisreport was due to receive
a visit from three members of his family that morning and his door was
unlocked by one of the landing officers. After opening the man’s door,
the officer carried on along the landing to continue unlocking prisoners
for their visits. A wing cleaner looked in on the man and saw that he
was not well. The wing cleaner fetched the officer who immediately
returned to the man’s cell and asked him what was wrong. He
explained that he could not walk and had not eaten or slept for two
days. He also said he was in pain and pointed to his stomach. The
officer went to speak to the Healthcare Officer (HCO) who was
downstairs on the first landing administering morning treatments.
38. The HCO explained to the investigation team that he was aware that
the man had recently been given Losec for abdominal pain. He
thought that this was suspected to be caused by a gastric ulcer. He
also knew that the man was due to have an ECG that afternoon and a
chest x­ray the following week. When the officer came downstairs to
speak to him, the HCO finished administering the treatments he was
dealing with and went up to the second landing. He arrived at the
man’s cell at about 9.30am. The man explained that he had not slept
well, felt weak and listless and that he felt he had heartburn. He did not
complain of any chest pains. The HCO told the investigation team that
he had received reports of lack of sleep and feeling unwell from
approximately half a dozen prisoners that morning. He thought that
this was because it had been a very hot and humid night. The HCO
gave the man 20 mls of magnesium trisilicate and told him that he
would ask the doctor to see him.
39. The HCO then went to try and contact the duty doctor to ask him to see
the man. The duty doctor would at this time of the day have been
doing his round of visits. These visits would have taken him through
the Segregation and Detoxification units and then on to a ward round of
the inpatient unit in Healthcare. Doctors in the prison do not carry
radios or pagers and it therefore took the HCO some time to find the
doctor. The HCO eventually located him in the Healthcare Centre and
agreed that he would take the man across to see him. He then walked
back to E wing with a wheelchair to collect the man.
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40. Three members of the man’s family had arrived at the prison to visit
him that morning. They were admitted to the prison and had been
searched, but once they entered the visits area they were told that the
man had flu and would not be attending for his visit. After the man’s
family learned of his death, they were very upset that they had been
told he had flu when they went to visit him that morning. They also felt
especially saddened that they had not been able to see him that
morning as it would have been their last chance to see him alive. The
investigation team was able to establish that, on the morning of 28
May, an officer from the visits centre went to E wing with a list of
prisoners who had visitors. The officer then asked E wing staff to call
out the names on the list and for those prisoners to come down to the
wing office. When the man did not come to the office, it appears that
one of the E wing staff told the visits officer that he was ill and would
not be attending. The prison was not able to confirm which officer from
the visits centre attended E wing, or to which E wing officer they spoke.
41. Another officer on E wing spoke to the man about his ill health during
the morning. At approximately 9.50am, the second officer spoke to the
man and noted in his prison records that he would be seeing the doctor
after lunch.
42. Also at about 9.50am, the first officer who had attended to the man that
morning told the wing’s SO that she was worried about the man and
she and the SO went to speak with him. The man indicated to the
officer and the SO that he would like to be able to sleep sitting up and
the SO arranged for a comfortable chair to be brought for him. The first
officer who attended to the man was given no specific instructions by
the HCO to monitor the man. She made an entry in the man’s prison
record noting that he was unwell and had been seen by a nurse. She
then checked on him a few times throughout the morning. When she
looked in on him at approximately 10.20am, the man was dozing in his
chair.
43. The HCO did not arrive back on E wing until shortly before 11.00am.
There is a cargo lift on E wing but it does not go up to the second
landing. For that reason, the wheelchair was left at the bottom of the
staircase on the first landing. The HCO then helped the man to walk
down the stairs to where the wheelchair was waiting. As they were
walking down the second of the flights of stairs, the man appeared to
feel faint and collapsed. Two prisoners who were on the first landing
helped to lift him into the wheelchair.
44. At this point, the man was conscious but was moaning. The HCO
pushed the wheelchair into the doctor’s room which is based on the
first landing. The man was beginning to lose consciousness but was
still breathing. The HCO tried to contact the duty doctor over his radio
but the battery was flat. There is a telephone in the doctor’s room and
so he phoned control and asked them to put a call out for Hotel 1 (a
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radio call sign for emergency healthcare assistance) to attend
immediately and for an ambulance to be called. The call was made to
the control room at 11.07am and the ambulance was requested at
11.08am.
