Individual at Holloway

The death in custody of
a woman at
HMP Holloway in March 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2007
This is the report of an investigation into the circumstances surrounding the death of a
woman in March 2005 at HMP Holloway.
The woman had been assessed by a doctor during her reception into Holloway in
February 2005 and had commenced a methadone detoxification programme the same
day. When a post mortem failed to ascertain her cause of death the Coroner appointed
a clinical pharmacologist to offer his opinion based upon the post mortem findings, the
toxicology report and other investigations. The conclusion was that the woman died as
a result of cumulative toxicity caused by her prescribed methadone. I extend my sincere
condolences to her family for their loss.
This investigation was carried out by two of my colleagues. A clinical review of the
woman’s clinical care and treatment was carried out by Islington Primary Care Trust
(PCT). In addition, a nurse consultant in substance misuse, carried out a review of the
management of the woman’s detoxification programme. A Suicide and Self-Injury
Prevention Consultant to the Prison Service Women’s Team conducted a review of the
woman’s F2052SH documentation. I am very grateful for all three of these additional
reviews.
I would also like to thank the Governor of Holloway and his staff for their help during this
investigation.
The first draft of this report was competed in September 2005. At that time, I was
instructed by the Metropolitan Police to delay its dissemination while the Crown
Prosecution Service (CPS) considered whether to bring a prosecution against Holloway
or any of its staff. In December 2006, I was informed that the CPS had announced a
preliminary decision that, as the evidence stood, there would be no criminal
proceedings. I very much regret that the woman’s family have had such a long wait.
The investigation has revealed a number of serious concerns about the care and
treatment afforded to the woman both while a patient in Holloway’s detoxification unit
and on her transfer to standard location. In particular, she was prescribed a methadone
detoxification programme when it was likely that she had little or no heroin addiction and
little previous experience of opiates or opioids.
I make six recommendations of my own. More detailed recommendations will be
found in the additional reviews.
This version of my report, published on my website, has been amended to remove
the name of the woman who died and those of staff, prisoners and organisations
involved in my investigation.
Stephen Shaw CBE June 2007
Prisons and Probation Ombudsman
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CONTENTS
Summary..........................................................................................................4
Investigation process......................................................................................6
HMP Holloway..................................................................................................7
Holloway's detoxification unit (H1)................................................................8
Key events........................................................................................................9
The woman's entry into Holloway in February 2005...............................9
The day before the woman's death.........................................................12
The woman's death...................................................................................15
After the woman's death...........................................................................17
Issues..............................................................................................................18
Cause of death...........................................................................................18
Management issues surrounding H1......................................................18
Clinical care...............................................................................................20
Clinical drug services...............................................................................21
Summary of the F2052SH review.............................................................22
Consideration of the issues.........................................................................23
Developments since the woman's death....................................................29
Recommendations ......................................................................................300
3
SUMMARY
The woman had a long history of alcohol misuse which had resulted in homelessness
and behavioural problems. She also had a history of acts of deliberate self-harm.
In early November 2004, the woman was remanded into Holloway after allegations that
she had breached a restraining order. The woman saw a doctor the following day. She
said that she was dependent on alcohol and crack cocaine. After verifying this with a
urine test, the doctor prescribed chlordiazepoxide and diazepam for detoxification. The
woman returned to court in mid November and was given bail.
In early December, the woman was remanded back into Holloway accused of a number
of further alcohol and drug related offences. The woman was only prescribed
chlordiazepoxide for alcohol detoxification on this occasion. She remained in Holloway
for the next three months until she was discharged in mid February 2005.
The woman was briefly back in Holloway several days later. She was again prescribed
chlordiazepoxide.
Having been released from Holloway, the woman was rearrested at the end of February
for a further breach of a restraining order. After spending two nights in police custody,
she was taken to Holloway. When the woman saw the doctor, she not only reported
alcohol and crack cocaine dependence but also said she was dependent on opiates,
saying that she had been taking heroin for the previous two months. A urine sample
proved positive for the substances that the woman had declared. In addition to being
prescribed chlordiazepoxide and diazepam, the woman was also prescribed methadone
for detoxification from heroin. As had happened during previous periods in custody, the
woman was assessed to be at risk of self-harm or suicide and an F2052SH form was
opened to provide appropriate monitoring and support. The woman was placed into
Holloway’s detoxification unit.
The woman remained in the detoxification until her transfer to standard location in early
March 2005. During interviews with my investigators, there were differing views given
by officers and nurses working in the detoxification unit about the woman’s condition.
Some of the officers thought the woman seemed drowsy at times, and two of them said
they spoke to nurses about this. In contrast, the nurses did not think there was anything
out of the ordinary about the woman’s condition. The one exception was one morning in
early March when a nurse observed the woman to be drowsy while she was waiting to
receive her next methadone dose at 8.25am. The methadone was appropriately
withheld and given later that morning instead.
Although there was disagreement between officers and nurses about the woman’s
condition, all staff said that they were surprised she had been prescribed methadone.
They all knew her to be someone who used alcohol but not heroin. However, nothing
was mentioned to any of the doctors at the prison.
Trying to reach an independent and objective conclusion on the extent, if any, of the
woman’s drowsiness during her detoxification was not helped by the fact that clinical
observations were not taken or recorded by the nursing team. (The term ‘clinical
observations’ refers to a patient’s vital signs such as pulse, blood pressure and
4
temperature.) Prison Service Orders require that clinical observations be taken for at
least the first 72 hours when stabilising patients undergoing detoxification. My
investigators were told that Holloway had ceased the routine taking of clinical
observations some time before the woman arrived in the prison. Pressure of work was
one of the reasons given. This is not acceptable and one of my recommendations
addresses this matter.
When the woman was transferred to ordinary location in early March, there were further
indications that she was not coping well with her detoxification programme. Two of the
officers in the unit said the woman seemed drowsier than most women going through
detoxification. This view was echoed by two of the prisoners who shared a dormitory
with the woman. Another prisoner, who was located in a different dormitory, thought the
woman was drowsy as she queued for her night-time medication at 7.30pm that
evening. This prisoner challenged the officer supervising the medication queue. She
asked him why, in view of her condition, the woman was going to be given even more
medication. The officer thought that the woman seemed okay. Nor did the nurses think
that there was anything untoward about the woman’s condition. During that night, two of
the women in her dormitory noticed she was coughing and snoring loudly. The night
officer (an Officer Support Grade) also noticed that she was breathing heavily.
At about 8.30am the next day, one of the other women in the dormitory tried to wake the
woman, realised she was dead and alerted staff. When the woman was examined, the
indications were that she had been dead for some hours.
A clinical pharmacologist was appointed by the Coroner to provide an expert opinion on
the woman’s cause of death. The clinical pharmacologist concluded that the level of
methadone given to the woman was suitable for a person who was used to taking opioid
type drugs, but would have been too high for a naïve user. He found that the
methadone accumulated to a toxic concentration in the woman’s body and ultimately
caused her death.
All of the evidence indicates that, although the woman was heavily dependent on
alcohol, she did not normally use heroin. The urine test at the end of February indicated
that she had used heroin during the five days since her last release from Holloway.
However, her claim that she was heroin dependent, and had been using the drug for the
previous two months, does not accord with the fact that she had been a prisoner in
Holloway for most of the previous three months. The various clinical reviews are
consistent in their opinion that the woman should have been questioned in more detail
about her claims before being prescribed methadone detoxification. Concerns are also
raised by the reviewers about the decision to prescribe diazepam.
My investigation also found some deficiencies in the woman’s care as a prisoner who
had been judged to be at risk of self-harm.
The specialist reviews make over 60 recommendations in total, some of which will
already have been addressed by Holloway. The vast majority of the recommendations
relate to clinical care and treatment of those undergoing a detoxification programme.
The remaining recommendations relate to the care and management of prisoners
judged to be at risk of suicide or self-harm.
5
INVESTIGATION PROCESS
The investigation was opened shortly after the woman’s death when my investigators,
visited Holloway and were given access to the woman’s records. Notices were issued
about the investigation and displayed around the prison. These invited any staff or
prisoners who felt they had relevant information to make themselves known to the
investigation team. One prisoner came forward in response to the notices.
