Individual at Ford

The death in custody of a man at
HMP Ford on 23 September 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2005
This is the report of an investigation into the circumstances of the
death from pneumonia on 23 September 2004 of a life sentence
prisoner at HMP Ford.
All deaths of prisoners in custody are investigated, including those
due to natural causes. The responsibility for carrying out these
investigations traditionally fell to the Prison Service itself, but has
now been passed to the Prisons and Probation Ombudsman (PPO) to
bring independence and greater consistency to the task.
The investigation was carried out by one of my Senior Investigators.
A clinical review into the man’s care and treatment was
commissioned from Western Sussex Primary Care Trust.
Just one, relatively minor, matter has arisen from this investigation.
We would like to extend our condolences to the man’s family for
their loss. I would like to thank the Governor of HMP Ford and her
staff for their help.
Stephen Shaw OBE February 2005
Prisons and Probation Ombudsman
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Index
Summary 4
Investigation Process 5
The Man 6
HMP Ford 7
The Events Leading up to the Man’s Death 8
After the Man’s Death 9
Level of Compliance with Prison Service Requirements 10
Findings 11
Conclusions 12
Recommendations 13
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Summary
The man died from pneumonia on 23 September 2004, at the age of
71, at outside hospital. At the time of his death he was serving a
life sentence at HMP Ford.
The man had a number of age related clinical conditions that were
managed appropriately and enabled him to lead an independent life
in prison. That included day release from the prison when he
worked part time in a nearby town. On 21 September 2004, the
man consulted prison Healthcare with an upper respiratory tract
infection (URTI), which the doctor treated with paracetamol. This
was appropriate for the man’s presenting symptoms at that time.
Within 24 hours, the man’s condition deteriorated significantly and
he was transferred to hospital, where he died two days later.
One of my Family Liaison Officers spoke by telephone to the man’s
next-of-kin, his adopted daughter.
This report makes a recommendation in relation to record keeping
practices by doctors who work in the prison.
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Investigation Process
My practice in cases of deaths from apparently natural causes is to
conduct an initial review to determine the extent of investigation
required.
My investigator visited HMP Ford on 30 September 2004 when he
spoke informally with the Governor, the Head of Residence, a
representative from Healthcare, and two of the prison chaplains.
The investigator was given access to the man’s records, including
his medical records. The investigator also met the Deputy Chair of
the Independent Monitoring Board (IMB). He said that he had no
concerns either about HMP Ford in general, or about the man’s care
and treatment in particular.
The man’s next-of-kin, his adopted daughter, was contacted by
telephone and letter. She raised no specific concerns, but was
interested to learn about her adoptive father’s cause of death.
Western Sussex Primary Care Trust carried out a clinical review.
No formal interviews with staff were conducted. This report is based
upon a thorough review of all relevant paperwork and upon the
clinical review.
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The Man
The man was sentenced to life imprisonment in 1986 with a
recommendation that he serve a minimum of 20 years. He served
time at a number of different prisons before being transferred to
HMP Ford. The purpose of moving the man to Ford was to prepare
him for his future release back into the community. As part of this
process, the man worked at a number of different community based
placements, both carrying out community work and working in paid
employment. The man had also had regular weekend release on
temporary licence.
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HMP Ford
HMP Ford is a category D open prison with a regime that includes a
community service department to help life sentence and long term
prisoners work towards their release.
Healthcare at Ford is staffed from 7.45am to 5.30pm each day and
has two full time nurses, supplemented by agency nurse support.
Healthcare operates as would a GP surgery, with GP consultations
being arranged on an appointment basis. There are no permanent
GPs on site. Instead, GP support is provided four mornings per
week through an agency based in Brighton. Although most
appointments are made for between 24 to 48 hours ahead,
Healthcare nurses will ensure that prisoners with more significant
clinical conditions are given priority. Prisoners presenting with
significant conditions will, if necessary, be referred to the out-of-
hours GP service, or direct to hospital. There are no in-patient beds
in the prison Healthcare unit.
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The Events Leading up to the Man’s Death
The man’s records reveal that he had a number of clinical
conditions. These were largely age related and were being
monitored through regular hospital appointments. For instance, he
had had a mild heart attack in 1996 and he was being regularly
reviewed by a consultant cardiologist at a London hospital.
In the final months leading up to his death, the man had several
consultations with Healthcare doctors in connection with symptoms
of sleeplessness, for which he was referred to an outside hospital for
investigations. On 2 September 2004, the man consulted
Healthcare complaining about an exacerbation of his symptoms of
angina and a note was made in his records that a further
cardiological opinion should be sought.
