Individual at The Verne

Investigation into the circumstances surrounding the
death of a man in July 2009,
at HMP The Verne
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
This is the report of an investigation into the death of a man in July 2009. The man
collapsed in his friend’s room at about 11.15pm on 13 July 2009. His friend alerted
the night officer who radioed for assistance. Within a few minutes officers arrived
and an emergency ambulance was called. Two officers attempted cardio pulmonary
resuscitation (CPR) until the arrival of paramedics at 11.23pm. The man was
confirmed dead at 00.17am by the paramedic. He was 58 years old.
The man did not have any next of kin recorded in his prison file and his friends
confirmed that he did not have any contact with family or friends whilst in prison. I
extend my condolences to his friends at The Verne and those who have been
touched by his death.
HM Coroner for Western District in Dorset was informed of the Ombudsman’s
investigation. A post mortem was undertaken which found that the man died of a
heart attack caused by coronary artery thrombosis (a clot in a heart artery).
The investigation was undertaken by one of my colleagues. A review of the man’
healthcare whilst in custody, was commissioned from Dorset Primary Care Trust
(PCT). I am grateful to a doctor for his report. I would also like to thank the
Governor of The Verne and her staff for their help and assistance. I am especially
grateful to the liaison officer.
I make one recommendation to the Governor in training night staff in the use of
defibrillators (machines used to restart the heart). I acknowledge the good response
by prison staff to the man collapse and the support offered to the man’ friends.
Additionally, I note the good practice of staff in following up that support to prisoners
on the wing. I make one observation regarding the endorsement in prison files of
prisoners who decline to provide their next of kin details to be recorded. Finally, I
note three areas identified by the clinical review for the attention of the Head of
Healthcare.
In this final report the Governor has partially accepted the recommendation and
accepted the three areas of good practice as noted in the draft report.
Jane Webb
Deputy Prisons and Probation Ombudsman January 2010
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CONTENTS
Summary
The Investigation Process
HMP The Verne
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was remanded to HMP Wormwood Scrubs in January 2006 charged with
drug importation. He was sentenced to eight years imprisonment on 31 March and
returned to the prison. The man transferred to The Verne on 15 January 2007.
On his reception into The Verne, clinical staff noted that the man had a history of
angina, asthma, high blood pressure and depression. It was further noted that he
had enlarged breasts following hormone therapy in the 1990s. The man was
prescribed medication for his illnesses and placed on a wing.
Over the next two years, the man regularly attended the healthcare unit for blood
pressure checks and support for his depression. In September 2007, with the
support of the doctor, an application for funding was made to Dorset PCT for plastic
surgery to reduce his breast tissue. In 2008 Dorset PCT told the doctor they could
not fund the operation.
Regular reviews of the man’ blood pressure were conducted, and were variable, but
often high. Following blood tests for high cholesterol medication was prescribed. In
May 2009, the man was seen in the healthcare unit with a swollen testicle. An
appointment was made for him to see a specialist. The man was admitted to
hospital on 26 May. His testicle had doubled in size and he was in pain. He was
discharged back to The Verne four days later, but readmitted overnight on 30 June
as the problem was not improving. A surgical procedure to remove a cyst was
planned for a future date.
On 13 July, about 11.00pm, the man was having coffee in a friend’s cell when he
collapsed onto the bed. The friend immediately alerted night staff and four officers
attended. Three of the officers carried out CPR whilst an emergency ambulance
was called. At 11.24pm, a paramedic attended to the man and CPR was continued
by prison staff. Further ambulance personal arrived and, despite intensive medical
care, the man was pronounced dead at 00.17am by the paramedic.
I note the three areas of suggestion by the clinical reviewer in relation to healthcare
issues for consideration by the Head of Healthcare. One recommendation is for the
attention of the Governor relating to training prison night staff in the use of
defibrillators. I acknowledge the good practice of staff who responded to the man’
collapse and the support given to prisoners following the death of their friend. Lastly
I make one observation about recording next of kin details.
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THE INVESTIGATION PROCESS
1. The investigation into the man’ death was opened on 23 July 2009, when my
colleague visited The Verne. She was met by the liaison officers and
reviewed the man’ prison and medical files. Copies of documents from those
files were given to my colleague. She met the Governor and explained the
process of the investigation. The Ombudsman’s terms of reference and
notices of investigations had been sent to the prison in advance of her visit.