My investigators spoke with representatives of the Prison Officers Association (POA)
and the Independent Monitoring Board (IMB) for their views on the prison in general and
the woman’s death in particular. Formal interviews were conducted with staff and a
number of prisoners.
One of my investigators, accompanied by one of my Family Liaison Officers, met the
woman’s parents and one of her brothers. The woman’s family were concerned that she
had been assessed at Holloway as having a drug dependency and put on a methadone
detoxification programme. They said that, during her previous times in custody, the
woman had not been put on methadone. Furthermore, in the brief period that the
woman was out of prison in between her final two periods in custody there was not
enough time for her to have developed a dependency on heroin. They said that her
problem had always been alcohol not drugs.
The woman's mother visited her daughter on the Friday before her death and found her
to be very drowsy, thirsty and hot. The woman told her mother that this was due to the
side effects of methadone and she would only be on this medication for a few more
days. The woman’s mother said that she spoke with her daughter on the telephone at
around 6.30pm in early March. The woman’s mother could not recall being concerned
about her daughter’s condition at the time, but when she subsequently listened to a
recording of the conversation she thought that her daughter did not sound herself. She
had been coughing a lot and was ‘not fully with it’. The woman had also written a letter
that evening which was very erratic. The woman’s mother felt that staff should have
noticed that her daughter was in a ‘drugged’ state. The woman’s family were also
concerned that the position of her bed on the night she died prevented her from being
properly observed by staff.
The woman’s family described her as physically very strong. They were concerned that
she may have taken illicit drugs in the prison and it was this that caused her death.
Three additional reviews have been carried out to assist this investigation. Islington
Primary Care Trust, which is responsible for the delivery of health care at Holloway, has
carried out a clinical review of the woman’s care and treatment. A nurse consultant in
Substance Misuse from the Department of Health has carried out a review of the
management of the woman’s detoxification programme. A Suicide and Self-Injury
Prevention Consultant, at that time employed by the Prison Service Women’s Unit,
carried out a review of the woman’s self-harm prevention documentation. This
investigation has also taken account of the views of the clinical pharmacologist
appointed by the Coroner to review information arising from the woman’s post mortem
and the toxicology reports to offer an expert opinion on the woman’s cause of death.
6
HMP HOLLOWAY
Holloway is a women’s local prison located in North London serving courts throughout
the South East of England. It accommodates just under 500 prisoners.
Holloway is a prison with many diverse functions. Its main role is to hold women on
remand or awaiting sentence. It also has a Mother and Baby Unit and a Young Offender
unit that holds girls and young women aged between 15 and 21 years old. Holloway
has a significant number of foreign national prisoners.
The majority of women arriving at Holloway suffer from alcohol and/or drug problems
that require detoxification. Many of the women also have mental health needs.
Holloway has a very transient population with only one in four still at the prison six
weeks after their initial reception. In 2003/04, Holloway accepted 6,500 new prisoners.
The woman’s death was the third at Holloway since April 2004 when I took over
responsibility for the investigation of deaths in prison custody.
Holloway’s Detoxification Unit (H1)
Holloway established the first ever prison detoxification provision in 1997 with almost
1,400 women being admitted for treatment in the first year. This figure rose steadily,
reaching a peak of almost 2,500 in 2003, before falling to 1,850 in 2004. Almost 14,000
women were safely and successfully treated at Holloway over this eight year period. In
2004, 8,592 women across England were safely and effectively managed in local
prisons using similar protocols and practice to that which had been founded and
developed at Holloway.
Over 60 per cent of all new prisoners received into Holloway require clinical
detoxification from opiates, alcohol and benzodiazepines. Prisoners receive health
screening on arrival and those requiring detoxification are admitted to the detoxification
unit (H1). The screening process includes separate assessments by a nurse and a
doctor on the day of arrival, with questions asked about drug and alcohol usage. Urine
testing is also carried out. Holloway once used a semi-quantative urine testing system
which gave a result showing precise levels of the drugs tested for. Semi-quantative
urine testing was subsequently replaced with a ‘dip and read’ test that only gives a
positive or negative result rather than a result showing levels of drugs in the urine. The
original semi-quantative urine testing machine became obsolete in 2001. An alternative
machine was obtained, but it proved inaccurate and was less safe than the standard ‘dip
and read’ tests. ‘Dip and read’ testing is used across the male and female prison estate.
Prison Health is investigating available machinery for semi-quantative testing.
For alcohol detoxification, Holloway uses chlordiazepoxide (Librium) usually for a period
of seven days. For opiate detoxification, methadone was used up to the end of July
2005 when it was replaced by Subutex as the standard choice. The methadone
detoxification programme, which is what the woman received, commenced at a low dose
of 10 milligrams (mg) twice daily, increasing to 30mg by day four, before steadily
reducing from day six and continuing on for 19 days. The standard methadone
detoxification programme was originally completed in ten days, but it was later extended
7
to 14 days. Finally, it was extended to a 19 day programme including a five day
stabilisation period for all opiate users in preparation for the new integrated drugs
treatment system (IDTS) standard (published by the Department of Health in 2006).
Current Prison Service Orders require that clinical observations of pulse and blood
pressure should be undertaken for a minimum of the first 72 hours following admission
into a detoxification unit. In addition, the procedure at Holloway required staff to monitor
women at the time of medication rounds and for the detoxification programme to be
adjusted or revised if appropriate. Adjustments to the programme included postponing a
dose of methadone if the woman was observed to be too sedated at the time it was
being dispensed. In such a case, a urine test would also be carried out and referral
made to a doctor if considered appropriate. In some cases, adjustments could be made
to an individual’s overall detoxification programme.
Originally, women would remain in H1 for a period of around five to seven days before
moving to the post detoxification unit (D1) when assessed to be well enough. In D1,
prisoners would be in the less intensive phase of detoxification and would begin to
participate in the general activities and regime of the prison. Women would be
transferred from D1 to ordinary location when considered medically fit to move, following
assessment by a doctor or senior nurse. In the summer of 2004, D1 was closed for a
number of reasons, including the need for refurbishment. D1 was re-opened in April
2005.
Historically, prisoners’ medical records at Holloway were paper based. In July 2004,
some paper based medical records were replaced by electronic records (the EMIS
system). Certain paper based templates, such as the First Reception Health Screen,
were set-up in EMIS in electronic form. Other templates, such as clinical observation
charts and care plans, remained paper based.
8
KEY EVENTS
The woman’s entry into Holloway
In early February 2005, the woman was arrested and taken into police custody. She
reported taking heroin and cannabis the day before and having taken alcohol that day.
The woman was given diazepam and Temazepam (sedative drugs to control agitation
caused by alcohol withdrawal and to assist sleeping). At Edmonton Crown Court she
was sentenced to six months imprisonment and taken into custody at Holloway.
Immediately prior to this, the woman had been in Holloway continuously from early
December 2004 to mid February 2005, and had also been there for four days later on in
February.
The senior nurse was on duty in reception at Holloway on the afternoon of the woman’s
arrival. The senior nurse said that nurses on reception do not usually see Prisoner
Escort Records (PER forms – used when a prisoner is passed from one agency to
another and which indicate if the prisoner might be at risk), nor do they usually see any
other paperwork. The senior nurse did not know the woman from her previous times in
Holloway but the woman looked vulnerable so, as the senior nurse on duty, she made a
point of choosing to conduct her preliminary healthcare screen (part of the standard
reception for new prisoners). This was around 4.00pm. The senior nurse recorded the
woman’s pulse as 90 beats per minute and blood pressure as 160/105 (indicating high
blood pressure). The woman reported that she been in prison the week before and was
back again having been sentenced to six months imprisonment for breaching an
injunction. The woman reported that she was withdrawing from both drugs and alcohol.
The senior nurse assessed the woman as displaying fairly severe symptoms of drug
withdrawal.
