Individual at Wakefield

Investigation into the circumstances surrounding
death of a man at HMP Wakefield in January 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2010
1
This is the report of an investigation into the circumstances of the death of a
man, a prisoner at HMP Wakefield, in January 2010. The man’s death was
sudden and unexpected. He had been diagnosed with a number of medical
conditions which were unrelated to his death from heart disease.
I would like to offer my sincere condolences to the man’s wife and family and
to all those affected by his passing. Prisoners and staff to whom my
investigator spoke, who knew the man well, were all saddened by his death.
One of my colleagues conducted the investigation. Ms A, Registered General
Nurse (RGN), Practice Nurse Facilitator, conducted an independent review of
the man’s medical care on behalf of an NHS District Primary Care Trust
(PCT). I am grateful to Ms A for her valuable contribution.
I would also like to thank the Governor of Wakefield and her staff for their
cooperation. I am grateful to the Head of Healthcare, who liaised with my
office and I appreciate the assistance of prisoners and staff on the man’s wing
who provided valuable information.
I make six recommendations. The man had a chronic back condition
following an injury at work some years before he went into prison. The clinical
reviewer judged that, while his routine care was adequate, the management
of his back condition fell short of comparable care in the community. I
endorse her recommendations regarding prescribing medication at Wakefield
and delays in access to necessary medical aids, as well as a further
recommendation regarding record keeping. I have previously made
recommendations regarding the standard of record keeping at Wakefield and
am disappointed to repeat it here.
Whilst I recognise that the man’s wife was satisfied with the support she
received from the prison after her husband died, I consider that the choice of
family liaison officer was inappropriate. I acknowledge that the individual
concerned undertook on the role while on annual leave and in the absence of
anyone else being available. However, he previously responded to the man’s
wife’s complaints about her husband’s medication and there could have been
a conflict of interest. I therefore make a recommendation regarding
alternative family liaison officers. My final recommendation is about the need
for privacy screens when officers are dealing with potentially distressing
events. I am pleased to note the tremendous efforts of three officers, namely
Officer C, Officer E and Officer D who tried to save the man’s life and
recommend that the Governor writes to commend them.
The National Offender Management Service have accepted three of my
recommendations and their response is documented on page 22 of my report.
Jane Webb
Acting Prisons and Probation Ombudsman October 2010
2
CONTENTS
Summary 4
The investigation process 6
HMP Wakefield 8
Key findings 10
Issues 18
Conclusion 21
Recommendations and commendation 22
Annexes
3
SUMMARY
The man was remanded into custody at HMP Manchester in June 2006 and
transferred to HMP Wakefield in December 2006. He was found collapsed in
his cell in January 2010. A post mortem examination discovered that he died
from ischaemic heart disease.
In the early 1990’s, the man sustained an industrial injury. He crushed three
discs in his back and endured a chronic and painful back condition from that
point. While in the community, the man benefited from effective pain
management. However, the investigation has found that pain management
for his chronic back condition by the healthcare department at Wakefield fell
short of the standards expected.
In May 2008, the man’s solicitor wrote to the prison on his behalf. He asked
for regular reviews of the man’s medication and for the prison to ensure that
the man was not left in pain.
Following this, the man’s wife wrote three letters of complaint to the Governor
during 2009. She said that her husband was not receiving the medication that
he needed and was entitled to. Given his disability and back condition, she
was also concerned at the distance he had to walk to his workplace.
The prison responded to her complaints appropriately on two occasions
confirming that a referral had been made to a physiotherapist and a change in
the man’s work place had been requested. The healthcare department’s
response to the third complaint letter, dated 22 May 2009, was less than
satisfactory as it did not specifically address the issues raised. The clinical
review highlights concerns regarding the man’s difficulties with his medication
and poor record keeping. The former Chief Inspector of Prisons raised similar
concerns about pharmacy services in her inspection report in December
2008. I consider that the length of time it took for the prison to resolve the
man’s medication, change his place of work and provide a back brace is
unacceptable.
The man had been suffering from chest pains for two to three weeks before
his death. He told his wife about this, but did not share his concerns with
discipline or healthcare staff. Prisoners who knew him were aware and urged
him to go to healthcare. He did so reluctantly, but did not tell them he was
suffering from chest pain, but said that he had a chest infection.
On 22 January, at 6.15pm, prison staff were making their evening checks
when they found the man unresponsive on his bed in his cell. Despite every
effort by wing officers and healthcare staff to resuscitate him, the man could
not be revived.
The prison did not have a family liaison officer who was available. The Head
of Healthcare agreed to undertake the task, despite being on annual leave. A
few hours after the death, he travelled to the home of the man’s wife,
accompanied by a police officer to break the news of her husband’s death.
4
The clinical reviewer has judged that, overall, the man’s routine care was
adequate. However, the management of the pain resulting from his chronic
back condition fell short of the standard expected and was not equal to what
he would have received in the community. I make six recommendations.
