Individual at Gloucester

Investigation into the circumstances surrounding the
death of a prisoner
at HMP Gloucester in February 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2008
This is the report of an investigation into the circumstances of the death of a
prisoner. The man who is the subject of this report was aged 56 when he died in
February 2006 in hospital. At the time of his death, the man was a remand prisoner
at HMP Gloucester.
The man who died had been admitted to hospital on 1 February after complaining of
‘upper abdominal pain’. Almost immediately, he was diagnosed with terminal cancer
of the pancreas.
I would like to add my own condolences to those already expressed by one of my
family liaison officers. It is hard to cope with any family loss, but losing someone
while they are in custody is especially difficult.
The investigation was led by one of my Investigators. An independent review into the
man’s medical care and treatment was undertaken by a doctor on behalf of the West
Gloucester Primary Care Trust (PCT). I am most grateful to him for his assistance
and for the help provided by another member of the West Gloucester PCT. I must
also thank the Governor and staff of Gloucester prison for their co-operation during
this investigation.
There are no recommendations arising from the clinical review of the man’s care, but
I make a recommendation of my own related to bed watch management checks and
the decisions made in this area. The man who died was unconvicted and in prison
for the first time. Yet he was to die while still chained to a member of staff. Leaving
aside the lack of dignity afforded to him in his final moments, this must have been
extremely upsetting for the member of staff concerned.
I am also critical of the way the prison handled liaison with the man’s family and
make a further recommendation designed to improve the management of the prison-
family relationship in the future.
More positively, I am pleased to commend bed watch staff for the sensitive and
professional approach they took to the man’s welfare.
This report has been amended to enable this anonymised version to read more
easier, however in essence, it is the same report.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2008
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CONTENTS
Summary 4
The investigation process 5
HMP Gloucester 6
Key findings 7
Issues 12
Recommendations 16
3
SUMMARY
The man died in February 2006 in an outside hospital while a prisoner at HMP
Gloucester. He had been in custody since 3 November 2005, when he was
remanded from Gloucester Magistrates’ Court.
The man complained of feeling unwell on 19 January. He was seen by the doctor at
the prison who ordered some blood tests and prescribed pain killers. On 25
January, following further consultation with the doctor, it was decided more blood
tests were needed and a gall bladder scan was also arranged at the local hospital.
On 1 February, an officer took the man to the healthcare centre after he had
coughed up blood. He was subsequently admitted to hospital. He was risk
assessed before he left Gloucester and it was decided he should have a normal
escort of two officers, one of whom would be handcuffed to him at all times.
After spending a few days in hospital, the man was diagnosed with terminal cancer.
The man and his family were told of the diagnosis, that curative treatment would not
be feasible and that his condition was deteriorating rapidly. Due to the seriousness
of his illness, the man’s solicitor made an application for release on bail but this was
unsuccessful. His condition continued to decline and he died in the early hours the
following day. His family were with him at the time.
The clinical review, carried out as part of this investigation, does not identify any
specific issues relating to the clinical care the man received. It says that he received
nursing and medical care comparable to that which would have been available in the
community. However, my report raises important issues relating to the management
of the bed watch, the decision to use and maintain handcuffs, and the prison’s
approach to family liaison.
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THE INVESTIGATION PROCESS
1. I was notified of the man’s death the morning he died and the investigation was
opened the following day. My investigator issued notices to staff and prisoners at
Gloucester telling them that an investigation would be taking place into his death,
and inviting those who wished to see the investigator to make themselves known.
2. My investigator was provided with the man’s prison record, and copies of the
notices, reports and other records associated with his death. She also visited
HMP Gloucester and informally interviewed staff involved in his care.
3. As part of her enquiries, my investigator made contact with the Coroner’s office to
inform him of our investigation and request a copy of the Post Mortem report.
She also spoke to the man’s solicitor.
4. A doctor from West Gloucester Primary Care Trust conducted a clinical review of
the man’s medical care.
5. My investigator gathered details of the man's next of kin and one of my Family
Liaison Officers, contacted his family. His brother was concerned that he had
not received appropriate care in the prison. He said the man who died had been
complaining for a long time and was not given painkillers. The family was also
upset that the man was handcuffed throughout his hospital stay right up until he
died. I hope this report goes some way in responding to the family’s concerns.