The senior nurse was very worried by the woman’s comments about feeling suicidal so
had opened an F2052SH. The senior nurse then took the woman to see the reception
doctor and also contacted the detoxification unit (H1) to let them know that the woman
would be arriving there.
The reception doctor saw the woman at just after 5.00pm. The doctor knew the woman
from her previous times in Holloway. The woman reported that she had an alcohol and
opiate dependency. As the doctor was speaking with the woman, he entered
information into her computerised medical records held on the EMIS computer system.
This system contains a template with questions to be asked and tick boxes to be
completed when interviewing those declaring a drug dependency. The doctor did not
explore with the woman the extent of her opiate usage – the amount of spend and
frequency of use – he told my investigators that this would be explored the following day
by the detoxification doctor. At Holloway, chlordiazepoxide (Librium) is used for alcohol
detoxification and, at the time, methadone was usually used for opiate detoxification.
The doctor was aware that the woman had not reported having a drug dependency on
the previous occasions she had been in Holloway. However, methadone would not be
given solely on a prisoner’s word that she was a user of opiates, it would be given only
with a positive urine test. In the woman’s case, her urine test confirmed the presence of
opiates so the doctor wrote a prescription of methadone and she was given 10mg that
evening. In addition, the doctor prescribed chlordiazepoxide for alcohol detoxification,
9
diazepam for benzodiazepine dependence, two inhalers for asthma and thiamine
hydrochloride (a vitamin supplement).
The woman was located in the detoxification unit (H1) and allocated to dormitory 23.
The following day, the woman was seen by the detoxification doctor. As a matter of
routine, all prisoners with drug or alcohol dependency are seen on the morning following
admission by a doctor for a review of their medical history and history of drug or alcohol
use. The detoxification doctor said that she knew the woman from previous times in
Holloway, although she did not know her very well. On previous occasions, the woman
had only declared dependency on alcohol and crack cocaine but this time she also said
she had been using heroin. This was confirmed when her urine test proved positive for
opiates, as well as for other drugs including amphetamines and crack cocaine. The
detoxification doctor asked the woman repeatedly about her claim to have been using
heroin, but the woman insisted. The detoxification doctor asked the woman how she
took heroin and the woman replied that she smoked it. The woman had been a bit
evasive, but because of her history of self-harm, the detoxification doctor did not want to
provoke her and felt it was better to give her medication rather than to withhold it.
My investigators asked the detoxification doctor about the record she made of the
woman saying that she had been using heroin for the previous two months given that
she had, in fact, been in Holloway for most of that time. The detoxification doctor said
there was no guarantee that the woman had not been using heroin while in Holloway,
but in any case the protocol at Holloway is that if a person declares they are a heroin
user and their urine test proves positive for opiates, methadone is prescribed.
The detoxification doctor acknowledged that the woman was on a lot of medication, but
she said that many women in Holloway are multi-drug users with complex needs. It is
therefore often necessary to prescribe a lot of medication for them, which they are able
to tolerate.
At interview, a number of nursing staff who knew the woman said they were surprised
about her being on methadone. They knew her as someone who would go through
alcohol detoxification, but not as a user of heroin. The nurses consistently said that
there was nothing about the woman’s condition during her time in H1 that was out of the
ordinary or which gave them any cause for concern.
One nurse told my investigators that the nurses spoke about the woman being on
methadone this time, however her urine sample had proved positive for opiates. It was
therefore a case of following normal practice. The nurse said that when women are
receiving methadone, clinical observations of pulse and blood pressure should be
carried out. She acknowledged that the taking of clinical observations had ceased some
time before the woman’s last period in Holloway due to a number of factors including
pressure of work and staffing problems. For the same reasons, Holloway had also
stopped issuing self-assessment questionnaires (a form for prisoners to complete with
details of their drug and alcohol use) and also ceased completing withdrawal monitoring
charts (on which a woman’s withdrawal symptoms would be recorded and scored).
A discipline officer in H1 remembered the woman from her various times in Holloway.
He said that the woman was no different to many of the women going through
10
detoxification at Holloway: typically they would not be very well for several days and
would then get well and move on to standard location. The officer made an entry in the
woman’s F2052SH form in early March that she was drowsy, but as far as he could
recall he thought he had made that note not long after she had had her medication.
When the woman attended for her morning methadone two days later, she was judged
to be drowsy by the dispensing nurse. The woman’s urine was tested, but proved
positive only for her prescribed medication. The woman’s methadone, which had been
due at 8.30am, was withheld and not given until later that morning. The nurse said that
a note should have been made about this both in the unit’s urine record book and in the
woman’s EMIS computer record, but in neither was a note made. Apart from that
morning, there was no other occasion when the nurse observed the woman to be
drowsy.
The woman was visited that day by the Community Mental Health Team. The mental
health worker told my investigator that the woman was a lot drowsier than she had ever
seen her before. However, the woman had been able to engage in conversation. The
mental health worker was not concerned about the woman seeming quite drowsy. She
assumed that staff would have recognised if she was drowsier than could be expected
for a person going through detoxification.
The following day, the woman’s heroin detoxification programme peaked with her
receiving a single dose of 30mg of methadone. On that day different discipline officers
made two separate entries in the woman’s F2052SH about her appearing drowsy. In
the morning an entry referred to the woman being ‘very groggy’ and in the evening an
entry was made that she ‘looks very tired.’
The next morning another entry (by a third officer) was made in the woman’s F2052SH
that she ‘seemed very drowsy’. Later that day, the woman was moved to dormitory 28.
This was apparently due to the other women in dormitory 23 complaining that her
snoring was disturbing them. The woman again had a single dose of 30mg of
methadone. The woman’s methadone doses began decreasing from the next day
starting with a dose of 25mg.
A discipline officer in H1 said that she had met the woman a number of times on
different occasions when she was in Holloway. The officer described the woman as a
pleasant person who never caused problems. Like the nursing staff, the discipline staff
were also surprised at the woman being prescribed methadone. When questioned by
one of the discipline staff, the woman said that she had been dabbling in a bit of heroin.
The officer said at interview that her concern at that remark was that ‘dabbling’ in drugs
is not the same as having a drugs ‘habit’. The officer made three separate entries in the
woman’s F2052SH form about her being drowsy. The officer said she had never seen
the woman in that condition during the previous occasions she had been in Holloway.
The officer mentioned this to nursing staff and was aware of the occasion when the
woman’s medication was withheld.
Another officer told my investigators that she knew the woman quite well and that she
felt they had quite a good rapport. The officer said that when the woman came into
Holloway on this last occasion, she was different to how she had been previously. On
this occasion the woman was drowsy and also disorientated at times. The officer made
11
entries in the woman’s F2052SH about this. However, the officer did not think that the
woman was markedly different to the other women going through detoxification,
although there was one occasion when she spoke to a nurse about her. The officer was
not certain of the occasion, but thought it might have been in early March when she
recorded in the F2052SH that the woman had asked her to go to the off-licence for her.
It had not seemed to the officer that the woman was joking when she made that remark.
The day before the woman’s death
At 8.30am on the day before the woman’s death an officer made an entry in the
woman’s F2052SH that she ‘looked very drowsy’. At 10.30am, another officer made a
note: ‘Has been on exercise, seems in good spirits. No concerns.’ However, at
12.20pm the officer noted in the woman’s F2052SH that she was ‘still very drowsy’. At
interview, the officer said that as the woman was still drowsy on the day before her
death – her final day in H1 before transfer to standard location – she spoke to another
officer about whether she was fit to relocate. They concluded that ‘on paper’ the woman
was fit to go and the decision, in any case, was one for the clinical staff to make. The
officer made an entry in the woman’s records: ‘No problems on detox.’
The nurse who authorised the woman’s move to standard location said that any of the
qualified nurses in H1 is able to authorise transfers to standard location. The nurse had
known the woman for a couple of years and had spoken with her earlier in the week
when she discovered that the woman was receiving methadone. The woman told the
nurse that the last time she had been at liberty she had been using drugs as well as
alcohol. The nurse said that the woman had been slightly drowsy earlier in the week – a
symptom of withdrawal – but there had been nothing about this to cause concern and
then she had settled. The nurse saw the woman just before she left H1 and there had
been nothing about her to give cause for concern. At 2.24pm, the nurse made an entry
in the woman’s EMIS medical record: ‘Fit for ordinary level from detox unit. Transferred
to B4 this pm.’
