Individual at Channings Wood

Circumstances surrounding the death of a male prisoner at
Channings Wood on 22 January 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2007
This is a report of an investigation into the death of a 66 year old man who died of a
heart attack on 22 January 2007 in his cell at HMP Channings Wood. He had been in
custody more or less permanently for over 36 years. I offer my sincere condolences to
all those touched by his death.
The investigation was undertaken by my colleagues and I join them in thanking the
Governor of Channings Wood and the appointed Liaison Officer, for their helpfulness
and co-operation during this investigation.
The deceased was a life sentence prisoner who transferred to Channings Wood in
1997. Over the ten years he was there, he had very much made it his home and
enjoyed the routine and personal security that Channings Wood afforded. I gather that
he was well respected by staff and prisoners alike, and his death undoubtedly had an
impact on many of them. Great care was taken by the staff at the prison to ensure he
had a fitting memorial service, and it is perhaps testimony to how he was regarded that
the service was so well attended.
My investigators were impressed by the way the man’s death was handled at the
prison. Staff ensured that he was treated with respect and dignity and that those
affected by his death had the opportunity to speak about their feelings. I know that
considerable effort went into attempts to trace a member of the deceased family to
notify them of his death. Sadly, this was unsuccessful. I hope that, if a family member
is ever traced, they can take comfort from the knowledge the deceased was treated
with great sensitivity and decency. I hope too that this report will provide an insight
into his life in prison and how he died. The man’s ashes were buried at the nearby
churchyard in the Parish of Ogwell and a headstone was kindly provided by the funeral
director.
This investigation has highlighted four issues that the Governor may wish to consider.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2007
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CONTENTS
Summary 4
The investigation process 6
HMP Channings Wood 7
Key Findings 8
Issues 11
Recommendations 13
Annexes
1 Clinical Review
2 HCSO’s statement to the Governor – 25 January 2007
3 Nurse’s statement to the Governor – undated
4 Nurse’s Interview transcript – 27 March 2007
5 Officer’s Interview transcript – 27 March 2007
6 Stores OSG Interview transcript – 28 March 2007
7 Prisoner’s Note of interview – 27 March 2007
8 Chaplain’s Interview transcript– 28 March 2007
9 Interview transcript Lifer governor – 27 March 2007
10 Head of Healthcare’s statement to the Governor – 25 January 2007
11 Head of Healthcare’s Interview transcript – 27 March 2007
12 Evidence considered – All prison documentation, including medical records (not
annexed to this report)
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SUMMARY
The deceased was convicted of murder in 1969 and received a life sentence. He
served his sentence at a number of different prison establishments, finally transferring
to HMP Channings Wood in 1997. He was a man who appeared to be content with
the routine and regime at Channings Wood and had no desire to move to another
prison.
The deceased worked on the gardens party until approximately six months before he
died. In the summer of 2006, he applied for a transfer and began work in the main
stores. He was described as a hard worker for whom nothing was too much trouble.
The man’s medical record showed that he appeared to be in relatively good health and
rarely had cause to visit the prison’s healthcare department. However, on 19 March
2002, he attended healthcare and complained of chest pains. An echocardiogram
(ECG) showed some abnormalities, and an ambulance was called. The man was
taken to Torbay Hospital where he had further tests which showed he had had a heart
attack. He remained in the Coronary Care Unit at the hospital for three days.
On his return to Channings Wood, he was seen by healthcare on 23 and 24 March
2002. He continued to be regularly monitored by healthcare who checked his blood
pressure, heart rate and his medication. On January 2007, the deceased attended
work in the main stores as usual. The stores Operational Support Grade (OSG)
recalled that the man had looked well and had spent the morning helping clear out an
old storeroom. So he had time to wash before lunch, he was allowed to leave work at
11.30 am. He collected his lunch and returned to his cell.
At approximately 1.40 pm, an officer unlocked the man’s cell. As the officer pushed
the door open, he felt some resistance and pushed his way inside. He saw the
deceased feet on the floor and, realising something was wrong, manoeuvred himself
into the cell. The officer saw the deceased lying on his left side on the floor. He
radioed for assistance before attempting to put the man in the recovery position.
Although not first aid trained, the officer could tell that the man had died.
