Individual at Acklington

INVESTIGATION INTO THE DEATH OF A MAN
AT HMP ACKLINGTON IN OCTOBER 2005
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
JUNE 2006
This is the report of an investigation into the death of a man who died at HMP
Acklington on in October 2005. He died of apparently natural causes. He
was 65 years of age.
I would like to add my personal condolences to those already expressed to
the family by my Family Liaison Officer.
The investigation has been undertaken by two of my colleagues. A clinical
review was undertaken by a doctor from Northumberland Primary Care Trust.
I am grateful to the doctor for his review and join my colleagues in thanking
the then Governor of Acklington, and his staff for their full cooperation during
this investigation.
Whilst I do not consider that anything could have been done to prevent this
man’s death, there were aspects of the prison’s response to his being taken ill
that were inadequate. Even though they do not appear to have had a
significant impact on this occasion, it is important that lessons are learnt to
prevent problems in the future.
The Northumberland Constabulary is currently investigating an allegation
against a member of prison staff in relation to the man’s death. I am issuing
my report in draft before knowing the outcome of the police investigation to
avoid unnecessary delay. Once the police investigation has concluded, I will
issue an updated version should this be required.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2006
CONTENTS
Summary 4
Investigation process 5
HMP Acklington 6
Events leading up to the death of the man 8
Events after the man’s death 11
Clinical Review and Police Investigation 13
Findings and conclusions 14
Recommendations 16
Good Practice 17
Response to the report 17
Summary
The man was sentenced to 15 months imprisonment in October 2003. He
was released in March 2004 on a two year licence, but was recalled to prison
in May 2004. He came into the custody of HMP Acklington in June 2004.
He had a long history of heart disease and was being treated for angina
following a heart attack in 1989. He received good chronic disease
management and preventative care whilst in custody. He was fit enough to
be employed at the prison’s tailoring workshop, which is where he chose to
work despite being of retirement age.
On the day that he died, the man went to work in the morning. At the end of
his shift, he returned to C wing along with the other prisoners for lunch. He
then spent the lunchtime period in his room. At 1:50pm, officers on the wing
called for prisoners to return to work. At this time, an officer shouted down the
landing to the man to tell him his afternoon probation interview had been
cancelled. There was no response. It was at this point that a fellow prisoner,
concerned that the man had not appeared, visited his room and saw him
sprawled face down over the table.
Staff responded to the call for assistance and the healthcare team were
alerted. Cardio Pulmonary Resuscitation was started and an ambulance
called. Despite 25 minutes of resuscitation, including the use of a defibrillator
and adrenalin, the man died before the ambulance arrived. The ambulance
was cancelled and his death was pronounced at 3:35pm.
This report concludes that there was nothing staff could have done to prevent
his death. However, it identifies some aspects of the response to his death
that could have been handled better, and makes a number of
recommendations.
Investigation Process
The investigation was opened at HMP Acklington on 2 November 2005. The
liaison officer and his colleagues produced the man’s prison, parole and
medical records for examination. Notices were distributed around the prison
informing staff and prisoners of the investigation.
A number of staff members, both prison and healthcare, were formally
interviewed along with the prisoner who found the man collapsed in his room.
A doctor from Northumberland Care Trust undertook a clinical review of the
medical care that the man received during his stay at Acklington.
My investigators contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the Post Mortem
report. Upon completion, my report will be sent to the Coroner to assist him
with his enquiries into the man’s death.
One of my Family Liaison Officers spoke with the man’s daughter and offered
to meet with her. At this stage, she did not wish to meet but was grateful for
the contact. She asked that we provide clarification of the medication that the
man was prescribed for his heart condition.
The Northumberland Constabulary is undertaking a separate investigation (an
allegation has been made against a member of prison staff about his conduct
towards the man). Once the police investigation is concluded, and should it
be required, I will issue an updated version of this report. It is hoped this will
be concluded by the time the adjourned inquest is held in December 2006.
HMP Acklington
HMP Acklington opened in 1972 as a category C prison. The jail is situated
on a former RAF station near Amble in Northumberland. It has the capacity to
house 882 prisoners.
The man’s room was situated on C wing in Residential block 1, which is a
block for vulnerable prisoners. Prisoners on C wing have courtesy keys to
access their rooms and they are free to move around their landing whenever
they wish. Rooms can be locked from the inside, but the lock can be
overridden by keys held by prison staff.
Northumberland Care Trust provides healthcare to the prison. Nurses are
employed along with a medical officer to deliver primary healthcare during the
daytime, seven days a week. The healthcare team is also responsible for the
administration of medication, either weekly or monthly, to prisoners who have
been assessed as capable of keeping it in their own possession. Prisoners
who require in-patient nursing care are transferred to an outside hospital or
another prison.