A senior nurse saw the woman on the morning of the day before her death. She said
the woman was fine that day. She had packed her bag for the move to B4 and seemed
happy to go to normal location.
At some time after 2.00pm that day the woman, along with three others from H1, were
taken to normal location – two were going to A4 and two, one of whom was the woman,
were going to B4. The escorting officer said he spoke to all four of the women and his
view was that the woman seemed no different to the others and there was nothing to
indicate any problems. The officer said that, on escorting the women, he carried their
paperwork while they carried their own bags. The officer first went to B4 where he
passed the woman plus one other to the receiving officer. The escorting officer said that
the practice was to inform the receiving officer when women were subject to F2052SH
monitoring. But when he mentioned that the woman was subject to such monitoring, he
realised that he did not have the relevant documents. The escorting officer took the two
remaining women to A4 and, on returning to H1, collected the woman’s F2052SH, which
had been with the doctor, and took it to B4. The escorting officer estimated that about
10 to 15 minutes elapsed between dropping off the woman in B4 and his return there to
deliver her F2052SH.
12
When a prisoner subject to F2052SH monitoring is discharged from the healthcare
centre to standard location, a discharge report should be completed. At 3.00pm, the
doctor completed the woman’s discharge report. In a section titled ‘Summary of in-
patient stay’, the doctor wrote: ‘Already located in [ordinary location]’. At interview, the
doctor said that before signing a discharge report of a prisoner he does not know, he will
first see her to ensure she is fit to be in standard location. However, as he knew the
woman, he would only have checked with staff that she was well that day.
The receiving officer said that he received the woman and one other prisoner into B4 on
the afternoon of the day before the woman’s death. The woman was not totally
focussed, but he said that is usual for women going through detoxification. The receiving
officer located the woman, along with the other prisoner, into dormitory 20. At the time,
the receiving officer was unaware that the woman was subject to a special watch as her
F2052SH form did not arrive until later on in the afternoon. When the F2052SH did
arrive, the receiving officer did not consider whether the woman should have been
asked to change beds. The bed that the woman occupied abutted the wall of the
dormitory toilet which meant that only the bottom of the bed was visible from the
observation hatch.
Another officer told the investigators that she was in fact the receiving office and the
woman’s records contain an entry by this officer to support this: ‘Rec’d onto B4 placed
into dorm 20, on [methadone].’ This officer said that women going through detoxification
are typically disorientated and unsteady on their feet. However, the woman was
unusually unsteady and drowsy and, when taken to dormitory 20, she stumbled into the
room. The other woman transferred in from H1 was located into the same dormitory.
My investigators spoke with three of the prisoners who shared dormitory 20 with the
woman. All three described the woman as very drowsy, and two of them described her
as being more drowsy than usual for someone going through detoxification. One of the
prisoners knew the woman from previous times in Holloway. She described the woman
as wobbly and said that she could barely stay awake.
The senior nurse, who had carried out the woman’s first reception health screen on
arrival at Holloway works on the level 4 houseblock in addition to working in reception.
The senior nurse was involved in the methadone administration round at 4.00pm on the
day the woman arrived on B4. As methadone is a controlled drug, it is issued separately
to other medication. When the woman reached the medication hatch she was looking
behind her talking to the other women in the queue. This caused her to sign her
methadone chart in the wrong place. The senior nurse told the woman off for doing this.
The senior nurse told the investigators that the woman had been well at that time. Had
the senior nurse been concerned, she would have withheld the woman’s methadone.
The officer who supervised the methadone queue at 4.00pm thought that the woman
was fine at that time. The officer next saw her at around 5.30pm when the rooms were
unlocked for prisoners to collect their evening meal. The officer asked the woman
whether she wanted to eat, but she said she did not. She also said that she was fine.
At about 6.30pm, the woman went to the wing office to collect a PIN number to allow her
to make a free telephone call, and also to ask for a visiting order for her parents. Two
officers were in the office and they spent some time with the woman. One of the officers
13
again described the woman as typical of those going through detoxification: ‘not 100%
with it and was slurring a few words, but she was okay.’ The other officer said that
communicating with the woman was very difficult. She had great difficulty in
understanding what was being said to her, and it was also difficult to understand what
she was saying in reply. The officer thought that the woman was drowsier than usual for
a person going through detoxification.
At around 7.15pm to 7.30pm, the final medication round of the day takes place. This is
when all other prescribed medication, apart from methadone, is issued. The prisoner
who had been immediately behind the woman in the medication queue, asked to speak
to the investigators. The prisoner said that she knew the woman from previous times in
custody. She knew the woman used alcohol, but not drugs. The woman was very
drowsy that evening. The prisoner had never seen her like that before and she was also
unlike any of the other women going through detoxification. The prisoner did not think
that the woman should be given any more medication that evening, and she mentioned
this both to the woman and to the officer supervising the medication queue.
The officer said that, when supervising a medication queue, his practice was to make
small talk with the women in the queue. He spoke with the woman and she seemed
okay other than that her hands were slightly shaky, which is a common symptom in
people going through detoxification. The officer said that he did notice that the woman
was issued with a large number of tablets and he recalled the other prisoner remarking
upon that. The officer said that he thought his reply was that it was a matter for the
doctors and nurses.
The dispensing nurse at the evening medication round said that when the woman
reached the medication hatch she asked if she was okay and the woman replied that
she was. There was nothing about the woman’s appearance to give the nurse any
cause for concern. Had she been concerned, the nurse would have withheld her
medication and would have referred her to the doctor.
The senior nurse who had given the woman her methadone at 4.00pm saw the woman
again at some point that evening – possibly around 7.30pm. The woman approached
her to apologise for signing the methadone chart in the wrong place. Again, there was
nothing about the woman to give the senior nurse any cause for concern.
A Senior Officer (SO) on duty on level 4 that day saw the woman on association at some
time between 6.00pm and 8.00pm. The woman seemed well, allowing for the fact that
she was going through detoxification. The SO had not known then which bed the
woman occupied in dormitory 20, although she discovered this the following day. She
accepted that the woman’s bed could not be easily observed from the observation
hatch. The SO added that she was unaware of bed choice for prisoners subject to
F2052SH monitoring previously being a factor for consideration.
One of the prisoners from the dormitory said the last thing the woman did that evening
was to start writing a letter to her parents. However, she was falling asleep as she was
doing so. Another of the women said that after the woman fell asleep she began to
make a lot of noise in her sleep. She was snoring and coughing. The prisoner said that
she woke the woman at some time around 11.00pm because of the noise she was
making. The woman seemed okay and asked for a cigarette.
14
The woman’s death
An operational support grade (OSG) on duty in B4 and C4 on the night of the day before
the woman’s death said that, upon starting a shift, she checks the women subject to
F2052SH monitoring. It was not ideal that the woman was in the bed next to the toilet,
but the OSG said that she could see the woman from her shoulders downwards. If she
had thought it necessary to do so, she would have asked her manager to have the
woman swap beds with one of the other women. Through the night, the OSG made
hourly entries in the woman’s F2052SH that she appeared to be sleeping. Once the
lights in the dormitories had been switched off, the OSG used a torch to check the
women subject to F2052SH monitoring. At about 3am, the OSG noticed that the woman
was breathing very heavily, but neither at that time, nor at any other time in the night, did
she have any concern about the woman’s well-being.
At night time, the F2052SH process requires the night officer to satisfy him/herself that
the prisoner is well, although prisoners are not woken at these checks. However, at the
final check before handing over to the day staff, the night officer is required to obtain a
response from all of the prisoners. Similarly, the oncoming day staff should also carry
out a roll call in confirmation that they have taken responsibility for the correct number of
prisoners, all of whom are well. In conducting her final check that morning the OSG
made an entry at 7.15am in the woman’s F2052SH: ‘Called and responded.’ When
asked about this entry, the OSG said that she had obtained a response from some of
the women in the dormitory and was told by them that the woman was asleep.
