Individual at Styal

Investigation into the circumstances surrounding the
death of a woman, a prisoner at HMP & YOI Styal, in
May 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2009
1
This is the report of an investigation into the death of a woman, a prisoner at
HMP & YOI Styal. The woman was taken ill in her room during May 2008 and
died shortly afterwards in hospital. I offer my sincere sympathy and
condolences to all of the woman’s family and friends for their loss.
I must apologise to the woman’s family for the delay in issuing my report. My
investigation was suspended for several months whilst I awaited the outcome
of the toxicology report. Following completion of the post mortem and
toxicology reports, the woman’s death was determined to have been caused
by acute asthma.
The investigation was carried out on my behalf by a colleague. An
independent review of the woman’s medical care in prison was carried out by
a clinical reviewer on behalf of the local Primary Care Trust. I am most
grateful to the clinical reviewer for the time that he has put into this
investigation.
I would also like to thank the Governor and staff of Styal for their full and
ready co-operation.
It is clear that the woman had much on her mind during her nine weeks at
Styal. She received a lot of contact and support from staff, particularly during
her first weeks in prison, and from her room-mate on Barker House.
Nevertheless, my report highlights several areas in which more could have
been done more for the woman. I am particularly saddened that the woman
was eligible for release on home detention curfew four days before her death,
but no decision was made about her suitability as the relevant forms had not
been completed on time. I make eight recommendations.
This version of my report, published on my website, has been amended to
remove the names of the woman who died and those of staff and prisoners
involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2009
2
CONTENTS
Summary
The investigation process
HMP & YOI Styal
Key findings
Issues
Conclusion
Recommendations
3
SUMMARY
The woman began a term of 33 weeks imprisonment at HMP Styal on 6
March 2008. The woman saw a nurse at reception and said that she had
used drugs for a number of years. She began a substance misuse
programme on the same day that continued throughout her time at Styal. The
woman also told the reception nurse that she was around eight weeks
pregnant, but did not want to have the baby. After discussing this further with
a prison doctor, the woman was referred to a local clinic and had a
termination around five weeks later.
In addition, the woman had a history of poorly controlled asthma. She did not
mention that the condition was serious and her community doctor’s surgery
was not asked for her records. Throughout her time at Styal, her substance
misuse, termination of her pregnancy and, later, her depression, were seen as
the priority. Although she apparently began to have difficulty breathing during
the last week or so of her life, the woman did not discuss this with staff at the
prison. I recommend that healthcare staff ensure that the patient’s community
medical records are requested for all new receptions who report a chronic
disease in their medical history. I endorse a recommendation made by HM
Chief Inspector of Prisons regarding chronic disease management at Styal.
On 5 May, the woman was seen by a nurse in a substance misuse clinic. She
was emotional and tearful following her recent termination. The nurse
therefore opened an ACCT form (the document used by the Prison Service to
monitor and support prisoners deemed to be at risk of suicide or self-harm).
The nurse later recalled that the woman showed no sign of having any
difficulty breathing during this assessment. A prison officer who undertook an
ACCT assessment interview with the woman later that day, agreed that she
neither showed nor spoke of any physical symptoms.
The following afternoon, the woman was apparently “breathing heavily” in the
kitchen, where she worked. A staff member in the kitchen took her to a
nearby house to borrow an inhaler, after which the woman said she was
“alright”. There is speculation that the woman did not have an inhaler at the
time and may have gone for some days without one. It is not clear whether
there is any truth in this.
At around 3.30am one morning in May, the woman woke her room-mate and
said that she was struggling to breathe. A nurse was called to the room but,
shortly afterwards, the woman went into cardiac arrest. The woman was
taken to a local hospital where she was pronounced dead at 4.58am. The
cause of death was acute asthma. Although it would have made no
difference to the final outcome, my report highlights several areas in the
response to the woman’s collapse that could be improved in future.
4
The woman’s eligibility date for release on home detention curfew was 3 May
2008. However, the necessary assessments were not completed and no
decision was made. Amongst my eight recommendations, I advise that the
Governor ensure that such assessments are completed in line with the
relevant national instructions.
5
THE INVESTIGATION PROCESS
1. The investigation was opened on 8 May 2008 when my investigator
issued notices announcing it to staff and prisoners. The notices included
an invitation to those who wished to submit information relating to the
woman’s death to make themselves known to my investigator. No
prisoners came forward as a result.
2. My investigator first visited Styal on 13 May. He toured the prison,
including visiting the room on Barker House where the woman lived, and
was given copies of the woman’s prison files. On 10-11 June, my
investigator visited Styal for a second time and interviewed the woman’s
room-mate and four members of staff. Another member of staff was
interviewed at my office in London on 24 June. My investigator returned
to Styal on 9-10 July to interview a further five members of staff and again
on 13 August when one additional member of staff was interviewed.
3. The investigation was then suspended for around three months whilst the
outcome of the toxicology report was awaited. A post mortem report had
shown that the woman had died of a massive asthma attack. However,
the results of the toxicology report indicated that the woman had taken a
potentially fatal quantity of methadone (medication used to treat the
withdrawal symptoms experienced when a patient stops using heroin).
The toxicologist commented that:
“It is possible that this concentration of methadone could prove fatal,
however this will depend on the degree of tolerance that the user has
acquired to the effects of the drug.”