45. The HCO briefly left the doctor’s room to fetch the emergency bag from
the treatment room which is next door. The man was then given
oxygen from the emergency bag. The HCO called to two prisoners on
the landing to help lift the man onto the treatment couch so that he
could start Cardiopulmonary Resuscitation (CPR). At about this time,
the duty doctor and the Healthcare Nurse (HCN) who was acting as
Hotel 1 arrived in the doctor’s room.
46. The HCN acting as Hotel 1 told the investigator that she received the
call to attend E wing and was there within one to two minutes. She
was given no further information about the nature of the emergency
and had not had any previous dealings with the man she was called to
attend to. When she first saw the man, he looked cyanosed (a blue
colour to his skin) and she could not find his pulse. She began CPR
immediately. The oxygen cylinders in the emergency bags do not last
for very long and the HCN had to ask for additional cylinders. Another
HCN, who had just arrived at the doctor’s room on E wing, went to
collect oxygen cylinders and the defibrillator machine from the
Healthcare Centre.
47. There was no output or response from the man for the duration of the
CPR. The defibrillator machine (which automatically gives an
indication of whether any heart rhythm can be established) indicated
that it could not be used on the man. The HCN acting as Hotel 1 used
the suction equipment to extract fluid from the man’s airway. No line
was inserted into him to administer drugs.
48. London Ambulance Service’s activation log showed that an ambulance
was despatched to the prison at 11.12am and arrived there at
11.20am. The first paramedic reached E wing at 11.27am. CPR had
been carried out by the HCN acting as Hotel 1 for approximately 15
minutes before the paramedics arrived, at which point they took over
the resuscitation. They were not able to establish any response from
the man and he was pronounced dead by the duty doctor at 11.32am.
49. The police were called and officers from the Metropolitan Police
attended the prison, visited the scene of the man’s death and took
statements from members of staff who had been involved.
50. The man’s family were visited by the duty governor on the afternoon of
28 May. She was accompanied by an SO who had recently been
trained in family liaison. They arrived at the family’s address at
4.25pm. The duty governor told the investigation team that she had
found the family visit very difficult. She thought that the man’s family
had taken the news of his death very badly and, understandably, were
13
extremely upset and emotional. The duty governor said that at points
during the visit she had felt threatened by the strength of emotion
shown. She explained that at one point during the visit a member of
the man’s family picked a knife up from the draining board and waved it
around. Neither the duty governor or the SO were personally
threatened with the knife and other members of the family acted quickly
to defuse and calm the situation. The duty governor said that, whilst
she fully understood how distressed the family were feeling, she found
the experience very intimidating.
51. The family was told they could visit the prison and see the man’s cell,
and a number of family members decided to do this. The man’s family
took the majority of his belongings from his cell when they visited the
prison. Amongst his belongings were packets of aspirin, Ibuprofen and
Omeprazole and a Salamon CFC­free inhaler. These medications did
not appear on the man’s prescription chart and it is unclear why they
were in his cell.
52. The prison did not initially discuss with the man’s family the possibility
of contributing to the costs of his funeral. Following a discussion with
my investigator, the prison wrote to the man’s family on 1 September
2005 and offered to contribute towards the cost of his funeral.
53. A post mortem examination of the man was carried out by a Consultant
Forensic Pathologist for Forensic Pathology Services. The pathologist
found the man’s death to have been caused by a heart attack and that
he had been suffering from coronary disease.
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Discussion of the issues
The medical care given to the man
The man’s initial assessment
54. The clinical review panel considered that the fact that the First
Reception Healthscreen form was inadequately completed, with seven
sections left completely blank. The lack of information documented
and questions asked did not permit an accurate assessment of the
man’s healthcare needs. It is acknowledged that Reception nurses
are often under pressure to see a high number of prisoners in a short
space of time, and this can affect the amount of information that is
obtained about a prisoner. However, despite the man saying that he
experienced chest pain, he was not referred for further medical
assessment as would have been appropriate. In addition, it was not
noted whether or not the man had a GP. If he did, the GP should
have been contacted to supply his medical notes. In turn, these may
have indicated whether he had been treated for chest pain before.
55. The review panel considered it surprising that the man was not seen
by a prison doctor shortly after his First Reception Healthscreen was
completed, despite reporting chest pain. A thorough history should
have been taken for him, including details such as the type, frequency
and duration of the pain experienced. Patients should be referred to a
‘Rapid Access Chest Pain Clinic’ if appropriate, or be seen by a
cardiologist or registrar. The panel also commented that, if a referral
is not deemed necessary, a note should be made in the medical
records of the action to be taken in the event of further pain.