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HMP GLOUCESTER
6. Gloucester is a small local prison that serves Gloucestershire and much of the
West of England and South East Wales. It is a category B adult local prison and
young offender remand centre, situated in the centre of the city. The prison is
made up of three wings, each with three landings holding 90-100 prisoners.
Gloucester can hold up to 330 prisoners in total.
7. At the time of his death, the Health Care Centre (HCC) was undergoing major
refurbishment. The establishment now has a small HCC on two floors.
Healthcare is provided by West Gloucester PCT. They have an 11 bed in-
patients facility predominately for patients with mental health problems and those
undergoing detoxification. This is staffed by mental health nurses (RMNs) and
healthcare assistants during the day and a trained nurse (RGN) and healthcare
assistant at night. Six GPs from a local practice in Cheltenham provide clinics
daily and are on call 24 hours a day. They also have several RGNs who operate
an out-patients clinic and provide reception cover. They also provide nurse led
clinics for phlebotomy, hepatitis B vaccinations, and health promotion. Dental
provision is one session per week and an optician is provided as necessary.
There is also a mental health in-reach team (MHIRT) consisting of two RMNs and
an occupational therapist, with support from a consultant psychiatrist.
8. In Autumn 2003, Gloucester was inspected by Her Majesty’s Chief Inspector of
Prisons. Her report indicated that there had been noticeable improvements at the
prison since the previous inspection in 2002.
9. The man’s death is one of seven I have investigated at Gloucester since I
became responsible for all such investigations in April 2004. Only one of these
deaths was from natural causes. I have found no similarities between that case
and the death of the man who is subject of this report.
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KEY FINDINGS
10. The man was remanded to HMP Gloucester in November 2005. On arrival, there
was no information of note on his Prisoner Escort Record (PER), a document
which accompanies all prisoners travelling between police stations, courts and
prisons. The PER indicated that no known risks had been reported by the man or
about him.
11. At his reception interview, the man was asked various questions relevant to
someone coming into custody from the courts. He was asked whether anyone
knew where he was and whether he had any pressing problems regarding
housing or legal issues. He was told of the emergency procedures at Gloucester,
and it was also explained what would happen to him during the next 24 hours. At
this point the man gave his brother as his next of kin.
12. At the same time, his Cell Sharing Risk Assessment (CSRA) was completed. He
said that he had no concerns about sharing a cell and was assessed as
presenting a low risk. (This means that there was no indication or evidence that
he would be a risk to himself or others and was therefore suitable to share a cell.)
13. The man was seen by healthcare staff on the same day for an initial assessment,
and it was recorded that there was nothing to note. His follow up health appraisal
(this is a more comprehensive and wide ranging health screening) took place the
next day. It recorded that this was his first time in custody, but nevertheless he
felt he had settled in well and felt ‘A1’. A note was made regarding some
difficulties he had experienced after being bitten by a dog. It was agreed this
should be reviewed as necessary.
14. Later that day, the man completed a legal aid form which said that he was
working prior to arrest and was due back in court in a weeks time. He also made
an application to Nacro Housing, saying that he wished to use their services as
he needed help with housing on release.
15. An Officer on A wing had a lot of interaction with the man during his induction.
He told my investigator that the man did not mention any concerns he had with
his health. Nor did he look unwell. He added that the man ‘did not moan’ and
kept himself to himself.
16. There are various entries in the man’s file, many by his personal officer. It is
noted that he was attending education daily, was seen as a ‘good prisoner’,
conformed to the regime and was quiet and polite to all. There is no mention of
his health or other concerns.
17. When the man appeared before the court again he was further remanded
pending medical reports from his solicitors. A week later, he was examined and
found fit for travel to court for a further appearance.
18. The first record of the man asking to be seen by Healthcare was in mid January
2006, when he was seen by the prison doctor. He reported experiencing upper
abdominal pain. Several blood tests were arranged. In the meantime, he was
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prescribed a painkiller with a plan to review the situation when the test results
were available. A week later, he was again seen by the prison doctor who then
had the test results. The doctor found the man had a slightly raised temperature
and still complained of pain. The doctor reviewed the blood tests and prescribed
Co Amoxiclav 375mg three times a day. He was due to return to court on soon,
but was told that an ultrasound scan of his gall bladder had been arranged at the
hospital. It was also decided that further blood tests were needed when he
returned from court. The man was advised that he should see his GP should he
was released on bail. In the event, he was returned to HMP Gloucester having
been further remanded.