4. A clinical review, examining the medical care that the woman received at
Styal, was carried out by a clinical reviewer, the Associate Director of
Clinical Effectiveness at the local Primary Care Trust. The clinical
reviewer discussed the cause of death with the toxicologist, and explained
the woman’s history and the level of methadone maintenance dosage she
was receiving at the time. The toxicologist considered that the level of
methadone in the woman’s blood was consistent with the 30mg dose she
was receiving. The clinical reviewer discussed these results further with
the pathologist who completed the post mortem report. Both the
pathologist and toxicologist agreed that the cause of death was
attributable to a very severe asthma attack. The clinical reviewer makes
the following comment in his clinical review:
“As far as can reasonably be determined, the woman died from a very
severe asthma attack; her then current levels of methadone and
diazepam were not contributory factors.”
5. Once the cause of death was clarified, my investigation was reopened on
12 January 2009. My investigator then interviewed a further five members
of staff in February and March. A total of 16 staff and one prisoner were
interviewed during the course of my investigation.
6
6. My former senior family liaison officer telephoned the woman’s mother on
22 May, to inform her of the investigation. The woman’s mother said that
any questions she wanted to raise had already been answered by the
prison. She went on to say that she had been treated really well since the
woman’s death and that the prison’s family liaison officer, had been
“fantastic”.
7. My report was sent in draft to the woman’s parents, the Prison Service
and the Lancashire Probation Area. The Prison Service’s response to my
recommendations is included in the ‘Recommendations’ section on page
26 of this report. The Lancashire Probation Area’s response is included in
paragraph 90. The woman’s mother gave the following comment to my
senior family liaison officer, in response to my draft report:
“We feel that our daughter was failed by the justice system. She
should have been at home on 3 May and maybe there would have
been a different outcome. Also the way we were told about her death
was very distressing. Nobody should have to hear over the phone of
their child’s death and this is something me and my husband will never
get over.”
7
HMP & YOI STYAL
8. HMP Styal opened as a women’s prison in 1962. In April 1999, the
population increased by 60 per cent following the opening of a new wing.
Styal is the only local prison for women prisoners serving the North West
and North Wales. It mainly holds women serving short sentences or those
on remand. The prison has an operational capacity of 460 women.
9. Styal is made up of two types of accommodation. There is a conventional
wing, Waite wing, holding around 135 women in cellular accommodation.
There are also 16 Victorian villas, including Barker House where the
woman lived. Each of the villas accommodates up to 28 women in shared
rooms of two to six people. Each villa also has a common room with
televisions, stereos, DVD players, and a variety of board games. These
houses have lower levels of staffing, with no staff on duty during the night.
Location on Waite wing or the houses is determined by the level of risk
that a woman presents.
10. Healthcare services at Styal are commissioned by the local Primary Care
Trust. A doctor is based in healthcare during the daytime and evenings on
weekdays. An on call service is available overnight and at weekends.
There are nurses on site 24 hours a day. During the night nursing staff are
based in the first night centre, as there are no inpatient facilities at the
prison.
11. HM Chief Inspector of Prisons conducted a full announced inspection of
Styal in September 2008. HM Chief Inspector reported that:
“Women had reasonable access to most health services, but there was
significant pressure on services and staff struggled to meet women’s
considerable mental and physical health needs.”
12. HM Chief Inspector went on to say that some clinical services were
“underdeveloped” and that “access to some health services was not as
good as in the community”. She noted that there were no chronic disease
(a disease that is long lasting or recurrent, including asthma) clinics and
her recommendations to the Prison Service included the following:
“Chronic disease management should be improved and women should
be seen regularly with support from community nurse specialists.”
13. In their annual report for 2007/2008, the prison’s Independent Monitoring
Board (IMB) noted difficulties in recruiting and retaining nursing staff.
They related this high turnover in staff to the challenges entailed in dealing
with a demanding population. The IMB also noted that the healthcare
budget was significantly under-spent during the year 2007/2008, as it had
been the previous year too. They made the following comment:
“Bearing in mind the nature of the Styal prisoner population and their
unique and varied health issues, it is unacceptable that the budget is
8
not managed in such a way to ensure all the resources needed by the
prison are acquired.”
14. The woman’s death was the sixth to have occurred at Styal since April
2004, when I began investigating all deaths in prison custody in England
and Wales. There has subsequently been one further death. The
woman’s was the second death due to natural causes. The earlier natural
cause death occurred just over a week before the woman died. It also
involved a woman who had arrived at the prison within a period of weeks
before she died and who was being treated for substance misuse. Other
than this, there were few similarities between the issues I have addressed
in the two investigations.
9
KEY FINDINGS
15. The woman had a long history of poorly controlled asthma. She had
attended Accident and Emergency in 2006 following a severe asthma
attack and she regularly saw her doctor in the community for treatment.
The clinical reviewer notes that, even when well, the woman had a peak
flow (a measurement of how well the lungs are working) of about half that
expected for a person of her age.
16. Shortly after her arrival at Styal, the woman was assessed by a prison
nurse for a first reception health screen (a routine health screen for all
new arrivals into prison). The woman told the nurse that she was around
eight weeks pregnant but did not want to have the baby. She also said
that she was using heroin, cocaine and benzodiazepines (sedative
medication to treat conditions such as anxiety or insomnia that is also
used recreationally and is addictive if taken regularly). The woman went
on to say that she was taking a maintenance dose of methadone in the
community and took fluoxetine (commonly known as Prozac) for
depression. She also said that she was asthmatic. The prison nurse
referred the woman to the prison doctors regarding her substance use and
her physical health.
17. Later that day the woman was seen by a prison doctor. The woman
elaborated on the information she had given the nurse earlier. She said
that she had taken two bags of heroin daily for 15 years and had smoked
crack cocaine daily for five years. The woman also said that she took
salbutamol (medication used to open up the airways in the lungs) for her
asthma. The prison doctor prescribed a course of diazepam (commonly
known as Valium) for detoxification from benzodiazepines and a course of
methadone as treatment for heroin addiction. The woman began by
taking 10ml dose of methadone, to be increased to 30ml over the course
of five days. The purpose of this course was to stabilise the woman’s
dependency before further treatment would be given.