Her Majesty’s Chief Inspector of Prisons (HMCIP) carried out an
unannounced inspection of Acklington in April 2003. The Chief Inspector’s
report described a ‘safe prison’ stating that the ‘low levels of self-harm and the
absence of self-inflicted deaths reflect well on the proactive approach taken
by staff’. However, the inspectorate highlighted concerns about the needs of
older prisoners, and those with health conditions requiring a level of care that
could not be provided at Acklington. In June 2005 the clinical team leader
began to address this by exploring the possibility of introducing clinics for
specialist conditions, such as those experienced by older people.
Since August 2004, there have been seven deaths at Acklington including that
of this man. Four of these were due to natural causes and three were
apparently self-inflicted. Investigations into all seven deaths have been
undertaken by my office or are in progress. Two previous recommendations
made that are echoed in this report are:
(cid:127) that staff should trained and equipped to recognise an emergency;
(cid:127) consideration should be given to provide first aid training for staff who
have contact with prisoners.
The prison has accepted that it should ensure that staff are trained and
equipped to recognise an emergency. A target date of 31 March 2006 was
set for discussions with the Head of Healthcare regarding suitable training.
The recommendation for providing first aid training for all staff was not
accepted by the prison. The prison’s response was that officers receive basic
training when they join the Prison Service and that refresher training is
decided at a local level.
Events leading up the death of the man
The man was sentenced to 15 months imprisonment in October 2003. He
began his sentence at HMP Woodhill, but transferred to HMP Lewes on 10
October 2003. He was released on 12 March 2004 on a two year licence, but
was recalled to prison on 27 May 2004 for breaching its conditions. At the
time of this recall he had no fixed abode having had his bail hostel
accommodation withdrawn due to breach of his licence.
He first served the remainder of his sentence at HMP Durham and came into
the custody of HMP Acklington on 11 June 2004. His extended sentence was
reviewed in January 2005, but the Parole Board concluded that he still posed
a risk to the public. He moved to C Wing and into a single room (C2-02) in
May 2005.
He had a long history of heart disease. His medical records indicate that he
had suffered a heart attack in 1989. Following this, he received treatment for
angina. he also suffered from hypertension (high blood pressure). Whilst at
Acklington he was prescribed a GTN spray, Aspirin, Atenolol and
Symvastation. He received regular monitoring and well-organised chronic
disease management and preventative care. He was last seen by healthcare
staff on 3 October 2005 for a flu vaccination.
Despite being of retirement age, he wanted to continue working. He had a
position in the tailoring workshop. On the morning that he died, he left his
room as usual and went to work following breakfast at 7:50am. That morning
he worked on the press in the workshop. The person in charge of his section
in the workshop that morning told my investigators that there was nothing
noteworthy about him that day. In her opinion, he appeared to be in normal
health. At the end of the morning shift, he returned to his wing with the others
for lunch at midday.
In line with the daily routine, a roll check was taken at 12:30pm and everyone
returned to their rooms before the afternoon session of work or education.
The second call for work would normally take place at around 1:40pm.
However, on this particular afternoon the call was made five to ten minutes
late. It is usual practice for prisoners who are not attending work to remain in
their rooms until this movement is completed. The man was in his room at
this time as he was expecting a meeting with probation. His door was locked
from the inside.
Two officers were on C wing supervising the second movement of prisoners
to work. They were the only officers on the wing. At 1:50pm, a prisoner in the
room opposite the man heard one of the officers shouting. The officer was
trying to tell the man that his scheduled probation interview had been
cancelled. This was not an ideal way of delivering the message to him. It
would have been more appropriate to wait until the end of the movement and
inform him in person. Alternatively, he could have asked another member of
staff to deliver the message as he was unable to leave his post at this time. A
prisoner heard a second call for the man from the officer and thinking it
unusual that he had not appeared or responded to this call, went to knock on
his door. He knocked several times but received no answer. The prisoner
lifted the hatch on the door to look inside and saw that the man was sprawled
on his table.
The prisoner immediately went to alert the officer that something was very
wrong with the man and that he should come and check on him. The officer
went to the man’s room and opened the hatch to look inside. He saw that he
was slumped on to his table and noticed that his ears had turned blue. His
initial thoughts were that this was a prank and that his ears had been painted.
He drew his keys and unlocked the door. On approaching him, he could see
he was unwell and felt for a pulse. There was none, nor any signs of
breathing, so he called for a prisoner on the landing to inform another officer
and ask him to telephone healthcare for medical assistance. The first officer
was not carrying a radio.
