Individual at Kirk Lodge

Circumstances surrounding the death of a man, in October 2004,
in a Probation Service Approved Premises.
Report by the Prisons and Probation Ombudsman for England and
Wales
June 2005
This is the report of an investigation into the circumstances of the death of a
man at Probation Service Approved Premises during October 2004. The
probable cause of death was a heart attack. It was known that the man had
been suffering with anaemia, hypertension and arthritis for some years and
details of his condition and treatment were obtained from the Inmate Medical
Record held by the Prison Service.
Since 1 April 2004, my office has been responsible for investigating all deaths
of Approved Premises residents, including those due to natural causes. A
senior member of my staff conducted the investigation with the assistance of
the Manager and (then) Deputy Manager of the premises. Only one formal
statement was taken, from the officer responsible for the man’s induction into
the premises. Otherwise, this report is based upon informal discussions
together with a thorough review of all the paperwork including the man’s
medical records. I am grateful for the assistance and co-operation that the
investigator received from the Probation Area, and from HMPrison for
providing the man’s Inmate Medical Record. Although a distant relative was
identified as the man’s next of kin, my office has had no contact with his
family.
The man was resident at the approved Premises for less than 24 hours and
staff did not have the opportunity to get to know him. Nevertheless his death
left its mark and his room mate was particularly affected. I offer my
condolences to the man’s family and to those who knew him.
STEPHEN SHAW
PRISONS AND PROBATION OMBUDSMAN
June 2005
*****************************************************************************************
CONTENTS Page No
Summary 4
The Approved Premises 5
Background Information on the man 6
The man’s Medical History and Treatment in Prison 6
Events leading up to the man’s death 7
Consideration & Conclusions 9
Recommendations 11
2
Summary
The deceased was aged 62 years who was sentenced to eight years
imprisonment in October 1999. As he had no suitable release address, he was
referred to a number of hostels and accepted by the Approved Premises in the
Probation Area. The man spent much of his sentence in HMP Albany but was
transferred to facilitate his release to the Approved Premises. He was
released, subject to supervision on licence, in October 2004
Prisoners are usually released in the morning but for a number of reasons,
including a death at the prison, it was not possible for the man to be released
until much later in the day. The man indicated that he did not take his
medication as usual on that day. After the induction procedure at the Approved
Premises, the man went to his room where his body was discovered the next
morning. It appears that he suffered a heart attack.
The investigation raised no issues about the level of care afforded to the man in
the short time he spent at the Approved Premises. However, the report draws
attention to shortcomings in the sharing of information between the Prison and
Probation Services at the point of discharge. The report makes two
recommendations.
BACKGROUND
The Approved Premises
1. Approved Premises, formerly known as Probation & Bail Hostels, are
approved by the Secretary of State within Section 9 of the Criminal
Justice and Court Services Act 2000. Their purpose is to provide
accommodation for persons granted bail in criminal proceedings and in
connection with the supervision and rehabilitation of persons convicted
of offences. Hostels can provide a supportive, structured environment
in the community for high risk and difficult to manage offenders. The
supervision of offenders accommodated in Approved Premises is
governed by the National Standards for the Supervision of Offenders.
2. The Approved Premises is one of two in the Probation Area. The
house has 32 beds and can accommodate up to 28 men and four
women in 11 twin rooms and six single rooms. The female beds are in
a self-contained unit. New residents are usually asked to share a room
in the first instance.
3. In the domestic areas of the house there is a laundry, television, dining
area and tea and coffee making facilities. Breakfast and dinner are
provided each day. A local doctor visits the premises weekly and the
local Forensic Mental Health team provides a visiting Community
Psychiatric Nurse as and when requested. The premises also has
links with a number of community organisations including a local
college that provides a computer training course and a basic skills
assessment programme.
3
4. The Approved Premises accepts offenders from the age of 18 who are
subject to Community Orders, Post Custodial Licence or bail conditions
imposed by a Court. The purpose of residence is to ensure that the
individuals concerned are subject to close oversight in the community
and there is an expectation that residents will participate in whichever
programmes the premises is operating. All residents are required to
pay a weekly rent.
5. Unless subject to specific curfew arrangements imposed by a Court, all
residents must be on the premises between the hours of 11 pm and 7
am. No alcohol or non-prescribed drugs are allowed on the premises
and the possession and taking of prescribed medicines must be carried
out in accordance with premises' policy.
