Individual at Lowdham Grange

Investigation into the circumstances surrounding the
death of a prisoner at City Hospital, Nottingham while in
the custody of HMP Lowdham Grange in January 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2008
This is the report of an investigation into the death of a man at the City Hospital,
Nottingham on 26 January 2008. He died of natural causes. At the time of his
death, he was in the custody of HMP Lowdham Grange.
The man had been ill for some time and was referred to City Hospital in late January
2008 after his condition at the prison had deteriorated. Once admitted to hospital, he
continued to worsen despite the best efforts of the medical team. A nurse
conducting routine checks discovered that the man had died at 6.50pm and a doctor
confirmed his death at 8.00pm. The man was a Dutch citizen and 60 years old.
I would like to offer my sincere condolences to his family and friends for their loss.
One of my investigators conducted the investigation on my behalf. In addition,
Nottinghamshire Primary Care Trust appointed a doctor to conduct a clinical review
into the man’s healthcare whilst in custody.
I would like to thank the Director of Lowdham Grange, and his staff for their co-
operation and assistance with the investigation. I would particularly like to thank the
appointed liaison officer, who has been immensely helpful in providing all the
necessary documents to my investigator.
The man had been in reasonably good health before his arrival at Lowdham Grange
just after Christmas 2007. The deterioration in his health was sudden and clearly
distressing. It progressed fairly quickly and the reasons for his condition were being
investigated at the time of his death. The initial post mortem indicates that his death
was caused by a series of tumours on the brain resulting in severe swelling.
I make no recommendations as I am satisfied that the man’s health needs were
appropriately addressed. Indeed, I commend staff on their prompt attention and
rigorous adherence to procedures in the management of his illness.
He had been subject to ACCT monitoring and support and I judge that this was
appropriate. However, it seems most likely that his mood and behaviour were
symptoms not of a depressive illness but had an organic cause. My report also
raises questions about the use of restraints on seriously ill prisoners.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2008
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Contents
SUMMARY..............................................................................................................................4
THE INVESTIGATION PROCESS.........................................................................................6
HMP LOWDHAM GRANGE....................................................................................................7
KEY FINDINGS.......................................................................................................................8
ISSUES.................................................................................................................................16
GOOD PRACTICE................................................................................................................19
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SUMMARY
The man was remanded into custody in July 2006. Following a lengthy trial, he was
sentenced to 15 years imprisonment in December 2007. Although initially held at
HMP Hull, he transferred to HMP Leeds at the start of his trial. At both prisons, his
only medical complaint was in relation to his diet. He had undergone an operation in
2001 during which he had had a ‘gastric band’ fitted. One of the after-effects of the
operation was that he needed to eat regular small meals. At both Hull and Leeds, he
was given a job in the kitchens, which meant that he was able to take his meals as
required.
Given his vulnerability because of the lengthy sentence he had received, the man
was placed on Assessment, Custody, Care and Teamwork (ACCT) monitoring by
HMP Leeds. (The ACCT process provides individual prisoners with greater levels of
observations and interactions if staff consider them to be at risk of either self-harm or
suicide.) However, the ACCT document was closed at the first review. The ACCT
was re-opened on 24 December 2007 by a member of the kitchen staff who felt that
he was not his usual self. The assessment highlighted that the man was not
sleeping and had concerns about his impending transfer to HMP Lowdham Grange.
On his arrival at Lowdham Grange in December 2007, he explained about his gastric
band and arrangements were made for his diet and weekly weight checks. The
ACCT monitoring was also reviewed during which he said that, although initially
apprehensive about going to Lowdham Grange, he felt fine now that he was there
and sharing a cell with his co-defendant. The man also said that he had never self-
harmed or tried to take his life and would not do so. The officer conducting the
review recorded that at times the man appeared confused. The document was
closed.
In January 2008, the man’s cell mate, told staff that he had concerns about his
wellbeing. A further ACCT document was opened and an assessment carried out.
During the assessment, the man gave few responses, but when asked whether he
felt depressed he said yes. An appointment was made for him to be seen by the
doctor. The following day, he was seen by the doctor who prescribed a course of
anti-depressant medication and referred him to the Mental Health Inreach Team
(MHIRT).