The second officer was in the office on the floor below at 1.55pm. The
message he received did not highlight the severity of the situation. It was not
clear who needed medical attention or the level of assistance required. This
officer immediately informed the Communications Room but there was no
request for emergency services at this stage. It was also not made clear that
an emergency response bag or defibrillator might be needed. The
Communications Room put a call out over the radio alerting healthcare staff to
make their way to C Wing.
A senior officer (SO) was duty senior officer for Residential 1 (A, B and C
wings) that afternoon. He was in the front office on B Wing when he heard
the call over the radio for healthcare to attend C Wing. The SO felt they might
benefit from additional help so he immediately made his way to the wing. B
Wing neighbours C Wing and is also part of the Vulnerable Prisoners Block.
The distance between them is short. The SO arrived at the man’s room at
1:56pm.
On arrival, the SO met both officers. At this stage, there were still prisoners
on the landing as it was mid movement time. One officer came down the
stairs to the ground floor and led the SO to the man’s room. The door had
been shut and the second officer was standing outside. The SO entered the
room. He found the man sitting on his chair and slumped over the table. His
face had turned a grey/blue colour and he was unresponsive. Fluid had
collected in his lower limbs. The SO has current first aid training so he lifted
him to the floor to assess him further and start resuscitation. As he lifted him,
he noticed that he had been incontinent. He began the first cycle of Cardio
Pulmonary Resuscitation (CPR). During this time, an officer secured the
landing to make way for the healthcare staff.
At 1:58pm, the Communications Room informed the orderly officer, and duty
governor, of the situation. The duty governor made his way to C Wing.
As the healthcare team were making their way to the wing, they decided to
collect the emergency response bag. A nurse went to fetch the bag from the
wing whilst a second nurse made her way to the man’s room. At 2.00pm, the
second nurse arrived at room C2-02. At this stage, she had still not been fully
informed of the situation. The SO was continuing to administer CPR. He had
completed six cycles. The second nurse quickly asked what had happened
and checked for vital signs. He had fixed dilated pupils, no pulse and was not
breathing. She immediately called for the defibrillation machine to be brought
over and for an ambulance to be called. The ambulance was called at
2:00pm. The Gate was advised that an ambulance had been called for and
they should be on stand-by. At this time, the first nurse arrived at the room
with the emergency response bag. The second nurse asked the SO if he was
happy to continue giving chest compressions and she took over managing the
airway using a bag and mask from the response bag.
At 2:05pm, the defibrillator was brought from healthcare to the room by a third
nurse. When this nurse arrived, the first nurse left the room to fetch a shot of
adrenalin to aid the resuscitation. The adrenalin is kept on H Wing. Staff told
my investigators that emergency equipment is spread across the prison so
that is more readily accessible to healthcare staff. The third nurse took over
airway management whilst the defibrillator was connected. One shock was
delivered. The defibrillator indicated that no further shocks were needed and
they should continue with CPR.
By 2:07pm, more staff had arrived. Two SO’s from the Care Team, the
chaplain, the orderly officer and a governor were all present. They all
remained on the landing whilst the healthcare team continued with CPR.
At 2:10pm, the first nurse returned and took over chest compressions. The
first SO went out onto the landing and began briefing the orderly officer. The
second nurse administered one shot of adrenalin. The team continued with
two to three further cycles of CPR until 2:17pm before reassessing the man’s
status. He had fixed and dilated pupils and there were no signs of a pulse or
breathing after 25 minutes of CPR. The team decision was to stop CPR and
the second nurse contacted a doctor who agreed with their decision. The
ambulance had arrived at the establishment but the paramedics were no
longer required.
Events after the death
The first SO secured the room and handed over to the security principal
officer (PO), who continued to manage the scene. The PO left the landing to
collect secure locks for the room from Security.
At 3:33pm, a doctor, the second nurse and the PO entered the room. The
doctor pronounced the man’s death at 3:35pm and the room was secured.
The prisoner who had the cell opposite was seen by the chaplain immediately
after the man’s death and was given thanks for his support by both the unit
staff and healthcare.
A staff debrief with the deputy governor, was held in the board room at
4:20pm. Initial statements from some of staff present during the incident were
given. The first officer did not attend because he was required elsewhere. The
duty governor commented on the lack of a ‘code blue’ status and how this
meant that healthcare staff were unaware of the situation before them. More
information could have meant they would have brought the defibrillator with
them to the man’s room. However, it was not clear this would have had a
significant impact upon the man’s situation.