56. The First Night Centre Tuberculosis (TB) assessment form was not
completed for the man. The full clinical review highlights the
importance of assessing TB in the prison population and recommends
a revision of the local and national policy on assessing and treating
TB in prisons1 .
The man’s treatment on 22 March
57. On 22 March, the man was seen by a doctor as he was experiencing
abdominal pain. The clinical review panel noted that the doctor
recorded that magnesium trisilicate was not helping to relieve his
symptoms, and he was prescribed Losec. The doctor did not
document any thoughts about the diagnosis and did not record any
more specific information about the pain. The panel considered that it
1 I acknowledge that in the Prison Service’s response to the draft report they commented that tuberculosis was not a
relevant factor in the man’s death. They therefore felt it inappropriate for the report to have examined this issue. The
conclusions reached by the clinical review panel are based upon the experience and expertise of the practitioners
involved and it is therefore not for me to prescribe which issues they consider to be relevant, or to challenge their
recommendations.
15
would have been appropriate to instigate tests and investigations to
rule out a diagnosis such as angina.
58. It is noted that none of the doctors who saw the man between 22
March and 26 May printed their names in his medical records.
Assessment of the man on 10 May
59. The man presented to the doctor feeling low and reporting some
features of depression. The doctor prescribed Prozac for the
treatment of his symptoms. The panel considered it would have been
appropriate to have offered the man the opportunity to discuss the
reasons for his depression and perhaps to have arranged a referral to
the mental health team. Neither of these things appears to have been
done.
The man’s treatment on 26 May
60. On 26 May, the man told a doctor about a family history of heart
disease. It appears this was the first time he had mentioned this to a
member of medical staff at the prison. The clinical panel considered
that his description of the pain he was experiencing appeared to
indicate that the man was suffering from unstable angina. He should
have been referred for further investigations urgently. If an ECG was
to be carried out (as was indicated in the notes), then this should have
been performed the next time he was experiencing the pain. The
panel added that a discussion between the multi disciplinary
healthcare team might have been beneficial in deciding the best
course of treatment for the man. It appears that the note made in his
medical records on 26 May ­ “no history suggestive of peptic ulcer” ­
contradicts an earlier entry made by another member of staff on 18
April.
The response to the man on 28 May
61. The review panel noted that the HCO who attended to the man on the
morning of 28 May took appropriate action in trying to contact the
doctor when his condition suddenly deteriorated that morning.
62. Since the man’s arrival at the prison, several opportunities to
investigate his chest pain had been missed. The staff who responded
to his report of illness that morning were therefore unaware of the
seriousness of his condition. Under the circumstances, the HCO
responded appropriately. The clinical panel commended the caring
approach of the landing officer in arranging for a chair for the man and
checking on him whilst he waited to be taken to Healthcare.
63. The panel noted that the HCO’s radio battery was flat when he tried to
contact the doctor as the man collapsed. They commented that, when
the emergency call was out for Hotel 1 to attend, no code or further
16
information was given. They considered that the emergency calls
coding system should be clarified and communicated to all staff. The
panel also commented that it would have been preferable for Hotel 1
to have taken the defibrillator machine with her when she responded
to the emergency call.
64. The nurse acting as Hotel 1 carried out CPR on the man on her own
for approximately 15 minutes, despite the presence of several other
members of healthcare staff including a doctor. The review panel
highlighted the need for medical staff (and prison officers if possible)
to be aware of the latest guidelines issued by the UK Resuscitation
Council. It was noted that one person CPR can be very tiring and ­ for
this reason ­ can become ineffective.
65. The panel commented on the importance of staff being aware of
where to locate spare oxygen cylinders and of the availability of full
size suction equipment on the wings.
Other issues raised by the clinical review panel
66. The review panel was concerned to note that aspirin, Ibuprofen and
an inhaler were found in the man’s cell after his death. None of these
items appeared on his prescription chart. It is not clear where the
man had obtained these medications from or whether he had actually
used any of them.
67. The panel noted that healthcare staff were not included in the debrief
that was held following the man’s death. This is not good practice.
