Individual at Belmarsh

Investigation into the circumstances surrounding the
death of a man
at HMP Belmarsh in January 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2008
This is the report of an investigation into the circumstances of the death of a man at
HMP Belmarsh in January 2005. The man’s cause of death was given as asphyxia
following epileptic fit with left ventricle failure. He was 25 years old. I extend my
sincere condolences to the man’s family and friends for their loss.
The investigation was carried by one of my colleagues and a clinical review was
carried out by a senior nurse from a hospital in a different area to the prison. (The
arrangements for the review were outside my normal arrangements.) I am most
grateful to the clinical reviewer. I would also like to thank the Governor of Belmarsh
at the time of my investigation and her staff for their help and assistance.
The man had been on remand in Belmarsh since June 2004. On two occasions, first
in July and then in October, he suffered a series of epileptic type fits. Each fit was
followed by a period of extreme involuntary violence. The man was taken to outside
hospital on both occasions, and each time remaining in hospital overnight. When he
went back to Belmarsh after his second hospital admission his discharge letter said
that he had refused clinical investigations.
In the early hours of a day in January 2005, the man suffered a third occurrence of
similar fits. Officers restrained him outside his cell and he was then taken to the
healthcare unit and put in a cell there. Due to the configuration of the healthcare cell
the man was placed in a kneeling position. Staff went back into the cell around 55
minutes later to put the man in a more comfortable position. However, when he was
checked he was found not to be breathing. He was taken to outside hospital where
he was pronounced dead.
The circumstances surrounding the man’s death were subsequently referred to the
Crown Prosecution Service (CPS) for consideration of a possible prosecution against
any of the staff who dealt with him. In September 2007 I was informed that the CPS
had decided there would be no criminal proceedings. I very much regret that the man’s
family have had such a long wait for the outcome of this investigation.
The investigation has revealed a number of concerns about the man’s care and
treatment. There seems to have been no consideration on whether he should have
been sent to outside hospital. The cell in healthcare was not fit for purpose and its
design led to the man being placed in a kneeling position with his back to the door. I
have made three recommendations. One is about control and restraint, another is
about storage of drugs. The third recommendation is about contact with families
following a death in custody. I also endorse a further 21 recommendations made in the
clinical review.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2008
2
CONTENTS
Summary 4
The investigation process 7
HMP Belmarsh 10
Key findings 11
The man’s cause of death 18
Issues 20
Recommendations 27
3
SUMMARY
The man was a 25 year-old remand prisoner at HMP Belmarsh who died in the early
hours of a day in January 2005. The man had been in custody since 6 June 2004
and had been in Belmarsh since 15 June 2004. On 7 July, he suffered several
epileptic type fits and was taken to the nearby Queen Elizabeth Hospital. The man
returned to Belmarsh with the advice that he should be referred to the hospital’s
neurology team should he suffer any more seizures.
On 25 October, the man suffered a further series of fits. There was an unusual
component in that each would be followed by an episode of extreme violence
requiring restraint by a number of officers. The evidence indicates that the violence
was totally involuntary. The man was again taken to Queen Elizabeth Hospital
where he stayed overnight. Having refused investigations into his seizures, the man
returned to Belmarsh staying several days in the prison’s healthcare unit. A care
plan drawn up at this time included that the man should be located in a single cell.
By January 2005, the man was in a shared cell with two other prisoners in
houseblock 3. At 2.48am one night that month one of the cellmates pressed the in-
cell call bell. An officer responded and the cell-mate pointed to the man who was
fitting on the cell floor. The officer called for support, including nursing assistance1.
Among the first of the staff to arrive was the Night Orderly Officer (NOO)2. The NOO
was aware of the violence that had been associated with one of the man’s previous
fitting episodes. In light of this and because there were three prisoners in the cell,
the NOO decided it best to wait for more staff to arrive before entering.
To try to minimise the risk of the man harming himself, an officer asked one of the
cellmates to place a pillow underneath the man’s head. When the cellmate tried to
do so, the man leapt up and began assaulting him. This prompted staff to enter the
cell at that point and several of them, including the NOO, received injuries. More
staff arrived and they were able to restrain the man and take him out of the cell.
When the two nurses in healthcare were contacted, they agreed that one (the first
nurse) would go to houseblock 3. When she arrived in the houseblock she found
that the man was already out of the cell and being held to the floor by officers. The
first nurse told the investigator that she checked the man’s pulse and respiratory rate
and both were normal. She then went to treat the man’s cellmate for the injuries he
had sustained.
Standard treatment for a person suffering a fit is to give rectal diazepam. The first
nurse spoke by telephone to the second nurse asking her to bring rectal diazepam to
the wing. When the second nurse checked the drug stocks she could not find any
supplies of this medication. There were, however, supplies of injectable lorazepam
(both lorazepam and diazepam come from the benzodiazepine family of drugs and
provide similar effects). The second nurse had earlier sent out a pager message for
the out-of-hours on-call doctor and, while waiting for him to ring back, she went to
houseblock 3. When she arrived she checked the man’s pulse and respiration. Both
1There are two nurses on duty in Belmarsh at night-time. The prison holds just over 900 prisoners.
2The Night Orderly Officer is the officer in charge of a prison at night-time.
4
were elevated, but that would be expected given that he had been struggling against
the officers. (The first nurse also said that she checked the man’s pulse and
respiration but neither nurse made any record of the readings.) The second nurse
said that she told officers that the man needed to be taken to healthcare.
Records made at Belmarsh show that staff began taking the man to healthcare at
about 3.28am. This was around 30 or more minutes from the time he had been
brought out of the cell. Staff said that for most of this time the man had gone through
periods of fitting, periods of sleep and periods of fighting. The officers carried the
man to healthcare under control and restraint. As the term implies, control and
restraint is a well-practised set of techniques used for controlling and carrying violent
and/or un-cooperative prisoners.
When they arrived in healthcare the man was taken to the Intensive Care Suite
(ICS). This was a cell designed specifically for holding prisoners deemed at high risk
of self-harm and therefore requiring a high level of visual checks. The cell was of
standard size (10’ 5” x 6’) but fitted with a solid bed plinth running across the width
and at the back of the cell. Officers kept the man under restraint in the ICS while
waiting for a decision about his clinical care and treatment.
The on-call doctor telephoned Belmarsh to discuss with the second nurse the
treatment options. They agreed that the man should be given an injection of
lorazepam and the second nurse administered the injection at about 3.45am. Once
the injection had been given, first the second nurse and then the officers left the cell.