An officer who was due to work a day shift in A4 arrived early for her 7.30am start. As
she walked through B4 and C4, she counted the prisoners in those wings. Night staff
are not able to go home until the day staff have carried out their own counts. By
counting the prisoners in B4 and C4, the officer allowed the night officer to go home and
also saved a job for the oncoming day staff in those wings. After counting the prisoners
in B4, the officer recorded the figures in the wing diary. The officer admitted at interview
that, although she counted the prisoners, she did not obtain responses from them all.
She said that most of the women would usually be asleep at that time so it was unusual
to obtain responses from them all. She acknowledged that she should have obtained
responses from the prisoners on open F2052SHs.
At 7.30am, another officer made an entry in the woman’s F2052SH: ‘Answered to check
by day staff.’ The officer said that he had not personally checked the woman at that
time. He made this entry after being told that another officer had completed a check of
all the prisoners. The officer added that F2052SH monitoring was often a team task,
with the officer carrying out a check then passing information to another officer who
might be the one to make the entries in the F2052SHs.
The residential nurse for the level 4 houseblock began dispensing the morning
medication. When she went to dormitory 20 she was told that the woman was still
sleeping so she proceeded down the corridor.
Another of the prisoners in the dormitory tried to wake the woman so she could have her
medication. The prisoner realised that the woman was dead and alerted the staff by
banging on the dormitory door.
15
An officer responded to the noise and was told by one of the prisoners that the woman
was blue in colour. Two officers went into the dormitory and checked the woman while
radioing for a Code Blue alert to be issued (a Code Blue alert is a warning of a life
threatening incident needing an immediate response from clinical and other staff). An
officer checked the woman for a pulse, but found no signs of one. Nor did she have
signs of breathing. The officer said that he was checking the woman’s mouth for
blockages in her airway when the first response nurse arrived and called for the blue
bag (a medical bag containing emergency resuscitation equipment, including oxygen,
and which is kept in the nurses’ room on each level).
The first response nurse said that she arrived in B4 in less than a minute from the Code
Blue alert. She said that when she went into dormitory 20 she saw the woman, but
there were no staff by her bed. The first response nurse said that the woman was
purple in colour. The woman had no pulse and she was not breathing. At that point, a
second nurse arrived as did other staff. The first response nurse was carrying a
‘response bag’ with basic emergency equipment, but she also asked for the blue bag as
that contains more equipment. The first response and an SO started attempts at
resuscitating the woman. A defibrillator was brought to the dormitory, but when it was
used it ordered that no shock should be given. Staff continued with their efforts to try to
resuscitate the woman until ambulance paramedics arrived when they took over.
However, all attempts at trying to resuscitate the woman proved unsuccessful and she
was pronounced dead at 8.52am.
The residential nurse said that she was returning to the B4 nurses’ room when an officer
called out to her that she was needed. Before being able to help, she first had to secure
her drugs trolley in the nurses’ room. She said she went to dormitory 20 and began to
check the woman for signs of breathing and a pulse. When the first response nurse
arrived, the residential nurse went back to the nurses’ room to collect the blue bag. Due
to lack of space in the nurses’ room, the blue bag hangs from a mounting fairly high up
on the wall. The bag was too heavy for the residential nurse to take down from its
mounting, but an officer came to the room to do this for her. The residential nurse then
returned to dormitory 20 with the blue bag. By then, sufficient clinical staff were already
present to give aid to the woman so the residential nurse‘s involvement was only to pass
over equipment from the blue bag. The residential nurse confirmed that there is no
defibrillator on level 4. Both levels 3 and 5 have defibrillators, so level 4 will collect one
of those if needed, as happened in the woman’s case.
A Principal Officer (PO) was the duty Orderly Officer on the day of the woman’s death.
The PO explained at interview that the Orderly Officer’s role is to ensure that the prison
regime is operating appropriately and to take control of incidents. The PO responded to
the Code Blue alert and, on arriving in B4, found clinical and other staff on scene
attempting to resuscitate the woman. The PO contacted the communications room to
check that the ambulance service had been contacted and was told that was the case.
The PO detailed officers to keep a log of events and to prevent unauthorised entry into
dormitory 20. During the debrief held later that morning, one of the two ambulance
crews which had responded to the 999 call reported being held up for a few minutes
while waiting to be escorted to A4. The PO said that the process that should be
followed is for the gate-house to be informed that an ambulance has been called, and a
member of staff deployed as escorting officer. The PO was uncertain about what
16
happened with the ambulance in the woman’s case. What he thought might have
happened was that, while the escorting officer was locking the security gate after the
ambulance had passed through, the ambulance may have continued on without waiting
for the escorting officer and perhaps got lost.
After the woman’s death
The woman’s parents live in North London. Holloway’s family liaison officer,
accompanied by a chaplain, visited the family later on in the morning of the woman’s
death to break the news in person. The prison offered to pay funeral expenses and
representatives from Holloway subsequently attended the woman’s funeral.
The family took up an offer to visit Holloway and they saw the dormitory where the
woman died. The family considered that the overall contact with Holloway had been
very good. They especially mentioned the family liaison officer.
The family’s only complaint was that it had not been possible to see the woman’s
body on the day of her death. They understood that this was due to a delay with the
police’s assessment of the scene rather than the fault of the prison.
17
ISSUES
Cause of death
Following the woman’s death, post mortem and toxicology examinations were carried
out. Her family wondered whether she might have taken illicit drugs in the prison and
whether this had caused her death. However, the toxicology result showed drug
concentrations in keeping with the levels of the woman’s prescribed medication. Hair
analysis indicated that she had not been a habitual user of opiates. The post mortem
examination found that the woman’s major organs were healthy and unremarkable
and the pathologist stated that her cause of death was unascertainable.
In a further effort to determine the cause of death, the Coroner asked for the expert
opinion of a clinical pharmacologist. The clinical pharmacologist assessed the risks
associated with each of the drugs that the woman had been prescribed and those
associated with combining all of them. Finally, the clinical pharmacologist considered
whether the woman’s death could have been caused by combining the various
medicines, and in particular whether the level of methadone in her body would have
been sufficient to cause death. The clinical pharmacologist wrote that there is little
risk of a metabolic interaction between the drugs taken by the woman, although he
also said that the combined action of chlordiazepoxide and diazepam will be additive
and both may deepen any sedation and mental confusion caused by methadone (and
vice versa). The clinical pharmacologist went on to say that the analysis of the
woman’s hair indicated that she had not taken methadone or other opioid drugs
regularly in the last six months of her life. The levels of methadone given to the
woman when she came back to Holloway the last time were suitable for a person who
was used to taking methadone, but were too high for a naïve user of the drug. As a
result, the prescribed methadone accumulated to a toxic concentration in the
woman’s body and ultimately caused her death.
In due course, the woman’s cause of death will be determined at her inquest.
Management issues surrounding H1
At their initial visit to Holloway, my investigators reviewed the woman’s records and
spoke informally with staff in H1 to gain an understanding about how the detoxification
unit operates. Having spoken with several members of staff, my investigators then
spoke with the head of healthcare, about some of their immediate concerns. For
instance, staff had said that for the previous year or so clinical observations had not
been undertaken of prisoners going through detoxification, nor were care plans being
written. The head of healthcare was unaware of these omissions. My investigators did
not interview the head of healthcare formally as he was suspended from work soon after
the investigators’ preliminary visit to Holloway.
Holloway’s deputy Governor, promoted to that post in January 2004, told my
investigators that in March 2002 she was Holloway’s Head of Residence. In that role,
she was in charge of the entire residential function of the prison – including the
healthcare and detoxification units. However, even upon her promotion to deputy
Governor grade, she was still a lower grade than the head of healthcare. The deputy
Governor believed that the head of healthcare took up post around the middle of 2002
18
and always reported directly to Holloway’s governing Governor. In the summer of July
2004, Holloway appointed a new governing Governor.
