Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of a man at HMP Albany,
In December 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2009
This is the report of an investigation into the circumstances surrounding the death of
a man, whilst a prisoner at HMP Albany. He died in hospital in December 2008. A
post mortem showed that the cause of his sudden death was heart disease.
The man’s next of kin are his father, brother and sister. I offer them my sincere
sympathy and condolences, as I do to all of his friends and acquaintances who have
been touched by his passing.
The investigation was carried out on my behalf by my colleague. Both he and I
would like to thank the Governor of HMP Albany and all his staff for their full and
ready co-operation during the course of our enquiries. I also thank the appointed
doctor for the clinical review he led on behalf of the Primary Care Trust (PCT).
This report recognises the actions taken by the staff during the emergency response
on that morning in December, when the man was found collapsed in his cell. I also
commend the good practice of the care team at HMP Albany in providing support to
staff. I make no recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2009
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CONTENTS
Summary
The Investigation Process
HMP Albany
Key Findings
Issues
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SUMMARY
The man was convicted and remanded to HMP Wandsworth in November 2004. He
was given an 11 year prison sentence in December 2004.
During October 2005 the man’s blood sugar was monitored for two weeks and he
was diagnosed with type two diabetes which was to be controlled by diet. He was a
life long smoker.
The man was transferred to HMP Albany on 20 April 2006. During his time at the
prison he saw the prison doctor on six occasions for cellulitis and eczema, and was
prescribed appropriate antibiotics and creams.
On 31 July 2008, the man told the doctor that he had been feeling light headed and
had experienced one episode of tunnel vision (central vision only). The doctor
recorded that this could be due to hypotension (low blood pressure) and high
cholesterol. He prescribed Simvastatin (which is used to control cholesterol levels
and prevent cardiovascular disease affecting the heart, arteries and veins).
The next occasion the man was seen in healthcare was four months later on 2
December when he had a routine influenza vaccination.
On 4 December, one of the man’s friends went to speak to him in his cell at 8.10am.
He found the man slumped on the floor with his head on the bed. The friend raised
the alarm and an officer immediately went to the man’s cell. He found him very
unwell and called for urgent medical assistance.
By 8.14am a nurse arrived at the man’s side, assessed the need for an ambulance,
and started cardiopulmonary resuscitation (CPR) assisted by a senior officer. The
first officer on scene used the cell intercom to contact the communications room to
make the emergency 999 call. Two healthcare assistants arrived carrying the
automated external defibrillator (which is used to analyse the heart rhythm and
advise whether an electric shock is required). The defibrillator was attached to the
man and it advised not to shock him but to continue with CPR. The nurse placed an
airway into him so that oxygen could be given manually. The healthcare staff
continued with CPR, as advised by the defibrillator, until the paramedics arrived.
The paramedics arrived at 8.25am and took over CPR from the prison staff.
Following a period of assessment, the paramedics decided to transfer the man to
hospital. Following assessment in the Emergency Department at the local hospital
the man was pronounced dead at 9.07am.
There are no areas of concern that arise from this investigation. My report shows
that the man had care equivalent to that he would have received in the community,
and recognises the swift professionalism of the emergency response and the work of
the care team.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 5 December 2008 when one of my investigators
issued notices to staff and prisoners. The notices included an invitation to those
who wished to submit information relating to the man’s death to make themselves
known. One prisoner came forward as a result and was interviewed.
2. My investigator visited HMP Albany on 18 December. During his visit he was
given copies of all the documentation relating to the man. They included his main
prison record, medical records and statements made by staff. During this visit my
investigator interviewed one prisoner. He returned on 12 January 2008 when he
interviewed seven members of staff and another prisoner.
3. The local Primary Care Trust appointed a clinical review panel to carry out a
review of the man’s clinical care. As on other occasions, I am grateful to the
appointed doctor for leading this review. My investigator and the clinical
reviewers jointly discussed aspects of the man’s treatment and healthcare whilst
he was at Albany.