18. The woman was seen the following day by a second prison nurse. The
nurse observed that the woman was pale and tired, and the woman told
her that she had not slept well. The woman had brought two inhalers to
prison with her and had asked that they be prescribed. The woman also
told the nurse that she suffered from depression and had taken Prozac in
the community. The nurse telephoned the woman’s community doctor’s
surgery to request details of her prescriptions. A fax was returned shortly
afterwards, outlining the woman’s medication as salbutamol and
fluticasone propionate (medication to treat asthma) inhalers, adalat (to
treat high blood pressure) and Prozac. These medications were
prescribed to the woman through the prison pharmacy the same day.
19. On 10 March, the woman was seen by another prison doctor. The woman
spoke about her pregnancy and requested a termination, saying she had
thought it through and was aware of the risks. The doctor made a referral
10
to a local hospital. On the same day, the woman moved from the first
night centre to a cell on Waite Wing.
20. The following day, the woman was seen in the substance misuse clinic by
a substance misuse nurse. (This was a standard review that all patients
receive on the fifth day of a methadone programme.) The woman said
that she was fine on her current dose of 30ml methadone and the nurse
observed that she showed no signs of withdrawal symptoms. The nurse
decided to keep the woman on her current dose of methadone in order to
maintain her tolerance levels. As the woman would only be in prison for a
short time the aim of her methadone programme was to ensure that,
should she resume taking heroin on release, her body would be able to
tolerate the drug and she would not accidentally overdose.
21. On 13 March, the woman moved from Waite wing to Barker House, one of
the small villas. An officer noted in her wing record that the woman was
polite and had no problems. Six days later, the gynaecology department
at the Wythenshawe Hospital contacted Styal, following the prison
doctor’s referral, to say that the woman was too advanced in her
pregnancy to qualify for their services. A referral was therefore sent to the
Whitworth clinic at St Mary’s Hospital, Manchester. They replied the
following day, having arranged an outpatient appointment at the South
Manchester Hospital on 27 March.
22. The woman was seen by a third prison nurse on 21 March, after reporting
swelling in her right leg. After examining the woman, the nurse advised
her to elevate and rest her leg. The woman also said that the Prozac was
making her feel unwell. The nurse made an appointment for the woman
to see a prison doctor.
23. Six days later, the woman attended her outpatient appointment at South
Manchester Hospital. On 29 March, she saw a prison doctor regarding
her Prozac. The woman told the doctor that she had stopped taking it a
week earlier as it made her feel unwell. The prison doctor noted that the
woman was experiencing excessive anxiety and her symptoms were
worsening. The woman asked for a change to her medication. The prison
doctor agreed, and prescribed a course of citalopram (which is used to
treat depression).
24. Having made an application for a nurse assessment, the woman was
seen by a triage nurse, on 4 April. The woman said that she had been
suffering a cough for two weeks and had itchy and cracked skin on her
hands and arms. The woman added that she suffered from Raynaud’s
phenomenon (narrowing of the arteries supplying blood to the hands,
resulting in cold, white fingers and pins and needles). The triage nurse
made an appointment with a prison doctor.
25. The woman was assessed the following day by another prison doctor.
She told the doctor that she had been coughing and producing green
sputum for two weeks. The doctor noted that the woman was asthmatic
11
and smoked 20 cigarettes a day. He examined the woman and observed
that her throat was clear but she had experienced some wheezing in her
chest. The doctor prescribed a course of amoxicillin (an antibiotic), plus
hydrocortisone cream for the woman’s skin complaint.
26. Two days later, the woman was reviewed by the same doctor she had
seen on 10 March. The woman was still low in mood and the prison
doctor therefore increased her dose of citalopram. On 9 April, the woman
attended the Whitworth clinic at St Mary’s Hospital for a consultation in
advance of her termination. Appointments were booked for 12 and 14
April for the two stages of her termination. The woman was seen by a
nurse the same day and said that she was feeling drained and emotional.
She was allowed to rest in her house for a day rather than go to work.
27. On 10 April, a fax was sent from the Offender Management Team at Styal
to the probation office in Fleetwood, Lancashire. The woman’s eligibility
date for release under the Home Detention Curfew Scheme (HDC,
commonly known as electronic tagging) was 3 May. The fax asked the
Lancashire Probation Area to comment on the woman’s suitability for
release on HDC to an address that she had supplied a week earlier. The
Probation Service was asked to reply by 24 April. No reply had been
received at the time of the woman’s death.
28. The woman subsequently went to the Whitworth clinic on 12 and 14 April
for her termination. She was next seen by healthcare staff at Styal on 16
April for a stop smoking clinic. After the clinic, the woman started using
nicotine patches. The following day she returned to healthcare for a
hepatitis B vaccination. On 22 April, the woman was given two days
house rest by a healthcare assistant after the woman said that she was
feeling uncomfortable and unhappy following her termination.
29. Five days later, the woman complained of toothache and was given
paracetamol at the treatment hatch in healthcare. On 30 April, she
submitted a healthcare application form saying, “I need an appointment for
nurse assessment and substance misuse.” On each of the following three
days, the woman again collected paracetamol for toothache.
30. My investigator spoke to the woman’s room-mate who said that the
woman had been “struggling with her breathing” for around a week and a
half before she died. She said that this happened mainly at night, when
the woman would wake up coughing, and that it got worse over the course
of the week. The woman also began to struggle when climbing stairs.
However, her room-mate did not think that the woman reported any of
these symptoms to healthcare staff.
