Individual at Littlehey

Investigation into the death of a man in hospital in
January 2007 whilst in the custody of HMP Littlehey
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2008
This is the report of an investigation into the death of a man at HMP Littlehey, who
died in hospital in January 2007. The day before, the man was taken to hospital by
ambulance for investigation after he had vomited a significant amount of blood in his
cell. He had not suffered similar episodes previously and did not complain at the
time of any pain. In the early afternoon on the day of his death, the man again
vomited significant amounts of blood and then went into cardiac arrest. Efforts by
medical staff to resuscitate him were sadly unsuccessful.
The post mortem indicates that the man, who was 75 years old, died of a ruptured
aortic arch aneurysm that resulted in bleeding into the lungs. This was caused by
atherosclerosis (blocking of the arteries). I offer my condolences to the man’s family
and friends.
The investigation was conducted on by behalf by one of my colleagues. I am
grateful to the Governor of Littlehey and his staff for their co-operation. I must also
thank the medical practitioner from the Cambridgeshire Primary Care Trust for
providing the clinical review into the man’s care and treatment in custody.
The man was one of what seems to be a growing number of elderly prisoners who
enter custody in poor physical health. He had been a lifelong smoker and suffered
with osteoarthritis in his knees, ischaemic heart disease, high blood pressure and
dermatitis on both legs that had progressed to venous ulcers. The clinical reviewer
concludes that the man had a high standard of clinical care in prison. Nevertheless,
he judges that the man’s death was unavoidable, accelerated as it was by years of
heavy smoking prior to his imprisonment.
I make no recommendations in this report, but would like to commend the sensitive
way in which the prison liaised with the man’s daughter (his next of kin) following his
death. She has praised the prison in warm terms, and this reinforces for me the
huge steps forward the Prison Service has taken in recent years in respect of family
liaison when a death in custody takes place.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2008
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Contents
SUMMARY..............................................................................................................................4
THE INVESTIGATION PROCESS.........................................................................................5
HMP LITTLEHEY....................................................................................................................6
KEY FINDINGS.......................................................................................................................7
Events leading up to the man’s death..............................................................................7
Events after the man’s death...........................................................................................8
Clinical review and post mortem......................................................................................9
ISSUES.................................................................................................................................10
Clinical management.....................................................................................................10
Family Liaison................................................................................................................10
RECOMMENDATIONS.........................................................................................................11
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SUMMARY
The man died in hospital in January 2007. He was 75 years old. The post mortem
report indicates that he died of a ruptured aortic arch aneurysm that resulted in
bleeding into the lungs. This was caused by atherosclerosis (blocking of the
arteries).
The man was a sentenced prisoner who had been in prison since June 2004. He
arrived at HMP Littlehey in October 2004, having previously been held in HMP
Chelmsford and HMP Wayland. This was his first experience of prison.
Staff and fellow prisoners described the man as in poor physical condition. His
medical records show that he suffered from arthritis in both knees, ischaemic heart
disease and dermatitis on his legs that led to venous ulcers. He also experienced
breathlessness on exertion but continued to smoke heavily despite staff advice to
give it up. During initial health screening it was established that the man had
suffered a heart attack some years previously. The clinical review carried out as part
of this investigation says that his death was unavoidable, and accelerated by years
of heavy smoking prior to his admission to prison. The review finds that the man’s
clinical care was of a high standard and entirely equitable with that he would have
received outside prison.
On 24 January 2007, an officer discovered the man vomiting up a significant amount
of fresh blood into the washbasin in his cell. A nurse was called and, on the advice
of the prison doctor, he was taken by ambulance to the local hospital for
investigation. He was described as fully conscious but did not complain of any pain.
Whilst in hospital, he was handcuffed and escorted by two prison officers in
compliance with standard security procedures designed to ensure public safety.
The man experienced a restless but pain-free night. By the early afternoon on the
day of his death, he was sitting in a chair and chatting to staff. However, at about
2.20pm the man began to cough up more fresh blood. Medical staff were alerted
and his handcuffs were removed to facilitate treatment. The man then lost
consciousness and cardio-pulmonary resuscitation began. Despite the efforts of
staff to resuscitate him, he was pronounced dead soon after.
