Individual at The Verne

Investigation into the circumstances surrounding the
death of a man,
a prisoner at HMP The Verne,
in hospital in June 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2009
This is the report of an investigation into the circumstances surrounding the death of
a man on 16 June 2008. At about 7.45am that day, the man collapsed at HM Prison
The Verne. He was taken to hospital where death was pronounced at 9.30am. At
the subsequent post mortem examination it was found that the man had died of a
heart attack. A Spaniard, he was 52 years old when he died.
I offer my sincere sympathy and condolences to the man’s family and friends for their
sad and untimely loss.
The investigation was conducted by my colleague.
I also commissioned a clinical review of the management of the man’s health needs
while he was in prison custody. This was conducted on behalf of the Dorset Primary
Care Trust. I am most grateful to the clinical reviewer for his contribution.
My thanks also go to the Governor and her staff at The Verne for their assistance
during the investigation. I am especially grateful to the prison’s liaison officer.
I have concluded that the man’s health needs were satisfactorily met and that his
fatal heart attack could not reasonably have been predicted.
One of the principal aims of my investigations is to help the Prison Service to learn
relevant lessons from each death. Although I am satisfied that the man’s death
could not have been predicted, I nevertheless urge the Governor to implement
recommendations I have made about the timing of health screens and about aspects
of the management of life-threatening events.
In addition to my recommendations, I am pleased to draw attention to three
examples of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2009
2
CONTENTS
Summary 4
Investigation process 5
HMP The Verne 6
Key events 7
Issues 13
Recommendations 17
3
SUMMARY
The man was arrested at Gatwick Airport on 21 June 2007. He was charged with
the illegal importation of drugs and later sentenced to six years imprisonment. He
spent brief periods at HMP Elmley and HMP High Down before transferring to HMP
The Verne in Dorset on 29 September. Although he was a heavy smoker and was
troubled by persistent back pain, the man neither showed nor complained of any
heart problems.
At about 7.45am on 16 June 2008, the man collapsed in his wing at The Verne.
Initially it was thought he was experiencing convulsions. However, he quickly lost
consciousness and was taken to hospital by ambulance. The man was pronounced
dead at the hospital at 9.20am that day. A post mortem examination found that he
had died of a heart attack.
My investigation found that the man’s fatal heart attack could not reasonably have
been predicted. A number of staff and one prisoner made determined attempts to
save his life.
I make five recommendations, one of which concerns the timeliness of reception
health screens. The other four concern aspects of the management of life-
threatening emergencies. I also draw attention to three examples of good practice.
4
INVESTIGATION PROCESS
1. The investigation was conducted by my colleague. On 19 June, my
investigator met with the Governor, a representative of the local branch of the
Prison Officers’ Association, a representative of the prison’s Independent
Monitoring Board, the Prison Intelligence Officer from Dorset Police, and the
prison’s Family Liaison Officer. My investigator explained the terms of
reference for the investigation. The following day, notices were issued to staff
and prisoners at The Verne to announce the investigation and to invite
anyone with concerns about the man’s death to make themselves known to
my investigator. Two prisoners responded. Those two prisoners and three
members of staff were interviewed informally. An informal discussion was
also held with a fourth member of staff.
2. I commissioned a clinical review of the management of the man’s health
needs while he was in custody. This was conducted on behalf of the Dorset
Primary Care Trust.
3. In July 2008, one of my Family Liaison Officers contacted the man’s brother
by letter, translated into Spanish, to an address in the Canary Islands
provided by staff at The Verne. A Spanish version of the Prisons and
Probation Ombudsman’s Information Leaflet for Families about the
investigation was sent at the same time. The letter invited the family to make
contact about any concerns or questions they wished the investigation to
address. No response has been received to date. Further attempts will be
made to inform the man’s family of the completion of the draft report and to
ascertain whether they wish to receive a copy.
5
HMP THE VERNE
4. The Verne is a category C training prison for up to 595 male adult prisoners
situated on the isle of Portland near Weymouth in Dorset. Most of the
prisoners at The Verne are foreign nationals.