The deputy Governor said that it was not long after the head of healthcare took up post
that it became apparent that there were difficulties in his working relationship with
Holloway’s lead clinician in detoxification. The deputy Governor said that the lead
clinician in detoxification told her that unsafe practices were developing in the delivery of
detoxification services, in particular that staff were not following protocols. The lead
clinician in detoxification had mentioned her concerns to the head of healthcare, but he
refused to accept that there were any problems. The deputy Governor herself began to
feel concern about practices in healthcare and she spoke about them when briefing the
new governing Governor on his appointment. The deputy Governor said that, when the
Prisons and Probation Ombudsman issued his reports into the deaths in 2004 of two
women at Holloway, the prison drew up action plans to deal with the Ombudsman’s
recommendations. The action plans were then submitted to the relevant unit managers
for them to take forward. The deputy Governor had been led to believe that the action
plans relating to healthcare were being taken forward.
The healthcare practice manager was appointed in January 2005. He is a non-clinician,
so his responsibilities were for the non-clinical functions of healthcare, such as the unit’s
budget, its IT systems, its administration team, and personnel issues. The healthcare
practice manager said he very soon began to have concerns about various aspects of
the healthcare unit, such as staff training and development, performance management
of staff, staff working relationships and control of the budget. When the head of
healthcare was suspended from work in April 2005, the healthcare practice manager
was asked to fill the post of acting head of healthcare. After taking on his new role, the
healthcare practice manager oversaw a thorough review of the processes and systems
in healthcare. This has resulted in many changes such as investment in staff training,
staff recruitment, and the introduction of new protocols and procedures for patient care.
Building work and refurbishment has also been undertaken, including the development
of a first night centre. The healthcare practice manager thought that staff morale has
improved and that the healthcare unit is now a safer environment for its patients.
The substance misuse adviser told my investigators that he has many years’ nursing
experience and in recent years had become closely involved in substance misuse
services, including setting up such a service at Wormwood Scrubs. In the Easter of
2005, he was invited to Holloway to review its detoxification services. The substance
misuse adviser submitted a report and in June 2005 commenced a two day per week
attachment to Holloway to take forward the recommendations. Areas that he identified
as needing work included a variety of staffing issues, such as staff training and
development, staff leadership, and team working. The substance misuse adviser was
also concerned that opiate detoxification prescribing at Holloway seemed to him to be a
‘one size fits all’ methadone regime. He is in favour of individual, needs driven,
prescribing in line with Department of Health prescribing practices. Upon first arrival in
Holloway, women are no longer automatically given medication on demand; instead they
are prescribed medication if they have symptoms that require it. The following morning,
women have a rigorous assessment and given the course of treatment that is the most
clinically appropriate for them. In some cases, that will mean women continuing only
with symptomatic medication. In addition, the plan was to commence using Subutex as
the usual drug of choice for opiate detoxification – used as a single agent, it is thought
19
that Subutex is a safer drug than methadone as it does not cause respiratory depression
and any adverse reaction to Subutex is not dose related. (Subutex replaced methadone
at Holloway in July 2005.)
The substance misuse adviser has reintroduced mandatory clinical observations – blood
pressure and pulse – to be taken on every day that a woman is in the detoxification unit.
It is also now a doctor’s responsibility to deem a person as fit for discharge to normal
location. He said that even though a woman has completed her detoxification
programme, it does not mean that she is ready for ordinary location – it would not be
acceptable for somebody to leave the detoxification unit if she is still experiencing
withdrawal symptoms. The plan therefore is for women to remain in the detoxification
unit for a further 24 hours to ensure that there are no residual symptoms or any other
problems that have not previously been identified. Closer checks are also to be
maintained of those women remaining on maintenance doses of methadone following
their discharge to ordinary location.
Talking about EMIS, the substance misuse adviser said that within the detoxification unit
the recording of information onto EMIS had simply become a ‘process’, with nurses
failing to use it as a communication tool, for instance for recording conversations with
patients. There was no audit mechanism in operation to check whether it was being
used properly, and no one had taken on ownership for it. Nurses have now been
instructed to recommence maintenance of paper records until the EMIS system can be
re-evaluated and staff have been fully trained and become competent in its use.
Clinical care
In accordance with the agreement with the Department of Health, the responsible
Primary Care Trust (PCT), in this case Islington PCT, was asked to undertake a review
of the woman’s care in Holloway. I am grateful to them for arranging a multi-disciplinary
review in this case and providing a comprehensive report of their findings.
• The woman’s declared two-month history of heroin usage was inconsistent with
her custodial record. It is very unlikely that she could have become dependent on
heroin in the brief interval between her final periods in custody.
• The woman was prescribed methadone, diazepam and chlordiazepoxide. The
prescribing of multiple sedative medications is questionable, when the evidence
of dependence was so weak.
• The systematic recording of data such as vital signs was not good.
• The repeated entries in the woman’s F2052SH about her appearing drowsy
should have been raised with senior clinical staff and should have led to a review
of her medication.
• The records suggest that a staff nurse made the decision to discharge the woman
from H1. The doctor signed the form after the woman had left.
• There is a possibility that the combination of methadone, diazepam and
chlordiazepoxide contributed to the woman’s death.
20
• The culture in Holloway at the time of the woman’s death did not encourage
clinicians to treat patients as individuals.
• There was no programme of training for clinicians in the detoxification unit.
• Holloway does not have a consultant or specialist for substance misuse services.
Islington PCT has identified 12 areas of learning to ensure Holloway has a safe,
effective and efficient service for substance misusers. I believe that the Prison Health
partnership board needs to consider these and their implementation, if not already
actioned.
Recommendation: The Prison Health partnership board should consider the
findings of the clinical review and develop an action plan to implement the
recommendations.
Clinical drug services
Holloway’s previous lead clinician in detoxification services now works for the
Department of Health as a specialist adviser in women’s drug services. She has had a
number of years experience in working with substance misusers in prison, including the
period at Holloway referred to above. She wrote her own report about the woman’s care
and treatment and her main findings were that:
• The woman’s electronic patient record did not provide sufficient information to
support the assumptions made about her current use of alcohol, opiates and
benzodiazepine.
• Entries made in the woman’s electronic records about her daily care are lacking
in detail.
• Had the woman completed a Self Assessment Questionnaire, this would have
provided valuable information about her drug and alcohol use.
• Apart from the baseline observations taken in reception, no record exists that any
further monitoring was made of the woman’s clinical observations.
• Although drowsiness was reported several times in the woman’s F2052SH by
discipline staff, there is no evidence apart from on one occasion that this
information was passed to the nursing staff.
I am aware that since the woman’s death significant development and
improvement to the drug services has taken place, and no doubt already
addressed many of the issues raised by the previous lead clinician in
detoxification. However, she has identified a significant number of learning
opportunities and I urge the Prison Health Partnership to consider carefully her
report and identify what areas, if any, still need to be addressed.
21
Recommendation: The Prison Health Partnership Board should review the
clinician of detoxification service’s report against current service provision and, if
required, develop an action plan to ensure safe and effective evidence based best
practice.
Summary of the F2052SH review
I am grateful to the review by the Suicide and Self-Injury Prevention Consultant of the
F2052SHs relating to four separate periods that the woman was in Holloway. The main
findings of which are that:
• Entries in the F2052SH were not always clear, signed, timed and dated.
• Entries were not always meaningful, with entries indicating simple observation of
the woman rather than interaction with her.
• Staff appear not to have read and acted upon instructions made in the F2052SH.
• Entries about recommended levels of observation/interaction were not always
explicit.
• Staff did not always adhere to recommended levels of observation/interaction.
• Information about provision of support to the woman was not always fully
documented.
• A discharge summary was not completed each time the woman was transferred
from healthcare to ordinary location.
• Reviews do not appear to have taken place following all incidents of self-harm.
• Management checks did not document areas of concern.
• Observations by night staff were not conducted at unpredictable intervals.
• Healthcare staff did not clearly document their involvement with the woman.