The response of discipline staff to the man’s condition
68. Healthcare staff have a duty to protect their patient’s right to
confidentiality. In doing so, they do not routinely divulge details of a
prisoner’s medical history to wing staff. The investigation team was
told that, on occasions where healthcare staff were concerned about a
prisoner and felt that they should be monitored, these concerns
should be passed onto wing staff. Wing staff should then record this
in the wing observation book. Both healthcare staff and officers said
that, in practice, this does not always happen.
69. The staff on E wing could not have been expected to have known how
ill the man was. They were not given any information by healthcare
staff and it appears that the man had not told staff he was feeling
unwell. He continued to socialise out of his cell, to collect his meals
and to play pool. Despite the man’s symptoms, his behaviour on the
wing did not appear to indicate that that he was feeling unwell. The
prisoner in the cell next door to the man told the investigation team that
the man who died was a quiet and proud man, and that he had not
seemed to attract any attention to the fact he was feeling ill. On 28
17
May, when the man’s condition appeared to have worsened
dramatically, the staff on E wing acted promptly and compassionately.
70. The man’s family informed the investigation team that his solicitor had
contacted the prison to communicate their concerns about the man’s
health. Unfortunately, at the time of writing, the man’s solicitor has not
been able to confirm whether this happened.
71. Wormwood Scrubs prison is located next to a large hospital. The
family of the man who died were concerned to learn that the
ambulance which attended the prison had not come from there, and
that there might therefore have been an unnecessary delay in the
arrival of the ambulance. Although this is not strictly within the remit
of my investigation, the investigation team has made some enquiries.
72. We were advised by representatives from the Department of Health
that 999 calls are automatically routed to the ambulance crew who are
the nearest crew available to respond. The investigation team was
also advised that the Healthcare Commission’s key target for
ambulance responses to ‘category A’ calls (emergency calls requiring
an urgent response) is for the ambulance to arrive with a patient within
14 minutes in an urban area and 19 minutes in an rural area. The
London Ambulance Service activation log does not give an indication
of when the call was received by them. It has therefore not been
possible to establish whether they received the call at 11.08am (when
the prison’s records indicate it was made) or some minutes later,
nearer to the time at which the ambulance was despatched.
73. The ambulance arrived at the entry gate ofWormwood Scrubs some
eight minutes after it was despatched. It then took a further seven
minutes for the ambulance crew to arrive onto E wing and attend to
the man. The investigation team was told by the head of security at
the prison that, although the gate staff are not issued with written
guidance on the procedures for letting an ambulance into the prison,
they are all aware of the need to allow the vehicle to gain entry as
quickly as is possible.
Equipment
74. The HCO who tried to contact the control room via his radio found its
battery to be flat. There is a telephone in the doctor’s room on E wing
and so he was able to telephone the control room without delay. The
HCO told the investigation team that it is not unusual for radios to go
flat with little or no warning. If the man had collapsed in an area
where there was no telephone nearby, the HCO might have had to
leave him unattended whilst he went to fetch help. It is noted that the
prison has subsequently addressed this issue. The investigator was
informed that new batteries have been purchased and consideration is
being given to the purchase of a new radio system. I welcome this.
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75. The HCN who was acting as Hotel 1 told the investigation team that
the small oxygen cylinders supplied in the emergency bags are not
adequate for more than a few minutes. Healthcare staff had to fetch
further supplies of oxygen as the cylinder was running out. The HCN
felt that, if full size oxygen cylinders were located in the treatment
rooms, this would avoid staff having to leave the scene of a medical
emergency to replace equipment.
76. However, I acknowledge that the prison’s Head of Healthcare
explained to the investigation teamthat the oxygen cylinders located
around the prison provide 40 minutes of oxygen. In addition, it was
her opinion that not all staff are aware of the number of cylinders
available and their locations around the prison. The investigation
team was also told that a decision had been taken to use smaller
portable cylinders rather than full size cylinders as this meant that a
prisoner could be treated in their cell or elsewhere if they needed
oxygen. Whilst the merits of this arrangement are clear, it is important
that all staff are made aware of where the oxygen cylinders are
located.
77. The investigation team was also told by the nurse acting as Hotel 1
that she had found the handheld suction equipment inadequate and
felt it was inferior to wall mounted suction equipment.