31. On 5 May, the woman was seen by the nurse at the substance misuse
clinic. The woman spoke about her termination and was observed by the
substance misuse nurse to be emotional, tearful and low in mood. She
told the substance misuse nurse that she had not been eating or sleeping
and said that she “felt like being dead”. The woman also said that she
12
had stopped taking citalopram a week previously as she felt that it was
“making her worse”. The substance misuse nurse told my investigator
that the woman showed no signs of struggling for breath and that she did
not speak about breathing difficulties.
32. As a result of the woman’s low mood, the substance misuse nurse opened
an Assessment, Care in Custody and Teamwork form (ACCT, the form
used by the Prison Service to monitor and support prisoners at risk of
suicide or self-harm). At around 4.45pm, the woman attended an ACCT
case review with a Senior Officer (SO) and a prison officer, followed by an
assessment interview with the prison officer. The SO made the following
observation:
“The woman has many issues at present including a recent
termination. The woman has stopped taking her medication as she felt
it was making her more depressed. Also struggling with the speed at
which she is being reduced from her diazepam. The woman has never
self-harmed and has no thoughts of suicide or self-harm … Happy to
remain on Barker with supportive friends.”
33. In addition, the prison officer told my investigator that the woman showed
no signs of any physical symptoms nor of difficulty breathing and that she
did not appear to be agitated. He and the SO decided on the level of
ACCT monitoring. The woman would be observed on four occasions
during the day and night, and staff should have three meaningful
conversations with her. The monitoring would remain in place until the
woman’s first scheduled ACCT review on 14 May. They also requested
an appointment for the woman to see a prison doctor to discuss her
medication.
34. The following morning, the woman was seen at roll check (a count of all
the prisoners) at around 7.50am by her personal officer. (Each woman is
assigned an officer who they can go to first with any problems.) The
woman told the personal officer that she was “okay”. At around 9.00am,
the woman left the house to go to the kitchens where she had been
working as a dish washer for around two weeks. From around 11.30am to
1.30pm, the woman returned to Barker House for lunch. She told her
personal officer that she felt “fine”.
35. In interview, the substance misuse nurse recalled seeing the woman
around lunchtime on 6 May. She remembered that the woman was
outside with some other women. The woman called the nurse over and
said that she had not been seen by the triage clinic. The substance
misuse nurse then went to the healthcare centre and arranged an
appointment for the woman for the following day.
36. Later that afternoon, the woman was taken ill in the kitchen. At afternoon
break, the women had asked if the door could be opened because it was
a hot day and very stuffy in the kitchen. A member of staff who works in
the kitchen told my investigator that the woman was “breathing heavily
13
because of the heat”. The staff kitchen worker said that her breathing was
not so heavy to the extent that the woman had difficulty breathing and so
she was not alarmed or worried.
37. The staff kitchen worker was told by one of the other women that the
woman did not have an inhaler. She therefore took the woman to
Nightingale House where she borrowed another woman’s inhaler. After
taking some breaths from the inhaler, the woman told the staff kitchen
worker that she was “alright”. The staff kitchen worker advised the woman
to get an inhaler from healthcare that night. Her medical record indicates
that the woman received a new salbutamol inhaler on 6 May, although it is
not certain when she received it.
38. At 7.30pm that evening, an officer noted in the woman’s ACCT document
that he had seen her at roll check and she had said she was “okay”. Her
room-mate said that the woman was no worse than normal that evening.
At 10.30pm, two officers visited the woman for her first ACCT check of the
night. The first officer noted that the woman was “lying in bed watching
TV, states fine when asked”. The two officers returned at 1.05am. On
this occasion it was the second officer who made the entry. He noted that
he had spoken to the woman and there were “no concerns”. At interview
with my investigator, the second officer recalled that the woman “wasn’t
wheezing or anything like that at all”.
39. At around 3.30am, the woman woke her room-mate and told her that she
was struggling to breathe. Her room-mate pressed a call bell on the
landing to alert staff to attend. When she returned to the room, the
woman was sitting on the edge of her bed and leaning over. The woman
then used her inhaler. At around 3.34am, the woman’s room-mate
pressed an alarm bell, alerting staff that urgent assistance was required.
40. At the same time, the second officer and a third prison officer arrived at
Barker House and made their way up to the woman’s room. The second
officer said that they found the woman “really struggling to breathe”. He
ran to the first night centre, where the response nurse is based overnight,
for assistance. The officer explained that he went for the nurse rather
than using the radio because the first night centre is just 50 yards from
Barker House and he would have had to go there anyway to escort the
nurse. (Nurses at Styal do not carry keys at night-time and so they have
to be escorted around the prison at night.)
41. As the officer was making his way to the first night centre, an SO and
another officer arrived at Barker House. The SO was orderly officer that
night, meaning that she was the most senior officer on duty and therefore
in charge of the prison. In interview, the orderly officer said that she found
the woman sitting on her bed having difficulty breathing. The response
nurse then arrived. The response nurse gave the woman an oxygen
mask to help her breathe.
14
42. The response nurse asked the staff to make sure that the woman
continued to take oxygen and radioed her colleague (who was based on
Waite wing overnight) to come to Barker House to assist. She then went
to the healthcare centre to collect a nebuliser (a device similar to an
inhaler which is used to treat severe asthma attacks). The response
nurse told my investigator that she opted to fetch the nebuliser herself
because the officers do not hold a medical suite key and because she
knew where to find the device. She said that it took her around three or
four minutes to collect the nebuliser and return to Barker House.
43. The orderly officer said she saw the woman’s hand turn blue whilst the
response nurse was collecting the nebuliser. She checked for a pulse and
said that she could feel “something moving”. There was also foam coming
out of the woman’s mouth. The orderly officer radioed the control room to
request an ambulance. The time was now 3.45am.