Another officer arrived at the deceased cell, closely followed by a Health Care Senior
Officer HCSO, who responded to the emergency call in his role as discipline officer,
rather than as healthcare officer, as the call did not specify the type of emergency.
The HCSO rang the communications room to request they call an emergency
ambulance and then returned to the deceased. By this time, two more members of
healthcare staff had arrived. They too were unaware of the type of emergency. One
nurse ran back to healthcare to pick up the defibrillator. The deceased was carried
outside his cell so there was more space to work on him, and resuscitation was
attempted even though there were no signs of life. The nurse returned with the
defibrillator about two minutes later and the staff continued to attempt resuscitation
until the ambulance crew arrived and took over.
The deceased did not respond to the resuscitation attempts. He displayed no
shockable heart rhythm, was very discoloured, and appeared to have been dead for
some time. All parties therefore agreed to stop the resuscitation. He was placed on
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the bed in his cell, covered by a blanket and the chaplain, who knew him well, said
prayers. The prison doctor pronounced life extinct at 2.50pm.
The Governor and the chaplain visited each prisoner on the deceased block to inform
them of his death and to offer support and the opportunity to talk. The Governor also
posted a letter telling all prisoners that he had died and providing details of a memorial
service. A debrief was held for the staff involved, and ongoing support was provided
by the chaplaincy and Care Team.
Prison staff tried to locate the man’s next of kin. However, he had received no letters
or visits since before his arrival at Channings Wood, and his next of kin details in his
prison record were out of date.
Over 70 people attended the man’s memorial service which was held at the chapel in
Channings Wood. He was cremated and his ashes were buried in the nearby
churchyard at Ogwell. The undertaker provided a plaque for him and a tree in his
memory is to be planted at the prison.
The post mortem examination revealed that the man had died from ischaemic heart
disease and coronary artery stenosis.
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THE INVESTIGATION PROCESS
1. I appointed two colleagues to conduct the investigation on my behalf. Notices
were issued to both prisoners and staff, inviting anyone who might have
information relating to the man’s death to make themselves known to the
inquiry.
2. My investigators were given access to all the deceased prison records,
including his medical records.
3. The next of kin details recorded on the deceased file had not been updated
since his arrival at Channings Wood. He had received no letters, nor had any
family visits, since 1992. Although the prison had made every possible effort to
contact a family member, they were unsuccessful.
4. My investigators visited Channings Wood on 27 and 28 March 2007 to carry out
interviews and visit the cell where the man lived and died. It was unfortunate
that they were unable to speak to the Health Care Senior Officer, as he was one
of the first officers to attend to the deceased. However the prison provided his
statement that he made to the Governor and other witnesses provided a full
account of the events of that day.
5. A clinical review of the man’s health care whilst in custody was undertaken with
the help of a panel by a Clinical Reviewer, Prison Health and Development
Manager at Devon Primary Care Trust.
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MP CHANNINGS WOOD
8. HMP Channings Wood is a category C training prison situated in a rural area
near Newton Abbot and built on the site of a former Ministry of Defence base.
There are five main two storey Living Blocks with 112 cells in each block.
9. The prison takes men who have a wide range of sentences. It contains a
specialist Therapeutic Community for tackling drug abuse and a vulnerable
prisoners unit specialising in Sex Offender Treatment Programmes. The prison
has 634 cells available and 33 of these can be doubled up to increase the
capacity to accommodate 667 prisoners. All prisoners, unless medically unfit or
of retirement age, are expected to work.
Healthcare
10. The healthcare centre at Channings Wood operates from 8.00 am to 8.00 pm
on weekdays and from 8.00 am to 5.00 pm at the weekend. General
Practitioner surgeries are held Monday to Friday. A Coronary Heart Disease
clinic is held. The deceased attended this regularly to have his blood pressure,
cholesterol and Body Mass Index monitored and his medication reviewed.
Prisoners who are assessed as suitable to hold their own medication collect
their prescriptions from healthcare each month. Otherwise, they are collected
on a daily basis.
Main Stores
11. The purpose of the main stores is to receive and issue items such as stationery,
staff uniform and cleaning materials. Prisoners unload deliveries, make up
cleaning packs for wings and carry out general duties such as cleaning and
tidying. The Head of Healthcare told my investigators that there is a system in
place for assessing prisoners’ suitability for all work, including the stores. Each
area of work lists the type of tasks involved in that particular job, and the person
making the assessment should decide whether a prisoner is capable and fit
enough to carry out the work.