They include addressing poor record keeping and an urgent review of the
prescribing services, together with an audit of prescribing by nurse
prescribers. A further recommendation asks that the prison ensure that there
are minimal delays to prisoners receiving medical aids/equipment. I also
consider there is a need for the prison to establish a working duty rota of
trained family liaison officers. Screens should be provided on each wing to
ensure the privacy of officers carrying out life saving actions. They will
preserve the dignity of the prisoner involved and reduce the risk of distressing
events being witnessed by other prisoners.
I am pleased to commend the efforts of officers who tried to save the man’s
life and persevered until the paramedics arrived.
5
INVESTIGATION PROCESS
1. The man died in January 2010. This office was notified of his death later
on the day of his death. Terms of reference and notices were issued to
staff and prisoners at Wakefield telling them that an investigation would be
taking place, and inviting those who wished to see the investigator to make
themselves known. The investigator, my colleague, reviewed copies of
the man’s core record, clinical record, and other records relevant to his
time in custody and his death.
2. The investigator also contacted HM Coroner to inform him of the nature
and scope of the investigation and to request a copy of the post mortem
report. The coroner’s officer told my colleague that the man died of
ischaemic heart disease.
3. My colleague visited Wakefield on 9 March. She toured the wing and met
Principal Officer A, the principal officer (PO) on C wing where the man
was located at the time of his death. She spoke with prisoners and staff
on the wing who knew the man.
4. A clinical review of the man’s clinical care was commissioned from an
NHS District Primary Care Trust and undertaken by Ms A, practice nurse
facilitator. Ms A focussed on the clinical care the man received at
Wakefield. Her review appears as an annex to this report.
5. One of my family liaison officers contacted the man’s wife, as his next of
kin, to advise her about my investigation and give her the opportunity to
raise any questions or concerns to be considered as part of this. The
man’s wife had a number of concerns regarding the care her husband
received at Wakefield. These included:
▪ Poor pain management for the man’s chronic back condition.
▪ Lengthy waits to see a doctor and receive medication.
▪ The prison had sent a response to her complaint about her husband’s
care that contradicted what her husband had told her.
▪ The man’s disability was not taken into account when allocating him to
work in the prison workshop. The workshop location was a long walk
from the man’s cell and he had to cope with several flights of stairs to
get there and back from his cell.
▪ Why her husband had received no medication during his first few
weeks in custody.
6. The man’s wife suggested to my family liaison officer that the investigator
speak with Prisoners A and B, prisoners and friends of the man, in the
course of the investigation. My colleague did so and was most grateful to
the man’s wife and Prisoners A and B for their assistance.
7. The man’s wife spoke positively about the help and support she had
received from the prison following her husband's death. She confirmed
that his property had been returned and the prison had paid the funeral
6
costs. I hope this report addresses the concerns she has about the care
her husband received at Wakefield and provides her with a better
understanding of the events leading to his death.
7
HMP WAKEFIELD
11. HMP Wakefield is part of the high security estate. On average, the prison
holds 740 men including a small number of remand prisoners and
category A and B prisoners1. It is a main centre for life sentenced
prisoners with a focus on serious sex offenders.
12. There are four main residential wings A, B, C, and D. B wing has a small
unit for remand prisoners and four cells adapted for prisoners with mobility
difficulties. Lifts had been installed on the wing and the man would have
been able to take advantage of this if he had wished to. A close
supervision centre (CSC), managed by the Head of Healthcare, houses
eight prisoners who pose exceptional risks.
12. The Independent Monitoring Board (IMB)2 report for the period May 2008
to April 2009, acknowledged the improvement in healthcare resources
following investment by the Primary Care Trust. Prisoners who used
healthcare services were observed to be well cared for. The IMB raised
concerns about inadequate support for prisoners with severe mental
health problems and suitability of accommodation for the ageing prison
population. At the time of their report, Wakefield held around 100
prisoners over the age of 60 years and 116 disabled prisoners. There
were approximately 240 prisoners in the 40 to 50 years age group who
were serving long sentences and who would increase the ageing
population. The IMB praised the effectiveness of the nurse-led Primary
Care Centre. Prisoners such as the man used the first contact services for
rapid assessment and management of acute and chronic conditions.
13. In her report following an announced inspection in December 2008, the
former Chief Inspector of Prisons described Wakefield as having built
upon improvements made over the past five years. Wakefield was
assessed as a prison performing reasonably well overall, although the
former Chief Inspector acknowledged there was more to be done.
14. The inspection highlighted a number of problems with pharmacy services
and medication management. This was an issue for the man while he was
at Wakefield and the subject of complaints to the Governor by his wife.
The investigator, my colleague and the clinical reviewer, Ms A, have
considered these matters later in this report.