44. Shortly afterwards, the response nurse returned to Barker House and, on
seeing the woman, realised she had entered cardiac arrest (her heart had
stopped beating). She and the healthcare nurse, who arrived at around
the same time, immediately began cardiopulmonary resuscitation (CPR).
The healthcare nurse also radioed a healthcare assistant and asked her to
bring a defibrillator from the healthcare centre. The healthcare assistant,
who was based on Waite wing overnight, arrived with the defibrillator
around four minutes later. The nurse attached the defibrillator which
instructed that she apply two shocks to the woman. After this, the nursing
staff continued to apply CPR until the paramedics arrived at around
3.55am.
45. At around 4.25am, the woman was taken to Wythenshawe Hospital by
ambulance. The nurse travelled with her and continued to apply CPR in
the ambulance with the help of a paramedic. The woman was
pronounced dead at 4.58am by a hospital doctor. A post mortem
examination later determined the cause of death to be acute asthma.
46. At around 6.00am, the duty governor (the on-call senior manager)
telephoned the woman’s parents to break the news of her death to them.
The duty governor said that he broke the news over the telephone rather
than in person on the instructions of the Governor. This was because of
the distance that the woman’s parents live from the prison, which is
around 60 miles.
47. The woman’s funeral was held on 16 May. My investigator found that the
prison’s contribution to the funeral arrangements was in accordance with
PSO 2710 (the Prison Service Order that sets out the actions to be taken
following a death in custody).
48. Around a week after the woman died, a Principal Officer (PO) reported to
the performance manager at Styal that she had overheard one of the
officers who responded when the woman was taken ill telling someone
that the response nurse had been asleep when the Officer had run to get
15
her assistance. The officer was based on the first night centre with the
response nurse. The PO later told my investigator:
“It transpired during the course of the [overheard] conversation that the
nurse may have been asleep on the first night centre without her boots
on and without her belt on.”
49. At interview with my investigator, the officer said that she was “there at the
time but to be honest I wasn’t really watching what the response nurse
was doing”. After reading a copy of the interview transcript, the officer
retracted this and said that “[the response nurse] did have her belt and
shoes off, but was not asleep”. The other officer said that the response
nurse was sitting on the sofa watching television. He added that he did
not see whether she was wearing her shoes or belt. The response nurse
told my investigator that she was lying on the sofa with her shoes off and
belt undone. She said that she was not asleep.
50. The response nurse was suspended from duty following this allegation.
An investigation into her conduct was undertaken by a reviewer on behalf
of the local Primary Care Trust. The investigation concluded that:
“The response nurse was ‘resting’ with her shoes removed, watching
television in the sitting room of [the first night centre]. She was not
asleep … It is not certain whether the response nurse’s belt was
loosened, undone about her person, or removed.”
51. The investigation recommended that no formal disciplinary action should
be taken against the response nurse and that her suspension from duty
should be lifted.
16
ISSUES
Retrieving information from the community doctor
52. In his clinical review, the clinical reviewer notes that the woman had a long
history of poorly controlled asthma and that her peak flow (a measurement
of how well the lungs are working) was around half that expected for a
person of her age. In 2006, the woman attended Accident and
Emergency following a severe asthma attack and she regularly attended
her community doctor’s surgery when she needed treatment.
53. During the woman’s reception health screen at Styal, she identified a
number of health problems including asthma. She also requested a
termination of pregnancy and was treated for substance misuse. It is
those two issues that dominated her healthcare at Styal, particularly
during her first six weeks of imprisonment. Given that the termination and
substance misuse were issues that had to be dealt with immediately, I
believe that their priority is understandable.
54. However, this meant that the seriousness of the woman’s asthma was
never determined by prison healthcare staff. The woman herself did not
reveal her history of poorly controlled asthma. I am unable to say why this
was, although it is clear that the woman had a lot on her mind when she
was in prison. On the woman’s second day in prison, her community
doctor’s surgery was contacted to confirm the medication that she was
taking. They were not, however, asked to provide the woman’s full
medical records. Prison Service Order (PSO) 3050 instructs that:
“When a prisoner enters reception … efforts should be made to retrieve
any information required from the prisoner’s GP or other relevant
service he/she has recently been in contact with.”
55. The former healthcare manager at Styal told my investigator that it is the
responsibility of healthcare staff on the first night centre to obtain doctor’s
records after obtaining the woman’s consent. However, she went on to
say that they do not have enough resources to staff the first night centre
and so this is not always carried out.
56. The clinical reviewer makes the following comment in his clinical review:
“Ideally all prisoners should have a medical summary from their
General Practice. It is recognised that this is problematic given the
high throughput in the prison. In this instance it is not clear that
possession of the records would have made a major difference in the
way [the woman] was managed.”
57. In the woman’s case, a lack of resources did not prevent her medical
records being requested from her doctor’s surgery. This could have been
done at the same time that the surgery was asked to confirm her
medication. I note the clinical reviewer’s comment that it is not clear if the
17
records would have made any difference to the way the woman’s medical
needs were managed at Styal. My view is that it can only be beneficial for
healthcare staff to have full access to the details of a patient’s medical
history.
The Head of Healthcare should remind staff to request community
GP records for all new arrivals in prison who report a chronic
disease in their medical history.