5. There are six identical wings, five of which hold a maximum of 86 prisoners
and one of which (C2) holds 92. In addition, D wing provides dormitory
accommodation with curtained bed spaces. A1 and C1 wings hold prisoners
who have attained the highest level in the incentives and earned privileges
scheme. A2 wing is the induction unit.
6. Health services are commissioned and provided by the Dorset Primary Care
Trust. The healthcare centre is a single storey building located at one end of
the prison. There are no inpatient facilities. Prisoners who need inpatient
care are normally taken to a hospital some 14 miles away.
7. The Verne was last inspected by Her Majesty’s Chief Inspector of Prisons in
August 2007. In the report of that inspection, published the following October,
the Chief Inspector made a number of recommendations about healthcare,
none of which is relevant to this investigation.
8. In their report on The Verne for the period November 2006 - May 2008, the
Independent Monitoring Board (IMB) drew attention to some aspects of the
provision of healthcare by the Dorset Primary Care Trust. However, these
issues too are unrelated to the findings of this investigation.
9. I have investigated two previous deaths at The Verne. These occurred in
November 2004 and March 2008 respectively. In my report of the
investigation into the first of those deaths, I drew attention to the absence of
defibrillators at The Verne and recommended that the Primary Care Care
Trust should provide a defibrillator to the establishment. I am pleased to be
able to record that this recommendation was implemented. I also note that,
since the man’s death, a second defibrillator has been acquired. However, I
have recommended that thought should be given to the location of one of
them in a more central location in the prison. None of the issues that arose
from the investigation of the other death I have investigated at The Verne is
relevant here.
6
KEY EVENTS
Arrest and appearance in court
10. On 21 June 2007, the man, a Spanish national, formerly resident in Alicante,
flew in to Gatwick Airport from Port of Spain in Trinidad. He passed though
the “nothing to declare” channel where his luggage was searched. In it was
found a large quantity of illegal drugs.
11. The man was arrested at 8.40am and taken into custody for interview in the
presence of an interpreter and a solicitor. That evening, he was taken to a
police station in Brighton. He remained in police custody until 25 June. His
medical record shows that he was regularly given paracetamol and ibruprofen
for back pain.
12. The man appeared before magistrates on 25 June, accused of the illegal
importation of drugs. He was remanded in custody at HMP Elmley.
HMP Elmley
13. The man spoke very little English. His ability to communicate was therefore
largely dependent on the use of interpreters.
14. The man’s medical records show that upon his reception he complained of a
history of back pain but was otherwise considered to be fit and well. During
his first reception health screen, with the aid of an interpreter, the man told a
nurse he had not seen a doctor in the previous few months and was not in
receipt of any medication. He said he consumed neither drugs nor alcohol.
However, he was heavy smoker.
15. His pulse rate was recorded as 73 beats per minute (i.e. within normal range).
His weight was 70kg. His height was recorded as 184cm and his body mass
index was 20.68. His blood pressure was measured as 102/65, which is
below normal limits. The man was given two paracetamol tablets for his back
pain.
16. Just over a fortnight later, the man failed to keep an appointment for a triage
assessment. However, the appointment did take place a week later. Once
again, the man complained of back pain. His medical record shows that an
appointment was to be made for him to be assessed by a doctor that
afternoon. At this appointment, a prison doctor prescribed Diclofenac 75mg
for his back pain.
17. The man remained at Elmley until 13 September when he appeared at Crown
Court and was given a six year prison sentence. He was transferred to HMP
High Down the next day.
7
HMP High Down
18. Upon his arrival at High Down, the man attended a “well man“ clinic. He
admitted to smoking 20 cigarettes a day and said he would not give up the
habit. He said there was no family history of serious illnesses.
19. The man’s blood pressure was recorded as 157/96, above the normal range.
(My investigator was advised that this is borderline high.) The man’s pulse
was 83. This is considered to be normal for a person who is a regular smoker.
The man also confirmed he did not have a pacemaker (a device fitted
surgically to a patient to regulate the heartbeat).
20. After two weeks at HMP High Down, the man was assessed as being fit for
transfer to HMP The Verne. The following table shows the questions asked
and his answers:
Does this prisoner have any outstanding hospital No
appointments?