19. Another Officer who worked on the man’s landing, and was also one of his
personal officers, described the man as a pleasant person but whom, in the main,
kept himself to himself. He said they often had chats but he did not go into any
personal detail. Nevertheless, the Officer was aware the man had plenty of
family support and lots of visits. He said the man spoke to some of the older
prisoners and often popped in and out of their cells for a quick smoke.
20. He said the man attended education in the mornings and was always the first to
arrive there. He often attended association in the afternoon, restricting himself to
a small group of friends. He spent most evenings reading in his cell, especially
reading magazines about model airplanes in which he had a real interest.
21. The Officer said he was on early duty on the morning in early February. He said
the man was usually one of the first up and waiting to be let out. But that morning
he was not, so he went into his cell. He noticed something spilt in the sink and,
when he asked the man about it, he replied that he had spilled some coffee. The
Officer was not convinced by this and, when he asked him again about it, he said
that he had had a nosebleed. The Officer told my investigator that he was not
convinced by the man’s responses and became worried that something was
wrong.
22. On the same day, the man’s personal record shows that he was taken to the
Healthcare Centre by an officer after coughing up blood. He was also still
complaining of abdominal pain. He was admitted to Healthcare at about 8.10am
and placed on half hour observations. His case was reviewed later that morning
and his medical record shows he was in pain and looked unwell. The man was
subsequently admitted to the surgical assessment unit at Gloucester Royal
Hospital.
23. The PER shows that the man left Gloucester prison at 10.30am after a full
search. He arrived at the hospital at 10.50am. The hospital risk assessment was
completed by a senior officer. It shows that it was a normal escort with two
officers attending the prisoner. An officer was to be handcuffed to the man at all
times. The form indicates that the restraints should not be removed for medical
treatment but could be removed in emergencies with the duty manager’s
authority. The form was signed by the duty governor that day. It was
countersigned by the deputy governor. A bed watch management check carried
out at 4.00pm that day noted that the man was undergoing tests and was
expected to be at the hospital for a further two days.
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24. The next day, a nurse informed the officer who was conducting the bed watch,
that the man was quite ill and would be at the hospital for ‘at least a week’. The
healthcare manager at HMP Gloucester contacted the hospital later that day. He
was told that they had no plans to discharge the man at that time. He maintained
regular contact with the hospital throughout the man’s stay there.
25. The hospital contacted HMP Gloucester again the following day. They were told
that the man might be suffering from cancer and confirmation was awaited. The
principal officer completed a review of hospital assessment form later that day. It
said that the man had been diagnosed with cancer of the pancreas, and that
visits would be allowed at the hospital during normal hospital visiting times. The
prison subsequently contacted his visitors to let them know. It was also noted in
the management check log for that day that the man was expected to stay in
hospital for another week.
26. Two days later, them man received a visit from members of his family. The same
day he had a scan and was seen by the care team at the hospital. It was noted
in his medical record that he had also been seen by the palliative care team. He
received further visits on each day of that week and near the end of the week he
was seen by a consultant who told him he would be discharged the next day. An
officer carrying out bed watch duties noted in the bed watch log that the man was
“very emotional after being given the bad news re condition, family to contact
solicitor re bail app.”
27. The duty governor that day spoke to the Officer about his entry in the log and
made a further note in the management checklist log saying ‘consultant says
ready for discharge. Dr wants to keep him until Monday (bail app). Perhaps 2
months left.’
28. The man was seen by doctor the next day and he told him he would be seen by
the palliative care team before he was discharged. The palliative care team also
spoke to the man’s solicitor who confirmed he would apply for bail the coming
Monday morning.