Emergency call system
12. The emergency call system at Channings Wood has recently been reviewed. It
was agreed that, rather than place the onus on the person making the call to
assess the type of emergency, staff should describe the situation through the
prison radio system, thereby allowing the appropriate staff to respond.
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KEY FINDINGS
13. At first glance, it seemed that there was very little to say about the man’s life.
By the time he arrived at Channings Wood in 1997, he appeared to have
disengaged from life outside of prison and, to an extent, from that inside prison
too. He had not received any letters or visits since 1992, and refused to take
part in lifer reviews, parole reviews or participate in any offender treatment
programmes.
14. However, after talking to staff about the deceased, my investigators found that a
very different and more vivid personality emerged. He was described as a man
who lived in the present rather than one who dwelt on the past, who liked his
routines and was very comfortable with prison life and its regimes. He was also
described as a sociable man who enjoyed football (he was a Glasgow Rangers
supporter and had a flag pinned up in his cell). He had an interest in current
affairs and read the Daily Telegraph every weekday. He also liked to complete
puzzles and quizzes from newspapers he regularly borrowed from the
chaplaincy and healthcare departments. The man attended the chapel
everyday and, although he was Church of Scotland, attended almost every act
of worship including Catholic Mass. He loved music and would play the organ
in the chapel and his own organ in his cell (this has now been placed in the
chapel). He wrote hymns to popular tunes which he regularly performed in the
chapel, and could be heard whistling around the prison whilst he went about his
daily routine. The man spent many years working in the gardens department at
Channings Wood where both staff and prisoners would stop for a chat with him.
A few months before he died, he applied for a change of employment and
began to work in the main stores.
15. Although there seems to be a system to assess prisoners’ fitness and suitability
for work, the deceased was only interviewed by the Stores Officer. The Stores
Officer asked whether he had attended a manual handling course, which he had
done, and also whether he had any back injuries, which he had not. My
investigators were told that the deceased was a hard worker and was always
the first to volunteer to help. He seemed to be well liked by his colleagues in
the stores, and by staff and other prisoners generally.
16. The deceased rarely troubled anyone and made few applications to be seen in
healthcare. In 2001, he received treatment to his fingers when he trapped them
between a board and a trolley, but that appeared to be the extent of his medical
problems until 2002.
17. On 19 March 2002, the man complained to healthcare of pains in the centre of
his chest that had come on the day before. His blood pressure and pulse were
taken and showed a slightly high reading. An echocardiogram (ECG) was
arranged and carried out later the same day. This showed some abnormalities,
and so an ambulance was called to take him to Torbay Hospital. He was
moved to the Coronary Care Unit where it was confirmed that he had suffered a
heart attack. He returned to Channings Wood at 6.00 pm on 22 March and was
seen in healthcare on 23 and 24 March. The hospital had prescribed the man’s
medication which was reviewed regularly by healthcare. After this heart attack,
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he was regularly assessed at the prison’s Coronary Heart Disease (CHD) Clinic,
where his blood pressure, pulse and cholesterol would be checked and his
medication reviewed. The deceased collected his medication monthly from
healthcare. He carried a medication spray, but was rarely seen to use it.
18. On 8 April 2002, a Cardiac Rehabilitation Nurse contacted the prison’s Physical
Education Department to arrange some gym sessions. My investigators have
been unable to establish whether the deceased had ever attended any of these
sessions, but from the available paperwork it does not appear that he did so.
19. Apart from going to healthcare on 25 October 2004 for something in his eye,
and one episode of dizziness and vomiting in December 2005, he did not
present any further cause for concern until 22 January 2007.
22 January 2007
20. The deceased attended work in the main stores as usual that morning. The
Operational Support Grade (OSG) in charge of the stores remembered that the
man appeared to be happy and well, and had been singing and whistling as
usual. He assisted the OSG clear an old storeroom so that it could be used as
a training cell. The OSG allowed the deceased to leave at 11.30am as it had
been a dirty job and he wanted to allow time to wash before lunch. As usual, he
took to his cell. (Prisoners were locked in their cells whilst they ate lunch.)