He continued to deteriorate and a week later, he was went to the Queen’s Medical
Centre in Nottingham. He saw a doctor and blood samples were taken but he
returned to prison within two hours. He had also become incontinent, and this was
causing staff concern as they had difficulty encouraging him to change out of his
soiled clothing.
The healthcare centre and MHIRT continued to monitor the man, and wing staff gave
daily support, but his condition rapidly deteriorated. As a result and following a
period of particularly bizarre behaviour, he was again admitted to City Hospital,
Nottingham in late January. Once admitted, the man was handcuffed despite his
deteriorating condition. Nursing staff monitored him closely and initially he had long
periods of consciousness, although his behaviour remained unusual.
4
The day after being admitted, doctors informed prison managers that the man was
likely to be ‘brain dead’ and unlikely to last the next 24 hours. At this point, the
restraints were removed and two staff remained at his bedside. At 6.52pm, a nurse
carried out a routine check on him and discovered that he had died. The doctor
confirmed the man’s death at 8.00pm on 26 January.
I make no recommendations, but my report explores the use of restraints, in relation
to gravely ill or dying prisoners. I also draw the Director of Lowdham Grange’s
attention to the recently revised National Security Framework (NSF) relating to such
matters.
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THE INVESTIGATION PROCESS
1. My investigator opened the investigation on 31 January 2008. Lowdham
Grange issued notices to staff and prisoners informing them of the investigation
process and inviting anyone who had relevant information to come forward. No
responses were received.
2. The investigator visited the prison on 26 February. He met the appointed
liaison, and was shown around the prison, including the residential area where
the man had been located. The investigator also visited the healthcare centre
where he spoke with the Clinical Manager, who had dealt with the man during
his time at the prison.
3. One of my Family Liaison Officers (FLOs) contacted the Dutch Embassy on 11
February to try to obtain details of the next of kin in Holland. During his visit,
the prison passed to the investigator contact details for the man’s ex-wife. The
FLO sent a translated letter to her, together with both English and Dutch
versions of the PPO leaflet. The FLO also supplied her e-mail address so the
family could make contact with my office. At the time of writing this report, the
family has not been in contact. They will be informed of the draft report and
sent copies if they wish to receive them.
4. HM Coroner was informed of the investigation. A copy of this report will be sent
to the Coroner to assist with his enquiries. The investigator also requested a
copy of the post mortem report.
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HMP LOWDHAM GRANGE
5. HMP Lowdham Grange opened in 1998. It is one of four private prisons run by
Serco Ltd. When it originally opened it had the capacity to hold 500 prisoners,
but has recently been extended. Located near Nottingham, it is a long-term
category B prison. Its role is to hold medium to long-term serious offenders
with sentences of over four years with at least 12 months left to serve.
6. Healthcare services in Lowdham Grange are provided in-house with good links
to the local Primary Care Trust (PCT). Many staff work 12-hour shifts. There
are no in-patient facilities, but there is 24-hour cover with one nurse on duty
overnight (7.00pm – 7.00am). A local doctor is contracted to provide three
clinics a week, and provides all the out-of-hours medical cover.
7. HM Chief Inspector of Prisons, Ms Anne Owers, last inspected the prison in
March 2006. Ms Owers found Lowdham Grange to be a largely safe
establishment, with mutually respectful staff-prisoner relationships. Of
healthcare, Ms Owers commented that the accommodation was inadequate
and there were concerns regarding the forthcoming increase in the prison
population and the department’s ability to cope with the extra numbers.
Staffing levels were struggling to meet the clinical demands of the patients and
mental health services were stretched. However, links with the Newark and
Sherwood Primary Care Trust were very good and the PCT provided excellent
clinical and managerial support to the prison.
8. The local Independent Monitoring Board (IMB) commented in their 2006 annual
report that Lowdham Grange had responded well to challenges presented to it.
9. Since 2004, my office has investigated four deaths from natural causes at
Lowdham Grange. The recommendations made following these investigations
bear no relevance to the death of this man.
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KEY FINDINGS
The man’s initial custody and time at HMP Leeds
10. In July 2006, the man was remanded into custody at Harrogate Magistrates’
Court, having been charged with importation of drugs. Following his remand,
he went to HMP Hull. He settled in quickly (this was probably helped by having
his co-defendant with him who also spoke Dutch).
11. He had concerns about his diet as he had undergone a gastric bypass
operation in 2001. This meant that he was only able to eat soft food and
needed a small meal every two hours. When he spoke to staff about this in
August 2006, he told them that he had not eaten properly for about 50 days.