There are set procedures for officers to leave a cell safely when dealing with a
potentially violent prisoner. The physical layout of the ICS meant that the only way
for officers to follow safe exit procedures was to place the man in a kneeling position
facing the cell bed with his back to the cell door. The man’s head was placed resting
to one side on the mattress. Once staff left the cell he was checked by staff looking
through the observation flap. A number of the officers refer to observing the man on
at least one occasion. Staff said that the man had a patch of blood on his shirt that
had probably come from his injured cellmate. They could see the patch rising and
falling as he breathed.
Meanwhile, the first nurse sat in the nursing room where she could observe the
dormitory room where the injured cellmate had been located. She could also watch
a television monitor linked to various in-cell cameras, including a camera in the ICS.
At about 4.40am, the second nurse told officers that the lorazepam should have had
an effect and that it was now time to go into the ICS to make the man more
comfortable by putting him onto the bed. When staff lifted the man onto the bed they
found that he was not breathing. Attempts were made to try to resuscitate him and
an emergency ambulance attended and took him to outside hospital. Unfortunately,
all efforts proved unsuccessful and the man was pronounced dead later that
morning.
The investigations conducted following the man’s death included obtaining expert
opinion from five clinicians and a forensic scientist. These opinions are summarised
more fully later on in this report. However, in brief:
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(cid:127) the injection of lorazepam did not cause or contribute to the man’s death
(cid:127) the Consultant Pathologist gave the man’s cause of death as asphyxia
following an epileptic fit with left ventricular failure
(cid:127) another Consultant Pathologist instructed by solicitors acting for the man’s
family concluded that the cause of death was multi-factorial with contributing
factors being epilepsy, the struggle and restraint and the position in which the
man was placed in the ICS.
The man was young and in seeming good health, apart from his apparent recent
history of fits. He died on a day in January 2005 and was clearly unwell that
morning. This investigation has found that the ICS was both an inappropriate and
inadequate facility for dealing with a person with the man’s needs. One of the
deficiencies was a fault with the CCTV recording equipment. The clinical review has
also raised concerns about the ability of the nurses to manage the man’s needs.
I believe that such an extended period of struggling with control and restraint lasting
well in excess of 30 minutes should have led to nursing staff considering very
carefully whether the man may have reached a state of complete exhaustion and
whether transfer to outside hospital was appropriate. It is not clear whether
admission to hospital would have prevented the man’s death, but it is clear that the
clinical monitoring when he was in the ICS was inadequate.
6
THE INVESTIGATION PROCESS
1. In all cases of a death in prison custody the police visit to conduct an immediate
investigation. In the man’s case the police concluded that the circumstances
surrounding his death should be submitted to the Crown Prosecution Service
(CPS) for consideration of possible criminal charges. The police instructed that
my investigation be suspended pending a decision by the CPS.
2. More than two and a half years after the man’s death, my office was informed
that the CPS had decided that there would be no criminal prosecution. My
investigation officially began on 20 September 2007.
3. Because of the complexity of the issues and the number of professionals who
had assessed the man’s clinical care, I decided to appoint a clinical reviewer
who was wholly independent of the prison. The clinical reviewer was an
Assistant Director of Nursing at a hospital outside of the area. The man’s
sister, his acting next-of-kin, and her solicitors agreed to this approach.
Greenwich Primary Care Trust, who would ordinarily have been required to
conduct the review, were informed of this arrangement.
4. My officer was given access to the majority of the documents collected by the
police during their investigation. This included the transcripts of their interviews
with all the staff who dealt with the man on the night of his death. My
investigator and the clinical reviewer interviewed nine of these staff for further
clarification of certain issues. They also interviewed Belmarsh’s Head of
Healthcare.
5. My investigator and one of my family liaison officers met the man’s sister and
her solicitors. On a separate occasion, my investigator and the clinical reviewer
met the man’s sister (with her solicitors) for further clarification of her concerns.
The man’s sister is a nurse and her concerns focussed, in particular, on the
nursing care provided to her brother. She pointed out that her brother had had
two previous episodes of violent fits and she could not understand how he
came to be in a shared cell in January 2005. She said that she had been given
differing versions about the sequence of events as they occurred that night and
she wanted to know clearly what occurred from beginning to end. She also
wanted to understand about the nursing care her brother received, including the
taking of clinical observations, how the nurses could have properly monitored
her brother once he was locked into the cell in healthcare, what further support
was available to the nurses that night, and why her brother was not transferred
to outside hospital. The man’s sister was also distressed about the delay in
being notified about her brother’s death, and that she was given the news over
the telephone.
6. When the draft version of this report was sent to the man’s sister her comments
included questioning of the way her brother was carried to healthcare. She
thought that his breathing may have been compromised given that his body
was in a slumped position. She wondered whether it would have been better
for staff to have used a trolley. A matter raised by her solicitors was to question
7
whether it was sufficient to have two nurses on duty at night for a prison holding
over 900 prisoners.
8
HMP BELMARSH
7. HMP Belmarsh is a modern local prison, serving primarily the Central Criminal
Court and Magistrates’ Courts in South East London. Belmarsh holds just over
900 prisoners in total. Around 40 percent of the cells at Belmarsh are single
cells. The other 60 percent are multi-occupancy cells.
8. Belmarsh received a full announced inspection from Her Majesty’s Chief
Inspector of Prisons (HMCIP), Ms Anne Owers, in May and June 2003. In the
introduction to her report, Ms Owers wrote:
“HMP Belmarsh is a core local prison, and one of the most complex in
England and Wales. It holds a highly diverse population: ranging from 18
year olds awaiting trial for minor offences, to some of the most serious and
high risk adult offenders … it is having to cope with the effects of
overcrowding [with most prisoners] being held two or three to a cell.”
9. In October 2007 Belmarsh received another full announced inspection from
HMCIP (this report was not released until after the issue of the first draft version
of my report). Under a section entitled “Clinical governance” Ms Owers wrote:
“Every prisoner had a clinical record, but we found examples of poor record
keeping …”
10. In its annual report for the period July 2004 to June 2005 the Independent
Monitoring Board (IMB) at Belmarsh wrote:
“There is approximately a 25% vacancy factor in the nursing establishment …
necessitating an expenditure … on overtime payments and agency staff.
Following a recruitment campaign 5 nurses were offered posts. However, this
was at a time when there was a moratorium on recruitment and although Health
Care was actually excluded from that moratorium, due to an unfortunate error
the appointments were not substantiated and the vacancies remain.”
“Healthcare is one of the Board’s major concerns within the prison.”
9
KEY FINDINGS
Events leading up to the night of the man’s death
11. In June 2004, the man was arrested and charged with a very serious offence
connected with incidents that had occurred outside a public house in East
London the previous day. The man was taken into police custody.