The review concludes: “Since the woman’s death, HMP Holloway has transferred to the
new procedure for managing prisoners identified as being at increased risk of suicide
and/or self-injury (ACCT). It would not, therefore, be fitting to make recommendations in
relation to staff’s adherence to F2052SH procedures. Whilst there is no evidence to
suggest that any lack of adherence to procedures for managing suicidal or self-injuring
prisoners contributed in any way to the woman’s death, a number of recommendations
are made in the context of improving the care provided to this very vulnerable group.”
The doctor has made eight recommendations in her review.
Recommendation: The Governor should develop an action plan to address the
issues identified to ensure a safe system is in place to support and manage those
considered to be at risk of suicide or self-harm.
22
CONSIDERATION OF THE ISSUES
Should the woman have been prescribed methadone?
The woman was not a stranger to Holloway. Each time she was received there she
underwent alcohol detoxification.
The woman had been in Holloway continuously from December 2004 to mid February
2005. Having been released then, the woman was back in a few days later before
being released four days afterwards. After six days, she once more returned to
Holloway. On reception this last time, the woman went through the usual health
screening process which included assessment of her use of alcohol and drugs. The
woman reported to the prison GP that she was a very heavy drinker. However, she
also reported that she had been using opiates. This was not something she had ever
reported previously. The woman’s urine test was positive for opiates and so
prescriptions for alcohol, opiate and benzodiazepine detoxification were written up.
The starting dose for the opiate detoxification was 10mg of methadone and she had
the first dose that evening.
The following day, the woman saw a detoxification doctor for a more detailed
assessment. The woman told the doctor that she had been using heroin for the
previous two months. The doctor knew from previous contact with the woman that
she did not ordinarily use heroin and she asked her repeatedly about this. However,
given that the woman declared that she had been using heroin and that her urine test
was positive, the doctor authorised the methadone detoxification programme to
continue. In response to my investigators’ question about how the woman could have
been using heroin for two months when she had been in Holloway for most of that
time, the doctor said that there was no guarantee that the woman had not been taking
illicit drugs while in prison.
It would seem from the evidence of the prison GP and the detoxification doctor that all
that was required for a woman to be prescribed methadone was for her to declare
that she was using opiates and provide a positive urine sample. The detoxification
doctor completed only a superficial exploration of the woman’s declared drugs use
and did not challenge her claim that she had been using heroin for two months. The
woman had been in Holloway for most of the previous two months and while I am not
naïve about the extent of drug taking in prison, it is implausible to imagine that she
had been using heroin throughout that time.
The PCT review panel say that it is very unlikely that the woman could have become
opiate dependent in the brief time she was at liberty before returning to custody.
They go on to say, however, that at the time of her death neither the culture nor
clinical governance systems within the prison encouraged or facilitated clinicians to
work with prisoners as individuals.
The lead clinician in detoxification services says in her report that further probing was
required to have justified the woman’s prescribing regime. The lead clinician also
criticises the failure to record and monitor the woman’s clinical observations.
23
In retrospect, it seems clear that the woman should not have been prescribed
methadone. The fact that such a prescription was written was due, in the main, to the
prevailing practices at Holloway at the time. In particular, that there was a standard
response to opiate use and the culture did not encourage clinicians to treat patients
as individuals.
Should the woman have been prescribed diazepam and chlordiazepoxide?
The clinical review concludes that it was possible for the woman to have become
alcohol dependent if she had relapsed into heavy drinking in the brief time she was at
liberty before returning to Holloway. In that case, the prescribing of clordiazepoxide
would have been justified. However, both the substance misuse consultant from the
PCT and the lead clinician in detoxification services argue that the woman would not
have become diazepam dependent in this time and so the prescribing of diazepam
was probably not warranted.
The woman’s reaction to the methadone prescription
My investigators were told consistently by both doctors and nurses that the safeguard
with the methadone detoxification programme was that women would be assessed
each time they were due to receive their next dose. Anyone assessed as drowsy
would have her methadone withheld and a urine test carried out. This happened to
the woman on one occasion when her dose of methadone due at 8.30am was
withheld until 10.50am. However, this was the only time that the woman did not have
her methadone when it was due. The woman’s electronic (EMIS) medical record
contains a reference to her seeming ‘quite spaced out’ on the evening of the next day,
but this occasion and the time that her methadone was withheld the previous day
were the only occasions when any of the nurses in H1 observed the woman to be
drowsy. Nurses had the opportunity to assess the woman four times a day when she
presented at medication rounds.
The evidence of the nurses contrasts with some of the evidence from the discipline
officers. The woman’s F2052SH contains references to her appearing drowsy on five
occasions in March. At interview, the discipline staff presented mixed views. All of
the officers described the woman as drowsy. Some said that she was drowsier than
the norm, although others said she was no drowsier than other women going through
detoxification. Officers said that they would mention to nursing staff if they had
concerns about how someone was coping with detoxification. An officer said that she
spoke to a nurse specifically about the woman in early March. However there is
nothing recorded in the woman’s medical record about this, nor about any of the
occasions when entries about drowsiness were made in the woman’s F2052SH.
Indeed, attempting to obtain any clear picture of the woman during her detoxification
was hampered by the lack of meaningful entries in her medical record.
Despite the fact that it is a Prison Service requirement that clinical observations
should be taken of prisoners’ pulse and blood pressure for at least the first 72 hours
while undergoing detoxification, the woman’s clinical observations were not taken
apart from the day of her first reception into Holloway. My investigators were told that
such observations, along with nursing care plans, Self Assessment Questionnaires
for prisoners, and completion of withdrawal monitoring charts, all ceased, perhaps up
24
to a year earlier, due to pressure of work in the detoxification unit. This clearly
compromised the quality of continuing care offered to individuals.
By the day of the woman’s death her daily doses of methadone had just begun to
decrease. The detoxification programme peaked with single doses of 30mg of
methadone in the early days in March. On the following two days she received single
doses of 25mg of methadone. In his report, the clinical pharmacologist, wrote:
‘The ability of individuals to tolerate methadone therapy depends on various
factors but one key factor is their previous exposure to opiates or opioids. The
fact that [the woman] was not used to taking opiates or opioids and was
therefore a naïve user of methadone is important in interpreting the
concentration of methadone detected in the woman’s blood in relation to her
death. In a study of ten deaths in subjects who, like the woman, had recently
started methadone maintenance therapy, Drummer [found] … the average …
blood methadone at post-mortem … was 0.37mg/L … So the concentration of
methadone reported … in the woman’s blood, 0.4mg/L is consistent with the
methadone fatalities described by Drummer. Therefore it would be
reasonable, on the balance of probabilities, to attribute the cause of the
woman’s death to methadone toxicity.’
I can see no reason to demur from the clinical pharmacologist’s opinion. Overall, I
conclude that the medical supervision and oversight of the woman’s detoxification
prescribing was of a standard significantly below that which could reasonably have
been expected.
The woman’s move from H1 to standard location (B4)
In the early afternoon on the day before her death, the woman was moved from H1 to
ordinary location. Usually, the woman would have gone to D1, the post-detoxification
unit, however D1 was temporarily closed at that time. The local protocol required that
before women moved out of H1, a nursing sister or doctor would assess them to
ensure they were fit to relocate. Against protocol, it was a staff nurse who authorised
the woman’s move. This nurse expressed the view that any qualified nurse could
authorise the transfer. It is therefore unclear whether the local protocol was even
known to the medical staff. Nor did the staff nurse talk to any of the discipline staff
about the woman, so the concerns the discipline staff had expressed about her that
morning remained unexplored.
When the woman was moved, her F2052SH was not taken with her as should have
been the case. It was awaiting completion of the discharge report by a doctor. The
escorting officer said that he knew the woman was subject to F2052SH monitoring
and he mentioned this to the receiving officer in B4.