Healthcare staff arranged with the kitchen for him to be provided with the
appropriate diet. It was also recorded that he was 50 per cent deaf. This,
along with his limited spoken English, made it difficult for him to understand and
converse with other prisoners and staff.
12. Apart from the issues with his gastric banding, the man reported very few other
medical problems. However, he said that he had suffered from backache,
headaches and neck pain for over 20 years. He was prescribed medication to
treat these but had little other contact with healthcare.
13. While at Hull, he was employed in the kitchens. This enabled him to meet his
dietary needs, as he was able to have his meals as he required them. He
settled into his job well and was considered a good worker.
14. The man was transferred to HMP Leeds via Leeds Crown Court in October
2006, to remain there during his trial. On his arrival, he said that he had no
immediate concerns but again mentioned his stomach problems. Over the next
week, he moved back and forth to court but finally managed to submit an
application to work in the kitchens about a week after arriving.
15. In November, he was introduced to his personal officer. The man explained
that he had found it necessary to contact his solicitor regarding his dietary
needs. He said that he had seen the doctor three weeks earlier but nothing
had been done. He told his personal officer that he was very concerned as he
was losing weight and feeling unwell.
16. In December 2006, he began work in the kitchens. He was very pleased about
this but was still waiting to see the doctor regarding his diet. (The wing history
document (P16) suggests that he was still waiting to see the doctor in January
2007.) However, he continued to work well in the kitchens and this enabled
him to eat at the necessary times.
17. He was convicted in February 2007, but sentencing was postponed while the
trials for other defendants took place. On his return from court, he appeared
well and gave no cause for concern. He continued his work in the kitchen and
made good progress. This resulted in him being recommended for enhanced
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18. In December 2007, he attended Leeds Crown Court for sentencing and
received a 15 year sentence. Due to the length of sentence, an Officer opened
an Assessment, Custody, Care and Teamwork (ACCT) document. The
Officer’s reasons for opening the ACCT were that the man was very tearful in
the treatment room when he attended to collect medication.
19. To find out how the man was feeling, another Officer carried out an
assessment. The man said that he had no thoughts of self-harm, despite
feeling low. He said that he was able to cope by talking with his cellmate, who
was also Dutch, and by working in the kitchen seven days a week. He said that
regular contact with his solicitor would help, as he wanted to contact his family.
He spoke about gaining category D status and eventually moving to an open
prison. The Senior Officer (SO) saw the man following the ACCT assessment
and discussed with him the issues that had been raised. The decision was
taken to close the document with a follow up in seven days.
20. He continued to work in the kitchen and appeared to be coming to terms with
his sentence. However, in late December a member of staff in the kitchen re-
opened an ACCT document. The reasons were that the man was normally
upbeat but had become very apathetic at work. The member of staff was
concerned and felt that the length of his sentence might have only just
registered with him. During the assessment, he confirmed that he was finding it
difficult to come to terms with his sentence. He also said that he was not
sleeping.
21. The assessor felt that the man did not understand some of his questions
despite having his cellmate with him to interpret. The assessor recorded that
he thought the man was having trouble concentrating and looked very distant
and vague. The man said that he had never attempted suicide or self-harmed
and had no thoughts or intentions of doing so. The assessor felt that his mental
state might have been affected by lack of sleep which was making him feel
spaced out. Following the assessment, the assessor concluded that the man
would benefit from medication to help him sleep and referred him to Mental
Health In-Reach Team (MHIRT).
22. Following the assessment, an SO carried out a case review. During the review,
the SO recorded that the man appeared withdrawn and his demeanour was
vacant. The man said that he realised that he might spend the rest of his life in
prison. His impending transfer to Lowdham Grange was discussed and he said
that he was concerned about relocating without his co-defendant. The SO
made a routine referral to the MHIRT who saw the man later that day and
arranged for him to be prescribed sleeping tablets. The next case review was
scheduled for the end of December.
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23. Over the next few days, staff observed the man and recorded that he seemed
very quiet. On Christmas Day, an Officer recorded in the ACCT that he had
spoken to the man and felt that he was a long way from being his normal self.
The ACCT document remained open when he transferred to Lowdham Grange
in December 2007.