29. The man remained in hospital over the weekend and received more visits from
his family. Late on the Sunday evening, an entry in the bed watch log records
that the man was very ill and was vomiting up blood. Early the next morning,
another Officer carrying out bed watch duties contacted HMP Gloucester’s
control room. He noted in the bed watch log that he had spoken to ‘senior staff
there re [the man’s] status on the cuffs’. He also mentioned that the man seemed
‘confused and his health was fast deteriorating and that it is now a concern for
staff who are with him.’ Later that day, a further entry in the bed watch log
records that the man seemed to have ‘perked up’.
30. The man had more visits that afternoon. At 2.25pm, the officer who had earlier
raised concerned about the man remaining cuffed, noted in the bed watch log
that ‘staff feel very awkward being cuffed to up to a dying man. I intend to
request removal during management visit.’ The deputy governor carried out the
management check that afternoon and noted in the management check log that
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the man was ‘very ill and not expected to last very long. Consideration could be
given to reducing escort strength.’ This entry was timed at 2.40pm.
31. The man had another visit that afternoon and ‘seemed very happy’. However, at
7pm it was recorded that he was very worried about the bail hearing the next
morning. At 7.30pm, the nurse was called by the bed watch officers after the
man became unstable and did not seem to know what was going on.
32. The next morning, the doctor saw the man again and said that he was too ill to go
home. Half an hour later, the doctor returned with the news that the bail
application had been denied. It had been decided that, as the man did not have
a fixed release, he was deemed at risk of absconding if released. The court also
asked for further reports to be compiled and agreed to look again at the man’s
case when this was done.
33. A hour later the officer again noted in the bed watch log that he was still
uncomfortable that the man was handcuffed despite being so ill. He later asked
deputy governor if the handcuffs could be removed and was told, ‘no … not at
this stage’, but with a promise that the matter would be raised later at a security
meeting. The officer said that both he and the medical staff at the hospital made
several requests for the handcuffs to be removed, but were informed repeatedly
that this would not be permitted.
34. Later that evening, another officer took over the bed watch duties and he
recorded that the doctor had asked for the handcuffs to be removed due to the
man’s deteriorating condition. This officer told my investigator that, at the
doctor’s request, he contacted the prison and spoke to the deputy governor. He
said he would not agree to the request for the handcuffs to be removed, but said
he would review it the next day. This officer than noted in the bed watch log that
he was awaiting a decision from prison control about removing the handcuffs.
Some family members visited that evening, including the man’s two sons who
stayed with him during the night.
35. A principal officer carried out the management bed watch checks the next day.
He signed the check log at 4.10pm. On the management checklist log he noted
that, ‘the prisoner’s condition is causing concern for the hospital staff.’
36. The doctor saw the man again in the early hours of the morning and said that he
was unlikely to last another 12 hours. At 4.00am, it was noted by a third bed
watch officer that he was breathing very slowly. He called the nurse to the man’s
bedside at 5.31am, the handcuffs were removed and it was noted that there was
no movement. The nurse then reported that the man had died. The doctor
confirmed death at 5.40am.
37. According to the clinical review conducted as part of this investigation, the
‘treatment and care provided to the man whilst he was in HMP Gloucester, from
the time of his admission in early November 2005 until his death, was both
appropriate and satisfactory and the same as that he would have received had he
been in the community. Once he complained of pain and symptoms associated
with this problem the healthcare team acted appropriately and arranged blood
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tests and emergency admission to hospital.’ The clinical reviewer noted that
pancreatic cancer is very difficult to diagnose and the man had became unwell
very quickly.
Events after the man’s death
38. One of the escort officers telephoned the prison and told the duty governor that
the man had died. Gloucester opened and followed its contingency plan in the
event of a death in custody.
39. The death in custody incident log shows the Governor was informed at 6.40am.
The Area Manager and the Prison Service National Operations Unit (NOU) were
informed at 6.55am and 6.57am respectively. The Coroners’ officer was
informed at 7.30am. The man’s nominated next of kin, was called at 7.45am.
Staff on duty at the hospital were provided with the support of the care team who
attended to speak with them.
40. The same day, the governor wrote to the man’s next of kin expressing his
condolences. He offered himself and deputy governor as contacts, should the
family need to contact the prison for any reason.
41. One of man’s sons and his partner visited the prison and spoke to a member of
the management team. They raised the issue of handcuffing but the
management team member told them that the hospital had not contacted the
prison to ask for them to be removed. They also talked about funeral expenses.