In addition, the deputy governor suggested that the ambulance protocol might
need a review. For future situations, the emergency services should be called
first, and cancelled if not eventually needed. The head of healthcare, agreed
that the protocol should be revisited and that the policy should also change so
that all staff working within the prison should be responsible for summoning
an ambulance if needed, rather than waiting for healthcare to do this.
During the debrief it was noted that there had been a considerable delay in
the verification of the man’s death. The Northumberland Primary Care Trust
policy states that community nurses are not permitted to verify an unexpected
death. Therefore, they were required to wait for a doctor to arrive.
The man had named his daughter as his next of kin. She lives in
Bedfordshire and there would have been a delay in informing her of her
father’s death should the Governor have delivered the sad news in person.
The police were therefore asked to notify her. On finding the next of kin
contact details Acklington’s police liaison officer informed Bedfordshire police
as requested they speak to his family. The police contacted his daughter at
11:20pm that evening.
Acklington’s family liaison officer, made contact with the family offering
condolences, assistance with the cost of the funeral and the opportunity to
visit the prison. The offer of financial assistance was duly accepted, but the
family declined the prison’s offer of a representative attending the service.
The funeral took place on Tuesday 1 November.
The following day, his daughter visited the prison and met with the Governor,
who showed her father’s room. She also spoke with a prisoner on C Wing
who had known her father.
Clinical Review and Police Investigation
Clinical Review
A doctor from Northumberland Primary Care Trust (PCT) undertook the
clinical review. The doctor analysed the medical records from both HMP
Durham and Acklington. He concluded that the man had received “excellent
chronic disease management” at Acklington. Regarding his collapse on the
day he died, the initial examination by the second nurse indicated that he was
likely to have already been dead when they started to resuscitate. The doctor
said that, as staff had nevertheless started resuscitation, they were correct to
continue doing so until it was clear that nothing further could be done. He
also commented that the healthcare team were correct to discontinue
resuscitation when it was obvious their efforts were ineffectual and he was
clearly dead.
The PCT is undertaking a critical event analysis to examine existing
procedural guidelines and address a range of governance issues. The doctor
wrote that, whilst this case highlighted the need for such a review, his care
was not in any way compromised.
Police Investigation
A letter from a prisoner on C Wing was sent to my investigators regarding the
death. The letter makes an allegation against a member of staff who
supposedly dismissed the man’s complaints of chest pains before he went to
work on the morning that he died. Allegedly, the prison officer told the man to
“get in line and go to work”.
The Northumberland Constabulary are undertaking a separate investigation
into this allegation. It is hoped that this investigation will be concluded in time
for the adjourned inquest scheduled to take place on 5 December 2006.
Findings and conclusions
I do not believe that healthcare or discipline staff could have done anything
further to prevent this death. However, during the course of this investigation
several issues have been brought to my attention that could adversely impact
upon future incidents.
The prison has an emergency response protocol which requires staff, when
raising the alarm, to identify the kind of emergency they are facing. If
someone requires an emergency response that needs a defibrillator or
breathing equipment, then a ‘code blue’ should be called. On alerting the
Communications Room to the man’s collapse, the second officer did not issue
a ‘code blue’ warning. This meant the healthcare team were not fully
prepared for the emergency when they arrived at the man’s room.
Fortunately, the nurses acted on their own initiative and one returned for the
emergency response bag before arriving at the room. However, further trips
were required to fetch the defibrillator and adrenalin. This could have been
prevented if an adequate alert had been given.
The problem in this case seems to have been lack of communication between
staff caused by poor equipment. Not all officers in Acklington carry radios.
For those who do carry radios, there is an additional problem with the battery
life of the radios and an apparent ‘dead spot’ on C Wing for radio
communication. In addition, there are no alarm points on the wing landing.
Alarm points are all located near the end of the corridors. The lack of radios
and infrequent alarm points mean that staff, and prisoners, are currently
relying on passing messages by shouting along landings, using prisoners to
deliver messages. This point extends to how the first officer chose to inform
the man of his cancelled appointment.
The officer, who was the first to enter the man’s room, did not have a radio.
He had to rely on a prisoner to take a message to a second officer; the only
other officer on the wing. The second officer was in an office on the floor
below. The message he received from the prisoner did not make the type of
emergency clear. I think it is extremely bad practice to use a prisoner to relay
details of an emergency. It leads to poorly informed and delayed
communication, and to staff being ill prepared for an emergency. In this case,
it may not have affected the outcome, but the prison needs to take urgent
steps to avoid similar problems in the future.