The man’s family
78. The man’s family were not told of his death until almost five hours
afterwards. The man was pronounced dead at 11.32am and his
family was informed at 4.25pm. The man’s family told the
investigation team that they had been very upset by the delay in being
told of his death. They felt that the delay was compounded by the fact
that they had been told that he had flu earlier that day. They felt that
the truth of the man’s condition had been concealed from them in
various ways throughout the day, and were very angry and distressed
about this. It is indeed unfortunate that inaccurate information was
passed on to the man’s family earlier that day.
79. The duty governor at the time of the man’s death told the investigation
team that she felt the news was broken to his family as promptly as
was possible. In the intervening period, she opened a Command
Suite and then acted as the Silver Commander. The Command Suite
was closed at 2.45pmand duty governor and the SO who
accompanied her then had to wait for a taxi to arrive to take them to
the man’s family address.
80. The duty governor explained to the investigation team that she and
the SO had difficulty getting a taxi from the prison and that this
delayed their arrival at the man’s home. It is important that the news
of a prisoner’s death is broken to their family as quickly as is possible.
Given the pressure the duty governor was under, consideration should
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perhaps have been given to another senior manager visiting the
man’s family along with the SO.
81. The duty governor told the investigation team that she and the SO had
followed the advice given in the Family Liaison Officer (FLO) training
on breaking the news of a death before they visited the man’s family.
The investigation team consulted with a Prison Service trainer who
had delivered this training to FLOs, including those at Wormwood
Scrubs. One session of the FLO training explores the factors that
should be taken into account when delivering such sad news to the
family of a prisoner who has recently died. Staff are advised to
contact the police to arrange for a Police National Computer (PNC)
check to be carried out on the address which they are visiting. They
are also advised to consider the environment and circumstances in
which the family live and any cultural and language issues that may
arise. Staff are advised to be aware of their own personal safety and
to consider whether it may be appropriate to be accompanied by
police officers. The training recommends FLOs be prepared for
families to react in many different ways, and advises that anger,
hostility and confusion are amongst the many understandable
reactions to be expected.
82. The duty governor had not personally attended the FLO training and
so worked closely with the SO to follow the advice given in the training
prior to breaking the news of the man’s death to his family. The duty
governor explained to the investigation team that she had not felt
sufficiently prepared for the reaction of the man’s family to the news of
his death, and felt herself and the SO to have been in a very
vulnerable position.
83. The SO felt very differently about the visit to the man’s home,
explaining that the FLO training had prepared her well for delivering
the news of a prisoner’s death to their family. She said that, whilst no
amount of training would prepare you for the strength of emotion you
were likely to face, she had not been surprised at the reaction of the
man’s family to hearing the news of his death. In addition to the SO’s
comments, the Prison Service provided the investigation team with
evidence of feedback from members of staff who had taken part in the
FLO training. They had found the training to be very useful in
preparing them for the reactions they may face. Subsequently, I have
observed the FLO training myself and can vouch for its sensitivity and
authenticity.
84. The SO had undertaken FLO training only a month prior to making the
visit to the man’s family. She told the investigation team that, at that
time, the prison had not formulated its own local policy for family
liaison following a death in custody, nor had it put in place a structure
to support and supervise the work of the FLOs. The SO also
commented that no debrief was held following the visit to the man’s
family; she felt this to have been a missed learning opportunity.
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85. The duty governor told us that no amount of training could have
prepared for her for the experience she was faced with, as she felt her
safety was compromised. However, I consider that her experience
highlights the importance of delivering FLO training to those members
of staff likely to deliver the news of a prisoner’s death to their family. I
also acknowledge that a draft family liaison protocol has now been
issued, which I welcome.
86. The family was told they could visit the prison to see the man’s cell.
Several of the man’s family members decided to do this. The prison
made every effort to facilitate their visit and ensured that members of
the man’s family were able to meet his friends from E wing.
87. The man’s family were concerned that his watch had not been given
to them along with the rest of his property. The investigation team
discovered that the watch was in the possession of the police and
made arrangements for the family to retrieve it from them. Following
discussions with the investigation team, the prison arranged for the
money fromthe man’s cash and phone credit account to be sent to his
family in the form of a cheque.
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Findings and Conclusions
88. The man had not given the staff on E wing any cause to be concerned
about his health until the morning of 28 May. The healthcare staff did
not pass on any information about the man to the officers on E wing,
who were unaware that he was awaiting further medical assessment.
The Governor may wish to consider whether the current advice to
healthcare staff for the passing of pertinent information about
prisoners to wing staff is adequate.