The man’s time at HMP Lowdham Grange leading up to his death
24. When the man arrived at Lowdham Grange in December, a member of the
healthcare team saw him. His previous medical records were checked and his
current medication recorded. He explained about his gastric band and how this
affected his diet. Arrangements were made for him to receive the correct diet
and to have weekly weight checks.
25. The open ACCT document that accompanied him was reviewed. A Safer
Custody Officer (SCO) carried out a further assessment the day after he arrived
during which the man said that he had been a little apprehensive about coming
to Lowdham Grange, but now that he was there he liked it. Again, he said that
he had never self-harmed and did not intend to do so. The SCO recorded that
the man appeared confused at times, but was unsure whether this was down to
the language barrier or poor hearing. The man talked about his family and said
that he was having a few problems in contacting his girlfriend. The SCO
explained that a case review would be held but the man said he did not want to
attend.
26. However, in fact he did attend the review despite his earlier statement that he
did not wish to. Also present were members of the healthcare team. The man
explained that he was happy to be at Lowdham Grange and was in a cell with
his co-defendant. In view of this and because there had been no previous self-
harm, the ACCT document was closed with a follow-up scheduled for early
January 2008.
27. The doctor also saw him in December. As well as discussing his gastric band,
the doctor made a referral for him to attend the diabetic clinic. The next contact
the man had with healthcare was in January 2008 when he was given his first
Hepatitis B vaccination.
28. In January, the SCO went to see the man in order to carry out the post closure
interview of the ACCT. During the interview, he said that he had no thoughts of
self-harm or suicide and was due to start work in a couple of weeks. He also
said that his cellmate and co-defendant, had been a great help and support to
him.
29. However, the following week, his cellmate told the Operational Manager, that
he was concerned about the man’s wellbeing. He said that the man was in a
low mood, acting strangely and out of character. He also said that he was
hardly speaking. In view of this, another ACCT document was opened.
30. The SCO again carried out the ACCT assessment. When the man was asked
what he considered his problems to be, he hardly responded. The SCO
10
31. Again, he changed his mind and actually attended the review, along with his
cellmate who translated for him. The man hardly responded to anyone during
the review and his cellmate said that this was unusual behaviour for him. The
decision was taken for him to be observed every 30 minutes until the doctor
could see him.
32. The man was seen the next day by the prison doctor. She recorded that he
was depressed but not suicidal, with psychomotor retardation (slowed psychic
or motor activity). She started him on a course of anti-depressant medication.
It was also recorded that the man should have regular contact with the
Registered Mental Health Nurse (RMN).
33. Later that morning, a PCO went to check on the man and found him in his cell.
He had soiled himself and was just sitting playing with the taps on his sink. The
PCO told my investigator that it took the man several seconds to acknowledge
his presence. The PCO informed the nurse of this. The man’s lunch meal was
collected for him, but he just stood outside his cell holding the railings and not
acknowledging anything.
34. After lunch, staff took him across to the healthcare centre where he was seen
by a nurse. The nurse asked him what he felt his problems were. He
complained of having had a headache for around three weeks but felt this was
down to anxiety over his long sentence. The nurse also recorded that the man
indicated during the interview that he might have been having problems on the
wing. In view of his seemingly bizarre behaviour and the nurse’s concerns, she
increased his ACCT observations to every ten minutes. She also said that if he
deteriorated further it should be increased to constant observations over the
weekend. The meeting lasted for about 20 minutes, then he returned to the
waiting room. While he was waiting, he vomited and nursing staff attended to
him.
35. After returning to the wing, staff continued to be concerned about his distracted
behaviour. They asked for someone to see him, so a Senior Psychologist went
to conduct an assessment. During the assessment, the man chose not to
answer questions relating to his mood. It was recorded that he had good eye
contact and was happy to discuss his children. When asked directly about self-
harm, he was emphatic that he would not self-harm or take his own life as he
had five children.
36. During the evening and throughout the night, the man was observed at regular
intervals as part of the ACCT procedures. At 10.00pm, while checking on him,
a PCO was informed by the man’s cellmate that he had lifted him off the floor
and back into bed. The PCO informed the duty nurse, but no entry or
information on any follow up action is recorded in the medical record.