Chronic disease management
58. The woman’s room-mate told my investigator that the woman had been
“struggling with her breathing” for around a week and a half before she
died. Her room-mate did not think that the woman reported her symptoms
to healthcare staff. The clinical reviewer makes the following comment:
“In retrospect this was a very severe asthma attack. It would appear
that the woman was not aware how seriously ill she was becoming. It
is possible that she was preoccupied by depressive symptoms
associated with her termination and preparation for her imminent
release. In the words of a respiratory physician, ‘people with poorly
controlled asthma quite frequently have become so accustomed to
continual breathlessness that they fail to recognise when they are
deteriorating abnormally’.”
59. At the time of the woman’s death there were no chronic disease clinics at
Styal. Regular attendance at such a clinic would give asthma sufferers
the opportunity to talk about and educate themselves about their
condition. It would also provide a regular opportunity to review a patient’s
medication and treatment.
60. As noted earlier, in her inspection report published in February 2009, HM
Chief Inspector of Prisons made the following recommendation:
“Chronic disease management should be improved and women should
be seen regularly with support from community nurse specialists.”
61. I am pleased to note that the prison provided the following response to
this recommendation, which is to be completed by December 2009:
“Service delivery options are being explored and we await the result of
a bid for a specialist respiratory nurse.”
I trust that the tragic lessons of the woman’s untimely death will add
emphasis to the decisions about chronic disease clinics.
Events of 6 May 2008
62. As I have noted in paragraphs 39-40, the woman was taken ill in the
kitchens on the afternoon of 6 May. She was said to be “breathing heavily
18
because of the heat” and required the use of an inhaler. The member of
kitchen staff who helped her said that she felt that it was quicker to get the
woman an inhaler from a nearby house than it was to take her to
healthcare.
63. None of the prison staff in the kitchen was aware at the time that the
woman was asthmatic. The staff kitchen worker told my investigator that
they now ask any woman who is interviewed for a job in the kitchen
whether they have any health concerns that staff should know about.
64. The staff kitchen worker said that, with hindsight, she worried whether she
should have taken the woman to healthcare. At the time she did not
consider that the woman’s symptoms were sufficient. It should also be
noted that the woman did not ask to see a nurse either. Nevertheless, it
would be advisable in future to inform healthcare staff if a woman is taken
ill so that they can decide whether further assessment is necessary. This
would also ensure that a record is kept of the events for future reference.
It is also worth noting that it is not appropriate for one prisoner to take
medication prescribed to another.
The Governor should remind staff to inform healthcare whenever a
prisoner is taken ill in their place of work.
65. There was speculation that the woman had not had her own inhaler for
some time before she died. The staff kitchen worker told my investigator
that she had to take the woman to Nightingale House to borrow another
woman’s inhaler, as she was told that the woman did not have one of her
own. The staff kitchen worker advised the woman to go to healthcare that
evening to get a new inhaler.
66. The woman’s room-mate was interviewed twice by my investigator. On
the first occasion, she said that the woman had been using her inhaler a
lot more in the week before she died. However, at the second interview,
she said that the woman had gone for some time without an inhaler,
possibly a week or two. It does not appear that the woman spoke about
this to any of the staff whom she saw on 5 May for her substance misuse
clinic or ACCT interviews. Indeed, both the substance misuse nurse and
the ACCT officer told my investigator that there was no sign that the
woman was struggling for breath when they spoke to her.
67. The staff kitchen worker told my investigator that after the woman’s death
she heard some “gossip” from some of the women that the woman may
have been bullied for her inhaler by other asthmatics. The woman’s room-
mate was adamant that this was not the case and that the woman had not
been bullied or had her inhaler taken from her. I have seen no other
evidence to support the claim that the woman was bullied whilst at Styal.
68. Her prescription charts confirm that the woman received a new inhaler on
6 May. This was the third that she had received at Styal, having also
19
been given inhalers on 7 March and 7 April. On each occasion, the
woman received a one month supply of salbutamol.
69. It is not clear when the woman received her inhaler on 6 May.
Medications which prisoners hold in their own possession are normally
collected at lunchtime, and her room-mate thought that this was the time
that the woman picked hers up. However, this would not explain why the
woman had to borrow an inhaler later that afternoon. It is possible that
she had left her inhaler in her room when she went to work and that the
staff kitchen worker misunderstood what she was told about the woman
not having one.
70. The clinical reviewer provided the following comment on the impact on the
woman’s health had she gone without her inhaler for some part of the day
before her death:
“In practice this is highly speculative but the salbutamol inhaler would
alleviate some symptoms but would not alter the progression of the
attack. Use of a steroid inhaler would help in modifying an attack if
used over several days. In serious attacks the only effective
treatments are prompt nebulisation, systemic steroids and a range of
drugs that can only really be administered in a hospital setting.”
71. I have been unable to determine whether the woman did go without an
inhaler for a period before her death. It is clear that she collected a new
inhaler on 6 May, although I cannot be certain when she did so. The
woman was seen using her inhaler when she was taken ill during the early
hours and the police confirmed that it was present in the room when it was
unsealed after her death.
Emergency response
72. When the woman developed breathing difficulties in the early morning her
room-mate pressed a call bell for assistance and, four minutes later, an
alarm bell. At around the same time, two officers arrived at Barker House
in response to the call bell. Having found the woman struggling to
breathe, one of the officers went to fetch healthcare assistance
immediately. He told my investigator that he ran to the first night centre,
where the response nurse was based, rather than using a radio. This was
because nursing staff have to be escorted around the prison at night as
they do not carry a full set of keys (this is a standard security procedure in
prisons during night patrol state). He would therefore have had to return
to the first night centre anyway to escort the response nurse. The officer
added that the first night centre is just 50 yards from Barker House, so it
did not take long for him to return.
73. Styal operates a code system for requesting assistance in a medical
emergency. A ‘code blue’ call indicates that a woman has stopped
breathing. It would apply to the woman’s circumstances as she was,
20
according to the officer who fetched assistance, “really struggling to
breathe” when he went for assistance.