42. The Governor wrote again to the family a few weeks later. He said he was sorry
not to have been at the prison when they visited and asked them to contact him
again about the issues they had raised.
43. The man’s funeral took place in later February. The family said they would be
happy for the chaplain and one of the bed watch officer to attend, but it is unclear
if anyone actually attended from the prison.
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ISSUES
Was the man given the right treatment at Gloucester when he complained of
being unwell?
44. The man’s next of kin was concerned about the medical treatment he believed
his brother had received. He understood from the many phone conversations he
had with his brother that he was in considerable pain, but had only been given
paracetamol despite telling staff how unwell he was feeling. However, I have not
found any evidence to substantiate these concerns. My investigator found the
officers on the man’s wing to be interested and conscientious in their duties, and
they were swift to act when they thought the man might be unwell.
45. It may have been the case that the man had felt unwell for some time, but there is
no evidence that he reported this to staff. It appears, from all accounts, that he
was a self contained man who went out of his way not to trouble anyone. Even
on the morning that officers first suspected he was ill, having found blood in his
sink, he pretended it was coffee and insisted he was fine. Furthermore, as
evidenced by the clinical review, once the man did see the doctor and reported
his aliments he was correctly dealt with.
Release
46. The man who is the subject of this report was held at HMP Gloucester as a
remand prisoner. As a consequence, the prison had no authority to arrange his
temporary release as it could have done had he been convicted and sentenced.
47. The man’s solicitor made a bail application on his behalf, but this was
unsuccessful because he did not have a fixed address. The court took the view
that the man’s offence was a serious one and asked for further reports, in
particular a victim interview. The court agreed it would look at another bail
application when these reports were made available. Sadly, he died before this
process was completed.
48. The decisions of the courts are outside my remit. However, it is manifest that
someone who is terminally ill should only be remanded in custody in the most
exceptional circumstances. Although I am not in possession of all the details, it is
not immediately apparent what those circumstances were in the case of the man
who died.
The use of handcuffs
49. The man had not been in custody long before he became unwell. In the short
time that he was at HMP Gloucester, staff had little time to form a relationship
with him. However, the officers who conducted the bed watch became friendly
with him. Several of the escorting officers said they were disturbed to see him
handcuffed up until the time he died.
50. The man’ son explained that on one occasion a doctor came to see him and
asked the escorting officers to wait outside the room. They explained that they
12
were not in a position to do that and the man’s son said they seemed genuinely
sorry and embarrassed about the situation. Eventually the doctor became very
angry and both officers left the room with one of them remaining handcuffed by
the closeting chain so that the man was stretched between his bed and the room
door. His son said his father took it in good humour, recognising that the officers
were just doing their job. However, his son said he found it very upsetting and
unnecessary.
51. Both bed watch officers made requests for the handcuffs to be removed and they
were supported in this by medical staff. The officer who relieved them for night
duty was told during the verbal handover that they had made a request for the
handcuffs to be removed and this request had been denied. He too said he was
uncomfortable being handcuffed to the man because it was obvious that he was
very unwell.
52. The deputy governor was the duty governor during the weekend just before the
man died and on the following Monday. When he was asked about his decision
not to remove the handcuffs, he said he was keeping the situation under review.
He also explained that, when he conducted the management check at the
hospital on the previous Friday, he raised the man’s condition at the evening
meeting. There are no minutes available of this meeting, but the deputy governor
said he told the other staff present of the man’s condition. He said consideration
was given to removing the cuffs but it was decided not to remove them and to
keep the situation under review.
53. When asked why he did not reconsider this decision in light of the requests by
both medical and discipline staff at the hospital, he said he could not recall being
contacted with these requests. However, he acknowledged that procedures
might have fallen down in this case.
54. The man’s family were keen to acknowledge that the medical staff and escorting
officers were very good and had been concerned about him. His ex-wife said she
felt the escort staff did not seem sure about what to do about the issue of
handcuffs. This anxiety seems to reflect the difficulty staff were in, as expressed
by their comments on the bed watch log.