12. While still in police custody, the man was taken to Stratford Magistrates’ Court
where he was remanded into HMP Pentonville. On 15 June, the man attended
court for a preliminary hearing and from there he was remanded into HMP
Belmarsh. During his initial health screening at Belmarsh, the man reported
having no significant medical problems. Nor had he reported any significant
medical problems during health screening at Pentonville.
13. On the morning of 7 July, the man suffered two fits each lasting three or four
minutes. A prison doctor examined him and referred him to Queen Elizabeth
Hospital for assessment and advice. In his referral letter, the doctor noted that
the man had no history of epilepsy. The man had at least one further fit either
in hospital or on his way there in the ambulance. He remained in hospital
overnight and he returned to Belmarsh the following day. The discharge
summary noted that there was no planned follow-up, but if the man were to
have any further fits he should be referred to the hospital’s neurology team.
14. On 25 October, the man suffered a further series of seizures in his cell and was
transferred to the healthcare unit. The man had further fits in healthcare and he
was given rectal diazepam. A note in his clinical records states: “…
experiences fits followed by extreme violence requiring restraint [by four officers
and use of handcuffs]”. The man was again sent to Queen Elizabeth Hospital.
15. Having remained in hospital overnight, the man returned to Belmarsh the
following day. The discharge summary from Queen Elizabeth Hospital said:
“Patient has refused all investigations and treatment for his seizures. He has
been informed of the risk of such decision but states wants nothing done. We
respect his wishes and have not initiated any management.”
16. On his return to Belmarsh, the man remained for a period in healthcare. An
entry in his clinical records made on 27 October said: “Doesn’t remember his
previous fits and states he just wants to go back to the houseblock. Appeared
confused by his situation.”
17. A care plan drawn up for the man on 31 October included a plan to minimise
the risk to him, as well as staff and other prisoners. The action taken to achieve
this was to locate him in a single cell (the healthcare unit at Belmarsh includes
some dormitory accommodation).
18. An entry in the clinical records made on 3 November said: ”[The man] reported
feeling worried about his fitting episodes stating ‘I want to get better.’” By this
10
time the man had been prescribed Epilim (a medicine used in treating various
forms of epilepsy).
19. On 10 November, a note was made in the man’s clinical records that he had:
“… remained stable on medication, no further fits, is able to return to [standard
location] …” An in-patient unit exit plan drawn up the same day included an
assessment by the receiving houseblock manager. He indicated that the man
should be allocated to a shared cell. The housblock manager told my
investigator that he could not recall carrying out the assessment. However, in
the case of a prisoner with a history of fits it would usually be preferable to put
him in a shared cell. The danger, otherwise, could be of him having a fit when
alone in a cell. In that situation there is always a possibility of the prisoner
swallowing his tongue. The houseblock manager added that he would always
place in a single cell a prisoner posing a risk of violence against other
prisoners.
20. The man left healthcare later that day and was located on houseblock 1. On 29
November, the man was moved to houseblock 3 and located into cell 3-24.
Cell 3-24 is a three bed cell.
The night of the man’s death
21. At 2.48am one of the man’s cell-mates pressed the cell call bell because the
man was having a fit. The night duty officer in houseblock 3 went to the cell,
looked in and saw what was happening. She then ran back to the wing control
centre (referred to by staff as the ‘bubble’) to telephone for assistance. She
contacted healthcare to say that the man was having a violent fit and that a
nurse was required. She also telephoned the Night Orderly Officer (NOO) to
report the same thing to her, and to advise that the man was in a three man cell
so dog handlers were needed for when the cell was unlocked.
22. The NOO with two officers were the first to arrive in the wing. The NOO said
that she knew the man because she had been the Orderly Officer in October
2004 when he previously had an episode of fitting. She said that what
happened then was that the man would have a fit, followed by an episode of
violent behaviour, and then fall asleep. That pattern repeated itself several
times in succession on that occasion. The NOO said that the man was clearly
unaware of what he was doing.
23. The NOO said that, when she arrived in houseblock 3 on this occasion she
looked into the cell and saw the man lying on the floor. Because of what she
had witnessed two months earlier, she did not intend to unlock the cell until the
arrival of more staff, including dog handlers. One of the cell-mates was
standing near the cell door and the NOO told him that staff would be coming
into the cell shortly. The NOO then spoke with the night duty officer about her
plans for dealing with the situation.
24. While the NOO was talking with the night duty officer, one of the other officers
went to the cell door and spoke to one of the cell-mates. She asked him to
place a pillow underneath the man’s head to reduce the risk of him injuring
11
himself. As the cell-mate attempted to do so, the man began assaulting him.
Out of concern for the cell-mate the NOO and two officers went into the cell.
The time was 2.54am. Two more officers arrived on the wing shortly after and
they also went into the cell.
25. The man was brought out of the cell. For around the next 35 minutes he
apparently suffered a series of fits when he would struggle violently.
Interspersed with the fits were periods when the man would fall into a more
relaxed state. More officers arrive and assisted with trying to control the man.
Two dog handlers were also present although they were there for general
matters of security and did not have any direct involvement with the man.
Several of the staff were injured in the struggle, including the NOO.
26. There were two nurses in Belmarsh that night. Both were in the healthcare unit
when the request was received for nursing support in houseblock 3. The
second nurse asked the first nurse to go to the houseblock as she (the second
nurse) was collecting the clinical records for prisoners due for adjudication
hearings3 the following day. When the first nurse arrived in houseblock 3 she
found the man being restrained on the landing outside his cell. The man was
lying front down with his head to one side. The NOO briefed the first nurse
about what was happening and about the man’s previous history of fits.
27. The first nurse checked the man’s pulse, timing it against her watch. She told
the investigator his pulse was a normal rate of 70 beats per minute. The first
nurse also listened to the man’s breathing which was also normal. She did not
have the man’s clinical notes with her so did not make a record of her clinical
observations. The first nurse said that the man was not fitting at this time.
However, he was a little bit agitated and was struggling against the restraint.
The first nurse told the man that she was a nurse and he grunted in reply. She
asked an officer to get the pillow from the man’s bed and she placed that under
his head. At this stage the first nurse tried to telephone the second nurse in
healthcare to tell her what was happening. The first nurse could not get an
answer from healthcare so asked the control room to contact the second nurse
to ask her to phone houseblock 3. While waiting for the second nurse to call,
the first nurse briefly checked the cell-mate who had been assaulted by the
man. He had some bleeding from wounds on his face and head but they
appeared superficial. As an interim measure the first nurse wrapped a towel
around his head and asked him to apply pressure to staunch any further
bleeding.
28. In her interview, the NOO said that she asked the first nurse if the man could be
moved to healthcare, but the first nurse did not respond. The NOO said that
there was a lot going on in the wing with the three prisoners, and she did not
feel that she was getting the advice she needed from the first nurse.
