Individual at Gartree

Investigation into the circumstances surrounding the
death of a man whilst in the custody of
HMP Gartree in May 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2008
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This is the report of an investigation into the death of a man who was a prisoner at
HMP Gartree. The man who died from natural causes on 22 May 2007. He was 53
years old.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
I would like to add my personal condolences to those already expressed to the
man’s family on behalf of this office by one of my Family Liaison Officers.
This investigation was undertaken by one of my investigators. He and I would like to
thank the Governor of HMP Gartree and her staff for their assistance. A doctor was
asked by Leicestershire County and Rutland Primary Care Trust to undertake a
review of the man’s clinical care and I also much appreciate his help.
I have noted the issues highlighted by the clinical reviewer and endorse the
recommendations made in the clinical review.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2008
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CONTENTS
Summary
The investigation process
HMP Gartree
Key events
Concerns raised by the man’s family
Clinical review
Conclusion
Recommendations
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SUMMARY
The man was born in 1954. He was 53 years old when he died on 22 May 2007 at
HMP Gartree. The man died from natural causes as a consequence of an acute
myocardial infarction (a heart attack), caused by narrowing of the main coronary
artery.
The man had been received into custody on 18 September 2001 after he had been
placed on remand. On 12 April 2002, he was sentenced to life imprisonment at
Preston Crown Court. The man was initially held at HMP Manchester and HMP
Preston, before being transferred to Gartree on 25 September 2002.
The man had suffered from epilepsy, asthma and arthritis for some time. He was
diagnosed with lymphoma (lymph node cancer) in November 2004.
Around 12:34pm on 22 May 2007, a prisoner on C wing heard a strange noise from
the cell occupied by the man across the hallway. The prisoner rang his cell bell and
explained what he had heard to a prison officer. The officer looked into the man’s
cell and saw him lying on the floor. The officer asked a colleague to request medical
assistance from the healthcare centre. The officer then returned to the man’s cell
accompanied by two other colleagues. They unlocked the cell door and one of them
checked for a pulse on the man but could not find one. Two Healthcare Officers
arrived soon after. They too could not find evidence of a pulse and immediately
commenced cardio-pulmonary resuscitation (CPR). When paramedics arrived at
around 1:10pm, they took over the man’s care. Resuscitation attempts were
unsuccessful and death was pronounced at 1:20pm.
The clinical review concludes that the man’s clinical care was appropriate and
equivalent to that available in the community. I have endorsed the two
recommendations in the clinical review.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 23 May 2007 when my investigator issued
notices announcing the investigation to staff and to prisoners. The notices
included an invitation to those who wished to submit information relating to the
man’s death to make themselves known to my investigator. My investigator
also studied all relevant prison records relating to the man. These included his
main prison record, medical records and statements made by staff.
2. The Leicestershire County and Rutland Primary Care Trust commissioned a
General Practitioner (GP) Investigator/Reviewer to carry out a review of the
man’s clinical care. I am grateful to him for undertaking the review.
3. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the Post Mortem report.
Upon completion, this report will be sent to the Coroner to assist him in his
enquiries into the man’s death.
4. One of my Family Liaison Officers contacted the man’s family. This gave them
the opportunity to discuss the purpose of the investigation and to raise any
concerns or questions that they would like explored and addressed. The family
had one concern relating to the man’s treatment while in custody. The man had
told his family that in December 2006 he had been knocked down some stairs
by another prisoner. He had also allegedly suffered chest pains at the same
time. The clinical reviewer and my investigator have explored these points and
I hope that this report helps the family better understand the events leading up
to the man’s death.
5. My investigator visited Gartree on 3 July 2007 and discussed aspects of the
man’s treatment with staff and the clinical reviewer.
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HMP GARTREE
6. Gartree is a category B prison whose principal function since 1997 has been to
accommodate and rehabilitate adult male life sentence prisoners. The average
tariff (minimum time to serve) for these prisoners is 15 years. Around 18 per
cent of the population now consists of prisoners sentenced to indeterminate
sentences for public protection. These prisoners typically have much shorter
tariffs.