Background Information on the deceased man
6. Probation records indicate that the man led a somewhat isolated adult
life, caring for his elderly mother who was not in good health. When his
father died, the man became the only breadwinner. To meet the
mortgage and household expenses he worked long hours in a factory
and found little time to socialise outside the home.
7. The man committed two separate sexual offences against his niece
and his great niece, twenty years apart, that did not come to light until
some time later. He accepted full responsibility for the offences and
pleaded guilty when he appeared in Court in 1999. Prior to this, he had
no convictions.
8. The man had no disciplinary problems during his sentence and he
achieved enhanced prisoner status. Despite suffering mobility
difficulties due to arthritis in his knees, he worked in the tailors' shop
where he said he was happy. He completed various courses, including
Sex Offender Treatment Programmes, and felt he had learned a lot
from the experience. The man was said to be a model prisoner who
had no adjudications against him. During the sentence his mother and
his brother died and the man was left without contact from any of his
extended family. He did not know the whereabouts of his victims and
hoped to obtain sheltered accommodation after a period in Approved
Premises.
The man’s Medical History and Treatment in Prison
9. The man was received into prison on in October 1999. During the first
'Reception Health Screen' he said that he had recently seen his G.P.
for anaemia, hypertension and arthritis. Despite having a history of
high blood pressure, the investigation found no documentary evidence
to indicate that this was checked by the health screener or the medical
officer later the same day.
4
10. In January 2000, the man was transferred to a prison on the Isle of
Sheppey and a further health assessment was undertaken. In
February 2000, the man was provided with a walking stick to aid his
mobility and the prison doctor carried out a full physical assessment.
The man’s blood pressure was found to be raised and a number of
blood tests were requested. The doctor asked to see the man again on
in April 2000.
11. The appointment could not be kept as the man was transferred to
another prison in March 2000. Again, he had a full clinical assessment
on reception and a further appointment was made for the following
week. He was then clinically reviewed and further blood tests were
requested.
12. Between March and July 2000, the medical officer saw the man on a
monthly basis, particularly for reviews of his cholesterol levels, and he
was prescribed medication. The reviews were changed to three-
monthly when his cholesterol level reduced. During his time at the
prison the man was reviewed regularly by healthcare professionals and
his chronic diseases were managed appropriately.
13. In June 2003, the man was transferred again. Between June and
September he was seen by healthcare on six occasions due to
problems with his chest and heart. He was given an Echocardiogram
(ECG) and his medication was reviewed. The prison doctor continued
to prescribe a range of medication for his arthritis, hypertension and
raised cholesterol that were dispensed by the prison.
14. There are no entries in the 'Continuous Medical Record' between
September 2003 and October 2004 to support an appropriate review of
his medication or a review of his clinical conditions. During October
2004, the man was transferred to the local prison as part of his
discharge planning, to facilitate his release to live at the Approved
Premises.
Events leading to the man’s death
15. The man was due to be released on a morning in October 2005. His
release was delayed while the prison ensured that the details on his
licence were correct and he had sufficient supply of his medication.
There was a further delay, due to the death of a prisoner, and the man
was not released until late in the afternoon. He arrived at the approved
Premises around 8.15 pm and was inducted by the duty probation
hostel officer who went through the rules with him. From the referral
form, staff at the Approved Premises were aware that the man suffered
with arthritis and had allocated him a ground floor room.
16. When he arrived at the premises the man was using a walking stick.
There was nothing on the referral form to indicate other health
problems but the man told the worker that he suffered with high blood
5
pressure and angina. He handed in his medication as he was required
to do, for it to be dispensed as necessary by hostel staff. He was
prescribed:
Enalapril 10 mg. twice daily
Frusemide 40 mg once daily
He told the worker that he would need to take medication before
retiring, as he had taken none all day. He said this was due to an
incident at the prison and he had been locked in his cell all day, before
being released. He therefore was given two enalapril tablets and one
frusemide.
17. The man did not indicate that he needed to keep any of his medication
with him and told the worker that he did not require anything else. The
probation hostel officer told the investigator that she thought the man
was a little flushed but she believed this was normal for someone with
high blood pressure. She said that he seemed quite well and did not
complain of feeling otherwise. The man then went to his shared room.
Following the man’s death, the resident who shared his room was
interviewed by police who found him to be, 'visibly shaken'. He said
that he had spoken with the man when he arrived and that all had
seemed well with him.
18. The room mate heard nothing untoward during the night and told the
police that he thought he had heard the man get up to use the
bathroom between 7 am and 8 am although he was not sure of this.