29. When the second nurse rang the houseblock, she and the first nurse spoke
about the man’s treatment. They agreed that he should be given rectal
3Adjudication hearings deal with alleged infringements of prison rules.
12
diazepam as this is standard treatment for a person suffering an epileptic fit
(this is what the man was assumed to be having). The second nurse went to
the drugs storage cabinet but she could not find any rectal diazepam4. She
then made a pager call to the out-of-hours on-call doctor. Records show that
the pager call was sent at 3.10am. She also located the man’s clinical records.
When the second nurse checked the man’s records she realised that he was
the same prisoner who had had an episode of fitting and violence some weeks
before. On that occasion, the second nurse’s involvement in the man’s care
had been with his treatment in healthcare after his return from Queen Elizabeth
Hospital.
30. The second nurse went to houseblock 3 to give assistance. When she arrived
she saw the man face down on the floor being restrained by several officers.
The second nurse checked the man’s pulse and respiration. His pulse was
around 96 beats per minute and his respiration about 27 breaths per minute.
She said that these are elevated scores, as would be expected when a person
has been struggling. The second nurse told officers that the man needed to be
taken to healthcare. As the doctor had not responded to the pager call, the
second nurse sent a second pager call at 3.20am.
31. At around 3.28am, staff set off to take the man to healthcare. He was carried
by staff using control and restraint techniques. It seems that staff dismissed the
option of using a trolley because of the difficulties and dangers if the man were
to struggle while on the trolley. Much of the move was captured on closed
circuit television (CCTV). The CCTV footage shows the man being carried face
up with his arms handcuffed behind his back. Each of the man’s arms and legs
was held by an officer, while a fifth officer supported his head. The footage
shows the second nurse walking alongside. The second nurse said that as
they went she spoke to the man several times to ask him how he was. The
CCTV footage supports this. The second nurse said that she also checked the
man’s pulse again and it was somewhere in the 90s (as with the previous
reading). The CCTV footage also shows the first nurse walking behind with the
injured cell-mate who was being taken to healthcare for further treatment. The
CCTV record indicates that it took around three to four minutes to make the
journey.
32. On arrival in healthcare, the man was taken into a cell known as the Intensive
Care Suite (ICS). This is a cell designed for holding prisoners who are at
increased risk of self-harm. Its design features include a reduced number of
ligature points and an in-cell video camera. To help reduce ligature points
further, the ICS does not contain a bedstead. Instead, the cell has a solid plinth
of the same length and width as a bedstead with a mattress placed on top. The
plinth is at the back and across the width of the ICS. Officers maintained their
hold on the man while waiting to hear from the nurses about his care and
treatment.
4When the drugs cabinet was checked after The man’s death it was found to contain a stock of
diazepam.
13
33. The doctor told the investigator that, when he was woken by the pager he saw
there had been two pager calls. The first call had failed to wake him. He
telephoned Belmarsh and spoke to the second nurse. She told him that the
man had had a fit and that he was now in the ICS. She said that the man was
still very agitated and also that there was no rectal diazepam. The doctor told
her to give an intramuscular injection of two milligrams of lorazepam to calm the
man. The doctor said that there was nothing about the conversation to cause
him to feel any concern. The doctor and the second nurse did not discuss the
option of sending the man to outside hospital. The doctor said that, in general,
a transfer to hospital at night time would be initiated by the nurses and they
would not even bother to telephone the doctor to ask for permission. Instead,
they would simply phone for an ambulance.
34. Once the doctor had confirmed the treatment plan, the second nurse collected
the medication, gave the injection and left the cell. The second nurse said that
she took one more set of observations of pulse and respiration at around this
time. The man’s pulse and respirations were much the same as they had been
before. The second nurse said that she did not think at the time that the man
needed to be transferred to outside hospital: he had been given lorazepam and
he was responding to questions with grunts.
35. Officers were still present and still restraining the man. Control and restraint
procedures include techniques for officers to safely exit cells. A Senior Officer
(the SO) told my investigator that the plinth, which lies crossways at the back of
the cell, does not allow staff to exit safely when dealing with a potentially violent
prisoner. Correct exit techniques require the final two officers to leave the cell
being able to stand either side of the prisoner’s back up until the final second.
The SO said that the man had used up a vast amount of energy during the
earlier struggle. To place him on his chest on the mattress would have carried
the risk of positional asphyxiation. But to have placed him on his back would
have made it difficult for staff to safely exit the cell in the case of the man
jumping up to assault staff. The SO decided therefore to put the man in a
kneeling position up against the side of the plinth with his head resting, to the
side, on the mattress (which meant that his back was facing the door). The SO
said that he checked that the second nurse was content with the man’s
position. At this point, officers left the cell and locked the door. The time was
then around 3.45am.
36. The door observation hatch was lowered and staff were able to look through to
check the man. No records were made of the frequency of checks, but at
interview most of the staff said that they looked through the hatch on one or
more occasions. The NOO said she looked into the cell the moment after staff
had exited. She might have checked the man on one more occasion but she
was not certain. An officer said that he looked into the cell once, within ten
minutes of the cell being locked. Another officer said that he checked the man
once and this was five to ten minutes after the door was locked. A third officer
said that he checked the man twice but he could not estimate the timings. The
SO said that he looked into the cell on two or three occasions all within 20 or 25
minutes of the cell being locked. The second nurse said that she looked
through the hatch many times throughout the time the man was in the cell. She
14
also said that she spoke to the man through the hatch and he grunted in
response. Most of the staff said that they could tell that the man was breathing
as they could see the rise and fall of a patch of blood on the back of his shirt
(the blood had probably come from the injured cell-mate).
37. The first nurse said that, after arriving in healthcare, she took the injured cell-
mate to the treatment room to dress his wounds. He was then located into
ward-room 1 – a multi-bed dormitory room. The first nurse went to the
healthcare office. The office is equipped with a monitor linked to several in-cell
cameras including the camera in the ICS. The equipment has movement
sensors so the monitor will draw the viewer’s eye to any movements. The first
nurse said that she decided to remain in the healthcare office as her position
there enabled her to look at both the man on the monitor and at the injured cell-
mate in ward-room 1 (ward-room 1 has toughened glass panels allowing for
easier observation of its patients). The first nurse said that she was not content
with the man’s position as she could not see his face. However, she did not
mention her concern about this until just before staff went back into the cell.
38. It was at about 4.40am that the second nurse told officers that the lorazepam
should have had an effect and that it was time to go into the cell to put the man
onto the bed to make him more comfortable. The second nurse went into the
cell together with the NOO and three other officers. When the man was lifted
onto the bed the staff realised that he was not breathing. Staff attempted cardio
pulmonary resuscitation (CPR) and an emergency ambulance was requested.