Is this prisoner on medical hold/any other medical No
reason?
Does this prisoner require regular medication? Not ticked
Does this prisoner need 24 hour healthcare input? Not ticked
Do you need the doctor’s opinion about this Not ticked
transfer?
Is there any risk of self-harm? No
Is there any clinical reason why this prisoner should Not ticked
not be transferred?
Awaiting transfer to hospital
Awaiting psychiatric referral
Care programme approach
Awaiting psychiatric referral
Is this prisoner fit for transfer? (In other words, are Yes (he is fit
there any medical reasons why he should not be for transfer)
moved to another prison?)
21. The man was transferred the next day.
HMP The Verne
22. Upon arrival at The Verne, the man was allocated to a unit where there were
other Spanish speaking prisoners. By all accounts, he soon settled and got
on well with a small group of prisoners who spoke his language. Although by
this time his use of English had begun to improve, the man remained
somewhat dependent on the ability of other prisoners to interpret for him when
speaking to staff and to help him fill in forms.
23. He was assessed by a prison doctor five days after his arrival. The doctor
recorded that the man complained of low back pain and prescribed Diclofenac
tablets that are designed to help relieve pain and inflammation as well as to
minimise the risk of side effects. The doctor also suggested that the man
should consider taking paracetamol - a mild painkiller - as an alternative.
8
24. On 26 October, a month after his arrival at The Verne, the man underwent a
further routine health assessment. The nurse who carried out the assessment
considered that there were no grounds for referring him to a doctor, although
she advised the man to try to reduce his level of smoking. The man told the
nurse he had no concerns about his health and did not think there was any
health information he considered to be important. He was assessed as being
fit for normal location (i.e. in a wing rather than in a healthcare centre), work
and any cell occupancy.
25. Healthcare staff continued to emphasise to the man the importance of
reducing his smoking throughout his time at The Verne. The only other
medical issue of note was the management of his back pain, for which the
man continued to receive Diclofenac, paracetamol and ibruprofen.
26. Although the man came to the attention of the healthcare department on
numerous occasions thereafter, the consultations were unrelated to any
complaints or issues of a significant nature, and no consultations raised the
issue of possible heart disease.
Events on 16 June
27. Shortly before 7.00am on 16 June 2008, the man unexpectedly collapsed in
his wing. Another prisoner located in the same wing as the man, made a
written statement to the Governor in which he described what happened.
28. My investigator interviewed two other prisoners and three members of staff
who, amongst others, were involved in the discovery of, and response to, the
collapse. Those staff were the first person to respond to the emergency, the
officer who asked for an ambulance to be called and the first member of the
healthcare team to respond.
29. The other prisoner said he first saw the man shortly before 6.50am. He was
walking along his landing in search of someone who might give him a
cigarette. The prisoner described the man as being “his normal self”. He said
he saw the man again in the recess about 45 minutes later and noticed that
he was carrying a blue plastic bowl and his glasses. After the morning roll
check was complete, the prisoner said he went to the wing office to collect the
keys to the cupboard where cleaning equipment was kept, and prepared to
empty the office rubbish. He then stood in the corridor, not far from the office,
to await breakfast.
30. The prisoner said that, at about 7.45am, he, the man, and another prisoner
waited at the entrance to the servery. He had earlier seen the man reading
the notices on the wall at the end of the corridor. During his conversation with
another prisoner, the prisoner noticed that the man had put one of his feet on
a cereal bowl that had been left on the floor. The prisoner said he continued
talking but heard a “scrape” and so turned and then saw the man “fall back
very hard”. The prisoner said the man was “straight” as he fell and made no
attempt to save himself with his hands. He explained that the man fell
9
31. The prisoner said he was then joined by an officer. The officer confirmed to
my investigator that, at about 7.40am, a prisoner ran to the office and told him
that someone had fallen. The officer went to investigate and found the man
unconscious on the floor near the servery entrance. The officer stressed that
there were no obvious signs of any injury to the man. Although he appeared
to be having a fit, the man was not breathing. The officer said that he asked a
second officer to seek assistance and then, with help from the prisoner, he
tried to “get (the man) breathing again”. The officer thought the man took in
air and therefore placed him in the recovery position. After about a minute or
so, it became apparent to the officer that the man was not breathing and that
he had no pulse.