2. Later, my colleague visited C wing and spoke to two prisoners who knew the
man. One of the prisoners was present when he collapsed on 13 July. My
colleague also spoke to the Chair of the Prison Officer’s Association, Officer.
The Chair of the Independent Monitoring Board, had already apologised to Ms
Gilbert that he would not be available to see her. Before my colleague left
The Verne, she spoke to a counsellor who regularly saw the man.
3. A review of the man’ healthcare whilst at The Verne was commissioned with
Dorset PCT. On 1 October, my colleague spoke to the senior nurse in the
healthcare unit.
4. The man did not offer any next of kin details to be recorded in his prison
records, therefore it has not been possible to identify any family or friends to
be involved in this investigation.
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HMP THE VERNE
5. The Verne is a category C training prison for up to 595 male adult prisoners.
There are six identical wings which include dormitory accommodation with
curtained bed spaces. A1 and C1 wings accommodates prisoners who have
attained the highest level in the Incentives and Earned Privileges scheme.
(The IEP scheme is a reward system for prisoners who adhere to prison
regime and participate in work, education and offending behaviour
programmes.) Those wings allow the prisoners to have own keys to their
rooms. Prisoners are not locked into their rooms and there is a certain
amount of freedom to move around the wing. However the prisoners must be
in their rooms for roll checks.
6. Health services at The Verne are commissioned and provided by the Dorset
Primary Care Trust. The healthcare centre is a single storey building located
at one end of the prison. There are no inpatient facilities and healthcare staff
are not on duty, in the prison, during the night. Prisoners who need inpatient
care are normally taken to the County Hospital in Dorchester, some 14 miles
away.
7. The Verne was last inspected by HM Chief Inspector of Prisons in August
2007. An extract from the summary of that report said:
“The healthcare department provided a good range of clinical services.
There was a range of nurse-led clinics, and an identified nurse for older
prisoners. There were good dental services, although the waiting list was
long. Mental health services were good, with dedicated primary care
nurses holding daily clinics. There were good relationships with the local
primary care trust, and opportunities for staff to work in the community to
maintain skills and knowledge of current practice. Many NHS outpatient
appointments were cancelled because of difficulties with staffing escorts.”
(In this final report, Dorset Community Health Service commented that
staffing escorts refers to prison officer escort, not healthcare staff.)
8. In their report on The Verne for the period November 2006 - May 2008, the
prison’s Independent Monitoring Board (IMB) also drew attention to some
aspects of the provision of healthcare by the Dorset Primary Care Trust. (IMB
members are volunteers who impartially monitor the prison and prisoners.)
9. The Ombudsman has investigated three other natural cause deaths at The
Verne. In my report into one of those deaths, attention was drawn to the
absence of defibrillators and recommended that the Primary Care Trust
should provide a defibrillator for use in the establishment. I will deal with this
in this issue section of the report. A previous death at The Verne was similar
to that of the man in that he also had died of a heart attack. However, that
death occurred during the day when healthcare staff were on duty.
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KEY FINDINGS
10. The man was received into The Verne on 15 January 2007. It was noted in
his first reception health screen that he had high blood pressure and angina
for which he was prescribed a Glyceryl Trinitrate (GTN) aerosol spray. The
man told the nurse he experienced mild depression when ‘things go wrong’.
11. A doctor examined the man the following day and noted that he had been
prescribed an anti depressant for two years to help stabilise his moods. The
doctor further wrote that the man had angina, asthma since childhood and
gynaecomastia (enlargement of breast tissue). The doctor concluded his
examination by recording that the man had considered gender realignment
but had stopped the full process following the death of his partner. A
medication regime was prescribed for the man, which included Atenolol, the
GTN aerosol spray and aspirin for angina, Citalopram for mild depression and
an inhaler for asthma.
12. On 23 January, the doctor referred the man to an ophthalmology department
out patient appointment at hospital following a suspected diagnosis of
glaucoma at an optician’s examination. Three weeks later, the man was seen
by a nurse. The nurse noted that the man had reduced the amount he
smoked but refused nicotine replacement therapy. He told the nurse that he
had not settled at the The Verne and had experienced several angina pains
since his transfer. The nurse arranged a blood test and to repeat his blood
pressure readings one week later.
13. The man saw the doctor on 14 March. He told the doctor he was not sleeping
and worried about sharing a cell with another prisoner. The doctor offered
advice on smoking cessation and prescribed Simvastatin, for high cholesterol.
In April it was noted that the man failed to attend smoking cessation sessions.