Staff continued with their efforts to try to resuscitate the man until they were
relieved by the ambulance paramedics at 4.54am. The man was taken to
outside hospital where he was pronounced dead at 5.40am.
After the man’s death
39. The man had not provided any information about his next-of-kin when he
arrived in Belmarsh. However, his records contained the names and addresses
of two potential relatives and directory enquiries were contacted for telephone
numbers. Directory enquiries were unable to help, so Belmarsh began ringing
the numbers listed in the man’s prison telephone records5. One of those listed
turned out to be the man’s sister. When she answered the telephone she was
told about her brother’s death. This was at 12.40pm. An unsigned and un-
attributed note made at Belmarsh said that the first choice would have been for
prison chaplains to visit to break the news in person. However, because it was
a Bank Holiday none could be contacted.
40. Following the issue of the draft version of this report the author of the unsigned,
un-attributed note mentioned above was identified to be one of Belmarsh’s
chaplains (although he now works elsewhere). The chaplain told my
investigator that as best as he could recall he was not entirely certain that the
person listed was the man’s next-of-kin, but if not she would be able to provide
that information. He said that he telephoned a prison close to the address to
5Prisoners use a PIN number when using the prison telephones so details are recorded of all calls
made (as with an itemised private telephone bill).
15
ask for a chaplain to visit the house, but there were no chaplains in the prison.
He also tried the parish chaplaincy for the area, but again no chaplains were
available. The chaplain was conscious of the time that it would have taken to
cross from one end of London to the other and he was worried that in the
meantime the news of the man’s death would have been released by the
media. It was for that reason that he decided to telephone.
16
THE MAN’S CAUSE OF DEATH
41. Following the man’s death a post mortem was carried out by a Consultant
Forensic Pathologist. Additional clinical opinion was provided during the course
of the consideration of possible charges against any of the staff. The other
clinicians who gave opinions were Professor of Neurology and Clinical
Epilepsy, a Professor in A&E medicine, a second Consultant Forensic
Pathologist and a Consultant Home Office Pathologist.
42. A Forensic Scientist for the Metropolitan Police carried out examinations of the
man’s blood and urine. The examinations detected no presence of lorazepam
in the man’s blood sample. The Forensic Scientist explained that, in the case
of an injection of two milligrams of lorazepam intramuscularly into the buttock,
he would expect the drug to be detectable in the blood within 15 to 30 minutes.
43. These findings mean that the man died within 30 minutes of the injection being
given. The findings also mean that the lorazepam did not cause or contribute to
the man’s death.
44. The Consultant Forensic Pathologist conclusions included:
”There was evidence of asphyxial type changes and in my opinion the most
likely sequence of events was a degree of left ventricular failure following
[The man’s] fit and violent behaviour aggravated by restraint that has
compromised his airway. I give the cause of death: 1a. Asphyxia following
epileptic fit with left ventricular failure and restraint.”
45. The Professor of Neurology and Clinical Epilepsy referred in his report to
SUDEP (Sudden Unexpected Death in Epilepsy) and concluded that, on the
balance of evidence and in the absence of other causes, SUDEP was the most
likely cause of death.
46. The Professor in A&E medicine explained in his report that lorazepam is a well-
known drug closely related to diazepam and that either of the two drugs can be
used in the control of excitable, violent or epileptic patients. The Professor
expressed surprise that the man was left in the kneeling position, saying that it
would have been more appropriate to have placed him lying on the bed in the
recovery position. In considering the cause of the man’s death, the Professor
explained that the extreme violence that the man displayed resulted in him
using up an extreme amount of energy. This would probably have resulted in a
marked rise in body temperature leading to a further increase in his body’s
demand for oxygen. As a consequence, his heart was not able to keep pace
with his body’s demands for oxygen and energy. This led to the man
developing left ventricular heart failure.
47. The second Consultant Forensic Pathologist and commented that:
“Asphyxiation, especially during restraint, does not have to be an all or
nothing process. Asphyxiation occurs when the body is not able to obtain
sufficient oxygen for its current needs … Asphyxiation can occur with
17
minimal obstruction to the airways when an individual has a high oxygen
requirement.”
48. The second Consultant Forensic Pathologist and also commented that leaving
an individual kneeling allows the chest to function correctly and is one of the
positions advised following restraint to allow for unhindered breathing. Having
considered all the evidence he concluded:
”The events surrounding [the man’s] death are well established but it is not
possible to determine which, if any, of these many events may have played
a part in his death and which, if any, can be excluded. Based on the
material available to me it is not possible to determine with any degree of
certainty the cause of death of …”
49. The Consultant Home Office Pathologist was instructed by Hickman and Rose
Solicitors (solicitors for the man’s family). He reviewed the reports from all of
the other clinical experts before setting out his own opinions:
“Deaths can occur following restraint. This may not be immediate. During
a struggle body chemicals involving the ‘fight’ or ‘flight’ reaction are
released. These chemicals which include adrenaline and nor-adrenaline
sensitise the heart and may lead to an abnormal rhythm occurring. This is
more likely in a person with a vulnerable heart. No obvious pre-existing
heart disease was identified in this case. Heart failure is a mode of death
rather than a specific cause of death. If someone is placed in a vulnerable
position, breathing may be compromised. The placing of a person in a
kneeling position could result in a degree of compromisation of the airway if
not fully conscious … Overall, the cause of death is likely to be multi-
factorial … including epilepsy and the struggle, position placed in and the
restraint.”
18
ISSUES
Should the man have been in a three man cell?
50. On arrival in prison all prisoners receive a cell sharing risk assessment. This
procedure is aimed at ensuring that the particular prisoner is safe to share a
cell. This is both in terms of his/her safety and the safety of potential cellmates.
Whenever there is a change in circumstances, a review of risk should be
undertaken. In the man’s case, there was no reason on first arrival in Belmarsh
for him not to be deemed suitable to share with others. However, on 25
October 2004, the man suffered a series of fits each of which was followed by
an episode of extreme violence. The man had to be restrained by a number of
officers and by use of handcuffs. After spending the night in outside hospital,
he returned to Belmarsh and for several days remained in the healthcare unit.
On 31 October, a care plan drawn up for the man in healthcare included that he
should be located in a single cell (the healthcare unit in healthcare has
dormitory accommodation as well as single cells).
51. The man remained in the healthcare unit until 10 November. On that day he
was found fit for discharge to standard location and in preparation for that a
healthcare in-patient exit plan was drawn up. The plan included locating the
man into a shared cell. The houseblock manager who made that decision was
unable to recall assessing the man that day. He said, however, that in the case
of a prisoner with a history of fits it was preferable to place him in a shared cell.
His cell-mates would be available to provide potentially life saving assistance in
the case of further fits. However, he would not usually place in a shared cell a
prisoner with a history of violence against other prisoners.