89. The man’s family was concerned about his health and believed that
he seemed in low spirits. His demeanour on the wings did not appear
to give staff or other prisoners reason to be concerned about him.
Once they were aware of the man’s condition on 28 May, the staff on
E wing showed concern and compassion and acted appropriately.
90. A clinical review panel considered whether the man received
appropriate medical treatment whilst in prison. The panel highlighted
a number of areas where his clinical care was not appropriate. In light
of the conclusions of the panel, I endorse the findings and
recommendations summarised below.
91. The panel noted that a new Prison Service Order (PSO 3050) had
been issued on Continuity of Healthcare for Prisoners. This covers
first reception, information management, transfer of prisoners and
release/discharge. However, the panel stated that the following
issues in respect of initial assessments for prisoners should be given
consideration by the Prison Service:
· The First Reception Health Screen should be used to assess the
mental health of the prisoner, check whether they require access to any
vital medication and to reassure them that they will have time to chat
the following day.
· A secondary health screen should be performed the next day to
discuss their past medical history and any current concerns.
Appropriate referral to the GP/mental health team should be made at
that stage if the prisoner has answered ‘yes’ to any questions.
Comprehensive notes of the conversation with the prisoner should be
made by the nurse in the clinical records. This would relieve the
pressure felt by nurses, prison officers and the prisoner on reception
into prison and also improve the initial health screening and
consequently the follow­up care provided.
· A general comments section added to the reception screen form would
enable the reception nurse to communicate important information
and/or the reasons for the form being incomplete, e.g. language
difficulties – interpreter required, heavy workload – further assessment
required.
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· Following the signature, the writer’s name and designation should be
printed.
I recommend that medical staff should be reminded of the
importance of accurate and thorough completion of initial
Healthcare Assessments. Consideration should be given to
amending the form used to complete these assessments
The Prison Service accepted this recommendation and made the
following comment: “An internal audit has taken place of both the Don
Grubin screen and the locally derived Part Two Healthscreen. It is
accepted that not all the documentation was completed as thoroughly
as it could have been and re­training is taking place. This will be
audited again in three months to check on progress.”
92. The clinical review panel also said that local and national policy for TB
assessment and treatment should be reviewed to take into account
the following factors:
· Prisoners have been shown to have high rates of active and
undetected tuberculosis (TB);
· Prisoners have been shown to have high levels of drug resistant TB;
· Incarceration is a known risk factor for TB treatment interruption;
· There is an increased risk of onward transmission in congregate
settings (confined shared air space);
· Prisoners are more immunocompromised than the general population
due to HIV and lifestyle factors (drugs and alcohol);
immunocompromised prisoners are at risk of TB infection and rapid
progression to active disease;
· There is a responsibility to prisoners and to staff to ensure that the risk
of TB transmission within the prison system is managed to as low a
level as is reasonably possible.
I recommend that the national and local policy for TB assessment
should be reviewed.
The Prison Service accepted this recommendation and made the
following comment: “TB management at Wormwood Scrubs is currently
being reviewed by London CSIP and a specialist TB nurse who works
in a prison. New NICE Guidelines on the management of TB have
recently been published. The Executive Summary of these guidelines
was distributed to all prisons.”
93. Appropriate tests and investigations should be arranged quickly, and
referral made to appropriate specialists to investigate the complaint,
confirm diagnosis and appropriate treatment.
I recommend that medical staff should be reminded of the
importance of following up on initial diagnosis.
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The Prison Service accepted this recommendation and made the
following comment: “System to be implemented whereby medical and
nursing staff follow up on tests and investigations during GP surgeries.
Hammersmith & Fulham PCT are assisting with the development of an
electronic records system to ensure that aspects of care do not remain
solely in the IMR which is located away from the practice surgery.”
94. Effective communication within the multidisciplinary team is vital if
patients are to receive the most appropriate and the highest standard
of care available. Medical staff should be reminded that, when
recording pertinent information about a prisoner, they should print
their name and designation along with the entry in the prisoner’s
medical records.
I recommend that medical staff should be reminded of the
importance of multidisciplinary communication.
This recommendation was also accepted by the Prison Service: “This
has always been a difficult area as staff believe they would be
breaching medical in confidence information. There has been some
work done around this externally and all areas of the prison are now in
possession of the SECURE Document which explains what information
may be shared and in what circumstances.”
95. Staff who respond to an emergency must go to the incident with
appropriate equipment. There should be full size suction machines
available in the treatment rooms on the wings. There should be
emergency sealed bags on every wing with appropriate equipment in
them.
