Individual at Wymott

Investigation into the circumstances surrounding the
death of a man at HMP Wymott in April 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
September 2006
This is the report of an investigation into the death of man who died from apparently
natural causes on 27 April 2006 at HMP Wymott. He had a significant history of
chronic diseases, including diabetes, heart and renal problems. He was 65 years
old.
I would like to add my personal condolences to those already expressed by my
Family Liaison Officer on behalf of this office.
This investigation has been undertaken by one of my investigators. I would like to
thank the Governor of HMP Wymott and her staff for their participation in the
investigation.
A doctor was identified by Chorley and South Ribble Primary Care Trust, to
undertake a review of the man’s clinical care, and I appreciate her assistance.
Whilst not directly relevant to the man’s death, I make one recommendation
regarding clinical records.
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 September 2006
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CONTENTS
Summary 3
The investigation process 4
HMP Wymott 5
Key findings 6
Clinical review 7
Conclusion 9
Recommendation 10
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SUMMARY
The man was born in 1941. He was 65 years old when he died on 27 April 2006 at
HMP Wymott.
The man had been released from custody in 2004 after serving an eighteen month
sentence. He was received back into prison after being sentenced to three years for
breaching an order banning him from contact with anyone under 16 years of age.
After spending some time in HMP Preston, the man arrived at Wymott on 6 July
2005. During his first health screen, it was noted that the man had suffered from
diabetes and heart problems. It was also noted that he had previously undergone
heart surgery.
On 2 January 2006, the man was admitted to a local hospital after suffering pains in
his chest. He was discharged from hospital on 6 January. Whilst the man was in
hospital, he was seen by a Consultant Cardiologist, who informed him that due to his
poor medical prognosis his life expectancy was in the range of 6-12 months.
On 19 February, the man had a myocardial infarction (heart attack) and spent five
days in the local hospital before again returning to prison.
Around 4:46pm on 27 April, prison staff entered the man’s cell and found him
unconscious on his bed. As they were unable to rouse the man, an ambulance was
called. Cardio pulmonary resuscitation (CPR) was immediately commenced and this
was continued by the paramedic and ambulance crew after they arrived on the wing.
As the paramedic and ambulance crew were unsuccessful in their attempts to
resuscitate the man, CPR was stopped at 5:18pm. The paramedic pronounced
death at 5:23pm.
The clinical reviewer concluded that the man’s clinical care was of a high standard,
although on a housekeeping point the standards of record keeping could be
improved.
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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 Chorley and South Ribble Primary Care Trust identified a doctor 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 was to give
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 at Wymott
and the clinical reviewer.
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HMP WYMOTT
6. Wymott is a Category C training prison for adult male prisoners. Over half of
the population are vulnerable prisoners, most of whom are sex offenders. The
prison is located on the outskirts of Leyland in Lancashire. The maximum
number of prisoners who can be held at Wymott is 1,045.
7. Provision of healthcare within the prison is the responsibility of the Chorley and
South Ribble Primary Care Trust. The healthcare centre has a doctor available
every weekday. Overnight and weekend cover is provided by local GPs who
are on call. There is also a qualified member of healthcare staff on duty at
these times. There is no in patient care facility at Wymott and prisoners who
require such care are referred to either HMP Preston or to local hospitals.
8. Medication is administered in 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 cell.
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KEY FINDINGS
9. The man arrived at HMP Wymott on 6 July 2005, after being previously held at
Preston prison. During that time, he had spent five days in a local hospital after
suffering a myocardial infarction (heart attack) before returning to prison to
recuperate as an in patient. On his arrival at Wymott, it was decided that he
should be given Vulnerable Prisoner status because of his age, the nature of
his offence and the publicity surrounding his case. During his health screen, it
was noted that the man had been diagnosed with chronic heart disease,
diabetes, hypercholesterolemia (very high blood-cholesterol level) and chronic
renal (kidney) failure. The man had also previously undergone heart surgery.
10. On 19 December, the man attended a local hospital for a scan of his heart. On
2 January 2006, he was admitted to hospital after suffering with pains in his
chest. The man was discharged from hospital on 6 January.