52. By November 2004, the man had suffered two episodes of fitting. The last
episode occurred the month before and was described as including extreme
violence. The violence, however, was directed against the officers who were
trying to restrain the man. No violence was displayed that day against other
prisoners. The houseblock manager probably believed that he was making a
decision that would serve the man’s best interests by placing him in a shared
cell. I would not wish to criticise him for that decision.
The control and restraint of the man
53. When the man was brought out of his cell he continued to struggle and for the
next 35 minutes staff endeavoured to restrain him. When staff thought it safe to
do so, they carried him to healthcare. Although most of the journey from the
houseblock to healthcare was captured on CCTV, this was not the case for the
initial struggle outside the cell.
54. ‘Control and restraint’ is the term used for the set of techniques used in
controlling prisoners who are violent and/or un-cooperative. There is no
suggestion that the man was being deliberately violent or deliberately un-
cooperative. Instead, it was his clinical condition that caused such behaviour.
Staff were aware of this from the outset, the NOO having witnessed the man’s
previous fitting episode.
19
55. Prison Service Order (PSO) 1600 contains guidance and instruction on control
and restraint. The latest version of PSO 1600 came into force in August 2005
(that is, after the man’s death). Earlier versions of PSO 1600 were silent on the
potential dangers associated with prolonged restraint. However, the version
issued in August 2005 does refer to these dangers:
“The amount of time that restraint is applied is as important as the form of
restraint and the position of the detainee. Prolonged restraint and
prolonged struggling will result in exhaustion, possibly without subjective
awareness of this, which may result in sudden death.”
I acknowledge the added guidance in the latest version of PSO 1600 but
recommend that the Prison Service consider supplementing the guidance
with an indication of the period of time beyond which restraint should not
continue. To assist in the provision of such guidance the Prison Service
may wish to undertake research into the correlation between prolonged
restraint and sudden death.
Carrying the man to healthcare
56. When staff decided that it was time to move the man to healthcare, they carried
him using control and restraint methods. The man’s sister, a trained nurse, was
concerned that the way her brother was carried may well have compromised
his breathing (the CCTV footage shows the man being carried face up with his
body in a slumped position). Her view was that more thought should be given
to carrying the patient on a trolley, especially if they can be placed in the
recovery position. In that situation there would be less likelihood of
compromising the patient’s breathing, especially when they have been under
restraint for a long period before that.
57. I believe that staff made the right choice in deciding to carry the man to
healthcare. Their evidence was that the man continued to struggle during the
journey to healthcare. Had the man been on a trolley, his safety and that of the
staff would both have been compromised. I am also satisfied with the way in
which the staff conducted the carry. I reach that conclusion based upon my
own viewing of the CCTV footage and based upon the opinion of a Control and
Restraint national Prison Service instructor who advised the CPS during their
deliberations.
Rectal diazepam and lorazepam
58. As the man was believed to be having an epileptic fit, the second nurse went to
get some rectal diazepam. However, she could not find any stocks in the drugs
cabinet. When the doctor subsequently rang Belmarsh in response to having
been paged, the second nurse told him that there was no rectal diazepam but
there were supplies of lorazepam. They agreed that the man should be given
an injection of this drug instead.
20
59. The Professor in A&E medicine, one of the clinical experts who commented on
the man’s cause of death, has explained that lorazepam and diazepam are
closely related and either can be used in treating an excitable or violent patient.
Toxicological investigations following the man’s death showed that he died
before the lorazepam had been absorbed into his blood stream. This means
that the lorazepam did not either cause or contribute to the man’s death. Nor
would it seem that the failure to give rectal diazepam had any bearing on the
man’s death. Even so, I am concerned that the second nurse was unable to
find any rectal diazepam (an emergency medicine). Belmarsh’s Head of
Healthcare said in interview that the pharmacist had checked the drugs cabinet
following the man’s death and found that it did contain a stock of rectal
diazepam. With the passage of time, I am clearly unable to resolve this
discrepancy.
I recommend that the Governor and Head of Pharmacy satisfy themselves
on the adequacy of arrangements for stocking and restocking the drugs
cabinet as well as the arrangements for monitoring of stock.
The Intensive Care Suite
60. Once the lorazepam injection had been given, staff left the man in the ICS. He
was kneeling, facing the bed with his back to the door and with his head resting
to one side on the mattress. The second Consultant Forensic Pathologist,
another of the experts who commented on the man’s death, explained that
leaving a person in the kneeling position allows the chest to function correctly.
However, the Consultant Home Office Pathologist considered that the kneeling
position could compromise a person’s airway to some extent if they were not
fully conscious. The Professor in A&E medicine has pointed out that it would
have been better to have placed the man lying down in the recovery position.
61. The man’s sister’s response to the first draft version of this report was to further
question the implications of leaving her brother on his knees. The problem that
staff faced in choosing how to leave the man was that the design of the ICS
does not easily allow staff to follow correct and safe exiting procedures when
dealing with a potentially violent prisoner. Staff needed to exit the cell safely
and regardless of the design of the cell they had few options in choosing how to
position the man. Had they placed him chest down on the floor that would have
put him at very obvious risk of positional asphyxia. Staff recognised the danger
of that and decided instead to leave him positioned on his knees. In doing so,
none of them believed that they had compromised the man’s safety. In light of
this report the Prison Service may wish to review cell-exit procedures that
maintain safety for both the prisoner and the staff, in particular whether
prisoners should be left in the kneeling position.
62. Having left the cell, staff kept a watch on the man by looking at him through the
observation panel. Most of the staff said that they looked into the room on one
or more occasions. Although staff could only see the man’s back, they referred
to a patch of blood on his shirt that they could see rising and falling as he
breathed. Meanwhile, the first nurse was in the healthcare office observing the
monitor linked to the in-cell camera in the ICS.
21
63. The timings for most of the events of that morning can only be estimated. It
would seem though that the lorazepam injection was given at about 3.45am,
and almost immediately after that staff left the cell. Almost an hour then passed
by before staff went back into the cell at about 4.40am. Examination of the
man’s blood and urine led the forensic examiner to conclude that death
occurred within 30 minutes of the lorazepam injection being given. That would
mean that death occurred at 4.15am at the latest. That in turn means that there
would have been no visible signs that the man was breathing for 25 minutes or
more before the cell was re-entered.
64. When two of my investigators visited Belmarsh shortly after the man’s death
they found two problems with the monitoring equipment. When they tested the
equipment, they found that the picture on the monitor remained static if the
person in the cell made only slow movements. The other problem was to do
with the video recorder that should have captured all the images. My
investigators were told that when the video tape was checked by the prison and
the police it was found that nothing had been recorded.