On 27 April, The man’ blood pressure was reviewed and found to be within
normal range (a normal range of blood pressure is 130/80).
14. A week later the man told the doctor that he was, ‘going through hell’, in this
prison because of his sexuality and was being harassed and wanted a single
cell. The doctor advised the man to speak to his personal officer as this was
a discipline matter. (It is unknown if the man spoke to his personal officer,
however he was given a single cell when he moved onto C1 wing in May.)
15. On 18 September, a nurse checked the man’ blood pressure which remained
within normal range. A month later, he discussed with another nurse his
concerns about his breasts. He felt that prisoners were making fun of him
which he found tiring and upsetting. The nurse agreed to speak to the doctor
and a registered mental health nurse. The doctor saw the man on 16
October, when they spoke about his enlarged breasts. The doctor wrote that
the man had not been taking hormone therapy for four to five years and his
breast tissue had not reduced. The doctor agreed to refer the man to a plastic
surgeon.
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16. A nurse saw the man on 22 October and he again mentioned the difficulties
he was having with other prisoners. He had no thought of harming himself but
had difficulty sleeping which was affecting his motivation. The man told the
nurse that he was now waiting for an appointment for the removal of his
breasts. The nurse told him she could see him again in two weeks if he
needed support.
17. On 14 November, the doctor received a letter from the out patient manager of
a hospital. The letter indicated that funding was not routinely provided for
breast surgery and application for funding would need to be secured through
the Primary Care Trust. The hospital would consider the referral once funding
was secured.
18. The man was seen by a nurse on 23 January 2008. He was generally unwell,
complaining of chest pain, heartburn and his fingers were white with pins and
needles sensations. The man told the nurse he had used his GTN spray
several times and his inhaler for his asthma over the previous three days.
The nurse discussed the man’ symptoms with the doctor who then prescribed
Omeprazole for indigestion, and said he would review him again in one
week’s time.
19. The following week, the doctor examined the man and wrote that he was
feeling better since taking Omeprazole. The doctor told the man that an
application had been made to the PCT for funding his breast surgery and he
was waiting for a response. On 1 April, a nurse reviewed the man general
health and noted that his blood pressure was in normal range.
20. Two days later, in response to the PCTs request for additional information,
the doctor wrote to the senior commissioning manager. The doctor gave a
medical history of the man’ general health and his hormone treatment in the
1990s. The doctor wrote that the man’ breasts were noticeable and causing
him great embarrassment. In conclusion the doctor said that the man had told
him that had been listed for surgery in London prior to his arrest.
21. On 25 April, the PCT wrote to the man and the doctor to inform them that his
application for breast surgery had been rejected. Three days later, the man
was seen by a nurse who noted his poor emotional state. He was upset
about his medication and the news that his funding for breast reduction
surgery had been rejected. The man felt he should not be prescribed
dispersible aspirin and said he had been bleeding from his rectum over the
last two days. The man preferred to take aspirin in tablet form.
22. The following day, the man was seen by the doctor who examined his rectum
and abdomen. He told the doctor that he had little energy and complained
about taking aspirin. The doctor asked for blood samples and told the man to
report any heavier bleeding. On 29 April, the doctor referred the man for an
out patient appointment with a colorectal (bowel) surgeon.
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23. The man saw a nurse on 23 June and told the nurse he was still getting some
occasional chest pain and shortness of breath whilst walking. His blood
pressure was high at 185/114. A week later, the nurse re-checked his blood
pressure which had improved but was still high at 173/96. The man told the
nurse that he had asked for a transfer from The Verne which would be
beneficial for him. The nurse arranged to check his blood pressure in two
weeks’ time.
24. The man declined to attend hospital for a sigmoidoscopy on 11 July. (A
sigmoidoscopy examines the bowel through a camera passed into the
rectum.) A nurse advised him to go to the appointment to check the
symptoms of his rectal bleeding. However, the man said he did not want to
go, he felt better and the medication had resolved the bleeding. He signed a
disclaimer form declining the procedure and attending the hospital. The man
told the nurse that he was still finding it difficult to settle at The Verne. The
nurse advised the man that she would speak to the doctor about his work in
the gardens which he found too strenuous.
25. On 17 July, a nurse checked the man’ blood pressure, which had risen to
171/121. He told the nurse that he had chest pain the previous evening and
used his GTN spray. The nurse said that the man should only work on light
duties and she would inform the allocations officer of this. (An allocation’s
officer arranges work placements within the prison.) The doctor prescribed
Amlodipine, a medication for high blood pressure.