32. In a statement he later submitted to the Governor, the officer explained what
happened next. He wrote:
“The prisoner thumped his chest two or three times then gave chest
compressions while I cleared his mouth and pulled his tongue away from
the back of his throat. I commenced mouth to mouth (without a mask) and
continued for about five or ten minutes. During this time the area was
cleared of prisoners. The prisoner was relieved by another officer. At
about 7.55am, the medical staff and an officer came to the scene carrying
resuscitation equipment. I swapped with the officer on the CPR
(cardiopulmonary resuscitation) for compressions for about ten minutes
and then I was relieved by the third officer. At that stage, there were no
signs of recovery, unassisted breathing or pulse. The nurse set up the
defibrillator and went through its procedures. The paramedics arrived
about 8.10am and joined us all in the effort of reviving the man and
eventually took over command. I went to the wing office to have a rest
and drink. I returned after about 10 to 15 minutes to assist again and get
the man on the trolley for transfer to hospital. The area was then cleared
of medical equipment and debris. All Prison Service staff were called for a
debriefing in the staff facility.”
33. A Senior Officer, the ‘A’ group manager, also made out a statement to the
Governor. He wrote:
“My first sight was of (the man) being given CPR by a prisoner. An officer
was beside him. I asked what the situation was to which the officer told
me he was not breathing. I asked if anybody was first aid trained.
Nobody replied. At this time several other prisoners were in the vicinity. I
asked the prisoners not involved to move away from the area, which they
did without any fuss. I then returned to the office to check on the progress
of the attendance of healthcare. I opened the outside wing office door and
saw the nurse walking towards the wing. I called to her to hurry. The time
10
was now approximately 7.55am. The nurse began to administer CPR to
the man. During this time, more staff began to attend.”
34. At interview, the nurse told my investigator she normally started her duties at
8.00am but, on 16 June, she started work 15 minutes early. She explained:
“When I was called over the radio after the man had collapsed, I was told
only that he’d had a fit. I hurried to A1 wing without taking any emergency
equipment with me. I believe I should have been given more information
about the man. Had this been the case, I would have taken the
emergency equipment with me straightaway. There is currently no
emergency code system for raising an alarm in a life threatening situation.
I think there should be one.”
35. Later in the interview, the nurse indicated that only one defibrillator was
available at The Verne. She added that it was stored in the healthcare centre
which is located at the end of the prison farthest from the accommodation
area. An officer was asked to fetch the defibrillator and two face masks.
36. The log of events recorded by the establishment shows that an ambulance
was called at 7.47am. At interview, the second officer told my investigator:
“I rang comms [i.e. the control room] at first because we thought the man
was having a fit. The nurse received the radio message and she rang me.
I said we had a prisoner that had collapsed and we thought he was having
a fit. She said, ‘I’ll read and check his notes and I’ll come straight over.’
Then, because he is a non English Spanish national, I raced upstairs to
get another prisoner who could speak both Spanish and English and
asked him to come and interpret. At that stage, I thought there might have
been a need for someone to speak to the man. When I got back I found
he wasn’t breathing. It was at that stage I called for an ambulance bv
calling comms again. I can’t remember exactly what I said but I would
have said something like ‘We need an ambulance because we have a
prisoner who is not breathing.’”
37. The ambulance arrived at the prison at 8.05am. The ambulance crew left
with the man for hospital at 8.43am. Further attempts were made to revive
him on the way to hospital but he was pronounced dead at the hospital at
9.20am.
38. The officer told my investigator he did not have a face mask with which to
protect himself from the transfer of body fluids whilst applying CPR. He
confirmed that he had been trained in CPR and felt competent to give first aid
to the man. During the interview, the officer’s trade union representative
offered the view that there should be more refresher training for staff in
emergency first aid.