65. The Head of Healthcare said that following the man’s death the ICS was
decommissioned as it had often been used in inappropriate circumstances. He
said that staff followed practice at the time in using the ICS, but the cell was not
designed for a prisoner with the needs and problems that the man was
presenting on that day. I am pleased that the ICS will no longer be used in
similar circumstances and so have made no recommendation.
The man’s clinical care and treatment
66. Several of the staff who were involved in dealing with the man were aware of
the previous occasion when he had had a series of fits, each followed by an
episode of apparent involuntary violence. On that previous occasion, the man
was taken to outside hospital and recovered without seemingly suffering any ill
effects. It seems likely that staff assumed or expected a similar outcome on
this occasion. There was no explicit discussion between the second nurse and
the doctor about whether the man needed to be sent to outside hospital
although neither, it seems, believed that there was any indication for that
course.
67. The Head of Healthcare, who is a nurse by profession, said that the difficulty in
dealing with a situation such as the man’s is that there is no other healthcare
situation where nurses would not be physically present with a patient suffering
periods of unconsciousness. His view is that, if it is not possible to have a
nurse present with the patient, the patient should not be kept in a prison setting
until the concerns have been dealt with.
68. The Head of Healthcare raises an interesting point. Most prisons have
healthcare units with accommodation for patients comprising cells that are to all
intents and purposes standard prison cells. Cell doors are usually kept locked
most of the time and almost always kept locked through the night. The
question that prison doctors and nurses need to ask themselves is whether the
22
patient’s clinical condition is one that can be managed safely given these
requirements.
69. The clinical reviewer has expressed concern about the ability of the nurses in
managing the situation. In her review, she concluded the clinical staff were
slow in taking charge of the situation and that the first nurse was not competent
to deal with the difficulties posed in managing a clinical emergency. The clinical
reviewer further concluded that record keeping and medicines management
were generally poor. She has also referred to the lack of clinical decision
making by the healthcare professional involved, including the fact that there
was no discussion about a possible transfer to the local acute hospital. Having
made those criticisms, the clinical reviewer has referred to the expert clinical
opinions briefly summarised earlier in this report. She has indicated that even
with all appropriate interventions and acute hospitalisation, the man’s death
might still not have been prevented given the time it would have taken for him to
reach hospital.
70. In my view, there should have been a formal discussion between the nurses
and the doctor about whether the man should have gone to outside hospital
with a record made of the decision. (The clinical reviewer has made a
recommendation about an escalation policy around transfer to outside hospital
and another about record keeping.) And I link this finding back to my previous
reference to the guidance contained in the current version of PSO 1600 and my
recommendation on supplementing the guidance.
71. One of the issues raised by the man’s sister was the taking of clinical
observations. Neither of the two nurses recorded observations but both said at
interview that they had taken such observations up until closing the cell door.
Some, but not all, of the officers said that they saw the nurses taking
observations. Whether clinical observations were taken is not a matter upon
which I feel able to judge conclusively. However, no recording of any
observations were made. Again, the clinical reviewer has made a relevant
recommendation.
Nursing cover at Belmarsh at night time
72. Belmarsh has two trained nurses on duty at night time. The prison holds just
over 900 prisoners. The solicitors acting for the man’s family questioned
whether that is an adequate staffing level. There is no set process or formula
for calculating the number of trained nurses that a prison should have on duty
at night time. Instead, the staffing level is at the discretion of the individual
prison. However, I can say that Belmarsh has similar nursing cover at night
time when compared to similar prisons. I can see no grounds to conclude that
this is an inappropriate staffing level.
Contact with the man’s family following his death
73. The man’s sister and next-of-kin was distressed about being told of her
brother’s death by telephone. I understand her feelings entirely. However,
Belmarsh held no next-of-kin details for the man so details of his visitors and
23
records of his telephone contacts were used to identify the likely family
members. This resulted in the telephone call to his sister. A note detailing the
contact with the man’s family explained that the preferred option would have
been for prison chaplains to visit her in person but as it was a Bank Holiday no
chaplains were available. Following issue of the draft version of this report I
discovered that the person who telephoned the man’s sister was a chaplain at
Belmarsh. The comment that “no chaplains were available” referred to there
being no chaplains available either at a prison close to the sister’s home, nor in
her local parish. Due to the time it would have taken him to travel from one side
of London to the other, the chaplain thought it best to telephone her.
74. As the man was young staff at Belmarsh should have expected that the news of
his death would come as a complete shock to the family. Even if no prison or
parish chaplains were available anywhere close to the man’s sister’s home, the
news should still not have been broken by telephone. In the first instance
Governor grade staff from a nearby prison should have been asked to make the
visit. If that proved too difficult to arrange, the local police should have been
asked. Since the man’s death more detailed guidance and instruction has been
issued by the Prison Service for dealing with this sensitive and difficult matter.
75. The man’s sister was also upset about the length of time it took for her to be
told the news (she was not told until after midday). The man was officially
pronounced dead at 5.40am. It does seem a little surprising therefore that
contact details for the family were not collected rather sooner. The man’s sister
told my Family Liaison Officer that it was only through the Coroner’s office that
she discovered that the prison should offer to pay funeral expenses. It may be
that policy and practice at Belmarsh has moved on since January 2005.
However, I would remind the Governor that families should always be informed
that the prison will meet reasonable funeral expenses.
I recommend that the Governor ensures, in the case of all deaths in
custody, that the prisoner’s next-of-kin are informed in an appropriate
manner and with the minimum of delay. An offer of funeral expenses
should always be made.
24
Treatment and support of staff
76. Several Belmarsh staff complained to my investigator about the way they were
dealt with following the man’s death. They said that their clothing was
confiscated by the police and they were supplied with ill fitting clothing and
footwear by the prison. They had to make their own way home, using public
transport, in this replacement clothing. Staff also felt unsupported in the days
and weeks following the man’s death.
77. Although it is extremely unusual, I can understand why the police took
possession of the clothing in this case. The police would have been briefed on
first arrival in Belmarsh that the man had been restrained for a considerable
amount of time shortly before his death. As a result, they had to consider the
possibility that staff might have been culpable and take appropriate precautions
to safeguard anything that could constitute potential evidence.
78. It was reasonable, however, for staff to have expected support from their
employer. In the circumstances, I consider it would have been appropriate for
staff to have been sent home by taxi. More importantly, arrangements should
have been made for the staff to have received full and on-going support from
the prison care team. The circumstances surrounding the man’s death were
undoubtedly exceptional. Even so, I would remind the Governor that, in the
case of any future deaths at Belmarsh, staff have a right to be treated in a
manner that complies fully with the requirements set out in the relevant Prison
Service Orders.