11
37. The following morning, the man’s cellmate spoke to another PCO about what
had happened the night before. He explained that the man had been cleaning
around the sink area at about 9.30pm when he had suddenly collapsed onto
the floor. He was conscious but according to his cellmate he was unable to
move. The cellmate said he had helped the man back onto his bed, but had
not informed any night staff or pressed the cell call bell. However, this
contradicted the entry made by the PCO in the man’s ACCT the previous night.
When asked to clarify this, the cellmate said that he had not fully understood
the original question and in fact had notified a member of the night staff.
However, he said that no healthcare staff had arrived. The PCO informed the
unit manager who in turn informed healthcare.
38. A nurse went to see the man at the request of wing staff. It was recorded that
he had not eaten since the previous morning. The nurse checked his blood
pressure which was 170 over 100, and recorded that he appeared vacant at
times and that his speech was slow. The nurse visited him throughout the
course of the day to check his pulse and wellbeing. The man managed to eat
his lunch and evening meal and appeared settled. However, it is recorded in
both the medical record and ACCT that he remained vacant and appeared at
times to be disorientated.
39. At 7.00am the following morning while carrying out the ACCT checks, staff
observed the man in the toilet. On the next three checks, he was still in there.
Although reassured by his cellmate that he was alright, staff notified the
healthcare centre. A nurse came to see him in his cell at about 9.00am. When
the nurse arrived he was still sitting on the toilet. The nurse recorded that he
appeared disorientated, unable to dress himself and had a vacant expression.
He had also been incontinent several times. The nurse said that the man
should be taken to the local hospital for further investigation into his condition.
40. Staff kept a close check on him while arrangements were made for him to be
taken to hospital. At 11.30am, the escort arrived at the Queen’s Medical
Centre, Accident and Emergency (A&E) Department. As staff helped the man
from the vehicle he collapsed and had to be supported. Once in A&E, he was
seen fairly quickly by a nurse and a doctor. An Electrocardiogram (ECG) (a
recording of the electrical activity of the heart) was carried out along with blood
tests. By 1.40pm, he was outside the hospital with staff awaiting transport to
return to Lowdham Grange.
41. Staff recorded that during the escort the man had been incontinent twice. They
arrived back at the prison at 2.45pm, and he was seen by a nurse. The nurse
recorded that, in addition to the tests carried out at the hospital, a sample of
urine was needed, and the man was to be reviewed by the prison doctor.
42. On the wing, he was spoken to by the SCO again. The SCO wrote that there
was poor eye contact, and when she spoke to him he continuously wrung his
hands. The SCO asked the man’s cellmate to ask him if he was afraid or
whether something had happened. The man replied no to both. His cellmate
told the SCO that a lot of prisoners on the wing were concerned about the
12
43. Staff continued to monitor him for the remainder of the day and it was recorded
that his behaviour continued to be ‘strange’. During the night, he appeared to
be agitating his cellmate as it was stopping him from sleeping.
44. The next day, a review of the man’s ACCT monitoring was held. Healthcare
and wing staff together with the Safer Custody Officer attended the review. The
man would not respond to questions put to him by either the SCO or the
Operational Manager and just stared at the ground. However, he did respond
when spoken to by the nurse. The review team felt that it would be better for
non-uniformed staff to conduct reviews in future as he appeared to respond
better to them. The SCO concluded that the man’s physical appearance had
changed significantly since his first arrival at the prison. She said that he was
unshaven and scruffy with a slumped posture, a dramatic difference to the
powerful man who had arrived just before Christmas. His cellmate was moved
at his own request as he felt unable to deal with his friend’s increasingly
strange behaviour. Due to his cellmate being moved to another cell, the
observations on him were kept at every ten minutes.
45. In mid-January, the man’s behaviour became increasingly bizarre. The
intention was for him to be transferred to the healthcare wing. However, this
did not happen as he was naked when staff went to collect him. He spent most
of the day naked in his cell, often sitting or standing in his toilet recess. This
continued into the following day. He responded to staff when they asked if he
was alright, but only by raising a hand. During the afternoon of the following
day, the man was finally moved to the healthcare centre.
46. A nurse saw him on his arrival at healthcare. A blood sample was taken and
she arranged to review him on the next day. When the nurse saw him the
following day he appeared brighter but was still not himself. The nurse spoke
with him about his incontinence and whether he knew when he needed to pass
urine. The man replied that he did but refused to answer any further questions
and just stared at the wall.