7. In common with the rest of the Prison Service, places on offending behaviour
related courses, which lifers must necessarily complete in order to progress
towards release on licence, are at a premium. It is not uncommon for prisoners
to have to wait up to three years to gain a place on some courses.
8. Gartree is part way through a major refurbishment that will continue for the next
two years. When complete, it will give Gartree a certified normal
accommodation of some 680 prisoners and make it the biggest lifer centre in
Europe.
9. Commissioning of healthcare within Gartree is the responsibility of the
Leicestershire County and Rutland Primary Care Trust. The healthcare centre
has 14 cells, provides 24 hour nursing care and has doctors from a local
practice who visit daily. Only two cells in the healthcare centre are for in-
patients as the remainder form part of the prison’s Certified Normal
Accommodation (CNA).
10. Medication is administered on a weekly and/or monthly basis to those prisoners
who have been risk assessed as suitable for holding it in their own possession.
It is administered on a daily basis to other prisoners, when either they are
considered to be at risk or the medication is considered unsuitable to be held in
their possession.
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KEY EVENTS
11. The man arrived at Gartree on 25 September 2002, after being previously held
at both Manchester and Preston. His medical history comprised epilepsy,
asthma, arthritis in his knees and lymphoma (lymph node cancer). A range of
medications was prescribed to the man to treat his various conditions and he
was allowed to keep these in his possession for self administration.
12. On 11 October 2002, a prison doctor at Gartree made a referral to a Consultant
Surgeon at a local hospital. The referral was made because the man had been
experiencing pain in his groin which appeared to be getting worse.
13. In a letter dated 4 June 2003, the Consultant Surgeon confirmed that he had
examined the man and had found a lump in his right groin. The Consultant
Surgeon said that he wanted to know what had caused the lump as the man’s
blood tests were normal. The Consultant Surgeon confirmed that he had
agreed to put the man on a waiting list for an exploratory operation on his groin.
The man’s condition continued to be reviewed by healthcare staff and they
regularly checked with the hospital about the proposed operation. A date for
the man’s operation was received on 3 September 2004.
14. On 15 October 2004, the man was admitted to the local hospital. He had a
gland removed from his right groin and this was sent to the laboratory to be
tested and studied.
15. In a letter dated 29 November 2004, another Consultant Surgeon confirmed
that tests had shown that the man had a follicular lymphoma. He said that this
type of cancer usually responds well to chemotherapy and arrangements were
then put in place for a course of treatment for the man.
16. In a letter dated 15 September 2005, a Consultant in Clinical Oncology
confirmed that the man’s cancer was now in remission.
17. During the evening on 14 December 2006, an officer was patrolling G wing at
Gartree when he observed the man play fighting with another prisoner. The
officer ordered the two prisoners to stop, but whilst he was giving the order the
man fell over. The man was taken to the healthcare centre with a swollen right
ankle and pain in his wrist and elbow. He was then taken to a local hospital by
ambulance with suspected fractures to his wrist and ankle. It was later
confirmed at the hospital that he had broken both his wrist and his ankle. The
man returned to Gartree later the same day and he was relocated in the
healthcare wing to recuperate.
18. On 30 March 2007, after his plaster was removed and he had completed his
physiotherapy, the man was discharged from healthcare and was housed in a
cell on C wing.
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19. During the afternoon on 15 May 2007, the man attended healthcare and
complained of having pains in his upper abdomen. An ambulance was called
and the man was again taken to a local hospital. A diagnosis of gastritis
(inflammation of the stomach) was made on the basis of his long term use of
diclofenac (the medication used to treat his arthritis). Gastritis is a common
side effect of the medicine. This diagnosis was made after a blood test and an
electro-cardio-gram (ECG) both showed no evidence of an acute heart
problem. The man returned to Gartree the following day.
20. On 20 May, when he was asked about his health the man said that he still had
slight stomach pains but he was definitely feeling better.
21. During the morning on 22 May 2007, the man told a Senior Officer that he did
not feel well. The Senior Officer told the man that he should see how he was
later. If there were any more problems, he was to use his cell bell. When
another officer was locking the prisoners up at lunchtime, at around 12:15pm,
the man told him that he still did not feel well. The officer asked him if he had
spoken to anyone about this during the morning. The man replied that he had
spoken to the Senior Officer. The officer asked the man what he had been told
by the Senior Officer and the man reported what they had agreed. The officer
confirmed this information with the Senior Officer and he then left the wing.