25
RECOMMENDATIONS
I make the following three recommendations:
1. I recommend that the Prison Service consider supplementing the guidance in
PSO 1600 to include an indication of the period of time beyond which restraint
should not continue. To assist in the provision of such guidance the Prison
Service may wish to undertake research into the correlation between prolonged
restraint and sudden death.
Prison Service response – Response to follow.
2. I recommend that the Governor and Head of Pharmacy satisfy themselves on
the adequacy of arrangements for stocking and restocking the drugs cabinet as
well as the arrangements for monitoring of stock.
Prison Service response – recommendation accepted. Comprehensive arrangements
are in place to check medicines stock and re-order appropriately in all clinical areas.
Clinical managers and Charge nurses are responsible for the clinical audit of all related
policies and procedures. Clinical audits are monitored within the Drug and Therapeutic
Committee and Clinical Governance Committee.
3. I recommend that the Governor ensures, in the case of all deaths in custody,
that the prisoner’s next-of-kin are informed in an appropriate manner and with
the minimum of delay. An offer of funeral expenses should always be made.
Prison Service response – recommendation accepted. The establishment now has
five trained Family Liaison Officers. All families since the death in custody of the man
have been informed by this method. The establishment has offered to pay funeral
expenses in all cases since the man’s death.
I also endorse recommendations 4 to 24, which have been drawn from the
clinical review:
4. It should be established to what extent the first nurse’s knowledge and skills
base have developed in the time since the man’s death. If appropriate, she
should have a period of supervised practice with some clear objectives set. I
recommend that she is not left in charge of healthcare at night unless it is
demonstrated that she is competent to do so.
Prison Service response – recommendation not accepted. It is not appropriate to take
measures today in relation to an incident three years ago in the absence of supporting
evidence that the concerns raised remain pertinent to the first nurse’s current
performance. In the intervening three years she has completed night duty, covered
Hotel 1 and 2, and as far as I am aware, has given no cause for concern, not has any
concern regarding clinical competence been raised within her SPDR reviews. In
addition, there has been significant joint investment in training and staff development
for all trained nurses.
5. Policy on Hotel 1 and Hotel 2 to be revised.
26
Prison Service response – recommendation accepted. Local policy and procedures
revised and implemented.
6. Green bag to be kept on each houseblock to save it being obtained from
Healthcare in an emergency situation. Green bag to be obtained for all Hotel
calls.
Prison Service response – recommendation accepted. Included in the revised
procedure.
7. Implement a record keeping awareness session for all clinical staff.
Prison Service response – recommendation accepted. Clinical Record Strategy
revised.
Electronic Medical record system introduced March 2008.
8. Audit to be undertaken of record keeping: recommend using the Essence of
Care (Department of Health February 2001) benchmark tool.
Prison Service response – recommendation accepted. Clinical Audit programme
instigated 2007.
9. Clear policy for monitoring acutely ill prisoners. This to include the taking and
recording clinical observations: blood pressure, pulse, temperature respirations,
and neurological observations.
Prison Service response – recommendation accepted. All admissions to the inpatient
unit receive a holistic nurse led assessment including a record of all baseline physical
and mental observations. Secondary referrals are made wherever appropriate.
10. Nursing staff to be trained in the use of oxygen therapy.
Prison Service response – recommendation accepted. Clinical management of
Oxygen therapy is included within the Belmarsh development programme, an
assessed clinical training package delivered to all registered nurses working within the
prison.
11. Nursing staff to be trained in managing emergency situations.
Prison Service response – recommendation accepted. Clinical management primary
assessment is included within the Belmarsh development programme, an assessed
clinical training package delivered to all registered nurses working within the prison.
All registered nurses required to cover medical response posts receive mandatory
training in CPR, use of defibrillator and first aid in the workplace.
12. Electronic medical record system to be implemented to aid easier and more
accessible communication.
Prison Service response – recommendation accepted. INPS Vision installed March
2008.
27
13. Education and training for nursing staff in the management of long-term
conditions.
Prison Service response – recommendation accepted. Clinical management of long
term conditions is included within the Belmarsh development programme, an assessed
clinical training package delivered to all registered nurses working within the prison
A GP led long term condition management clinic was established on a weekly basis in
2007. All nursing staff are required to work as a part of the multidisciplinary team
approach to long-term condition management.
14. Regular training updates on emergency situation management. Annual
resuscitation training. Training compliance to be audited.
Prison Service response – recommendation accepted. Training database maintained
by Clinical Lead Primary care, including compliance with mandatory training for nurses
covering emergency response duties.
15. Policy to be devised on the management of prisoners when they arrive in
Healthcare under restraint. This policy to be audited.
Prison Service response – recommendation accepted. Existing policy to be reviewed
and revised (Lead - Head of Healthcare). Work on this is on-going.
16. Full set of observations to be completed on all prisoners immediately on
entering Healthcare under restraint.
Prison Service response – recommendation accepted. Existing policy to be reviewed
and revised (Lead – Head of Healthcare). Work on this is on-going.
17. IMR documentation to be revised to incorporate entries from multi-disciplinary
team.
Prison Service response – recommendation accepted. INPS Vision installed March
2008.
18. Intensive Care Cell to be decommissioned for all prisoners regardless of their
condition.
Prison Service response – recommendation accepted and implemented.
19. CCTV Monitoring not be used as a tool to observe a prisoner whilst in an
unstable condition. CCTV monitoring is no substitute for physical clinical
observations.
Prison Service response – recommendation accepted and implemented.
20. Quality of visibility through hatches rose as an issue. Simply observing through
the cell hatch is not sufficient to see if a person is breathing or not. Cleaning
contract to provide hatch cleaning as part of cleaning specification of the cell.
28
Prison Service response – recommendation partially accepted. All single cells in
Healthcare have hatches which can be opened to facilitate observation.
Dimmable lighting has been installed to all wards and a works project has been
commissioned to explore the possibility of installing dimmable lighting in all single cells
to facilitate observation without disturbing the patient.
21. Escalation policy to be devised with alert scoring built in so staff have a tool to
support decision making rather than relying on each others thoughts and
opinions.
Prison Service response – recommendation accepted. See response to
recommendation 15.
22. Breaking bad news policy to be reviewed.
Prison Service response – response to follow.
23. Policy around debriefing to be reviewed/revised and audited. GP should be
part of cold debrief.
Prison Service response – recommendation not accepted. Multi-disciplinary, multi-
professional cold debriefs occur after every untoward incident including deaths in
custody. GPs are involved wherever appropriate.
24. Policy and practice around distribution of medication to be revisited in light of
this case. Medicines management audits to be undertaken across the prison.
Prison Service response – recommendation accepted. Administration of medicines
policy revised and implemented September 2007; includes clinical audit strategy.
29