Individual at Acklington

Investigation into the circumstances surrounding the
death of a man in hospital in December 2004
while a prisoner at HMP Acklington
Prisons and Probation Ombudsman for England and Wales
October 2005
This is the report of an investigation into the circumstances surrounding the
death of a 70 year old man who died in hospital while a prisoner at HMP
Acklington on 29 December 2004.
The man had become unwell on 13 December and was admitted to a nearby
local hospital as an emergency that evening. He was diagnosed as having
pneumonia and later transferred to intensive care at a general hospital where he
was further diagnosed as suffering from myocardial infarction. He was treated
for both conditions but his health worsened. He was pronounced dead at 4.05
pm on 29 December.
A post mortem examination was performed by a pathologist on 30 December.
The cause of death was multi-organ failure with a severe and overwhelming
infection of the lung, and chronic obstructive pulmonary disease.
I offer my sympathy and condolences to the family of this man for their loss.
The investigation was carried out on my behalf by one of my investigators. As
part of the investigation, she asked the Northumberland Primary Care Trust to
conduct a review into the clinical management of this man. I am most grateful to
the doctor appointed for undertaking this review. My thanks also go to the
Governor and all Acklington staff. I appreciate the willing co-operation that has
enabled the investigation to be completed.
This was an elderly man with a chronic illness. He was cared for appropriately
throughout his time in custody. His death was entirely natural and could not have
been avoided.
Stephen Shaw CBE
Prisons and Probation Ombudsman
September 2005
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CONTENTS
Summary
Investigation
Acklington Prison
Prison History
Clinical Review
Examination of the issues
Conclusion
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SUMMARY
This is the report of an investigation into the death of a man who died in hospital
on 29 December 2004. The man was serving a prison sentence at Acklington
prison. My investigator reviewed the man’s records and spoke to staff and
prisoners at Acklington. This report describes the circumstances that led to the
death and looks at the care he received while in prison custody.
The man had been in prison since 1998 and at Acklington since 27 September
2004. He was a smoker and had a history of respiratory problems, which had
previously been treated at the chronic disease management clinic at HMP
Frankland.
On 13 December 2004, while in his cell at Acklington, the man developed severe
breathing difficulties. On discovering him, a fellow prisoner alerted the wing staff.
He was taken to the local hospital and later to a regional hospital. As his
condition worsened, he was transferred to the intensive care facility. After 14
days in intensive care, the man suffered multi-organ failure and died.
I conclude, on the basis of the evidence I have seen, that this death was
unavoidable, and that he was well cared for by the prison. I make no
recommendations.
This version of my report, published on my website, has been amended to
remove the name of the deceased and the names of any staff or prisoners who
were involved in this investigation.
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INVESTIGATION
The investigation was opened on January 28 2005. My colleague visited
Acklington and met with managers. She also arranged for Ombudsman’s notices
to be issued to staff and prisoners, identifying the scope of the investigation and
inviting anyone who wished to see the investigator to make themselves known.
The local Primary Care Trust was contacted to undertake a clinical review.
One of my Family Liaison Officers contacted the man’s son to see if he wanted to
be involved in the investigation. He said that he did not have any particular
questions about the care his father received, but would like to see a copy of my
report in draft, in due course.
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ACKLINGTON PRISON
Acklington is a Category C prison for convicted adult male prisoners. A former
RAF station, situated near to the small town of Amble in Northumberland, it was
acquired by the Prison Service in 1971 and the prison opened in 1972.
Acklington has an operational capacity of 882 category C prisoners serving any
sentence up to and including life. Approximately 45 per cent of the
establishment’s population are vulnerable prisoners. The accommodation
consists of ten living units of various designs.
The prison offers a number of accredited Offending Behaviour programmes
including drug rehabilitation facilities, sex offender programmes, enhanced
thinking skills, and a healthy relationships course. Standards audit unit last
visited in November 2002 at which time Acklington received a rating of 81 per
cent.
A wide range of activities are provided by an education department, industrial
workshops, painting and decorating shops, amenity gardens, market gardens, a
laundry and a gymnasium.
The healthcare department provides Primary Care Services from 7.30 am until
7.45 pm Monday to Saturday, and from 8.30 am to 5.30 pm on Sundays. There
is no in-patient facility. Whilst there is no full time medical officer, a local GP
provides a daily surgery Monday to Friday, and an emergency surgery on
Saturdays. There are on call arrangements for a local doctor to cover nights on
an emergency basis.
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PRISON HISTORY
The man returned to Durham to begin his sentence following his conviction. On
reception, it was noted that he suffered from asthma and he received the
appropriate treatment for that condition from the prison’s healthcare department.
On 25 November 1998, he was transferred to HMP Frankland. While there the
man was treated for his condition in the prison’s chronic disease management
clinic. His asthma was well controlled.
He was a quiet and well behaved man in prison, and did not come into contact
with the disciplinary system. He was polite to staff and socialised with a small
circle of other prisoners with whom he got on quite well.