4. My investigator contacted HM 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 in his enquiries into
the man’s death.
5. One of my family liaison officers contacted the man’s family to inform them of the
investigation. The family had no specific issues that they wished the investigator
to consider.
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HMP ALBANY
6. Albany is a category B training prison situated near Newport on the Isle of Wight.
It opened in 1967 on the site of a former military barracks. Albany offers a varied
regime with education and several offending behaviour programmes. At the time
of the man’s death, the prison could hold up to 566 adult male prisoners. The
average age of Albany’s population is 48 years old, which is considerably higher
than in most prisons.
7. There are five wings (A – E) which are almost identical and hold between 94 and
96 prisoners in single cells with in cell power and access to electronic night
sanitation (this is when the cell door unlocks for a limited time to allow the
prisoner to go to the toilet). There are three small ‘spurs' on each landing, with
communal recesses containing showers, toilets and wash basins. There are also
two 40 bed units (F and G) which comprise single cell accommodation with en-
suite facilities.
8. Health services at Albany and at the other two prisons on the Isle of Wight are
commissioned by the Isle of Wight NHS Primary Care Trust (PCT). The prison’s
healthcare is clustered with HMP Camp Hill and provided by HMP Parkhurst. In
total, Parkhurst provides healthcare to 1,500 or so prisoners on the island.
Prisoners’ daily medical needs at Albany are catered for by way of out-patient
clinics and core day primary nursing cover. There are three nurses on duty from
7.30am to 5.30pm, Monday to Friday. During weekends and evenings, one
member of healthcare staff is on duty. Doctors from a local community practice
attend Albany for three hour sessions four times each week. Evenings and
weekends are covered by on call doctors from the local PCT. There is no
nursing or healthcare cover based at Albany during the night.
9. The most recent report on Albany published by the HM Chief Inspector of
Prisons, followed a full announced inspection in November 2007. The Chief
Inspector’s report noted that public protection and the range of activities provided
were good. Offending programmes were of a very high standard. However, the
Chief Inspector noted that relationships between staff and prisoners were distant
and mistrustful. There were insufficient work places and systems to protect
prisoners against bullying and self-harm were not sufficiently robust. At the time
of the inspection there was a serious shortage healthcare staff which meant that
only the basic health interventions could be delivered.
10. The latest report from the prison’s Independent Monitoring Board (IMB) was for
the period 2006 – 2007. The IMB drew attention to the limited access for
prisoners with mobility problems, but said that the management team was aware
of this. Every effort was being made to accommodate prisoners with mobility
difficulties in appropriate locations. The IMB report also commented on the
limited availability of staff for escorts to accompany prisoners to the local hospital.
The report said, “This problem will not go away due to the age of our prisoners.”
11. My office has investigated six deaths due to natural causes at Albany during
2008. There are no common factors between the circumstances surrounding this
investigation and those into the previous deaths.
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KEY FINDINGS
12. Following conviction in November 2004, the man was remanded to HMP
Wandsworth. On arrival at the prison he underwent an initial health screen. He
said that he had no previous health conditions and was not taking any
medication. He explained the history of diabetes in his family and that he had
been tested at a hospital close to his home address for Huntington’s Disease and
was awaiting the results. It appears that healthcare staff at Wandsworth did not
obtain the man’s medical history from his GP in the community.
13. On 10 December, the man returned to court and was sentenced to 11 years in
prison. He remained at Wandsworth following sentence.
14. The man was informed on 15 February 2005 that the prison had received a letter
from the consultant neurologist at the local hospital. The letter provided
confirmation that he would not develop Huntington’s Disease.
15. Three weeks later on 8 March, the man fainted in the laundry. He was seen by a
second nurse who recorded that he had a cut to his elbow which was cleaned
and dressed. He told the nurse that he had not eaten any breakfast. The nurse
took his blood pressure and recorded that it was within the normal range.