47. He returned to the residential wing but continued to deteriorate over the coming
days. A week later, a psychiatric assessment was carried out due to the
decline in his mental state. When asked, the man did not confirm or deny any
depressive symptoms but did say that he was not suicidal. The review
concluded that his symptoms were suggestive of a depressive illness and that
he required long-term anti-depressant medication, daily support and to be
reviewed in a week.
48. A nurse was called to see him on the wing at 11.30pm that night. When she
arrived she found him slumped on the floor. The nurse was able to gain a
‘sluggish’ response and persuaded him to stand up. On investigation, it
13
49. Staff continued to support him and attempted to engage him in conversation.
However, this was becoming increasingly difficult. The man was regularly
wetting himself and staff found it difficult to encourage him to change his wet
clothing.
50. In late January, the MHIRT attended the wing to see the man. On entering his
cell an odour was noted and patches of urinary incontinence were visible on his
bedding. During the assessment, he displayed facial animation in response to
jokes but no verbal response. The MHIRT arranged for his clinical record from
his earlier visit to the Queen’s Medical Centre (QMC) to be obtained. This was
to provide a baseline for ongoing investigations. It was also decided that the
doctor should see him as an urgent case that afternoon.
51. At lunchtime, the man did not collect his meal so an officer took it to him. When
a member of staff checked on him about 30 minutes later, he was standing at
his table picking at his food with his trousers down. The Deputy Healthcare
Manager was called to the wing to see him at 2.55pm, and found him sitting on
his bed with his trousers down. He was also eating food from a bowl,
regurgitating it, and eating it again. Staff continuously coaxed him and offered
help. The healthcare manager contacted the doctor to see the man for an
assessment.
52. The doctor saw the man at 4.00pm. After consultation with other members of
the medical team regarding the deterioration in his condition, it was decided
that he should be admitted to the City Hospital, Nottingham.
53. The man was admitted to City Hospital at 5.40pm that day. Following his
arrival, blood tests and other routine checks were made before he was
allocated a bed. During this time, he remained handcuffed by a standard
handcuff and an escort chain. (This is known in the Prison Service as ‘double
cuffing’.) The man slept for most of the night but continued to be incontinent.
Nursing staff attended to him regularly throughout the night.
54. Over the next two days, his condition remained very much the same and he
was given a scan. Following this, the consultant explained to the man that he
might have an abscess on his brain. The consultant told him that this would
explain the problems that he had been experiencing. The man acknowledged
what was being explained but was unable to respond verbally.
55. At 2.30am the following day, the man fell asleep. Nursing staff continued to
check on him regularly. At 9.20am, a nurse informed the escort staff that he
could remain like this for some time. Initial plans were made to move him to
intensive care but it was decided that this would not be of any benefit to him. A
doctor informed the escort staff that they believed him to be possibly ‘brain
dead’ and that he did not have long to live. This information was passed on to
the prison. In view of the man’s deteriorating condition, the security manager
14
56. At 6.52pm that day, while carrying out a routine check on the man, a nurse
discovered that he had died. A doctor certified his death at 8.00pm.
Events following the man’s death.
57. The prison contacted the Dutch Embassy which had been listed in lieu of the
man’s next of kin. In turn, the Embassy contacted the Dutch Ministry of Foreign
Affairs to inform the family.
58. The prison remained in touch with the Embassy and obtained contact details for
his ex-wife. The prison offered to meet the funeral costs and, at the request of
the family, arranged for his body to be flown back to Holland. (Initially it was
thought that the prison would arrange the funeral and the man’s ashes would
then be handed over to the Dutch Embassy.)
59. The post mortem concluded that he died of a glioblastoma multiforme in the
frontal lobes of the brain and an early associated bronchopneumonia.
Glioblastoma multiforme is the most common and aggressive type of brain
tumour.
60. Staff at Lowdham Grange were offered the support of Staff Care and Welfare if
they felt that they needed it. The man’s cellmate and co-defendant, was
informed of his death sensitively and also offered support.
15
ISSUES
ACCT monitoring and follow up actions
61. The opening of the ACCT document was appropriate given the behaviour
displayed by the man. The assessments and follow up multi-disciplinary case
reviews were well documented. It was clear that all efforts were made to
support him and that early healthcare and Mental Health in Reach involvement
made a difference to his care. It should also be noted that the regular contact
also enabled staff to identify the effect that the man’s illness was having on the
cellmate and to make the necessary arrangements for him to be moved.