11. Whilst the man was in hospital, he was seen by a Consultant Cardiologist who
informed him that his poor medical prognosis meant that his life expectancy
was likely to be 6-12 months. A letter on the file, dated 6 January, reports on a
consultation with the man that day. The letter stated that the man’s prognosis
was poor and that he was on maximal medical therapy. The letter confirmed
that the poor prognosis had been discussed with the man. The letter also
pointed that any further heart attacks would affect the time the man had left.
12. On 19 February, the man had another myocardial infarction and spent five days
in outside hospital before returning to prison. On 2 April, the man experienced
severe chest pain and was again admitted to a local hospital. He remained in
hospital for a further two weeks, before he returned to Wymott on 16 April. The
man was seen as an outpatient on 24 April when some minor changes were
made to his medication.
13. Around 4:46pm on 27 April 2006, when prison staff were carrying out a roll
check they noticed that the man had not presented himself at the door of his
cell. When a Prison Officer entered the man’s cell, he found him unconscious
on his bed. As the officer was unable to rouse the man, he immediately
summoned urgent assistance. The Wing Governor and another then came to
assist. Staff lowered the man onto the floor of his cell and were then joined by
another officer. An ambulance was called and staff immediately commenced
cardio pulmonary resuscitation (CPR). Staff applied a defibrillator which stated
that there were no signs of circulation and to continue with CPR.
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14. When the paramedic and ambulance crew arrived, they decided to move the
man onto the landing (which had been cleared of prisoners) and they took over
responsibility for CPR. As they were unable to resuscitate the man, the
resuscitation attempts were abandoned at 5:18pm. The man was pronounced
dead by the paramedic at 5:23pm.
15. The prison contacted the man’s family to inform them of his death and to offer
condolences and support. A Principal Officer maintained contact with the
family and assisted with arrangements for the funeral. The prison provided
financial assistance for the funeral costs.
16. The post mortem report records the cause of death as due to natural causes as
a consequence of coronary artery atheroma with left ventricular hypertrophy (a
degenerative change in the inner and middle coats of the arteries around the
heart resulting in an enlarged heart).
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CLINICAL REVIEW
17. As noted, the clinical review was undertaken by a doctor, on behalf of Chorley
and South Ribble PCT. She found that the man had suffered from significant
long-term chronic diseases (heart disease and diabetes) and noted that his
condition had been diagnosed as terminal four months before his death.
18. 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 reviewer concludes that the man received a high standard of care and
support during his time in prison. There was no indication that his care was at
any time less than would have been received in the general community. (I note
that the man continued to smoke despite his health problems and staff at the
prison were unsuccessful in their attempts to support him to stop smoking.)
19. The reviewer judged that the medical records for the man were for the most
part legible and provided a clear account of his care throughout his time in
custody. The records covered a five year period and contained entries from
three different prisons and correspondence from four different hospitals.
However, she says that the introduction of an electronic patient record could
resolve a number of issues relating to the chronological recording of patient
information and should be implemented as soon as possible.
An electronic patient record system should be introduced as soon as
possible.
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CONCLUSION
20. The man returned to prison in June 2005. He died of coronary artery atheroma
(a degenerative change to inner and outer coats of arteries in the heart) in April
2006. The man had arrived in prison with a number of heath problems. He
had a history of heart related disorders and diabetes. In January 2006, the
man was told that he had between 6-12 months to live and that this was
dependent on whether he had further heart attacks.
21. In light of the findings of the clinical review, and my own investigation, I
conclude that the man’s medical care was entirely satisfactory. I have
endorsed one recommendation from the clinical review to be addressed by the
Chorley and South Ribble Primary Care Trust in partnership with the Governor
of Wymott.
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RECOMMENDATION
Medical
An electronic patient record system should be introduced as soon as
possible.
Accepted - Plans were announced in June 2006 to speed up implementation of the
electronic record. A date will be set for early 2007 for initial pilots and a detailed
action plan of roll out will be produced by the end of 2007.
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