39. The nurse confirmed that she had been trained in CPR and had undergone
refresher training in March 2008. She added that she was not aware that a
11
Informing the man’s next of kin
40. The prison’s family liaison officer arranged for the man’s next of kin – his
brother, who lives in Gran Canaria – to be informed of the man’s death by the
Spanish Embassy. This was achieved on 20 June.
41. Later, the man’s brother was given an opportunity to view the man’s room at
The Verne and to meet senior members of staff.
42. With the consent of his brother, arrangements were made for the man to be
cremated on 23 June. The man’s brother was able to travel to Weymouth to
attend the service. Representatives from the prison also attended. Flowers
were sent to the service by the Governor, who also offered to meet the costs
of the cremation.
Support for prisoners and staff
43. The prisoners in A1 wing were asked to assemble in a large room in the wing
where they were told of the man’s death and offered support by staff.
44. The prison officers who were involved in the discovery of the man’s collapse
and who attempted to revive him were debriefed on the same day and offered
appropriate support. However, the nurse told my investigators she was not
aware a debrief had occurred.
12
ISSUES
45. Here I examine:
 Whether the man’s health needs were satisfactorily met while he was in
custody.
 Whether the response to his collapse on 16 June was prompt and
appropriate.
 Whether appropriate courtesies and support were offered to the man’s
next of kin in the aftermath of his death.
Were the man’s health needs satisfactorily met while he was in custody?
46. Here I rely heavily on the findings of the clinical review.
47. The clinical reviewer concludes as follows:
“I believe that the man had good care at The Verne. He was given pain
relief for his back and his visual and dental problems were dealt with.
Very few people (about 1:100) who sustain a fatal heart attack outside
hospital can be successfully resuscitated. One in three people who have
a heart attack have the man’s experience: they die without prior warning.
“Healthcare staff should be congratulated for persistently encouraging the
man to stop smoking.
“The PCT should look at the purpose of the reception screening procedure
when prisoners move between prisons. The man had been at The Verne
for four weeks before his blood pressure and smoking habits were
recorded. Had he died during that time, this report might have been far
less mellow in its tone.”
48. I agree with this recommendation but suggest it should be expressed as
follows:
The Governor, in conjunction with the PCT, should ensure that health
screens on newly arrived prisoners at The Verne take place as soon as
possible after the prisoner’s arrival.
Was the response to the man’s collapse on 16 June prompt and appropriate?
49. The clinical reviewer comments as follows:
“When people collapse, they often convulse because of a sudden lack of
oxygen to the brain and it appears they are having a fit. The man was
appropriately treated for a fit by being placed in the recovery position.
When it was realised he was not breathing, resuscitation was started and
when the defibrillator was brought from healthcare it was deployed
appropriately.
13
“The officer should be warmly congratulated for performing mouth to
mouth resuscitation without protection between himself and the patient.
Whilst the risk of being infected by someone who has a serious disease
through saliva is minimal, performing mouth to mouth resuscitation is a
very unpleasant experience. The officer did so without concern for his
own safety.
“Provision of some form of barrier membrane on every wing might
encourage the more fastidious to do as well as the officer.”
50. I agree with this recommendation but suggest that it is expressed as follows:
The Governor, in conjunction with the Primary Care Trust, should
ensure that protective face masks are issued to all staff likely to come
into contact with prisoners for use during the application of cardio-
pulmonary resuscitation. These should be carried on the belt.
Appropriate training in their use should be provided.
51. The clinical reviewer also comments:
“The nurse should be thanked for arriving at work early. Her presence will
have reassured those doing the initial resuscitation and her expertise was
quickly brought to bear. I was disappointed that she and her colleagues
who attended subsequently were not included in the debrief that was
properly given to the prison’s own employees. In my experience, they
have been included in the past and should be in the future.”
52. I agree with the clinical reviewer.
The Governor, in conjunction with the PCT, should ensure that
healthcare staff involved in the management of life threatening
emergencies are debriefed alongside their Prison Service colleagues.
53. During the course of the investigation a Spanish speaking prisoner said to my
investigator:
“None of the nurses or staff are trained in CPR. Only one is and he is a
fireman. The Governor said the officers are trained in CPR. One of the
officers told me that is not true.”