The man’s daughter, his next of kin, has asked why she was not told that her father
had been referred to hospital for investigation. The man had declined to make
contact with his family whilst he was in prison, but my investigation has found that
reasonable attempts were made to contact his daughter when his condition
deteriorated. Since the man’s death, his daughter has praised the prison for their
sensitivity and support. I have been pleased to highlight this as good practice in my
report.
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THE INVESTIGATION PROCESS
1. The investigation into the circumstances surrounding the man’s death was
opened by one of my investigators when he visited HMP Littlehey on 13
March 2007. He spoke to a number of staff and to one prisoner. Notices
were also issued to staff and prisoners to tell them about the investigation and
giving them the opportunity to speak with the investigator. No responses
were received to my notices.
2. The Governor and his staff produced the man’s prison records for review.
These included his medical record and bed watch logs.
3. Cambridgeshire Primary Care Trust was commissioned to conduct a clinical
review into the care and treatment that the man received at Littlehey.
4. One of my Family Liaison Officers (FLO) had telephoned the man’s daughter
(his nominated next of kin) on 14 February. The FLO offered her and the
family the opportunity to meet to discuss the purpose of the investigation, and
to raise any concerns or questions they would like to be addressed. The
man’s daughter had nothing but praise for the way in which the prison has
supported her following the death. However, she was concerned that she had
not been told that her father had been taken to hospital, although she
appreciated that no one knew how seriously ill he was or anticipated his rapid
deterioration.
5. My investigator contacted Her Majesty’s Coroner by letter to inform him of the
nature and scope of the investigation, and to request a copy of the post
mortem report. A copy of this report will be sent to the Coroner to assist him
with his inquiries.
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HMP LITTLEHEY
6. HMP Littlehey is a category C prison, with an operational capacity of 706 male
offenders but a typical occupancy of around 690. It first opened in 1988 with
eight residential wings. Two additional units were added to the prison in 1997
and 2003; all rooms on these units have privacy locks and individual showers.
7. Approximately 10 per cent of the prisoners are serving life sentences. A small
proportion of the prisoners are category D which enables them to work in the
community. The prison offers a sex offender treatment programme as well as
extensive industrial work and education opportunities.
8. The prison was last inspected by Her Majesty’s Chief Inspector of Prisons on
an unannounced visit in December 2005. HMCIP subsequently wrote that,
“Littlehey is to be commended for further improvements that it has made since
our last inspection. It remains a safe and respectful prison, which has
successfully integrated a large population of sex offenders and other
vulnerable prisoners into the general population. The prison has expanded
access to purposeful activity and begun to focus on the national resettlement
agenda. Littlehey is an impressive and improving prison, working with some
very high risk prisoners. Staff are to be commended for establishing a
fundamentally safe and respectful environment, but further expansion of
purposeful activity is required, together with strengthened sentence planning
work.”
9. Provision of healthcare within the prison is the responsibility of
Cambridgeshire Primary Care Trust, with the General Practitioner (GP)
service being provided by a local NHS practice. A wide range of health
promotion clinics is available.
10. Medication is dispensed on a weekly and/or monthly basis to those prisoners
who have been risk assessed as suitable to hold it in their possession. It is
administered on a daily basis to other prisoners when they are considered to
be either at risk, or the medication is considered unsuitable to be held in their
possession.
11. A wing is a small residential unit. Its population consists mainly of elderly,
vulnerable prisoners who have single cells. My investigator was told both by
staff and a prisoner’s representative that prisoners tend to help one another
out when they are not fully mobile.
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KEY FINDINGS
Events leading up to the man’s death
12. At about 11.40am on 24 January, prisoners were unlocked on A wing to allow
them to collect their lunch from the servery. The wing officer noticed that the
man had not come out of his cell to collect his food so he went to the cell to
ask if he wanted any sandwiches. The man was standing at his washbasin
and the officer saw that he had blood coming out of his nose and at the side
of his mouth. The man then vomited into the washbasin. The wing officer said
that the man was fully conscious but looked terrified. He then vomited
violently again into the washbasin, bringing up dark congealed blood. The
officer told my investigator that the man had vomited a considerable amount
of blood.