The ACCT reviews, together with recording and sharing of information
between all departments at Lowdham Grange, should be highlighted as
good practice. These robust procedures and practices identified the
needs of the man, as well as recognising and preventing further
unnecessary distress to his cellmate.
Healthcare intervention
62. The healthcare staff at the prison, along with the MHIRT, had regular contact
with the man from the onset of his symptoms. The treatment given for
depression was appropriate, given they way he presented. However, the
nursing staff kept this under review, and when his condition deteriorated they
acted quickly in referring him to outside hospital. These actions are supported
by the clinical reviewer who says in his review:
“The working diagnosis whilst the man was in HMP Lowdham Grange was
that he was suffering from depression, and this is not surprising since he
had not long been sentenced. The physical symptoms associated with his
depressive illness, namely the psychomotor retardation, withdrawal, lack
of spontaneity, enuresis, poor appetite and obsessional behaviour were all
consistent with a diagnosis of depression. However, when he began to
vomit and display increasingly bizarre behaviour he was referred to
Accident and Emergency at the CHN [City Hospital, Nottingham]. There,
a working diagnosis of a urinary tract infection was made, largely because
of the history of incontinence and from the results of some blood tests; but
there was no confirmatory urine sample taken. Ten days later the man
declined further and was sent back to the CHN, again as a possible
urinary infection.”
63. The reviewer goes on to say that in his opinion:
“The healthcare staff were wary that the physical decline could not be
solely attributed to the depression and that additional, and as yet
unknown, pathology existed. The fact that the unknown pathology turned
out to be a brain tumour was not considered and noted in the inmate
record.
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“With hindsight, the diagnosis of a brain tumour could have been
considered earlier in the course of this illness but the working diagnosis
of depression was reasonable, and in any event, the fatal outcome
would not have changed.”
No criticism should be levelled at the healthcare department for failing to
diagnose the man’s brain tumour whilst he was in their care. However, this
case should be included for discussion at the next clinical audit meeting at
HMP Lowdham Grange’s healthcare department.
64. In terms of the medical treatment provided, the reviewer finds no significant
shortcomings in how the man was managed whilst at HMP Lowdham Grange.
Transfer to City Hospital, Nottingham
65. When he was transferred to City Hospital, the man was escorted by two
members of staff and ‘double cuffed’. I acknowledge that he was a category B
prisoner who had just been sentenced to 15 years imprisonment. However, I
would have expected the prison to have taken into account the man’s medical
and physical condition when completing the risk assessment and the
healthcare department to have provided information. It appears that neither
were considered and therefore he was treated as any other category B
prisoner.
66. As a result, a 60 year old man with an illness that had already stripped him of
his dignity was made to sit with his hands cuffed together and another chain
adjoining him to officers for three days. Reviews of the risk assessment over
the following days continued to indicate the same cuffing arrangements, despite
the deterioration in his condition. I recognise the prison’s actions in removing
the restraints in late January 2008. However, it was not until the duty manager
became aware that the man was not likely to live beyond 24 hours that this
decision was made.
67. The balance between public protection and the compassionate management of
seriously ill or dying prisoners is a difficult one to strike and one that I frequently
address in my reports. In four recent reports on the deaths of prisoners held at
Birmingham, Gartree, Maidstone and Norwich, I have been critical of the lack of
flexibility in local policy on bed watches. There are, of course, many factors to
consider when arranging a bed watch and I appreciate they involve
discretionary judgements. In this man’s case, the management checks and risk
assessment reviews were carried out frequently, and in accordance with the
National Security Framework (NSF) guidelines.
68. As previously mentioned, I have addressed these matters in earlier reports. In
one of them I emphasised that consideration should be given to including in the
NSF explicit instructions on how to deal with gravely ill or dying prisoners in
outside clinical environments. The Prison Service accepted this
recommendation. In addition, a review of the use of restraints during hospital
escorts and bed watches has been undertaken following the case of ‘G’ in the
High Court last November (2007). The policies within the NSF have been
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GOOD PRACTICE
The ACCT reviews, together with recording and sharing of information between all
departments at Lowdham Grange, should be highlighted as good practice. These
robust procedures and practices identified the needs of the man, as well as
recognising and preventing further unnecessary distress to his cellmate.
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