54. My investigator ascertained that the person described as a fireman was one
of the officers who helped in the attempts to revive the man. During an
informal discussion with my investigator, the officer confirmed he was trained
in CPR. The nurse and the first officer also confirmed they were similarly
trained. The investigation found no evidence to suggest that any of the
healthcare or discipline staff who were involved in attempts to revive the man
were impeded by any lack of training. However, the trade union official who
accompanied the officer at his interview suggested that there should be more
refresher training for staff in emergency first aid. I consider that this is a
matter the Governor may wish to explore further.
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55. The investigation found that there was, at the time, only one defibrillator
available in the prison and that it was stored in the healthcare centre, a
building sited farthest from the accommodation area of the prison. (I
understand that since the man’s death, a second defibrillator has been
purchased.) Although there was no evidence that the length of time taken to
fetch the defibrillator from the healthcare centre was relevant to the man’s
death, it is clear that matters were not helped by the distance involved.
56. The clinical reviewer points to the need for a review of the siting of
defibrillators. I agree and recommend as follows:
The Governor, in conjunction with the PCT, should consider relocating
one of the defibrillators to a more central point in the prison.
57. The nurse told my investigator that she did not know the precise details of the
man’s collapse when she was first asked to go to A1 Wing to tend to him.
She believed that a code system should be used to alert staff to different
types of emergency so that appropriate first aid equipment is deployed from
the outset. Although there is no evidence that the delay in deploying a
defibrillator altered the outcome for the man, any such delay in a future
emergency could be critical.
The Governor should consider the merits of introducing a code system
by which staff can be alerted to life threatening emergencies such that
appropriate emergency first aid equipment is rapidly deployed.
58. Notwithstanding the points I have made above, I am satisfied that every effort
was made to save the man’s life. I commend those involved, including the
other prisoner, for their attempts to do so. The Governor will wish to ensure
that the other prisoner’s actions are noted in his prison file and should
consider whether any more formal commendation should be made.
Were appropriate courtesies and support offered to the man’s next of kin in
the aftermath of his death?
59. I consider that the news of the man’s death was communicated as speedily as
possible to his next of kin, given the difficulties experienced by the prison and
the Spanish Embassy in tracing him.
60. The Governor wrote a letter of condolence to the man’s brother. The
Governor also offered to meet the full costs of the cremation. Flowers from
the prison were on display at the cremation service and representatives of the
prison were present. The man’s brother was later given an opportunity to
view the man’s room in The Verne and to meet senior members of staff.
61. I consider that the family was offered appropriate kindness, support and
courtesy by the Governor and her staff. This reflects very well both upon the
establishment and upon the Prison Service as a whole.
15
LIST OF RECOMMENDATIONS
1. The Governor, in conjunction with the PCT, should ensure that health screens
on newly arrived prisoners at The Verne take place as soon as possible after
the prisoner’s arrival.
2. The Governor, in conjunction with the PCT, should ensure that protective face
masks are available to all staff likely to come into contact with prisoners to use
during the application of cardio-pulmonary resuscitation. These should be
worn on the belt. Appropriate training in their use should be provided.
3. The Governor, in conjunction with the PCT, should ensure that
healthcare staff involved in the management of life threatening
emergencies are debriefed alongside their Prison Service colleagues.
4. The Governor, in conjunction with the PCT, should consider relocating one of
the defibrillators to a more central point in the prison.
5. The Governor should consider the merits of introducing a code system by
which staff can be alerted to life threatening emergencies such that
appropriate emergency first aid equipment is rapidly deployed.
(In addition to these recommendations, I have suggested in para 58 that the
Governor ensures that the other prisoner’s actions in coming to the aid of the man
are noted in his prison file, and that consideration is given to a more formal
commendation.)
Good practice
1. The officer should be warmly congratulated for performing mouth to mouth
resuscitation without protection between himself and the man.
2. Healthcare staff should be congratulated for persistently encouraging the man
to stop smoking.
3. The nurse should be thanked for arriving at work early on 16 June.
16