13. The wing officer went to a nearby office to telephone the Control Room to ask
for a member of the healthcare team to attend the man’s cell immediately.
The wing officer said that the man was fully conscious and co-ordinated. In
the meantime, other prisoners were being locked up by other members of
staff. The officer returned to the man’s cell.
14. The Control Room contacted the staff nurse by radio to ask her to come to the
man’s cell. The staff nurse said that, before doing so, she contacted the
prison officer who advised her that the man should be taken to hospital for
further investigation. The staff nurse then attended the man’s cell and was
shocked at the amount of blood he had vomited in and around the toilet area.
The staff nurse told the man to lie down on his bed so that she could assess
him and clean him up. The staff nurse took the man’s blood pressure and was
surprised to find that it was relatively normal despite the apparent loss of
blood. The nurse was told by the man that he was not in any pain, had not
experienced previous similar episodes and did not know what all the fuss was
about.
15. The staff nurse then used her radio to contact the Control Room to request an
emergency ambulance. An ambulance was called at 12.25pm and arrived at
Littlehey at 12.35pm. In the meantime, the nurse stayed in the cell and
started to clean the blood from the man’s face. She told my investigator that
the man remained conscious and insisted on walking to the ambulance. The
ambulance left the establishment for hospital at 1.23pm.
16. In compliance with the prison’s security procedures, the man was escorted by
two officers who applied handcuffs removable only in the event of medical
necessity and authority from a governor. During his stay in hospital, a log of
events (known as a bed watch log) was also maintained by the escorting
officers. The log shows that the man’s bloodstained clothing was to be taken
back to Littlehey to be incinerated.
17. At 5.40pm, the man was moved from the hospital’s Accident and Emergency
Department to the Medical Assessment Unit. At 8.45pm, the log shows that
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18. Records show that the man had a restless night and that he was moving his
legs about. At about 7.45am on 25 January, he was out of bed, having a
wash, but complained that he had to wear handcuffs. By 8.04am, the man
was sitting in a chair. At 8.45am, he was seen by a consultant and told that
he might have to spend another night in hospital for assessment. The staff
nurse told my investigator that she telephoned the hospital that morning. She
was given the impression that, following tests, the man would be returning to
prison later that day.
19. The bed watch entry for 12.40pm records that the man had taken lunch and
was talkative with his escorts. At 1.40pm, he was taken to the toilet with no
concerns raised. At 2.00pm, it was noted that the man was going to be
transferred to another ward later that day.
20. At about 2.20pm, the man began to cough. The senior officer (SO) offered
him a drink of water which he declined. The SO then offered him the use of a
spittoon to bring up phlegm. This was also declined. The man then began to
vomit a large amount of blood. Medical staff were called and moved him from
a chair to his bed. The SO removed the man’s handcuffs to allow medical
treatment.
21. At about 2.27pm, the SO telephoned the Control Room at Littlehey and
notified the duty governor that the man had suffered a cardiac arrest and was
receiving cardio respiratory resuscitation (CPR). Officers were given authority
by the duty governor to remove his handcuffs in order to facilitate medical
treatment. The duty governor also decided that, in view of the circumstances,
the man’s next of kin should be informed of the situation. The prison records
show that, at 2.30pm, the Principal Officer (PO) left a message with the man’s
next of kin to contact Littlehey as soon as possible. The police were also
informed of the man’s condition and were asked to make contact with the
man’s daughter.
22. At about 2.47pm, the SO reported to the Control Room at Littlehey that CPR
was continuing on the man. He also asked whether the man’s next of kin had
been informed. At 2.55pm, medical staff told the SO that, as the man was not
responding to the resuscitation effort, CPR would be stopped. At 3.00pm, the
man was pronounced dead.