The resident in the next door room told the police that he had heard
nothing suspicious during the night or early morning. The night duty
worker carried out her final check of the premises around 7 am, visiting
each room as required, when all was well.
19. The man did not appear for breakfast but the hostel residential worker's
morning round of the premises was delayed when a resident burned
toast and activated the fire alarm around 9.15 am. At 10.05 am when
the residential worker entered the man’s room during her round, she
found him sitting on the bed, slumped backwards, unconscious. The
worker immediately called the emergency services and when they
arrived, it was clear that the man had died.
Consideration and Conclusions
20. Appropriate prescribing for older people and monitoring of their
conditions are key objectives for the Prison Service in delivering
effective care. This man was admitted to prison, in 1999, with a
number of pre-existing medical conditions and on prescribed
medication. The Inmate Medical Record indicates that his conditions
were well managed until his transfer to in the summer of 2003.
However, although the prescription charts record that the man’s
6
medication was re-prescribed, there is no other evidence to indicate
that his health needs were either monitored or reviewed between
September 2003 and October 2004. The apparent failure to review the
man in a timely and appropriate manner fails to meet the standards laid
down in the National Service Framework for Older people.
I recommend that the Prison Service should take steps to ensure that
local policy reflects compliance with the National Service Framework and
that evidence based reviews and monitoring of prescribed medication
take place as required.
21. The extent of information about a prisoner's medical condition and
needs that the Probation Service can obtain from the Prison Service
varies. It is dependent upon a number of factors including local
practice. The investigator was told that in many cases it is difficult to
obtain information from prisons, due to issues of confidentiality and, if
an Approved Premises bed is required at short notice, it may not be
possible to obtain letters of approval from offenders. Consequently,
probation staff are often reliant upon information that offenders disclose
themselves.
22. In this man’s case, there is no evidence that there was any healthcare
involvement in his discharge planning. The only information included
on the referral form to Kirk Lodge completed by a probation officer, and
in Probation Service electronic records, related to arthritis, the man’s
lack of mobility and his need for travelling allowances. The Approved
Premises Manager confirmed that there was no reference to any other
medical conditions and no mention of any life threatening illness.
Although the man told the probation hostel officer of his high blood
pressure and angina, there was no other information confirming the
extent of the conditions or their prognosis. I am satisfied that
possession of more detailed information about the man’s condition
would not have prevented his death but there could be situations in
which knowledge of medical conditions becomes crucial.
23. The National Offender Management Service is being developed with
the overall intention of joining the work of the Prison and Probation
Services to provide a seamless, more effective service. It intends to do
this by introducing end-to-end management of each offender, ensuring
that work in custody is built upon in the community. Whilst I readily
accept that offenders' rights to privacy and confidentiality must be
respected, nevertheless, I would suggest that such end-to-end
management should include the sharing of proper health care
information when offenders are released from custody to Approved
Premises, where the duty of care continues.
I recommend that the Prison, Probation and Healthcare Services develop
a protocol that reflects the use of a single, multi-disciplinary, assessment
tool, to identify health and social care needs and how they can best be
met on release into the community.
7
I recommend that the Probation Area reminds staff to take a pro-active
approach in obtaining sufficient information from the Prison Service to
allow a comprehensive assessment of health and social care needs.
(Since the draft report was issued, the Probation Area has confirmed that the
recommendation is accepted. The Area has said that it will engage in
negotiations with the Prison Service to review the findings and
recommendations of the report and to identify ways in which improvements can
be made to the release of health and medical information from custodial
establishments.
The Governor of the prison has also said that he will appoint a Senior Manager
to ensure that work is undertaken with partners in the Criminal Justice System,
to implement the recommendations.)
STEPHEN SHAW
PRISONS AND PROBATION OMBUDSMAN June 2005
Local Recommendation
I recommend that the Probation Area reminds staff to take a pro-active
approach in obtaining sufficient information from the Prison Service to
allow a comprehensive assessment of health and social care needs.
National Recommendations
I recommend that the Prison Service should take steps to ensure that
local policy reflects compliance with the National Service Framework and
that evidence based reviews and monitoring of prescribed medication
take place as required.
I recommend that the Prison, Probation and Healthcare Services develop
a protocol that reflects the use of a single, multi-disciplinary, assessment
tool, to identify health and social care needs and how they can best be
met on release into the community.
****************************************************************************
8
9