22. Around 12.34pm, a prisoner in cell number 232 on C wing was sitting down
doing some course work. As he got up and walked towards his kettle he heard
a crash. The prisoner initially did not think anything of it but after a couple of
minutes he looked through the gap of his cell door towards the man’s cell (229)
which was across the hallway. When interviewed for my investigation, the
prisoner said the man wore prison clothing and the top was quite bright. He
said that, when he looked over towards the man’s cell, he could see him on the
floor against his cell door and he could also hear him making a strange noise.
The prisoner rang his cell bell to summon assistance from prison staff.
23. An officer responded almost immediately. She opened the observation flap in
the cell door and asked what was wrong. After she had been told about what
the prisoner had heard, she looked into the man’s cell. She saw that the man
was lying on the floor with his head wedged up against the cell door. The
officer ran and asked her colleague to request medical assistance from the
healthcare centre. Her colleague made a request via the prison
communications room. The officer then returned to the man’s cell and was
accompanied by two other colleagues.
24. The officer unlocked the cell door and held the man’s head to enable her
colleague to push the door open. Once the door was opened sufficiently, her
colleague stepped over the man’s body and reached for a pillow. He gave the
pillow to the officer who placed it underneath the man’s head. The officers
ensured that the man’s airway was clear. One of the officers checked for a
pulse but could not find one. The officer who was holding the man’s head
noticed a faint pulse emanating from the area around his temple.
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25. When the Head of Operations for Gartree arrived at the man’s cell he asked
staff in the prison communications room to call an ambulance. He was
accompanied by a Principal Officer and a Senior Officer. The Head of
Operations relieved the officer who had found the man and, as she left the cell,
two Healthcare Officers arrived. The Healthcare Officers could not find
evidence of a pulse and immediately commenced cardio-pulmonary
resuscitation (CPR). When the paramedics arrived at around 1:10pm, they
took over the man’s care. Resuscitation attempts were stopped at 1:20pm and
death was pronounced by the paramedics.
26. When the prisoner who raised the alarm was unlocked after lunch he asked
about the man. An officer told him that the man had passed away. The
prisoner told my investigator that the prisoners on that spur of C wing were then
allowed to go to their afternoon activities (work/education/gym). As the
prisoners left the spur they were asked if they wanted to talk to someone from
the chaplaincy or a Listener (a prisoner who has been trained by the
Samaritans to give support to fellow prisoners) about what had happened. The
spur was closed after the prisoners left so that no-one else could gain access.
27. Gartree made arrangements for staff from HMP Manchester to contact the
man’s family to inform them of his death. A Senior Officer was appointed as
Gartree’s family liaison officer. He contacted the family on the day after the
man’s death to offer condolences and support. The Senior Officer maintained
contact with the family and assisted with the arrangements for the funeral.
(The prison provided financial assistance with the cost of the funeral.) The
man’s popularity was demonstrated by a collection by prisoners on his wing
that raised £138. This was used to buy a wreath, with the remainder being
given to charity.
28. The post mortem report records the man’s death as being due to natural
causes, as a consequence of an acute myocardial infarction (a heart attack),
caused by thrombotic occlusion and atheromatous stenosis (narrowing) of the
right coronary artery.
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CONCERNS RAISED BY THE MAN’S FAMILY
29. The man’s family raised a concern relating to his treatment while in custody.
The man had told his family that in December 2006 he had been knocked down
some stairs by another prisoner. He also apparently suffered chest pains at the
same time.
30. In response to the concern raised by the family, my investigator looked into the
circumstances surrounding the incident when the man was injured. In his
statement to my investigator, an officer confirmed that on 14 December he had
observed the man play fighting with another prisoner and had ordered them to
stop. Unfortunately, whilst the officer was giving the order, the man fell over.
The man was later taken to hospital and treated for injuries to his wrist and
ankle. The officer’s statement mirrored the information in the man’s main
prison records and medical records that my investigator had studied.