26. Three weeks later, the man’ blood pressure reading was noted to be 168/92
which had improved since he had started the Amlodipine. On 28 August, a
greatly improved reading of 143/85 was recorded. The man was also noted to
be happier working with the fish ponds, watching television and making
friends. The man had a blood test on 25 September and a month later his
prescription of Simvastatin was increased as his cholesterol levels had risen.
27. The man saw the doctor on 4 November and his blood pressure had risen to
180/106. He told the doctor that he had reduced his smoking and felt his
angina was well controlled. Six weeks later, the doctor again noted that the
man’ angina was improving and his blood pressure, whilst above normal
range, was recorded at 169/91.
28. On 20 January 2009, the man had a blood test, which showed improved
results. A month later, the man saw a nurse who noted that his blood
pressure reading was high at 194/94. He told the nurse that his blood
pressure had been up and down for years. The man said he needed a heart
by pass operation but would not be allowed to have one as he refused to give
up smoking.
29. A doctor saw the man on 9 March. He told the doctor that although the PCT
refusal to fund his breast surgery still concerned him he had no thoughts of
self harm. The doctor increased his medication for depression and noted that
his blood pressure was high at 224/109. On 1 April, a blood pressure check
showed that the man’ reading had improved at 175/91, but still above normal
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range. Two weeks later another improved blood pressure reading was
recorded at 166/87.
30. The man saw the doctor on 11 May, he had pain in his testicle and on
examination, the doctor thought he could feel a cyst. A referral for the man
was made to hospital .
31. Between 13 May and 26 May, The man was seen three times by nurses and a
doctor complaining of pain and swelling in his scrotal area. Medication was
prescribed but the man was admitted to hospital on 26 May as his testicle had
swollen to double the normal size and he was in pain. The man was escorted
by two officers and restrained by an escort chain. (An escort chain is a 1.8
metre length of chain with one cuff attached to an officer and the other cuff to
the prisoner.) He was discharged back to The Verne on 30 May, and a cyst
was diagnosed in his scrotum. Antibiotic medication was prescribed. An out
patient appointment would follow, when a surgical procedure would be
considered.
32. On 1 June, the man was prescribed with medication to help him sleep. Three
days later, he saw the doctor who noted that, whilst his testicle was still
swollen his symptoms were improving. A fortnight afterwards on 15 June, the
doctor discussed the man’ condition with the urologist as the swelling was
increasing. Two weeks later, the man was given a sick note by the doctor to
excuse him from his work duties.
33. The man was re-admitted to hospital on 30 June. The swelling to his testicle
was still present and worsening. He was again escorted by two officers and
restrained on an escort chain. An ultrasound procedure (a scan using high
sound waves) confirmed that the man had a cyst. Antibiotic medication was
prescribed and arrangements made for a surgical removal of the cyst. The
man returned to The Verne the following day.
34. On 7 July, a doctor reviewed the man and noted that the swelling in his
scrotum was not improving. The doctor recorded that the swelling was
worsening and he prescribed Promethazine Hydrochloride (an antihistamine).
The doctor made contact with the urologist to ask for the surgical procedure to
be expedited.
35. At about 10.00pm on 13 July, the man went to see a friend for coffee. (The
regime on C1 wing allows prisoners to have their own rooms with keys and
freedom to move around the wing.) This was a usual habit for the two friends.
The man sat in chair and after an hour, his friend thought that he looked
unwell. Suddenly he seemed to fall from the chair and across the friend’s
bed. The friend saw urine on the floor and was unable to rouse the man. The
time was now 11.10pm.
36. The man’s friend immediately left his room and ran to the wing office on the
ground floor. He told an Operational Support Grade (OSG) that the man had
collapsed in his room. The OSG ran upstairs to the man’s friend’s room and
saw him lying on the bed. The OSG made an urgent radio call for
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assistance. Shortly afterwards, the Night Orderly Officer (NOO), a Senior
Officer (SO) and another officer responded and arrived in the man’s friend’s
room. The officers moved the man to the floor, into the recovery position and
The officer went to the wing office to telephone for an emergency ambulance.
Two more officers then joined their colleagues in the room.