74. The clinical reviewer makes the following comment regarding the
emergency response:
“[The woman] was already very seriously ill at the time the prison staff
were called. In attacks of this nature resuscitation outside of a hospital
is near impossible as the lungs are clogged with thick mucous plugs. I
discussed the issue of earlier intervention with the Respiratory Team at
East Cheshire NHS Trust. Successful treatment would necessitate at
least two nebulisations using a combination of drugs. Treatment would
need to have been initiated about 20 minutes before the arrest
occurred so realistically the guards would have needed to have been
called 15-20 minutes earlier. Treatment must be initiated before the
lungs have become totally obstructed as the aerosol that loosens the
mucous will not penetrate otherwise. Ideally, in severe attacks
treatment and monitoring should take place in a unit with rapid access
to intensive care.”
75. Had the officer radioed a ‘code blue’ call for assistance before leaving
Barker House, the response nurse might have been ready to return with
him as soon as he arrived at the first night centre. It is clear from the
clinical reviewer’s assessment that saving a few seconds in these
circumstances would not have made a difference to the final outcome.
However, there might be occasions in the future when such intervention
could be crucial.
The Governor should remind staff of the importance of using the
radio code system to request urgent assistance from the response
nurse.
76. Around a week after the woman died, an allegation was made that the
response nurse was asleep when the officer requested her assistance.
An officer was in the first night centre at the time, was overheard telling
colleagues that this might have been the case. The officer later told my
investigator that the response nurse“ did have her belt and shoes off but
was not asleep.” The officer who went to fetch the nurse said that she
was sitting on the sofa watching television and he could not see whether
she was wearing her shoes or belt. The response nurse herself said that
she was lying on the sofa with her shoes off and belt undone, but was not
asleep.
77. The response nurse was suspended from duty following this allegation.
An investigation into her conduct was carried out on behalf of the local
Primary Care Trust. The investigation concluded that the response nurse
was “resting with her shoes removed. She was not asleep.” She went on
to say that “it is not certain whether the response nurse’s belt was
loosened, undone about her person, or removed.” The investigator
21
recommended that no formal disciplinary action should be taken against
the response nurse and that her suspension from duty be lifted.
78. I am unable to say from my own investigation whether the response nurse
was asleep or not. By her own admission, she had removed her shoes
and undone her belt. As I have noted in paragraphs 77-78, a short delay
in attending to the woman would not have made a difference to the final
outcome. However, it is clearly unacceptable that the response nurse was
not in a position to respond immediately to the emergency.
The Governor should remind all night staff of the importance of
being able to respond to an emergency situation at all times.
79. After attending to the woman and giving her oxygen, the response nurse
went to the healthcare centre to collect a nebuliser. She told my
investigator that she went to collect it herself because the officers do not
carry a key for the medical suite and would not know where to find the
equipment. Shortly afterwards, when the woman went into cardiac arrest,
a healthcare assistant was asked to collect the emergency bag and
defibrillator from the healthcare centre.
80. The response nurse requested the healthcare nurse’s assistance at
around the same time that she went to collect the nebuliser. It might have
been better if she had remained with the woman and asked the healthcare
nurse to collect the equipment on her way to Barker House.
81. As there are no inpatient facilities at Styal, no staff work in the healthcare
centre at night. The response nurse is based on the first night centre. It is
puzzling that emergency equipment is locked in an empty building,
separate to the response nurse.
The Head of Healthcare should arrange for emergency equipment to
be moved to the first night centre during night patrol state.
Home Detention Curfew
82. Having begun a term of 33 weeks imprisonment on 6 March 2008, the
woman was eligible for release on Home Detention Curfew (HDC) on 3
May, eight weeks and two days after her arrival at Styal. PSO 6700
provides the following instruction to prisons regarding when to start the
process of assessing whether a prisoner is suitable for release on HDC:
“The risk assessment for Home Detention Curfew must where possible
be commenced ten weeks before a prisoner’s eligibility date. In cases
where the prisoner is not sentenced until there are less than ten weeks
to go until their conditional or automatic release date, the assessment
must be commenced immediately … arrangements must be made
therefore to request [the necessary] information immediately upon
reception.”
22
83. The PSO also provides a timetable for completing the assessment
process for HDC. Ten weeks before the eligibility date (so “immediately
upon reception” in the woman’s case), the prisoner must complete a form
giving details of their proposed release address. The woman signed this
form on 2 April, four weeks after she arrived at Styal and four and a half
weeks before her eligibility date.
84. Eight weeks prior to the eligibility date, an assessment form must be sent
to the Probation Service for completion and return within ten days. This
form was faxed to the probation office in Fleetwood on 10 April, just over
three weeks before the woman’s eligibility date. The form was due to be
returned by 24 April. On the day of the woman’s death (three days after
her eligibility date), it had still not been returned. A line manager in the
custody office at Styal said he expected that they would have started to
follow up the omission at around the time of the woman’s death.
85. Five weeks prior to the eligibility date, a form for comments by the
prisoner’s personal officer must be completed. This was sent to Barker
House on 10 April, but had also not been returned on the day of the
woman’s death. The woman’s personal officer said that she had recently
joined the Prison Service and was still in training at the Prison Service
College on 10 April. She did not receive the form and it is not clear what
happened to it after it left the custody office.
86. The woman died in custody in the early hours. Had the relevant
assessments been completed on time she could have been released to
her home on 3 May. I cannot say whether she might still be alive had she
been released on her HDC eligibility date. However, it is the case that the
woman spent the last few days of her life in prison rather than at home
with her family. I do not think that the system in place to track and monitor
the progress of HDC application forms is adequate. Particular importance
should be given to obtaining the completed forms when the HDC date is a
short time away. I am also critical of the performance of the Lancashire
Probation Area.