1 Prisoners are risk assessed and given a category based on their offence and the risk that they pose to the public
should they escape. There are four levels: A, B, C and D. Category A prisoners are those whose escape would be
highly dangerous to the public, the police or to the security of the state. Category B are prisoners for whom the
highest security conditions are not necessary but for whom escape must be made very difficult.
2
All prisons in England and Wales have an Independent Monitoring Board (IMB). The IMB is staffed by volunteers
from the local community. The IMB have access to every area of the prison, including attending meetings,
adjudications and segregation reviews, answering prisoners’ queries and investigating complaints. The IMB is
required to publish an annual report.
8
15. There have been a number of deaths at Wakefield since 2004, when my
office took over responsibility for conducting investigations into all deaths
in prison custody. Although recommendations have been previously made
about record keeping, there are no similarities between the man’s death
and those of previous prisoners.
9
KEY FINDINGS
16. The man was born in 1949. He was married and lived with his wife before
his imprisonment. Records show that it was his intention to return to the
family home upon his release.
17. The records also show that the man left school without any qualifications.
He held a number of jobs throughout his working life. They included
factory work, a carpet fitter and an assistant shop manager. While
working as a gas appliance fitter he sustained a serious injury to his back
in which three discs were crushed. He had been unable to work since that
time. The man was registered disabled.
18. The man was sentenced to ten years imprisonment in July 2006, and sent
to HMP Manchester. He continued to deny his offences throughout his
sentence and appealed against his conviction and sentence. His appeal
was unsuccessful. Despite this, he chose not to attend meetings with
prison and probation staff to discuss the work he needed to complete to
reduce his risk of re-offending and increase his chances of being released
early on parole licence.
19. Upon his arrival at Manchester, the man was given the opportunity to
make a telephone call to his family to let them know where he was. The
man’s wife’s telephone was turned off and she could not be contacted.
Meanwhile the man was located on the induction wing to learn about the
prison and the prison regime. An entry in the prisoner personal record
document on 28 July, shows that the man had already been selected for
transfer to HMP Wakefield. However, this did not happen until December
2006.
20. A first health assessment was undertaken in which the man said he did
not wish to see a doctor. The man was assessed as suitable to be located
on a wing, go to work and share a cell. The question about whether he
had any concerns about his physical health was unanswered. No medical
information was received from an external source, but the man said he
saw his doctor around four months before but could not remember why.
He confirmed that he was receiving prescribed medication, temazepan3,
cocodamol4 and diclofenac5 . There is no evidence that the member of
healthcare staff who completed the form considered whether the man
might need medication or physically examined him. The screening form
asking for a medical history was not completed.
21. The man was interviewed by wing staff when he arrived on the induction
unit later that day. He told them he was taking painkillers and sleeping
tablets. No other issues were identified. The wing sheet noted that the
man had disability requirements but that he had not been allocated
suitable accommodation at that time.
3 Temazepam is sedative used to treat insomnia.
4 Cocodamol is used for pain relief.
5 Diclofenac is used as a treatment for anti-inflammatory relief.
10
22. An entry in the man’s prison wing sheet on 28 July, shows that the
chaplaincy at Manchester contacted his wife that day and told her he was
in prison. The man’s wife was very distressed at the news.
23. Throughout the early part of his sentence at Manchester, it was recorded
in the man’s wing sheet that he had settled well into the prison, obeyed the
rules and regulations and went to work. He was noted to be clean and
tidy, and polite to staff.
24. The man transferred to Wakefield on 15 December 2006. He was
interviewed by prison staff the same day and neither the man nor the staff
had any concerns. An entry in the clinical record dated the same day
shows that the man was seen by a member of the healthcare staff in
reception. It is impossible to determine which member of staff saw the
man as entries, although dated, are not timed and the signatures are
illegible. The entry recorded that the man had a chronic back problem and
was taking diclofenac and paracetamol and using Deep Heat cream. He
appeared happy to be at Wakefield.
25. The man was seen at a First Contact clinic6 on 12 February 2007. His
attendance was recorded by a handwritten entry on a contact sheet in his
clinical record. He was allocated to work in the textiles workshop and
asked to be put on the afternoon shift as he found it difficult to move about
in the morning. Healthcare staff agreed and said they would ring C wing,
where the man was located, to confirm that this was appropriate.
26. There is evidence of the man’s attendance at four subsequent First
Contact clinics on 16 April, 20 April, 4 May, 25 June and 2 August 2007,
where he was seen by nursing staff. His chronic back problem was noted.
The man’s ongoing difficulty getting medication for pain management are
apparent on each occasion and he had been advised to report sick. The
investigator noted that there are no corresponding entries in the
computerised clinical record. I address the matter of the importance of
good record keeping in the Issues section of this report.
27. The man’s wing history sheet required two detailed entries from his
personal officer7 per month. An entry by his personal officer for 8 March
said that while not necessarily isolating himself from other prisoners, the
man was a private man who preferred his own company.