21. At approximately 1.40pm, an officer was responsible for unlocking prisoners on
Living Block 2. When he came to unlock the deceased cell, the officer felt some
resistance behind the door. He was concerned as usually the deceased came
out of his cell as soon as it was unlocked.
22. The officer called to the deceased whilst trying to inch the door forward, and it
was then that he saw the man’s feet by the door. The officer immediately
radioed for assistance and manoeuvred himself into the tight space between the
door and sink. The deceased was lying on his left side on the floor, and the
officer began to make space to put him in the recovery position. It appeared
that the call for assistance was interpreted as a call for discipline staff rather
than healthcare, and another discipline officer arrived next. The first officer told
the second that he thought the man had died. Although the first officer was not
currently first-aid trained, he told my investigators that he had seen many dead
bodies during his career in the Marines and he noticed that the man had
urinated.
23. Fortunately, the next to arrive was the HCSO who had responded in his role as
discipline officer rather than as a healthcare officer. The HCSO immediately
rang the Communications Room to ask that they call an emergency ambulance.
24. A nurse also responded to the emergency call together with the Head of
Healthcare, although neither was aware of the type of call they were attending.
Both believed it might be an assault on an officer as there had been some
unrest amongst prisoners during the preceding fortnight.
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25. When the nurse and Head of Healthcare arrived at the cell, the HCSO was
already attempting to resuscitate the man. They asked that somebody run back
to healthcare to collect the defibrillator. This took approximately two minutes.
The healthcare staff observed that the deceased appeared discoloured and was
lying in the recovery position. The Head of Healthcare suggested they take him
onto the landing to give them more room to work. Prison Service Order
15/2006 says that, unless rigor mortis of the limbs has clearly set in,
resuscitation should be attempted. As this was not the case, the Head of
Healthcare and the HCSO took over attempting resuscitation. The nurse
returned with the defibrillator which indicated that there was no shockable
rhythm. The HCSO, Head of Healthcare and the nurse began Cardiopulmonary
Resuscitation (CPR), alternating periodically between the tasks of breathing and
compressions. They continued for approximately 15 to 20 minutes until the
paramedics arrived.
26. The paramedics attempted to insert a line (Venflon) into a vein in the man’s
hand, but this was unsuccessful. They could not find a pulse, and there was no
heart rhythm, so they checked with the healthcare staff and decided to stop
working on him. The deceased body was returned to the bed in his cell and
covered with a blanket. The chaplain attended and said prayers over his body.
A doctor was asked to come to the prison and pronounced life extinct at 2.50
pm.
27. The Governor and chaplain visited each cell on the deceased block to inform
fellow prisoners of his death. One young prisoner was particularly affected and
an officer allowed him to go to the cell door to say goodbye.
28. A letter to all prisoners about the man’s death was posted by the Governor. It
also provided details of a memorial service. A debrief was held for staff, and
ongoing support was provided by the chaplaincy and care team. The chaplains
also made themselves available to prisoners who wished to talk.
29. Prison staff went to great lengths to try to trace the deceased next of kin. They
tried the obvious routes, such as the local prisoner database and core records,
but the address given for the man’s brother was out of date. The deceased had
not had any visits or letters since before he arrived at Channings Wood. Staff
also contacted the police and his previous prison, but all attempts proved
unsuccessful.
30. There seemed to be a general air of sadness about the man’s death and it is a
testimony to his popularity that over 70 people attended his memorial service.
The chaplain took photographs of him lying in his coffin at the undertakers in
case a member of his family was ever identified. The photographs were sealed
and passed to the Deputy Governor and his belongings were stored. The
deceased was cremated and his ashes buried in the nearby churchyard at
Ogwell. The undertaker provided a plaque for him and a tree in his memory is
to be planted at the prison.
31. The post mortem examination revealed that the man died from ischaemic heart
disease and coronary artery stenosis.
10
ISSUES
Clinical care
32. The deceased had no history of recorded heart trouble until his heart attack in
2002. Healthcare quickly responded to his complaint of chest pains and
tightness in his chest, and carried out an ECG the same day. They ensured the
deceased was taken to hospital by ambulance and kept in contact to apprise
themselves of his condition. Once he returned to Channings Wood, his blood
pressure, cholesterol and pulse were regularly checked at the Coronary Heart
Disease Clinic and his medication was reviewed.