16. Two days later, the man was reviewed by the prison doctor. The cut to his elbow
was checked and re-dressed. The doctor also recorded that the man had
eczema on his right leg and ankle. He prescribed Fucibet cream (a cream used
to treat eczema which is infected with bacteria). A review was set for one week
later when the doctor recorded that, although the condition had improved, he
needed to continue using the cream.
17. On 23 October 2005, the man saw the prison doctor again. It was recorded that
the eczema on his right leg had flared up again and become infected. The man
was also concerned about the family history of diabetes. The doctor conducted a
urine test and, from the result, assessed that he had type two diabetes which
could be controlled by diet without the need for any medication. However the
doctor requested that the man should have his glucose checked twice a day for a
two week period. The daily checks were carried out by healthcare staff with a
diabetic chart being completed. This confirmed the diagnosis of type two
diabetes.
18. The man was next seen by the doctor on 16 December because he was again
suffering from eczema. The doctor repeated the prescription of Fucibet Cream,
along with a seven day course of Clarithromycin antibiotic (a treatment of skin
infections).
19. The next appointment with a doctor was on 22 February 2006 - again for eczema
that had become infected. A further seven day course of Clarithromycin antibiotic
was prescribed, in addition to the man continuing with the Fucibet cream. The
doctor recorded that, once the infection had cleared, the man needed to be
prescribed a long term eczema medication cream. A month later, he was seen
by the doctor to review his eczema. It was no longer infected and the doctor
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prescribed Betnovate cream (a medium strength steroid cream to suppress the
symptoms of eczema).
20. On 20 April 2006, the man transferred to HMP Albany. He was seen by the
nurse who was the first on scene, on reception for a routine health check. The
nurse said that he was type two diabetic, but did not take any medication and had
no other health worries. The nurse made a referral for the man to see the
diabetic liaison nurse.
21. Seven days later, a third nurse saw the man in the general medical clinic. He told
the nurse that he was a diabetic and had skin problems for which the doctor at
Wandsworth had prescribed cream. In response to routine questions, the man
said that he had no history of depression or any thoughts of self harm. He did
say that he smoked 20 cigarettes a day but had never taken illegal drugs. He
told the nurse that he had previously suffered from a blocked artery and had a
heart bypass operation several years earlier. The nurse assessed him as being
fit for exercise and employment.
22. The doctor saw the man on 4 May. Blood samples were taken for a diabetic
screen. The doctor recorded that the man had an infection of the hair follicles in
the bearded area of the face and that his teeth were in need of attention. A
referral was made for him to see the dentist.
23. The next time that the man was seen in healthcare was on 13 October when he
had a neurovascular assessment (a medical check and assessment of the
nerves, arteries and veins) by a fourth nurse. The results of the assessment
were normal and he was given health advice about foot care.
24. The man went to healthcare again on 24 October and saw the doctor who
recorded that he had cellulitis (infection and inflamation of the skin) around his
right ankle. The doctor prescribed Flucloxacillin (antibiotic for treatment of
cellulitis) and more Fucibet cream.
25. On 4 January 2007, the man was seen in healthcare by a fifth nurse as he had
felt faint at work that morning. He told the nurse that he had not had his
breakfast, but after eating something felt much better.
26. The man was next seen in healthcare on 2 March. He told the fifth nurse that he
was experiencing pain in his feet. The nurse carried out an examination and
recorded that one of his toes on his left foot was discoloured. Because of his
history of diabetes, an appointment was made for him to see the prison doctor.
The man said that he was keen to give up smoking and was advised to apply for
the smoking cessation course.
27. Four days later, the doctor saw the man again. The doctor recorded that the man
had cellulitis and an infected nailbed, and that surgical intervention might be
required if the infection did not settle down. In addition, the blood supply to his
leg was limited because a leg artery had been removed during his previous heart
bypass surgery. The doctor prescribed Flucloxacillin and Fucibet cream.