55. The man was taken to hospital in early February and diagnosed with terminal
cancer just two days later. It is clear that, from the moment he arrived in hospital,
he was very poorly and escort staff became increasingly uncomfortable with the
use of handcuffs. Although daily management checks on his condition took
place, I have not seen any evidence to show that the level of escort and restraints
was reviewed.
56. In the event, the man, a remand prisoner not convicted of any crime, died in
chains. This situation must have been deeply distressing for both his family - and
for the officer who was required to be handcuffed to a dying man while his family
had their last moments with him. I find it particularly unacceptable that this
situation was allowed to continue despite requests from both escort staff and
medical staff for the restraints to be removed.
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The Governor of Gloucester should ensure that, within two months of
receiving this report, the local contingency plans for the use of restraints
on prisoners on bed watch are reviewed and, where necessary, revised to
ensure that decisions show the reasoning behind them and are
documented properly.
The Family
57. The man’s family received a letter from governing governor expressing his
condolences. He gave himself and the deputy governor as contacts should the
family need to get in touch. A few days later, one of the man’s sons and his
partner visited the prison. As the governing governor was not there, they were
received by a member of the management team. They asked why the handcuffs
had not been removed and she apparently told them that the prison had not been
contacted by the hospital to request this. The man’s son said they also had a
conversation about funeral expenses at this time. He said he was given the
impression that they would only receive help with funeral costs if they were in
receipt of benefits. He said he was left with the clear feeling the family would not
receive any such help from the prison.
58. The governor wrote again to the family after this meeting to say they should
contact him if they wished to discuss these matters further. However, after what
they had been told, the family felt that this would have been fruitless.
59. PSO 2710 ‘Follow up to deaths in custody’ was implemented on 4 January 2006.
In chapter 4, it provides clear guidance on the prison’s responsibilities in the
matter of liaison with a bereaved family. There is also substantial supplementary
advice available on the Prison Service intranet. The PSO says that the prison
should offer to pay reasonable funeral expenses, regardless of whether the family
are entitled to apply for a grant from the Social Fund. The PSO also requires a
contact log to be kept recording all contact between the prison’s Family Liaison
Officer and the family.
60. I was sorry to learn that the prison did not make any further contact with the
man’s family. At such a difficult time for the family, I would expect the prison to
take the initiative. It is the prison’s responsibility to provide a liaison officer for the
family. Although the Governor wrote and gave himself and the deputy governor
as contacts, the family did not feel he made clear they would have a liaison
officer to deal with their questions and concerns. No family liaison log was kept
and I am unable to say what, if any, consideration was given to the man’s family
after his death.
61. The man’s funeral took place near the end of February. The family said that they
invited the chaplain and an officer, but do not know if anyone from HMP
Gloucester attended as no-one made themselves known to them. The prison
was not approached by the family for any financial support for funeral costs. The
family say that this is because they were given discouraging and misleading
information when they visited the prison. I consider that the standard of family
liaison offered by the prison in this case was poor and failed to comply with the
instructions in PSO 2710. The Governor may now wish to consider making an
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offer of financial assistance towards the costs of the funeral in line with Prison
Service policy.
The Governor of Gloucester should review, with immediate effect, the prison’s
policy on responding to the needs of families after a death in custody. Within
two months of the publication of this report, he should produce a local
protocol explaining what support will be offered to a family bereaved by a
death in custody. Specifically he should ensure that bereaved families are
provided with trained liaison staff who have a thorough understanding of the
provisions of PSO 2710. A family liaison log must be kept in all cases.
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RECOMMENDATIONS
The Governor of Gloucester should ensure that, within two months of receiving this
report, the local contingency plans for the use of restraints on prisoners on bed
watch are reviewed and, where necessary, revised to ensure that decisions show the
reasoning behind them and are documented properly.
The Governor of Gloucester should review, with immediate effect, the prison’s policy
on responding to the needs of families after a death in custody. Within two months
of the publication of this report he should produce a local protocol explaining what
support will be offered to a family bereaved by a death in custody. Specifically he
should ensure that bereaved families are provided with trained liaison staff who have
a thorough understanding of the provisions of PSO 2710. A family liaison log must
be kept in all cases.
Good Practice
I am pleased to commend bed watch staff for the sensitive and professional
approach they took to the man’s welfare. The Governor should arrange for my
commendation to be shared with the staff concerned.
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