28. At the First Contact clinic on 20 April, the man told Nurse A, a registered
general nurse, that he used a lower back brace at home. However, the
prison security department would not allow it to be sent in as parts of it
were made of metal. Only a back brace made entirely of fabric was
permitted. Nurse A planned to speak to the prison doctor to arrange for a
6 First Contact clinic is run by nursing staff for prisoners with chronic conditions/health needs.
7 A personal officer is allocated to each prisoner and is a personal point of contact in case of
difficulties.
11
referral to the Surgical Appliances Department at Pinderfields Hospital if
the prison could not provide a back brace.
29. The security department was unable to give permission for the brace.
Doctor A, one of the prison doctors, wrote to the Surgical Appliances
Department on 10 May, asking them to assess the man for a fabric back
brace. The matter was still not resolved in September when the residence
governor sent a memorandum to healthcare asking for a formal medical
decision. This was because the security department required the brace to
be medically prescribed before allowing the man to have it. The residence
governor confirmed that he had the brace as the man’s wife had posted it
directly to him. Doctor A replied to the residence governor on 12
September, that she had referred the man to the Hospital on 10 May, but
had not had a response. In the circumstances, she asked if the residence
governor could issue the brace to the man as he needed it to help ease
his low back pain. The clinical record shows that the man was in
possession of the brace when he visited the prison doctor on 24 October.
The clinical reviewer has considered the matter of the delay in the man
receiving the back brace.
30. In June, the man was given permission to visit his dying sister in Hospice.
His good behaviour towards hospice and prison staff was recorded. On
15 July, a member of the chaplaincy team broke the news to the man that
his sister had died.
31. The clinical record shows that throughout 2007 and 2008, the man
continued to visit the healthcare department regularly for medical reviews
and repeat prescriptions for diclofenac, ibuprofen gel, paracetamol and
medication for an ongoing skin condition. However, on 27 May 2008,
following a visit to the man at the prison, the man’s solicitor wrote a
complaint letter to the Governor. The solicitor said that the man had three
crushed discs, sciatical nerve damage and mobility problems and was
registered disabled. The man had told his solicitor that he had been
prescribed paracetamol, ibuprofen gel and 75mg of Dicoflex (a brand of
diclofenac) and was still in considerable pain. He said that he did not have
an appointment with a doctor until 30 May. The solicitor asked that the
man’s medication be reviewed regularly to ensure that the man was not
“left in pain”.
32. The Governor of Wakefield replied to the man’s solicitors on 11 June,
saying that she would ensure that the man’s medication was regularly
reviewed. There followed an exchange of correspondence between the
man’s solicitor and the prison about the man’s medical care. Through his
solicitor, the man complained that he expected to see a doctor on 30 May,
but saw a nurse who arranged for his next three month’s supply of
medication to be made available. When he went to collect his medication
on 8 June, he was told that it was not there. The man put in an application
to see a doctor but saw a nurse again on 17 June.
12
33. The clinical record supports the man’s version of events. Nurse B, a
prescribing nurse, reviewed him on 30 May and prescribed diclofenac,
ibuprofen gel and medication for his skin complaint. On 17 June, The man
told Nurse B that he received the paracetamol for the first week but was
told that no more was available. Nurse B planned to discuss this with the
pharmacy department. The next entry in the clinical record, dated 26
August, shows that the man saw Doctor B, a prison doctor, and asked for
a repeat prescription.
34. The man’s wife wrote to the Governor early in 2009, to complain that her
husband continued to have problems with his medication. The man’s
medication in the community had been effective and she asked if the
prison could contact the man’s community doctor and obtain his medical
records. She was also concerned about the distance he had to walk and
the number of stairs he had to use to get from his cell to work. The Head
of Healthcare replied that the problem arose because two similar items
had been prescribed and, as a precaution, the pharmacist would not give
them to the man. A referral had been made to a physiotherapist and a
change in the man’s workplace was being actively pursued. (A note in the
clinical record shows that the man had the physiotherapy assessment on
18 May.)
35. On 8 April, the man’s wife wrote to the prison again, to say that her
husband was still not receiving the right medication, there were items
missing and there had been no change in his work location. The prison
responded again saying that the man had now received six month’s
medication; a change of labour form had been submitted and a referral
made to a physiotherapist. A copy of the man’s wife’s letter would be sent
to each of the labour board, disability team and the physiotherapist.
36. The man’s wife wrote a third letter of complaint on 22 May, saying that her
husband was again without his medication and that Doctor A had not
renewed his prescription despite being asked to do so on 9 May. (There is
no entry in the clinical record to say that the man saw the doctor on this
date.) The man had apparently been told to report as sick until he saw the
doctor but told his wife that he did not want to do this as “he likes to keep
going”. The response from the then Head of Healthcare on 29 May, was
that the prison had ensured that his medicines were administered on time
and that all patients have to see a doctor for a review throughout the year.