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28. On 24 May, the man was seen by a sixth nurse in healthcare. He told the nurse
that his right ankle had been slightly swollen for the previous four days and the
skin was very itchy and warm to the touch. The nurse recorded that the skin was
flaky and taut but not broken, and his toes were normal. An appointment was
made to see the prison doctor. Seven days later the man was examined by a
second doctor who diagnosed that the man had cellulitis of the right leg and
ankle, and repeated the previous prescription.
29. The man was seen as an emergency appointment in healthcare on 18
September. He told the sixth nurse that he had swelling around his right eye and
had suffered a headache for two days, but otherwise felt well. The nurse
recorded that there was no discharge coming from his eye, no foreign bodies in
his eye, and no sign of any injury. The nurse arranged for him to see the prison
doctor the same day. The man saw the second doctor who recorded that he had
cellulitis of the eyelid and who wanted to review him in three days. The second
doctor prescribed Flucloxacillin and Chloramthenicol (antibiotic eye drops). The
second doctor reviewed the man on 21 September when he recorded that the
cellulitis was clearing up.
30. The next occasion the man attended healthcare was on 14 December 2007 when
he had another neurovascular assessment conducted by the fourth nurse. The
results of the assessment were again recorded as normal.
31. On 24 April 2008, the man was seen in healthcare by the nurse who was first on
scene, who recorded that he had extensive eczema on both arms and referred
him to to see the prison doctor the same day. The doctor saw him and recorded
that he had atopic eczema (chronic inflamation of the skin) on both elbows and
lower arms. The doctor prescribed Flucloxacillin, Fucibet cream, Paracetamol
and Diprobase cream (for treatment of eczema).
32. The man was next seen in healthcare by the second doctor on 31 July. He told
the doctor that he had been feeling light headed and had experienced one
episode of tunnel vision (central vision only). The second doctor recorded that
this could be due to hypotension (low blood pressure) and high cholesterol. The
doctor prescribed Simvastatin (used to control cholesterol levels and prevent
cardiovascular disease affecting the heart, arteries and veins).
33. There was no further contact with healthcare until 2 December when the man
was given a routine influenza vaccination by a seventh nurse.
Events of 4 December
34. The early morning cell check on the man’s wing (C wing) on 4 December 2008
was conducted by the officer who was first on scene. He told my investigator that
he looked in on the man at approximately 7.00 am and saw him lying on his bed
apparently asleep. The officer said that the cells were unlocked at approximately
7.25am when prisoners came out to make drinks and toast.
35. My investigator spoke to a prisoner who occupied the next cell to the man. He
said that he saw the man going to collect his hot water at approximately 7.40am.
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36. One of the man’s friends told my investigator that he went to speak to the man in
his cell at approximately 8.10am. His friend said that he found the man with the
top half of his body lying on his bed with his legs to one side on the floor. His
friend said he nudged the man to see if he was asleep but got no response. He
immediately went to call an officer. He went to the wing office and asked the
officer who was first on scene to have a look at the man as he did not appear to
be well.
37. The officer who was first on scene went up the stairs to the man’s cell. He told
my investigator that he found the man with his head on the bed and his legs on
the floor. He called to him but got no response. He then lifted the man’s head up
to find the eyes fixed and his face very hot and covered in perspiration. The
officer checked the side of the man’s neck and felt a faint pulse. The officer told
my investigator that he knew the man needed medical assistance and, because
he did not have a radio, immediately went to the wing office to call healthcare.
38. At 8.12am, the officer who was first on scene spoke to a colleague in healthcare
and asked for urgent assistance from healthcare staff. The officer went straight
back to the man’s cell. He checked him again and thought that his condition had
deteriorated. He placed him on his side in the recovery position.