I recommend that the policy for equipment and action required in
an emergency should be reassessed.
In responding to this recommendation the Prison Service referred to
their response to the recommendations regarding resuscitation training
and the provision of equipment (please see below).
96. Healthcare staff (and, if possible, prison officers) should receive
annual up­dates to ensure they are aware of the latest guidelines on
resuscitation.
I recommend that the UK Resuscitation Council guidelines should
be followed.
This recommendation was accepted by the Prison Service: “Training
now being organised through Hammersmith and Fulham PCT and the
Resuscitation Council. One group of staff up to date with two further
training sessions to follow. Due to be completed by end Sep 2006.”
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97. I endorse the clinical review panel’s view that, in common with many
prisons, the initial healthscreen for the man appears to have been
completed when the nurse was under pressure. In addition, First
Reception Healthscreens are likely to be carried out when the prisoner
is stressed and tired. The combination of these factors is not
conducive to eliciting thorough and accurate information about a
prisoner’s health needs. The man appears to have been reluctant to
complain about his illness, and therefore the seriousness of his
condition was not as evident to healthcare staff as it might have
otherwise been. However, there were several missed opportunities
when he could have been referred for specialist investigation into his
on­going chest pain. While it is not possible to say whether earlier
action would have prevented the man’s death, correct diagnosis early
on could have resulted in the appropriate treatment being
administered in time to alter the course of events
98. The HCO’s radio had gone flat when he tried to contact the control
room to request an ambulance. He told the investigation team that it
is not unusual for radios in the prison to go flat with little or no
warning. I welcome the Governor’s swift action to remedy this
problem.
99. The HCN acting as Hotel 1 was heavily involved in attempting to
resuscitate the man. She told the investigation team of the
inadequacies of the suction equipment used within the prison. She
also discussed her concerns over the size of the oxygen cylinders
available and the speed with which they ran out. The Head of
Healthcare said that, in her opinion, not all staff are aware of the
location of the cylinders.
100. The Governor may wish to ensure that all staff are aware of the
locations of oxygen cylinders around the prison.
I recommend that the Governor gives consideration to equipping
each of the treatment rooms with wall mounted suction
equipment.
The Prison Service rejected this recommendation. They made the
following comment: “The small cylinders were purchased specifically
for the emergency bags because they were mobile. The nurse has
given factually incorrect information. Each cylinder holds up to 40
minutes of oxygen and given that there is already one on each wing
and one in the emergency bag there would have been over an hours
worth for this particular incident. Ambulances have never been
delayed at the gate and in fact the paramedics were on scene within 15
minutes as per the report.
“Installation of full size cylinders is unnecessary given the amount of
oxygen currently being used by the establishment and has a health and
safety implication since they are very heavy.
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“It is also not accepted that wall mounted suction should routinely be
installed in the GP Surgeries, however, it may be necessary to review
the type of hand held suction equipment currently available in the
emergency bags.”
101. The duty governor told the investigation team that she felt the news of
the man’s death was broken to his family as promptly as was possible.
Understandably, in the hours following his death, the staff at the
prison had numerous procedures to follow. However, given the
importance of informing a prisoner’s family promptly, consideration
should perhaps have been given to whether this could have been
done at an earlier stage ­ possibly by another senior manager from
the prison.
102. The duty governor and the SO had very different feelings about the
reaction of the man’s family to the news of his death. The Prison
Service provided evidence of positive feedback from those who had
taken part in the FLO training. Experiences such as that of the duty
governor highlight the value in delivering FLO training to those
members of staff likely to deliver the news of a prisoner’s death to
their family.
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List of recommendations
1. I recommend that medical staff should be reminded of the
importance of accurate and thorough completion of initial
Healthcare Assessments. Consideration should be given to
amending the form used to complete these assessments.
2. I recommend that the national and local policy for TB assessment
should be reviewed.
3. I recommend that medical staff should be reminded of the
importance of following up on initial diagnosis.
4. I recommend that medical staff should be reminded of the
importance of multidisciplinary communication.
5. I recommend that the policy for equipment and action required in
an emergency should be reassessed.
6. I recommend that the UK Resuscitation Council guidelines should
be followed.
7. I recommend that the Governor considers to equipping each of
the treatment rooms with full size oxygen cylinders and wall
mounted suction equipment.
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