Events after the man’s death
23. The Senior Officer telephoned the duty governor to inform her of the man’s
death. Littlehey then implemented its contingency plan for deaths in custody
that included informing the police, the Independent Monitoring Board and the
Prison Service’s National Operations Unit. The area in which the man was
being treated was preserved as a potential crime scene until the arrival of the
police at about 3.20pm.
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24. At about 5.20pm, the man’s daughter called Littlehey in response to the
message which had been left on her answerphone. The PO told her the sad
news of her father’s death. The daughter agreed to contact other members of
the family and her father’s partner to tell them of his death.
25. At about 6pm, the SO and the second SO returned to Littlehey where they
were debriefed by the duty governor and the PO and reminded of the support
they could receive from the prison’s care and support team.
26. On 26 January, the Governor sent a letter of condolence to the man’s
daughter and offered a contribution towards funeral costs. The Governor also
invited the family to attend the prison’s memorial service (this offer was
declined). An SO was appointed as the prison’s family liaison officer (FLO).
Together with the deputy governor, they visited the man’s daughter at her
home. The daughter told my own family liaison officer that the prison FLO, the
deputy governor and the PO were able to answer all her questions concerning
her father and she was appreciative of all the support and kindness shown to
her. She also said that, following her father’s death, she had received a card
with over 70 signatures from prisoners and staff, from which she has derived
much comfort.
27. The wing officer said that the prisoners located near to the man’s cell were
told of his death on 26 January. The Samaritans and Listeners (prisoners
trained by the Samaritans) were also told in case prisoners needed support.
The wing officer told my investigator that, although staff and prisoners were
aware of the man’s ill health, they had been surprised at the quick
deterioration in his condition.
28. A memorial service was held for the man in the prison chapel. The Governor
also sent a letter to the hospital, acknowledging the efforts of medical staff in
trying to save the man.
29. The deputy governor and the prison’s family liaison officer attended the man’s
funeral.
Clinical review and post mortem
30. The clinical review found that the man’s quality of care was of a high standard
and equitable with what he would have received in the wider community. The
clinical reviewer concluded that the man’s death was unavoidable and had
been accelerated by years of heavy smoking prior to his admission to prison.
31. The post mortem indicated that the man died from a ruptured aortic arch
aneurysm that resulted in bleeding into the lungs. This was caused by
atherosclerosis (blocking of the arteries).
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ISSUES
Clinical management
32. The man entered prison with a number of health problems that were managed
in an appropriate and timely manner. He was a heavy smoker. Despite
concerns about his health and advice from staff to stop smoking, he showed
no inclination to do so. The clinical review says that his quality of care was of
a high standard and that his death was unavoidable. The man rapid
deterioration was unforeseen, dramatic and not preventable.
Family Liaison
33. The man chose not to maintain contact with his family whilst he was in prison.
This was despite the efforts of some of his family to sustain contact through
the prison chaplain. When he was taken to hospital, the prison did not
immediately contact his daughter as he was fully conscious and his condition
was not considered to be critical. Furthermore, for public protection reasons,
families are not usually informed when a prisoner is transferred to hospital for
routine investigation or treatment.
34. When it became apparent that the man’s condition was critical, it was decided
to contact his next of kin. Unfortunately, a response was not received until
some hours after his death. This aside, the man’s daughter has praised the
prison in warm terms for the support shown. She has cited in particular the
deputy governor, the prison FLO and the PO. It is clear to me that that a high
degree of sensitivity and compassion was shown to the family which has
eased their sense of loss.
The Governor should commend the prison’s Family Liaison Officer as
well as the PO and the Deputy Governor, for the supportive way in which
they liaised with the man’s next of kin, and the high level of sensitivity,
professionalism and compassion displayed, and commented on by
members of the family.
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RECOMMENDATIONS
1. The Governor should commend the prison’s FLO, as well as the PO and
the Deputy Governor, for the supportive way in which they liaised with
the man’s next of kin, and the high level of sensitivity, professionalism
and compassion that has been displayed and commented on by
members of the family.
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