The emergency services were not called until the second nurse arrived at the
man’s room. The current policy at Acklington is that the responsibility falls to
healthcare staff when it comes to requesting an ambulance. However, Prison
Service guidance makes it clear that time must not be wasted in summoning
emergency assistance. Therefore, if discipline staff are first on the scene they
should not wait for healthcare to arrive before deciding if an ambulance is
required. The head of healthcare has already raised this issue within the
prison and has redrafted the operational protocol lines to state:
“The summoning of a ‘999’ ambulance is not restricted to the
Healthcare staff. All staff working within the prison who discover
someone seriously ill or injured can and should summon a ‘999’
ambulance without delay.”
At present the PCT’s Nursing Policy for the verification of death limits
community nurses to verifying expected deaths alone. This means that a
nurse cannot verify the death of someone who dies unexpectedly, for example
of a heart attack. In such cases, a GP or on-call locum has the responsibility
to refer the death to the Coroner. A review of this policy is currently being
considered by the healthcare manager with the support of a doctor from the
PCT.
Healthcare staff told my investigators that emergency equipment is spread
across the prison grounds to make it more readily accessible when required. I
am unsure of the logic behind this policy as staff still have to travel to more
than one location if they need access to a defibrillator, adrenalin and an
emergency response bag. This may hinder a quick healthcare response to an
emergency situation.
Recommendations
1. The Governor should remind wing staff always to use emergency
codes when summoning assistance to an emergency.
2 The Governor should consider revising the prison’s policy to make
discipline staff equally responsible for calling emergency services. An
ambulance can always be cancelled if on arrival the healthcare team
decide it is no longer necessary.
3 The Governor should consider increasing access to radios for all
discipline staff and/or consider increasing the number of alarm points
on the wings.
The clinical review also makes a number of recommendations, which I
fully support:
4 The Primary Care Trust should examine how procedural guidance
could be improved with particular reference to:
(cid:1) Group directions for nurses
(cid:1) Nurse certification of death
5 The Primary Care Trust and the Governor should review the need
for more cardiac defibrillators and agree where they should be best
situated.
6 The Primary Care Trust and the Governor should review the training
needs of all staff, both clinical and discipline, who may be involved in
resuscitation, with the aim of updating existing levels of training and
increasing the numbers of staff with such skills.
7 The Governor should consider with the Head of Healthcare where
emergency response equipment is kept in the prison. Equipment
should be readily accessible to ensure the quickest possible response.
The clinical review notes that recommendations 4, 5 and 6 are already
being addressed and will be taken forward via clinical governance
activities or at the Prison Health Development Group.
Good Practice
The clinical review also identifies the following areas of good practice.
(cid:2) Excellent and well-organised chronic disease management and
preventative care.
(cid:2) Clear computerised medical records.
Response to the report
The Prison Service has accepted the recommendations put forward in this
report.
Actions to taken for each recommendation are:
1. The Governor will issue a notice to staff reminding them to always use
emergency codes when summoning assistance to an emergency. All
managers will be advised of this, as will Communications Room staff. Target
date for completion - April 2006.
2. The Governor will issue a notice to staff and advise all managers that
discipline staff are equally responsible for calling emergency services and this
should not just fall to healthcare staff. Target date for completion - April 2006.
3. Head of Security at HMP Acklington will evaluate and advise the
Governor on the cost and feasibility of:
(cid:127) increasing access to radios for all discipline staff; and
(cid:127) increasing the number of alarm points on the wing.
Target date for the evaluation – April 2006.
Clinical Recommendations
4. Group directions for nurses: Patient Group Directions are being
considered by an NHS working party. Once complete they will be passed to
Northumberland Care Trust to assess and approve. Target date for
completion – September 2006.
Nurse verification of death: Working party from the Primary Care Trust and
Clinical Director of Nursing will consider the need to amend the
Northumberland Care Trust policy to allow nurses to verify death. Target date
for completion – September 2006.
5. The issue of increased access to defibrillators will be discussed with
the Prison Officer’s Association (POA). These discussions will identify the
way forward, including provision, location and staff training. Target date for
completion – May 2006.
6. Meetings will be arranged between the Healthcare Manager, Head of
Residence, Health and Safety Advisor and Training Manager to discuss
needs, method and delivery of appropriate first aid training. The aim will be to
update existing levels of training in resuscitation and to increase the number
of staff with such skills. Target date for completion – May 2006.
7. The Head of Healthcare and Head of Residence will identify suitable
locations for emergency equipment to be kept in the prison. Once agreed,
appropriate equipment and instructions will be provided and put in place.
Target date for completion – May 2006.