33. The clinical review identified as good practice the fact that the deceased had
been regularly reviewed as part of the Coronary Disease Clinic, and also noted
that the medical records were well ordered and maintained.
Emergency calls
34. The Head of Healthcare explained that, unlike most prisons, the emergency call
system at Channings Wood does not identify the nature of the emergency. It is
thought that staff would feel pressurised to assess the nature of the assistance
which was required. I recommended in an earlier report in 2006 that a coded
call system should be introduced, and I repeat the recommendation now.
The Governor should reconsider the use of a coding system to alert staff
responding to an incident to the nature of the emergency, and allow them
to bring the necessary equipment.
35. If such a system had been in place, healthcare staff would have been better
prepared and equipped to respond to the discovery of the man, and would have
known immediately that the defibrillator was required. As it was, there was
some confusion as staff believed they were responding to a discipline incident.
The clinical reviewer says that the emergency call did not identify the nature of
the incident and that, whilst this did not materially change the outcome, the
procedures require formalising for consistency in future cases.
Assessment for work
36. Despite the deceased heart attack in 2002, it does not seem that he was
properly assessed for his transfer to work in the stores although there does
seem to be a system in place to do so.
37. The prison has since responded to this recommendation and confirmed that
there is a system is already in place, although it did not appear to have been
implemented in this man’s case. The system assesses a prisoner’s suitability
for work and re-assesses it when their work status changes.
38. The prison described a system where each main activity required of a particular
job is broken down into its core components. When a prisoner is seen by a
doctor, they identify any areas or components of work that may be unsuitable.
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The prisoner is then allocated work based on this information. If a prisoner’s
work status changes for medical reasons they are reviewed and their labour
status is re-categorised.
The Governor should ensure that the existing system for assessing the
fitness for prisoners to work is implemented in all work areas.
Attempts to trace next of kin
39. Although the prison made every attempt to try to locate a member of the
deceased family, this was unsuccessful. His next of kin details had not been
updated since his reception into Channings Wood in 1997.
40. The prison has provided information that a system to update next of kin details
is already in place. A general review of all next of kin records was carried out in
May 2006 and again in May 2007. This is to be repeated annually. In addition,
prisoners are invited to update their next of kin records at any time they choose
to do so and a pro-forma is available for this purpose. It appears that Mr
Donaldson chose not to update these details.
The Governor should ensure a system is in place routinely to check and
update prisoner’s next of kin details.
First aid training
41. The first officer to enter the man’s cell, said that he had not received any first
aid training since he joined the Prison Service and, had he attempted
resuscitation, it would have been carried out incorrectly.
42. The prison provided information that first aid training is available to all grades of
staff. This training, however, is specifically targeted towards all staff of Senior
Officer grade, as this is the only grade of staff always guaranteed to be on duty
at the prison.
The Governor should ensure that a cross-section of discipline staff are up
to date trained first aiders.
Allowing a prisoner to say goodbye
43. If the officer who showed the humanity to allow a prisoner who was very close
to the deceased to say goodbye can be identified, he or she should be
commended. The officer was careful not to breach any rules and did not allow
the prisoner to enter the cell. Nevertheless, his act showed compassion and a
sense of understanding about the prisoner’s feelings. Unfortunately, the
interviewee who told investigators about this was unable to recall the officer’s
name.
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RECOMMENDATIONS
1. The Governor should reconsider the use of a coding system to alert staff
responding to an incident to the nature of the emergency, and allow them to
bring the necessary equipment.
The prison accepted this recommendation and reconsidered the use of a
coding system to alert staff to the nature of an emergency. However, after
consideration they have decided to retain their current system.
2. The Governor should ensure that the existing system for assessing the fitness
for prisoners to work is implemented in all work areas.
The prison accepted this recommendation. Although the system did not
appear to be implemented in this particular case, one is already in place to
identify suitable work allocation and to review any labour changes for
prisoners.
3. The Governor should ensure a system is in place routinely to check and update
prisoners’ next of kin details.
The prison provided information that a system was already in place to
annually update prisoners next of kin details.
4. The Governor should ensure that a cross-section of discipline staff are up to
date trained first aiders.
The prison accepted this recommendation and added that first aid training
is available to all grades of staff. Training is specifically targeted at Senior
Officers, as a member of staff at this grade is always on duty in the prison.
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