The response did not acknowledge or address the specific issue of the
man not receiving his medication. The clinical review highlights concerns
regarding the man’s difficulties with his medication and poor record
keeping by healthcare staff.
37. The investigator spoke with Prisoner A, the man’s friend. Prisoner A
confirmed that the man told him that he had received stronger medication
in the community. He was aware that the man suffered from chronic back
pain because of an industrial injury. The man’s clinical record says that
the accident happened around 1993/1994 when he was moving an
unstable 45 gallon barrel. He fell, but managed to avoid the barrel falling
13
on top of him. Prisoner A said that the man first worked in the trimming
and packing workshop at the prison. This involved carrying boxes which
caused him pain. The man moved to a second workshop which was more
suitable work and also nearer to his cell. Prisoner A told my colleague that
the prison had offered the man a wheelchair, but he refused. He also said
that the man told him that he had a history of a heart or angina problem in
his 20’s.
38. My investigator spoke with Principal Officer A, a principal officer in the
wing where the man was located. Principal Officer A said that the man
was located on the ground floor of the wing because of his mobility
problems, but the wing had a lift to the upper floors. Principal Officer A
was aware that the man could manoeuvre himself up and down the stairs
without using the lift.
39. Prisoner B, a prisoner and the man’s friend, was aware of the man’s
difficulties getting his medication. The man expressed his view to him that
his medication had been changed because of costs.
40. The man continued to visit the healthcare department regularly for
physiotherapy and to renew his medication. He last visited healthcare on
12 November where a review was undertaken by Doctor C, a prison
doctor.
41. The man’s wing record gives consistently good reports of his behaviour
and attitude to staff and others throughout his sentence. However, while
compliant with the prison rules and regulations, the investigator noted that
the man did not discuss his pain management difficulties with wing staff.
They were unaware of his problems with medication.
21 January 2010
42. Head of Healthcare and Wakefield liaison for this investigation told the
investigator that telephone calls made by prisoners were recorded. He
had listened to a recording of a telephone conversation between the man
and his wife made on 21 January. (Although my investigator was given a
CD copy, the recording could not be accessed.) Apparently, the man told
his wife that he had been suffering from pains in his chest and legs for two
to three weeks. However, there is no evidence that he shared these
concerns with either healthcare or discipline staff. Head of Healthcare
said that the man made a similar call the night before he died, telling his
wife that he felt very ill with pains in his chest and arms but again, did not
share this with prison or healthcare staff.
43. Prisoner A told the investigator that the man had a cold two weeks before
he died and had complained of pain and tightness in his chest. He was
urged to see a doctor as another prisoner had suggested that he might
have a chest infection. Prisoner A recalled that the man had gone to the
healthcare centre and told them that he thought he had a chest infection
but did not tell them he had chest pain. Prisoner A thought that if the man
14
had told them he was suffering from chest pain and not a chest infection, it
would have been dealt with as a matter of urgency. There is no evidence
in the clinical record that the man went to healthcare complaining of a
chest infection.
22 January
44. On the morning of Friday 22 January, Prisoner A remembers the man
leaning against his cell door complaining of chest pain. He told him to go
to the doctor. He offered to get him water and the man went to lie on his
bed. By lunchtime, when Prisoner A returned from work, the man was
looking better, but did not want his lunch. Prisoner A told him that he
would see him tonight and would get him some water. He arrived at the
man’s cell at around 4.50pm. The man offered his dinner to Prisoner A as
he did not want it. Prisoner A thought that he did not seem too bad as he
had asked for some hot water. Prisoner C, another prisoner who knew the
man, said that he spoke with him that afternoon. He told him he did not
feel well and so Prisoner C advised him to go to healthcare. The man
replied that it was a waste of time as they would not do anything.
45. Officer A, a prison officer, knew the man well. She described him as a
person who liked to have a laugh and a joke. She said that staff did not
know he was unwell and she thought that he did not want to burden them
with the knowledge. He never complained to officers about anything and
she described him as a model prisoner.
46. Officer A said that most of the wing staff left at 5.00pm, leaving herself and
Officer B, another officer, on duty. She said there was paperwork and
checks to do before the night staff arrived at around 8.00pm. Before going
off duty, she and Officer B made a full roll check (physical count) of the
prisoners at around 6.00pm, which was earlier than usual. Officer B
checked one side of the wing while Officer A checked the other. They
started on the top floor of the wing, opening cell observation panels and
speaking to prisoners as most were awake. She said that they worked
their way down to the ground floor and she checked the cells on the left
side of the landing and Officer B checked those on the right. The man’s
cell was on Officer B’s side. Officer A said she was standing outside the
kitchen as there were no cells on that side, when Officer B reached the
man’s cell at around 6.15pm.
47. Officer B looked through the observation panel and saw that the man was
lying in an awkward position on the bed. He said he shouted and kicked
the door to get a response. Officer B could not see the man’s face, but he
noticed that his shins and the lower part of his arm were purple.