37. The two officers commenced cardio pulmonary resuscitation (CPR) with
mouth to mouth resuscitation and were re-joined by an officer. The officers
then took turns administering CPR. (A defibrillator was not used by the
officers. A defibrillator is a machine that delivers an electric shock to the
heart.) The SO went to the wing office and spoke to the Ambulance Service
by telephone, to inform them of the severity of the man condition. The SO
then made his way to the gate (the main entrance of The Verne) to meet the
ambulance and escort it to the man. The man’s friend was taken to the room
of another prisoner, so he could be cared for following the collapse of his
friend. The prisoner is a Listener, which is Samaritan trained prisoners able to
offer support to other prisoners in times of crisis.
38. At 11.24pm, a paramedic arrived at the cell and began to examine the man.
The paramedic asked the officers to move the man into the corridor area of
the wing to give more room and took over the medical responsibility for the
man care. The officers continued to assist with the CPR until the arrival of
two ambulance technicians.
39. Despite emergency medical care, the man was pronounced dead at 00.17am
on 14 July by the paramedic. He spoke to the man’s friend and told him of his
friend’s death and offered to take him to see the man. He was too distressed
and therefore declined to see the man.
40. The man’s friend remained in the Listener’s room for several hours being
supported by his friend and the officers. At 5.00am, he was taken to the
Listener’s suite for some rest and accompanied by two more Listeners who
continued to support him. A hot de-brief was held at 1.50am by the Duty
Governor with a member of the staff care team and all personnel that had
assisted in the man’ collapse.
41. No next of kin were traceable through prison records and so the chaplain
arranged the funeral and a memorial service which was held in the prison
chapel.
11
ISSUES
42. A review of the man’ healthcare was undertaken by a doctor on behalf of
Dorset PCT. The doctor examined the man’ medical records and the events
leading to his death.
Clinical care
43. The doctor noted that the man had high blood pressure, raised cholesterol,
angina, depression, breast enlargement and an epididymal cyst. (An
epididymal cyst is a growth of non malignant cells in the testicle.) It was also
recorded that The man was mildly overweight and a smoker. However, the
doctor said that none of those illnesses were verified from an outside source.
44. The man regularly attended healthcare for appointments with the doctor and
nurses. He was offered help to stop smoking and given dietary advice to
lower his cholesterol. The man was supported by healthcare staff when he
experienced difficulties with anxiety and depression. The doctor noted that all
the man’ medical complaints were dealt with appropriately and promptly.
45. The doctor said:
“The medical notes are kept in computerised format and are, therefore,
clear, chronological and annotated with the name and profession of the
person with whom the man consulted. The notes are of a good quality.
The care the man received was comparable to what he could expect in the
community and the advice of National Service Frameworks for
Hypertension and Coronary Heart Disease were followed. An additional
consideration, however, could have been made by the prison medical
service of referring him [the man] for a cardiological assessment in view of
his angina and high blood pressure readings.”
46. The post mortem report listed the man’ cause of death as coronary artery
thrombosis, alongside diseased heart arteries. This was consistent with the
man’ medical history and his failure to stop smoking. His collapse on the
evening of 13 July was due to a massive cardiac attack which was confirmed
from the statements by the witnesses for that evening. The doctor noted that,
in his opinion, the epididymal cyst and infection were not a contributory factor
to the man’ death.
47. the doctor concluded his review by suggesting three areas that could be
examined and said :
(cid:127) “I am aware there are problems obtaining medical record records of
prisoners prior to their sentence, but I believe every effort should be
made to verify a prisoner’s account of their medical problems.
(cid:127) “Chronic disease management is an important component on primary
care and although the man’ high blood pressure and angina was
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managed adequately at an individual level, I did not gain the
impression there was a system in the prison to manage all prisoners
who have vascular disease.
(cid:127) “The man died at a relatively young age of a disease which was known
to be present and symptomatic (if not consistently) for at least two
years. I felt consideration for a cardiological opinion should have been
considered as he was experiencing symptoms despite standard
medical treatment.”
48. The doctor wrote that none of those factors suggested that the man’ care was
compromised through being in prison. I note the findings of the clinical review
and ask that the Head of Healthcare and Governor consider the doctor’s
comments.
Response to the man’s collapse
49. Four officers attended to the man following the emergency alert from the
OSG. The SO and one officer moved the man from the bed onto the floor
and were joined by two more officers. At around 11.15pm, these two officers
started mouth to mouth resuscitation and CPR and were re-joined by the
officer. On the arrival of the paramedic, the three officers continued with CPR
until 11.40pm when the ambulance personnel joined them. The officers
remained with the man, continuing to offer help until he was pronounced dead
at 00.17am the next day.