The Governor should put systems in place to ensure that risk
assessments for release on HDC are completed in accordance with
the timescales set down in PSO 6700.
A copy of this report should be sent to the chief officer of the
Lancashire Probation Area in view of my findings in paragraph 30
and my comments in paragraphs 85-89.
87. The Lancashire Probation Area provided the following response to my
draft report:
“The first point is that we would normally expect to receive eight weeks
notice of a request for HDC suitability. In this case the prison states
that the form was faxed to our Fleetwood office on 10 April 2008, giving
us just nine working days to complete the form.
23
“The more substantive point is that we have no trace of having
received the fax at our Fleetwood office. I am not aware what the
Prison Service policy is in relation to the transmission of restricted
information. However, the National Probation Service Policy on
restricted information states ‘that a fax should only be sent where a
receiver is standing by the fax machine waiting for transmission. The
sender should then confirm the fax has been correctly received in full’.
It also states that ‘a fax should never be sent to an unattended
machine’. As far as we are able to establish this did not happen in this
case.
“As this was a non statutory case we would not have been expecting
an HDC request. We are unable to shed light on what happened to the
fax after it left the prison. We will re-visit our procedures to ensure that
we have a clear record of such requests received in the future.”
Breaking the news of the woman’s death to her family
88. Prison Service Order (PSO) 2710, which provides instructions for the
aftermath of a death in custody, says that Governors must:
“Arrange notification to the next-of-kin and any other person reasonably
nominated by the prisoner as soon as possible in a suitable manner,
giving an accurate factual account of what has happened.”
89. The accompanying Family Liaison Officer (FLO) Guidance recommends
that:
“The family should be informed face to face as soon as possible after
the death. Wherever possible this should be done by a dedicated
Family Liaison Officer working alongside the Chaplain, or Governor or
most senior individual available together with the Chaplain.”
90. The woman had notified the prison that her next of kin was her mother
who lives in Blackpool, around 60 miles from Styal. At around 6.00am on
the day of the incident, the woman’s parents were informed of her death
over the telephone by the duty governor. The duty governor told my
investigator that he broke the news over the telephone rather than in
person on the instructions of the Governor, on account of the distance that
the woman’s parents live from the prison.
91. The FLO guidance says that distance from the prison is a factor that
should be taken into account when determining how to break the news of
a death. However, I do not consider 60 miles to be a prohibitive distance
and take the view that staff from Styal could and should have visited the
woman’s parents in person. Even if distance was a reasonable issue, the
guidance says that a FLO or chaplain from an area nearest the family
home could be asked to break the news. There are a number of prisons
24
in the North West which are close to Blackpool, and some are within 20
miles of the town.
The Governor should ensure that, whenever reasonable, the news of
a death in custody is broken to the next of kin by a member of prison
staff, face to face, in accordance with national instructions.
25
CONCLUSION
92. The woman had a very difficult time during the two months that she spent
at Styal. She had a lot of contact and support from healthcare staff
regarding a variety of issues. Her termination, substance misuse, and
depression were understandably seen as priority issues. It is possible that
the pressure of these issues was one reason why the woman did not tell
anyone that her asthma was more severe than it was thought to be.
93. My report highlights several areas in which more could perhaps have
been done for the woman. I am particularly disappointed that she was still
in prison several days after she could potentially have been released into
the community on HDC. Nevertheless, I cannot say that the woman’s
death would have been prevented had she received that further support
that could have been provided.
26
RECOMMENDATIONS
1. The Head of Healthcare should remind staff to request community GP
records for all new arrivals in prison who report a chronic disease in their
medical history.
Accepted – we have implemented a process which sees a proforma faxed
to the individual’s GP within 24 hours of their disclosure or diagnosis of a
chronic condition. In addition we have appointed a respiratory nurse to
address issues of this nature on site.
2. The Governor should remind staff to inform healthcare whenever a
prisoner is taken ill in their place of work.
Accepted – this will be completed through issuing of notices to staff and
raised at staff briefings on periodic basis.
3. The Governor should remind staff of the importance of using the radio
code system to request urgent assistance from the response nurse.
Accepted – this will be addressed through the issuing of a notice to staff
and inclusion in security and radio induction training.
4. The Governor should remind all night staff of the importance of being able
to respond to an emergency situation at all times.
Accepted – this will be addressed through the issuing of a notice to staff
and will be enforced through regular checks by night orderly officers and
monthly duty governor visits.
5. The Head of Healthcare should arrange for emergency equipment to be
moved to the first night centre during night patrol state.
Accepted – there is now a set of emergency response equipment and
nebuliser available on the first night centre.
6. The Governor should put systems in place to ensure that risk assessments
for release on HDC are completed in accordance with the timescales set
down in PSO 6700.
Accepted – systems will be put in place to reduce the maximum time for
the commission of HDC assessments on a woman entering Styal already
in the lead in time to HDC. Our target is to ensure all assessments have
been sent off within seven days of reception unless in exceptional
circumstances. In addition we will introduce a system which identifies
when external agencies have not responded and automatically generate a
chase up of this missing documentation.
27
7. A copy of this report should be sent to the chief officer of the Lancashire
Probation Area in view of my findings in paragraph 30 and my comments
in paragraphs 85-89.
Accepted – see paragraph 90
8. The Governor should ensure that, whenever reasonable, the news of a
death in custody is broken to the next of kin by a member of prison staff,
face to face, in accordance with national instructions.
Accepted – this will remain our priority and will be highlighted within the
contingency plans for a death in custody.
28