48. Officer B called Officer A over as he was concerned and both officers
looked through the panel. She said that the man knew her better than
Officer B and, if she called to him, she was confident he would answer her.
She thought that he could have been sleeping but she could not see his
face. His arm was curled up and one leg was off the bed. She noticed
15
that the bottom part of his arm was mottled and his fingernails were white.
There was no response to her bang on the door. They opened the door
and went into the cell. Officer B saw that the man’s face was grey in
colour. Officer A thought he had passed away. Neither officer was
recently trained in first aid or resuscitation techniques.
49. They relocked the cell and Officer A went to summon assistance while
Officer B remained outside. She ran up to the second floor to the wing
office where Principal Officer B was located in his role as Oscar 18. While
running to the office, she used her radio to call for nursing assistance.
She said that there was a code blue 9on ‘C’ wing. She told Principal
Officer B that a prisoner was not responding. He locked the wing office
doors and ran down to ‘C’ wing with Officer A.
50. They reached the cell and Principal Officer B used his radio to call for an
ambulance through the prison control room. The Incident report records
Principal Officer B requesting the ambulance at 6.15pm. While he was
doing this, two officers from ‘A’ wing, Officer C, who was trained in first aid
and Officer D, responded to Officer A’s call for medical assistance over the
radio net. Officer B unlocked the cell and went in with Officers C, D and A.
51. In his statement, Officer B said Officers C and D immediately took charge.
Officers A and B said that because of the small cell, Officers C and D
moved the man off the bed outside to the corridor. Officer A said she and
Officer C felt for a pulse but could not find one.
52. Officer C started chest compressions for cardiac pulmonary resuscitation
(CPR). Officer D held the man’s head and also tried to find a pulse at the
man’s wrist and throat but was unsuccessful. Officer E, an officer trained
in first aid who worked on ‘B’ wing, also went to the cell. In his statement,
Officer E said that, similarly, he had heard the code blue call for healthcare
staff to attend ‘C’ wing. He reported to Principal Officer B and told him he
was trained in first aid.
53. Officer E said that Officer C looked tired and he took over CPR from him.
Officer C then gave breaths to The man. The officers exchanged places
when one tired.
54. Nurse C was Hotel 510 at the time the man was found collapsed in his cell.
It was at 6.14pm and she was in the healthcare centre inpatients unit in
the prison at the time. Upon hearing the call for medical assistance, she
stopped at the healthcare primary care centre to collect the emergency
response medical bag and the defibrillator.11
8 Oscar 1 is the officer in charge of the operational running of the prison.
9 The prison uses colour codes to describe the type of medical emergency: red indicates a blood related
incident and blue means not breathing.
10 Hotel 5 is the emergency radio call sign for the nominated healthcare worker who has to respond to
medical emergencies in the prison.
11 A defibrillator is an electronic device which sends an electric shock to the heart to restore the normal heart rhythm.
Defibrillation is performed to correct life-threatening fibrillations of the heart, which could result in cardiac arrest.
16
55. Nurse C said she arrived at the man’s cell at 6.20pm. She saw that he
was lying on the floor outside his cell, unconscious and very blue. Officers
C and E were carrying out CPR. She was told that an ambulance had
been called.
56. Officers C and E continued with CPR. Principal Officer B asked for the
man’s shirt to be removed so Nurse C could attach the defibrillator pads to
his chest. The defibrillator advised that CPR should continue and both
officers confirmed to Nurse C that they were happy to do so. There was
fluid in the man’s mouth and throat and she and Officer E turned the man
on his side to try to clear his airway. Despite this, both officers continued
with CPR. The paramedics arrived at 6.24pm, when the defibrillator was
making a second check of the man’s heart. After receiving an update of
the situation, they took over the man’s care. Despite the efforts by prison
staff, the paramedics pronounced the man’s death at 6.45pm.
After The man’s death
58. No family liaison officers were available at the prison. The investigator
was told that there was a shortage of staff who were willing to undertake
the role. Although he was on annual leave, the Head of Healthcare,
assumed responsibility for contacting the family. He told the investigator
that he was accompanied by a police officer to break the news to the
man’s wife and arrived at her home at quarter past midnight. He spent
around two hours and waited until other family members arrived to support
her.
59. Although the man’s wife has questions about her husband’s care, she
spoke positively to my family liaison officer about the support she had
received from the prison following his death. She confirmed that the
prison returned the man’s property and paid for the cost of his funeral.
60. A Hot Debrief12 was held on 22 January. Staff present at the man’s cell
were given the opportunity to share how they felt with colleagues. They
were offered support from the Staff Care and Welfare Team or the
Employee Support Services. They reviewed how the situation was
managed and the lessons that had been learned. Staff identified that
more first aid trained staff were needed. They also suggested there may
have been some delay collecting the emergency treatment bag from
healthcare. Events showed that screens would have been advantageous
as CPR had to be carried out on the landing because of lack of space in
the cell.