31. The clinical reviewer did not feel that the fall contributed to the man’s death and
there was no evidence of heart problems when the man attended hospital after
his accident.
32. After receipt of the draft report, the man’s family raised the following additional
concerns. The family felt that the man would have received a number of
'health-checks' prior to receiving chemotherapy, and questioned why any
problems with his heart were not identified at this stage, particularly as there is
a long history of heart problems within their family. The family questioned why
the prison did not inform the family (in particular the man's sister) of his ill
health. The family also said it was not easy to contact someone in prison and
they felt there was a need for the prison to provide families with information
when someone is in poor health.
33. A prison doctor stated that the man was having regular checks both by the
hospital and the prison. As part of those checks, it was noted that he had mild
hypertension. In September 2006 it was felt that, although his blood pressure
was not very high, it would benefit from slightly better control and therefore the
man was started on a mild blood pressure tablet. As part of the man’s general
monitoring, an electro-cardio-gram (ECG) was carried out which showed only
the mild changes that do occur with slightly high blood pressure but no signs of
ischaemic heart disease. The prison doctor confirmed that the man had never
presented with any symptoms to suggest that he had angina or heart disease
and therefore, any more invasive investigations would not have been
appropriate.
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34. In response to the additional issues raised by the family, the clinical reviewer
said, “There are issues related to his (the man’s) care and the potential to
mitigate against him having cardiac disease. In General Practice it has
become common to look for and treat the risk factors for heart disease and this
has become even more prominent since the introduction of the Quality and
Outcomes Framework (QoF) which rewards practices for levels of screening
and prevention work. The man would have been offered monitoring of his
blood pressure, cholesterol levels and smoking in a more systematic way than
his records suggest was the case in Gartree. He was noted to have high blood
pressure and was put on tablets but had problems with side effects. It was
decided to monitor his blood pressure after this but this was not done regularly
or in a planned way. I can only find one record of a cholesterol level in his
notes and that was raised at 7.8 which, combined with a high blood pressure
and smoking would have put his risk of cardiovascular disease at more than
20% in the next ten years and a cholesterol lowering medication may have
been appropriate. I could see no evidence that this had been suggested.
Systematic recording of problems and risk factors will assist in the reduction of
long term health problems in the same way that QoF has in wider general
practice. The use of information technology is central to this and I was pleased
to hear that this is now being put in place. This will also ensure that allergies
are not overlooked.”
35. In relation to the issue of informing the family of the man’s poor health. Gartree
has to make every effort to respect patient confidentiality. I appreciate that
efforts should be made to ensure that relatives are made aware of serious
health concerns. However, this is not always possible. It is not always the
case that people want their loved ones to know about the state of their health.
Healthcare staff need to respect patient confidentiality as well as the patient’s
own wishes.
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CLINICAL REVIEW
36. As noted, a review of the man’s medical care was undertaken by a doctor on
behalf of Leicestershire County and Rutland Primary Care Trust. The review
found that the man had suffered from significant long-term chronic diseases.
37. From the medical records, it was clear that the man was seen regularly by
healthcare staff and, when necessary, referred to secondary care services.
The clinical review concludes that there are no circumstances indicating that
the man’s death could have been anticipated or prevented.
38. The clinical reviewer says that when the man collapsed he was in a situation
that maximised his chances of survival. He had been heard to collapse and
help was available rapidly. This would not necessarily be the case for anyone
living in the wider community. Unfortunately, attempts to resuscitate the man
were not successful despite the prompt attention.
39. The clinical reviewer draws attention to issues related to the man’s care and
the potential to mitigate against him having cardiac disease. The clinical
reviewer says that in general practice it has become common to look for and
treat the risk factors for heart disease. This has become even more prominent
since the introduction of the Quality and Outcomes Framework (QoF) which
rewards GP practices for levels of screening and prevention work. The man
would have been offered monitoring of his blood pressure, cholesterol levels
and smoking in a more systematic way than his records suggest was the case
in Gartree.