In August 2000, he complained of indigestion but there was no obvious cause.
He therefore underwent a series of tests, but still no underlying cause could be
found. An appointment was made for him to go to hospital for further
investigations. Late in the evening, prior to his appointment, the man refused to
go and so the root of the problem was not established. Following this, it appears
that he did not complain of any further gastric discomfort at Frankland or
Acklington.
On 16 January 2004 the man was re-categorised to “C” and considered suitable
for lower security conditions. On 27 September he was transferred to Acklington
and allocated to H wing. He was seen by the doctor and it was noted that his
asthma had been well controlled with becotide and ventolin. This treatment was
continued at Acklington.
The man seems to have been a somewhat distant individual and did not interact
very much with staff and other prisoners. After a member of staff spoke to him, it
transpired that, following his time at Frankland, he was finding the more relaxed
regime at Acklington difficult to cope with. He was apparently considering asking
for a transfer to a prison with a more disciplined regime.
The staff on H wing thought it would be a good idea to move him to C Wing
where there were older prisoners and a more sedate pace of life. The man was
happy with this suggestion and, following his move, he seems to have settled in
quickly. He impressed the staff there as a very quiet man who was polite, with
clean and tidy habits.
Despite having made several attempts to give up tobacco, as he had been
advised, the man was unable to do so. He smoked 12 cigarettes a day which
aggravated his respiratory condition.
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On 12 December a staff nurse attended to the man when he had an asthma
attack that lasted about ten minutes. After that, he appeared to recover and he
was left calm and relatively comfortable. He was referred to the prison GP for a
medical review, and was to be seen by the doctor in due course. Up to this point
his stay at Acklington had been without note. He had been in reasonable shape,
given his chronic health condition.
At around 8.00 pm on 13 December, a prisoner spoke to an officer who was on
duty on the wing. He said that the man seemed to be having trouble breathing.
The officer immediately alerted the prison control room of the problem and, when
it became apparent that the man was having what seemed to be an asthma
attack, an ambulance was called. This call is logged as having taken place at
8.05 pm. The ambulance arrived at 8.15 pm and emergency aid was given to the
man by the paramedic crew.
After they had attended him, he was assessed by the crew as requiring hospital
treatment. He was therefore taken to the general hospital at 9.00 pm. However,
because of a shortage of beds there, he was taken during the night to another
hospital where upon examination it was suspected that the man had pneumonia.
Due to the seriousness of his condition, he was later transferred to the intensive
care unit of the regional hospital, arriving on 17 December.
Later that day, the diagnosis of pneumonia was confirmed and evidence of a
recent myocardial infarction was found. The man was sedated and put on a
ventilator and was unconscious for long periods.
Prison staff were present at his bedside and appear to have conducted the bed
watch in a professional and sensitive manner. Given the man’s incapacity, the
officers appropriately did not apply restraints and were helpful in ensuring
unimpeded access for medical staff. Medical staff at the prison maintained an
updated summary of the man’s progress.
His condition deteriorated, and on 21 December a tracheotomy was performed to
allow him to breathe. A prison manager visited and assessed the situation that
day. It was apparent that the man was gravely ill, and the chances of a breach in
security were very low. The bed watch officers were therefore withdrawn and
daily telephone reports monitoring his condition were made to the prison.
The man’s condition continued to deteriorate further and the next day his family
was alerted that he might not recover. On 26 December, it was noted in the
patient summary maintained by the prison that it was thought unlikely that he
would regain consciousness. He died on 29 December.
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CLINICAL REVIEW
The clinical review was undertaken by a doctor appointed by the Northumberland
Primary Care Trust. The report found that the man had received care that was
equal to or exceeded that which he might have expected in the community. The
report makes no recommendations regarding the clinical care the man received.
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EXAMINATION OF THE ISSUES
This was an elderly man whose clinical condition was fully recognised while in
prison custody. It appears that he received good care at the establishments
where he had served his sentence, including Acklington.
The clinical review makes clear that that his asthma was well managed, and
there seems no doubt that the medical arrangements at Acklington were
adequate in the event of the man’s final illness.
The man suffered an asthma attack on the day before he was admitted to
hospital, but appeared to have satisfactorily recovered after treatment from the
prison healthcare team. He was left calm and comfortable with an appointment
to seen by the doctor in due course.
On discovering the man in distress during the evening of 13 December, an
emergency ambulance was promptly requested. The ambulance arrived at the
prison within ten minutes, which is an acceptable response time.
The security arrangements at the hospital seem to have been suitable, striking a
good balance between public protection and sensitivity to the situation.
Handcuffs were not used. Escorting staff conducted themselves professionally,
and were withdrawn when it became apparent that the man was seriously ill and
not likely to pose a risk to the public.
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CONCLUSION
This was a 70 year old man who suffered poor health. I consider that his death
was unavoidable. The prison dealt appropriately with his illness, and treated him
respectfully as his life ended.
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