12The purpose of the “Hot” debrief is to acknowledge what happened, acknowledge the role of the staff involved,
normalise the situation and ensure that immediate needs of the staff have been met.
17
ISSUES
Clinical care
61. Ms A, RGN at an NHS District Primary Care Trust (PCT) reviewed the
man’s clinical care. Her review is based on prison medical records and
liaison with the investigator, my colleague. Ms A identified issues
regarding the management of the man’s chronic back condition.
Specifically, prescribed medication that was not available, together with
the absence of entries in the clinical record relating to their prescription
and poor record keeping.
62. Nevertheless Ms A concludes that, overall, the routine medical care given
to t\he man at Wakefield was appropriate. However, there was no
multidisciplinary approach in the management of his chronic back
condition and no management plans or an identified clinician responsible
for supervising or co-ordinating his care. Ms A assesses that “there were
occasions when his pain management was less than acceptable”. She
highlights significant concerns regarding the confusing systems in place
for recording and prescribing medication. Ms A makes three
recommendations regarding these issues which I endorse.
63. The clinical review acknowledges that the man was offered annual
medical reviews, but refused routine blood screening tests. Ms A advises
that the man did not appear to have any symptoms or signs that could
have prevented his collapse.
Prescribing medication
66. The former Chief Inspector of Prisons found that prescriptions for in-
possession and administered medications were written on standard
prescription forms:
“… charts were not correctly completed to indicate which
medications were to be administered and which were daily or
weekly in possession and they were not correctly annotated by
nurses to indicate whether medication had been
administered/collected or the patient failed to attend. Prescriptions
were often written up for three months supply and did not include a
diagnosis. Prescribers did not always record prescribed items on
system one13.”
The clinical reviewer found similar instances of poor recording in the
man’s clinical record. In her clinical review, Ms A said there were
“significant concerns regarding the confusing systems in place for
recording and prescribing medication”. She also noted that the First
Contact sheet information was not recorded in the clinical record.
Accurate record keeping is not optional and records should be kept
13 System One is the computerised healthcare recording system
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according to the Nursing and Midwifery Council’s standards. Ms A
makes a recommendation regarding an urgent review of the systems
and processes for prescribing medication, with which I concur.
The Head of Healthcare should undertake an urgent review of the
systems and processes in place for prescribing current and repeat
medication, including recording in the clinical record.
The Head of Healthcare must remind healthcare staff that accurate
and timely record keeping is essential in accordance with the
standards of the Nursing and Midwifery Council.
Nurse prescribers
67. Ms A also found apparent discrepancies between the medication
prescribed on the prescription sheets and the information documented
in the clinical record. She has made a recommendation in this regard
which I endorse.
The Head of Healthcare should ensure that an audit of prescribing
by nurse prescribers is undertaken in order to establish the
appropriateness of prescribed medication, against the needs
identified in the clinical record.
Family liaison
68. The Head of Healthcare, Segregation Unit and Close Supervision Unit,
was on annual leave when he was contacted by the prison and asked to
undertake the role of family liaison officer. He told my investigator that this
was in the absence of any other liaison officer being available and as he
had been trained. It is commendable that he agreed to carry out the role
in these circumstances to assist the prison.
69. However, in doing so, I consider that the prison, albeit unknowingly,
placed Head of Healthcare in a difficult position. There are copies of
letters within the clinical record showing that Head of Healthcare
responded to complaints from the man’s wife about his medical care. She
has also raised a number of issues around the man’s medical care with
my office. I judge that, in this instance, given the nature of previous
concerns and correspondence, there was a conflict of interest regarding
Head of Healthcare’s role as family liaison officer and as Head of
Healthcare. As this did not impact adversely on the communication
between Head of Healthcare and the man’s family, I make no formal
recommendation on this specific point. However, I consider that given the
nature of the population at Wakefield prison and the consequent regularity
with which deaths or other serious matters occur, it is essential that
sufficient trained family liaison officers are available.
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The Governor should ensure that there is a permanent rota of staff
trained in the role of family liaison officer available to undertake the
position in the event of future deaths at the prison.
Medical aids
69. The man used a back brace support before he went into prison. He asked
for a brace in April 2007, which he did not receive until six months later in
October 2007. The matter was not resolved until the residence governor
intervened by writing to the healthcare department asking for a formal
medical decision regarding the brace, so the security department could
consider it. I believe that this was an unacceptable and unnecessary
delay caused through poor communication between the security and
healthcare departments. The clinical reviewer has considered the matter
of the unacceptable delay, again I endorse her recommendation.
The Governor and Head of Healthcare should review internal
communication systems to minimise delays in prisoners receiving
medical aids/equipment. Items not held in the healthcare department
should be obtained and made available to the prisoner as soon as
possible.