50. There are no healthcare or nursing staff on duty during the night shift at The
Verne. Following the man’ death the officers continued to work the night duty
and ensured his friend and the Listener were cared for.
51. I am satisfied that the SO managed the emergency to a high standard. He
supervised prison staff and ensured that the paramedics had immediate
access to the prison on their arrival. Later, he supported staff and prisoners
following the man’ death.
The SO and three officers who responded to the man’ collapse in a professional
manner and their attempt to resuscitate him is noted as good practice. Furthermore,
I note the care they afforded to the man’s friend and Listener.
Use of defibrillator
52. A defibrillator was not used in the resuscitation attempt on the man. The
Listener told the investigator that he thought it would be useful to have
defibrillators on all the wings. A previous death in custody at the Verne raised
recommendations about the lack of defibrillators in the prison and one
defibrillator is now sited in the healthcare unit. A second defibrillator is on
order and will be located outside the healthcare centre in a central location for
easy access in an emergency.
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53. It is clear from the clinical review that the man had a massive heart attack and
received prompt attention from prison staff who used appropriate resuscitation
techniques. However, as no healthcare or nursing staff are on duty during
night shift I recommend that at least one night shift officer is trained to use the
defibrillator and is aware of its location..
At least one member of staff on night duty should be trained in the use
of a defibrillator and be aware of its location in the prison.
Care of the prisoners following the man’ death
54. His friend was deeply affected by the man’ death. Following the man’s
collapse on 13 July, his friend was taken to the room of a Listener for support
and care. The Listener told my colleague that the friend was distressed by
the man’s serious condition. Later, a paramedic came to see the man’s friend
and told him that the man had died. An officer then visited the friend to see
how he was and if there was anything the officers could do to help.
55. The man’s friend was allowed to remain with the Listener throughout the
night. The officers gave them tea making supplies to aide their comfort and
continued to check on the man’s friend’s wellbeing. He was moved to a
Listeners suite, in another part of the prison, at 5.00am to get some rest. He
was accompanied by two Listeners to continue his care.
56. The Listener told my colleague that he was given an opportunity for a de-brief
with a Samaritan and the care offered by C wing staff had been excellent.
Furthermore, a governor clarified questions he had following the man’ death
and gave her support to himself and the friend. I am pleased to acknowledge
the care given by prison and C wing staff to support the man’s friend and the
Listener in the days following the man’ death.
Next of kin information
57. The man did not offer any next of kin details to the prison on his reception.
His file only noted his solicitor, who acted for his criminal case, as a next of
kin. When contacted the solicitor was unable to offer any information on
relatives or friends of the man.
58. Prison records showed that he did not receive any visitors. This was
supported by his friends who told the investigator that the man did not have
any contacts outside of the prison.
59. I suggest that the prisoner’s records should be annotated to show that they do
not wish their next of kin to be named or contacted.
.
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CONCLUSION
60. The man was suffering from heart related disease and, despite being advised
to stop smoking, continued to do so. He was unhappy about the PCTs
decision not to fund his breast surgery and found prison life challenging.
However, he eventually settled at The Verne and made some close friends. It
is sad that no family details were known to prison staff and that he did not
have any contacts outside of prison.
61. The response from prison staff to the collapse was timely and carried out in a
professional manner together with the support they provided to the prisoners
affected by the man’ death. Like the clinical reviewer I am satisfied that the
medical care the man received was equitable to that in the community.
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RECOMMENDATIONS
For the Governor
At least one member of staff on night duty should be trained in the use of a
defibrillator and be aware of its location in the prison.
Partially accepted – “Oxygen and other emergency healthcare equipment
are now located in the Segregation Unit in the centre of the prison. The
defibrillator is located in the Healthcare unit. Another is on order. It has been
considered that the present system of having the defibrillator in the Health
Care where trained staff can access it, is at present more appropriate.
However, Emergency Kits are being provided by the PCT on the wings.”
Good Practice
1. The SO and three duty officers responded to the man’ collapse in a
professional manner and their attempt to resuscitate him is noted as good
practice. Furthermore, I note the care they afforded to the man’s friend and
the Listener .
Accepted
2. I acknowledge the care given by prison and C wing staff in their support of the
man’s friend and the Listener in the days following the man’ death.
Accepted
3. I would ask the Governor to ensure that when a prisoner does not want any
next of kin details to be recorded their file should be endorsed appropriately.
Accepted
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