On 21 September 2004, the man consulted Healthcare about a
condition wholly unrelated to any of his chronic conditions. His
consultation that day concerned a throat infection – clinically, an
upper respiratory tract infection – and he also reported that there
was some blood staining in his sputum. The Healthcare doctor
noted that the man’s chest was clear and that his respiration was
normal. The Healthcare doctor prescribed paracetamol, advised the
man to take fluids and told him to rest from work for four days. In
the early afternoon of the following day, 22 September, the man
returned to Healthcare complaining that he was coughing blood. On
examination, he was found to be having difficulty in breathing. He
was also found to have a rapid pulse and was sweating. Pneumonia
was the tentative diagnosis and a 999 call was made to the
ambulance service for the man to be rushed to outside hospital.
A nurse from Healthcare telephoned the hospital later in the
afternoon of 22 September and made a note that the diagnosis of
pneumonia had been confirmed and that, although stable, the man
was gravely ill. At 4.30pm on 23 September the nurse telephoned
the hospital for an update and was told that the man was still stable.
However just after 9pm that evening, the hospital telephoned
Healthcare to say that the man had serious respiratory problems
and had been moved to the intensive care unit. The hospital had
informed the man’s relatives of this development.
When the Healthcare nurse telephoned the hospital for a further
update on the morning of 24 September, she was told that the man
had died at 10.30pm the previous night.
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After the Man’s Death
In compliance with its contingency plan relating to deaths of
prisoners, HMP Ford notified the Coroner, the IMB and other official
parties of the man’s death.
The prison’s Head of Residence was the Duty Governor on 24
September and she heard of the man’s death when she came on
duty that morning. When she contacted the outside hospital she
discovered that news of the man’s death had been passed to the
partner of the man’s adopted daughter. The Head of Residence
asked one of the prison chaplains to make contact with the man’s
next-of-kin.
The chaplain made contact and advised the man’s next-of-kin about
the processes involved in dealing with a death and making funeral
arrangements. At the next-of-kin’s request, one of the prison
chaplains subsequently conducted the man’s funeral service.
Prisoners at Ford made a collection to purchase a wreath.
When the PPO investigator visited Ford on 30 September, all the
necessary information had been gathered together for the purposes
of the investigation. Arrangements were made for the investigator
to speak to relevant members of staff.
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Level of Compliance with Prison Service Requirements
Standards of clinical care in prison are intended to mirror those
available in the outside community. The clinical aspects of the
man’s care are described in the clinical review. This indicates that
while in prison the man’s clinical needs were recognised and
adequately dealt with, in particular there was no unreasonable delay
in transferring him to hospital upon the development of his final
illness.
The post-incident response by Ford was fully compliant with Prison
Service instructions and policies on managing a death in custody.
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Findings
The man was transferred to Ford open prison in April 2000, with a
view to his future release. Towards that end, the man worked in the
community and had periodic weekend leave on temporary licence.
At 71 years-of-age, the man seems to have been a reasonably
active man and he self-described his health as good. The clinical
review refers to a relatively straightforward medical history, albeit
including a number of age-related clinical conditions for which the
man was receiving appropriate treatment and medication.
The man’s consultation with Healthcare on 21 September 2004 was
unconnected to any of his pre-existing clinical conditions. Instead,
his consultation that day was to report a throat infection. The man
also reported blood staining in his sputum. The doctor’s
examination revealed that the man’s chest was clear and that his
respiration was normal. The doctor prescribed paracetamol, advised
the man to drink extra fluids, and also suggested he stay off work
for four days.
The man returned to Healthcare the following day with symptoms
indicating a significant deterioration in his clinical condition. He was
noted to be having difficulty in breathing and it was also noted that
he was coughing blood. A tentative diagnosis of pneumonia was
made and he was rushed to outside hospital. Although it is recorded
that the man’s condition stabilised in hospital to some extent, he
died less than 36 hours after his admission.
The question to be asked in this case is whether the seriousness of
the man’s developing clinical condition could have been identified
sooner, specifically whether it should have been recognised at his
consultation on 21 September. The clinical review of the man’s care
and treatment, has explained that production of blood stained
sputum is not necessarily a sinister symptom as it can occur in acute
upper respiratory illness. The clinical review goes on to conclude
that there is nothing in the man’s records to indicate that he should
have been referred to hospital on 21 September.
The review does refer, however, to the doctor’s failure to note
whether he advised the man to return to Healthcare if his condition
were to deteriorate or fail to improve. The man was very
knowledgeable about clinical matters so I am certain he would have
needed little advice on how he should proceed, but in this regard he
was an exception.
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Conclusions
The man was well cared for in HMP Ford. There was no indication on
21 September that he needed to be sent to hospital that day.
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Recommendations
I recommend that Healthcare staff ensure that they always advise
prisoners to return to Healthcare if they fail to respond to the
prescribed treatment. I also recommend that a brief note be made
in the medical record that such advice has been given.
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