39. The nurse who was first on scene and the officers colleague arrived at the man’s
side at 8.14am. The nurse quickly assessed him and instructed the officer to call
for an ambulance. The officer used the intercom system to speak to the
communications officer to call an ambulance. A senior officer also arrived and
assisted the nurse with cardiopulmonary resuscitation (CPR).
40. Two healthcare officers arrived at 8.19am bringing the automated external
defibrillator. It was attached to the man and it advised not to deliver an electric
shock but to continue with CPR. The nurse who was first on scene put an airway
into the man so that oxygen could be given manually. The healthcare staff
continued with CPR, as advised by the defibrillator, until the paramedics arrived.
41. The paramedics arrived at 8.25am and took over CPR from the prison staff.
Following a period of assessment they decided to transfer the man to hospital.
The prison staff assisted the paramedics to move the man from his cell to the
ambulance. The ambulance left the prison at 8.56am. Two other officers
accompanied the man to the hospital but – quite rightly – no restraints, such as
handcuffs, were used. Following assessment by a doctor in the Emergency
Department at the local hospital, the man was pronounced dead at 9.07am.
Events immediately following the man’s death
42. A debrief was held for all the staff involved later that morning. Each member of
staff was informed that support was available both whilst at work and when off
duty. Contact numbers were given for the care team and a governor grade. All
the staff who spoke to my investigator said that they had nothing but praise for
the care team, specifically mentioning the governor grade.
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43. Another governor held a personal briefing with prisoners on C wing to inform
them of the man’s death. Arrangements were made for Listeners (who are
trained by the Samaritans to give support) to be on C wing to be available for
prisoners who wished to speak to someone.
44. A third governor and the Reverend visited the man’s family in person later that
day to inform them of the sad news that he had died. The man’s father said that
the family were aware that his son was in Albany but, due to his own poor health
and the cost of visiting, the man’s last contact with the family had been some ten
months earlier. The family were offered financial assistance with the funeral
costs and the Reverend offered to conduct the funeral service.
45. The family expressed their gratitude for being visited and told in person. They
also wished their blessings to be passed on to the staff who had tried to save the
man.
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ISSUES
Clinical care
46. The clinical review finds that the quality of healthcare given to the man was good
and equivalent to what he would have received in the community.
47. The review does comment that, in the community, medical records are
automatically transferred to a new doctor. It is accepted that this does not
happen for prisoners, who are not registered with prison doctors, and that it
would be impossible to have a blanket policy to do the same within the Prison
Service. The man’s initial reception was to Wandsworth. It would be expected
that any medical records obtained by Wandsworth would have been transferred
to Albany, including any external records. However, as there is no evidence to
suggest that Wandsworth sought the records, this would explain why Albany did
not receive the man’s medical history. Neverhteless, I am satisfied that the
absence of the community records did not affect the treatment given to him.
Emergency response
48. A fellow prisoner raised the alarm with staff at approximately 8.10am and within
four minutes, by 8.14am, the request had been made for an emergency
ambulance, CPR was started and a defibrillator was being used. The staff in
attendance continued CPR, as directed by the defibrillator, until the paramedics
arrived at the man’s side and took over the attempt to resuscitate him.
49. The staff who responded to the man’s need for emergency assistance acted with
great speed and professionalism. The clinical reviewer highlights the response
time and commends all the staff involved in the attempt to resuscitate him. I
believe the Governor should recognise the professionalism displayed by the staff
who were directly involved in the swift emergency assistance provided to the
man.
Care and support for staff
50. All staff interviewed by my investigator as part of this investigation wished to
place on record their thanks for the support made available to them following the
man’s death. The care team provided both work and off duty contact details so
that staff were able to speak to someone whenever they wished. In particular,
the governor grade was praised for the personal support he gave to staff. The
Governor should recognise the work of the care team, and in particular the
governor grade, for the support and care given to staff.
51. Save for these commendations, I make no other recommendations as a result of
this investigation.
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