Response when the man collapsed
70. I am pleased to make commendations regarding the efforts of Officer C,
Officer D and Officer E in responding to the emergency call, taking
command of the situation and attempting to save the man’s life. Sadly,
they were unsuccessful. However, comments made to my investigator by
prisoners, and staff who were present at the man’s cell and the officers’
statements show that their efforts were over and above that required of
them.
The Governor should write to Officer C, Officer E and Officer D
commending them for their tremendous efforts in trying to save the
life of The man.
71. The hot debrief meeting held on 22 January with staff identified, among
other issues, a need for screens on the wings. CPR had to be carried out
on the landing due insufficient space to do this effectively in the cell. The
man was found in the evening after prisoners had been locked in their
cells and the observation panels on the cell doors may have been closed.
However, it is possible that future events may occur during the day and,
unavoidably, in full view of prisoners. Screens on the wings would assist
staff give dignity to the prisoner and help to reduce the risk of other
prisoners witnessing such events.
The Governor should provide privacy screens for each wing, to be
used by medical and discipline staff involved in medical
emergencies. These will also reduce the risk of prisoners witnessing
distressing events and will give dignity to the prisoner.
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CONCLUSION
71. The man had served over three years of his sentence when he died from
ischaemic heart disease in January 2010. Although he had a longstanding
chronic back condition following an industrial accident, he had not shown
any signs or symptoms of heart disease and his death was sudden and
unexpected.
72. Prisoners who knew the man well said that he had chest pain for a few
weeks before his death and they advised him to go to the healthcare
centre. However, he told healthcare staff that he had a chest infection and
said nothing about chest pain.
73. The clinical reviewer is satisfied that, overall, the man’s routine care was
appropriate. However, there were occasions when pain management for
his chronic back condition fell short of the standards expected. The
investigation has found that this supports the man’s wife’s concerns
around her husband’s medication. The method of recording and
prescribing medication is inadequate and needs to be reviewed.
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RECOMMENDATIONS AND COMMENDATION
1. The Head of Healthcare should undertake an urgent review of the
systems and processes in place for prescribing current and repeat
medication, including recording in the clinical record.
Accepted. Medicines Management Process mapping exercise to be
undertaken Aug 2010 to address clinical issues relating to medication
prescribing/dispensing/administration. Paracetamol Protocol completed.
Systm 1 training undertaken.
Auto consultation added to Systm 1.
Prescription Chart audit completed – action plan ongoing.
In-Possession Policy refreshed Aug 2010 – undergoing ratification.
2. The Head of Healthcare must remind healthcare staff that accurate
and timely record keeping is essential in accordance with the
standards of the Nursing and Midwifery Council.
Accepted. With effect from April 2010 resources were made available to
deliver SystmOne training one day per week; this will be ongoing
throughout 2010. As part of the staff appraisal system all staff have been
issued with Record Keeping standards in accordance with the Nursing and
Midwifery Council. Record keeping audit completed for 2010 – action plan
written.
Training session on record keeping and professional accountability
planned for Sept. 2010.
3. The Head of Healthcare should ensure that an audit of prescribing by
nurse prescribers is undertaken in order to establish the
appropriateness of prescribed medication, against the needs
identified in the clinical record.
Accepted. Audit of Nurse Prescribers currently being undertaken – self
audit process followed by NHSWD and continuous in practice.
4. The Governor should ensure that there is a permanent rota of staff
trained in the role of family liaison officer available to undertake the
position in the event of future deaths at the prison.
Partially Accepted. At the time of the DIC, there was a Family Liaison
Rota in place, and there still is one in place. Unfortunately, the On Call
FLO was not contactable at the time, therefore an alternative FLO had to
be deployed.
The Head of Healthcare does not feel there was any conflict of interest
with regard to the letters he sent to the man’s wife. The family themselves
never raised any issues or concerns regarding these letters during the
Head of Healthcare’s visits to their home.
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5. The Governor and Head of Healthcare should review internal
communication systems to minimise delays in prisoners receiving
medical aids/equipment. Items not held in the healthcare department
should be obtained and made available to the prisoner as soon as
possible.
Partially Accepted. Due to the high security nature of the prison there will
be a delay in the prison receiving the equipment due to it having to be
checked and x-rayed. This is reviewed on a case-by-case basis but the
prisoner will be kept informed should there be any further delays in them
receiving it.
6. The Governor should provide privacy screens for each wing, to be
used by medical and discipline staff involved in medical
emergencies. These will also reduce the risk of prisoners witnessing
distressing events and will give dignity to the prisoner.
Partially Accepted. We recognise the need to ensure the deceased is
afforded Dignity and Decency in death. However, we would access the
method of delivering this on a case by case basis.
We will look to source an appropriate method of ensuring the Dignity and
Decency following a DIC, and develop a local protocol with or Dedicated
Search team, who manage the scene immediately following such an
incident.
Commendation
The Governor should write to Officer C, Officer E and Officer D
commending them for their tremendous efforts in trying to save the life
of the man.
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