Two officers each claimed to have been the receiving officer. Both said that they
were unaware that the woman was subject to F2052SH monitoring when she arrived
in B4 and when located into dormitory 20. The bed that the woman occupied abutted
the room’s toilet thereby reducing its visibility from the observation window. It is not
clear when the staff in B4 became aware that the woman was subject to special
monitoring, but even when this occurred no one thought about the position of the
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woman’s bed and whether she should have been moved to another that was more
visible. This is despite the fact that Prison Service Orders state that a prisoner
subject to F2052SH monitoring should occupy a bed that can be clearly observed.
Good practice would be for the discharging nurse to talk to the discipline staff about
any issues or concerns they wished to raise about an individual.
Recommendation: The Head of Healthcare should review communication lines to
ensure the timely transfer of relevant information pertinent to an individual’s care
and treatment.
The woman’s condition when in B4
The staff nurse who authorised the woman’s transfer from H1 to B4 said that the she
seemed her usual self that afternoon. The staff nurse made an entry in the woman’s
medical record that she was fit for ordinary location.
The escorting officer who took the woman from H1 to B4 said that she carried her bag
as she went to B4 and seemed no different to any of the other three women moving
to ordinary location that afternoon. There had been nothing about the woman to
cause the escorting officer any concern about her suitability to move.
There was some inconsistency about the woman’s appearance as recounted by the
discipline staff in B4. Two different officers claimed to have received the woman into
B4. One of them said that when the woman arrived at dormitory 20, she stumbled
into the room. This officer said that women going through detoxification were usually
disorientated and unsteady on their feet, but that these symptoms were more
pronounced in the woman than was normal. The other officer who claimed to have
received the woman into B4 described her as no different to any other woman going
through detoxification. Another officer did not see the woman when she first arrived
in B4. He saw her when she came to the wing office at about 6.30pm for help with
some administrative matters. This officer said the woman seemed drowsier and more
difficult to communicate with than is typical of someone going through detoxification.
The senior nurse who had seen the woman in reception saw the woman on two
separate occasions on the afternoon before she died. The first time was at 4.00pm
when she gave the woman her next dose of methadone. The senior nurse said that
the woman had not been paying attention when she reached the medication hatch as
she was chatting to the other women in the methadone queue. This caused her to
sign the medication chart in the wrong place. The senior nurse said that the woman
was well at the time, and later that afternoon approached her to apologise for what
had happened earlier. Again, the woman seemed well.
My investigators spoke with three of the four prisoners who shared the same dormitory
as the woman. All three described the woman as very drowsy. Two described her as
being more drowsy than usual for those going through detoxification.
Another prisoner from B4 was standing behind the woman at the time of the final
medication round at 7.30pm. This prisoner said that the woman was already drowsy
and she queried why the woman was being given even more medication.
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The officer, who was supervising the medication queue heard what the prisoner said
but did not think that the woman was different to any other woman going through
detoxification. Nor did the nurse who actually issued the woman’s medication at that
time.
The night before the woman’s death
The dormitory doors were locked at around 8.00pm. It would seem that the woman
fell asleep not long after. The other prisoners in the dormitory said the woman was
making a lot of noise in her sleep, snoring quite loudly and/or coughing. At around
11.00pm, one of the prisoners woke the woman because of the noise. The woman
had seemed quite well at that time and asked for a cigarette.
An OSG, the night officer, said she noticed the woman breathing very heavily at
around 3.00am, but there had been nothing to give her any cause for concern. The
OSG said that, despite the position of the bed, she could see the woman from her
shoulders down (this does not accord with the opinion of my investigators who
thought that only the lower half of the woman’s body would have been visible). I am
uncertain, therefore, whether the OSG was able properly to observe the woman
through the night as required in accordance with F2052SH monitoring procedures.
However, I acknowledge that she had been placed in a difficult position given that the
day staff had not asked the woman to change beds when they became aware that
she was subject to special monitoring.
The lead clinician in detoxification services pointed out in her clinical review that noisy
breathing can suggest opiate toxicity. Staff in B4 might not have been aware of this.
The lead clinician concluded that it is more likely that this symptom would have been
recognised/noticed in a second stage detoxification unit as opposed to ordinary
location.
The morning of the woman’s death
At 7.15am, the OSG carried out what should have been a check that all prisoners
were present and were well and not a simple head count. Although the OSG’s
F2052SH entry indicated that she had obtained a response from the woman, she said
at interview that she had in fact relied on the other women in the dormitory telling her
that the woman was asleep.
Before night officers are permitted to go off duty, oncoming day staff must carry out
their own count to satisfy themselves that they have taken over the correct number of
prisoners, all of whom are well. An officer acknowledged that, while she counted the
prisoners, she did not obtain responses from all of them. She said that it was usually
impractical to obtain responses from all of the women, but she should at least have
obtained responses from the women on open F2052SHs.
Although it was the officer who made the count who recorded the numbers in the wing
file, it was another officer who wrote in the woman’s F2052SH that she had
responded when checked by the other officer. His explanation for doing so was that
completion of F2052SHs was often a team task.
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The discovery of the woman’s death
When medication was being issued at about 8.30am, one of the women in the
dormitory tried to wake the woman. On doing so, the prisoner realised that the
woman was dead and alerted the staff. Staff entered the dormitory, radioed for
assistance and checked the woman for presence of vital signs. Nursing staff
responded quickly and resuscitation was attempted, but all efforts were to no avail.
Descriptions of the woman’s condition when found all indicate that she had been
dead for some time. Nevertheless, certain aspects of the response to the code blue
alert warrant comment. The first response nurse was clear in her mind that when she
reached the room about one minute after the code blue had been issued and there
were no staff around the woman’s bed. This does not accord with the evidence of the
first staff on scene who said that they were in the midst of checking the woman at the
point that the first response nurse arrived and took charge of the situation. I cannot
resolve this conflict in the testimony.
Upon the first response nurse’s arrival, the dispensing nurse went to the level 4
nurses’ station to collect the blue bag. Due to the lack of space in the nurses’ station,
the blue bag is mounted on a wall. The height of that mounting combined with the
weight of the bag meant that the nurse was unable to take the bag down and an
officer had to go to the nurses’ station to do this for her. The investigators were also
told that level 4 does not have its own defibrillator, so one had to be collected from
another level. When it was used, it instructed that the woman should not be shocked.
Recommendation: The Head of Healthcare should review the location and storage
of equipment to ensure it is easily available when required in the event of an
emergency.
At the debriefing of the morning’s events, one of the two ambulance crews reported
that they had had some difficulty in gaining access. It seems the reason for this was
that only one member of staff acted as a guide and escort to the ambulance crew.
Recommendation. The Governor should review Holloway’s arrangements for
escorting emergency ambulances to ensure that they arrive at the appropriate
location with the absolute minimum of delay.
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Developments since the woman’s death
Since the woman’s death, two senior healthcare staff have been involved in reviewing
healthcare provision at Holloway, including Holloway’s delivery of detoxification
services. One of the major changes introduced is the replacement of methadone by
Subutex as the principal drug of choice for opiate detoxification. Subutex is judged as
being a safer drug than methadone as it does not cause respiratory depression. A
senior member of healthcare staff told my investigators that women now remain in H1
until they have completed their detoxification programme and have their clinical
observations taken throughout their stay in the unit. It is now a doctor who is
responsible for authorising transfers from H1 to standard location. Both of the senior
healthcare staff also told my investigators about investment in certain staffing issues,
such as staff training and development.
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RECOMMENDATIONS
1. The Prison Health Partnership Board should consider the findings of the clinical
review and develop an action plan to implement the recommendations.
2. The Prison Health Partnership Board should review the clinician of detoxification
service’s report against current service provision and, if required, develop an action plan
to ensure safe and effective evidence based best practice.
3. The Governor should develop an action plan to address the issues identified by the
doctor to ensure a safe system is in place to support and manage those considered to
be at risk of suicide or self-harm.
4. The Head of Healthcare should review communication lines to ensure the timely
transfer of relevant information pertinent to an individual’s care and treatment.
5. The Head of Healthcare should review the location and storage of equipment to
ensure it is easily available when required in the event of an emergency.
6. The Governor should review Holloway’s arrangements for escorting emergency
ambulances to ensure that they arrive at the appropriate location with the absolute
minimum of delay.
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