40. The clinical reviewer says that healthcare staff had noted that the man had high
blood pressure. He was put on tablets but had problems with side effects. It
was then decided to monitor his blood pressure but this was not done regularly
or in a planned way. The clinical reviewer could only find one record of a
cholesterol level in the man’s notes. This showed that it was raised at 7.8
which, combined with a high blood pressure and smoking, would have put him
at risk of cardiovascular disease in the next ten years. This would also indicate
that a cholesterol lowering medication might have been appropriate. The
clinical reviewer could see no evidence that this had been suggested.
41. The clinical reviewer also draws attention to the man’s epilepsy as another
problem that was long standing and needed regular review. There is some
evidence that reviews took place in that there are checks on the blood levels of
his epilepsy medication (carbamazepine), but the clinical reviewer could not
find a record of the presence or absence of seizures in the man’s notes.
42. Another issue the clinical reviewer discovered in the records is that of the man
having a possible allergy to penicillin. This is clearly recorded on the reception
screening on 26 September 2002, although after this date the man was given
penicillin based drugs on two occasions. There was no record of adverse
events after these prescriptions. The clinical reviewer suggests this may be
because the ’allergy‘ was not actually an allergy but a separate problem that at
the time was thought to be an allergic reaction.
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43. The clinical reviewer notes that there were two occasions when the man was
unhappy with changes in his medication. The first was the stopping of
amitriptyline (as a pain killer) within the prison. The man had been on this
medication for pain and was unhappy to have it stopped. The clinical reviewer
judges that it was appropriate to stop the drug in the prison generally, and in
the man’s case in particular. (Amitriptyline can be very toxic to the heart,
particularly in overdose but also in those patients with heart disease.) The
second change was the stopping of the codeine prescribed when the man
attended outside hospital on 15 May 2006. The clinical reviewer says codeine
is an effective painkiller, but it is also a drug of abuse and not appropriate within
the prison setting for most situations.
44. The clinical reviewer concludes that there were several areas that might be
opportunities for learning and change. The first relates to the recording of
health information. A similar concern had already been expressed earlier in
2007 in a review of a death at the prison, and is being addressed by the Head
of Healthcare at Gartree. The clinical reviewer concludes that systematic
recording of problems and risk factors will assist in the reduction of long term
health problems in the same way that Quality and Outcomes Framework has in
wider general practice. The use of information technology is central to this.
Both the clinical reviewer and I are pleased to hear that this is now being put in
place. This will help to ensure that allergies are not overlooked in the future.
45. Although he recommends that policies are developed for chronic disease
management, the clinical reviewer recognises that the move to an information
technology based health record will make this a more practical proposition:
An Information Technology (IT) based systematic chronic disease
management procedure should be developed within the prison’s health
care system.
46. The clinical reviewer judges that the man would have benefited from a more
individually tailored approach to taking up help to stop smoking. The clinical
reviewer says he would like to see an attempt made to tailor this assistance:
Assistance to help prisoners to stop smoking should be tailored to their
individual needs.
47. In the clinical reviewer’s opinion, the man’s death was one that could not have
been directly avoided. The man’s lifestyle and particularly his smoking made
him vulnerable to heart disease. The clinical reviewer judges that this could
have been dealt with more thoroughly, although the man’s reluctance to stop
smoking would have reduced the effectiveness of any other interventions.
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CONCLUSION
48. The man moved to Gartree in September 2002, and died there of natural
causes in May 2007.
49. Given the generous collection following his death, and the comments made by
staff and prisoners at Gartree, it appears the man was a respected and well
liked prisoner.
50. In light of the findings of the clinical review, and my own investigation, I
conclude that the man’s medical care was satisfactory. I have endorsed the
two recommendations from the clinical review. These need to be addressed by
the Leicestershire County and Rutland Primary Care Trust in partnership with
the Governor of Gartree.
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RECOMMENDATIONS
Medical
1. An Information Technology (IT) based systematic chronic disease
management procedure should be developed within the prison’s health
care system.
Accepted locally – This is in progress and will be ultimately based on the Quality
Outcomes Framework (QoF) and supported by the Primary Care Trust. At
present we have patient management lists for chronic disease management.
2. Assistance to help prisoners to stop smoking should be tailored to their
individual needs.
Partially accepted – Pharmacy technicians provide this service at present.
Prisoners are seen individually for assessment before group cessation work
takes place. However, at present only NRT patches are available due to security
and prescribing issues.
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