Individual at Guernsey State Prison

Investigation into the circumstances surrounding the death
of a man at Guernsey Prison
in July 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2009
At the request of the Minister for the Home Department, I was invited to investigate the
death of a man that occurred at Guernsey Prison in July 2008. Although Guernsey
does not fall within my geographical remit, I agreed to investigate the man’s death in
line with my terms of reference for England and Wales. My office has also developed
a protocol for investigating any future deaths at the prison.
The man was found collapsed in his cell in the early hours of 11 July by a member of
the prison staff. He had been sentenced to six weeks imprisonment after being found
guilty of driving whilst under the influence of alcohol. I join my investigator and my
family liaison officer in offering sincere condolences to the man’s family and friends for
their sad loss.
I wish to thank the Governor of Guernsey Prison and the deputy governor, for making
the necessary facilities and information available to my investigator, and for the
assistance of the prison’s liaison officer.
In the course of the investigation, I asked for a clinical review to be carried out into the
care and treatment the man received in custody and I must thank the appointed doctor
for his assistance. However, as I judged that further issues should be explored, and
as the appointed doctor had since retired, I commissioned a further report from
another doctor. This was done with the full agreement of the Governor and Her
Majesty’s Comptroller. I am extremely grateful to the clinical reviewer.
I have been concerned to read the clinical reviewers judgement that, had the man’s
medical condition been recognised earlier and more appropriately treated, the likely
outcome would have been favourable. That said, I have been pleased to learn from
my investigator of the attempts made by prison staff to resuscitate the man. My
investigator also gained a favourable view of the relationships between prisoners and
staff.
I must apologise for the delay in issuing my report. This has been caused by the need
for the second clinical review, and the availability for interview of the medical staff
concerned.
My report makes 16 recommendations and identifies three areas of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2009
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CONTENTS
Summary 4
The investigation process 5
Island of Guernsey Ordinance of the States 8
Guernsey Prison 9
Findings 12
Issues 27
The clinical reviewer’s conclusions and recommendations 36
Response by the Health and Social Services Department 39
Conclusion 40
Recommendations 42
Good Practice 43
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SUMMARY
In June 2008, the man was sentenced to six weeks imprisonment and taken to
Guernsey Prison to serve his sentence. When he arrived at the prison, he was
assessed by a nurse who found his blood pressure to be raised. She performed an
ECG, and the ECG machine’s interpretation of his ECG trace indicated the presence
of left ventricular hypertrophy (enlargement of the main chamber of the heart). The
nurse telephoned an on-call doctor. She gave her advice, and arrangements were
made for her to see the man the following day.
After examining the man, the doctor decided on a care plan which included obtaining
an electro cardiograph (ECG) and, if necessary, admission to hospital. Over the
course of the following two weeks, he had further episodes of chest pain, including
prolonged episodes of night time chest pain.
At 12.35am on 11 July, the man was taken ill. The night manager contacted a doctor
at the local hospital but, because his symptoms had subsided, it was thought
appropriate that he should remain in prison rather than be taken to hospital.
Just over one hour later, the man was seen by an officer sitting in his chair, rolling his
head from side to side. The officer called for assistance but, instead of entering the
cell to offer help, he left the area to continue with his duties. This was in the mistaken
belief that he should not enter a cell alone.
In response to the officer’s request for assistance, staff arrived and went into the cell to
help the man. Despite their efforts to resuscitate him. members of the St Johns
Ambulance Service determined that he had died.
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THE INVESTIGATION PROCESS
1. Once my office had been notified and had agreed to investigate the man’s
death, the investigation was allocated to a senior member of my staff. He was
assisted by one of my family liaison officers (FLOs), and later by another of my
investigators.
2. Prior to travelling to Guernsey in September 2008, my family liaison officer
contacted the man’s family. She explained my role and offered them the
opportunity to meet her and the investigator. The purpose of offering the
meeting was to invite the family to contribute towards my report and to ask any
questions they wanted me to examine. The man’s wife and son agreed to meet
my investigator and FLO when they arrived on Guernsey to begin their
investigation.
3. On 8 September, the investigation team travelled to Guernsey to begin their
work. The following day, they met a number of managers and staff at the prison
to explain my role. Also at that meeting were members of the local Panel of
Visitors.
4. In addition to meeting prison staff, at the invitation of the man’s wife my
investigator and FLO went to the family home. They were made very welcome
by the man’s wife and her son. .
5. During their meeting, the man’s wife said the police had been helpful and had
disclosed a number of documents to her. These included witness statements.
The early disclosure of the police documents has assisted the man’s family
become well informed about the circumstances surrounding his care in prison.
This has also enabled them to consider the additional questions and concerns
for my investigation to consider. I trust that my report will help them understand
what happened after he was received into Guernsey prison.
6. At the meeting, the man’s wife handed my investigators a copy of the “Island of
Guernsey Ordinance of the States”. (I explain later the purpose of the
Ordinance.) She referred my investigators to section 109 which says,” Every
officer shall notify the Governor of the case of any prisoner who, whether he
complains or not, appears to be out of health or whose state of mind appears to
be deserving of special notice and care and the Governor shall forthwith notify
any such case to the Medical Officer.”
7. My investigator and FLO discussed the wording and implications of the
Ordinance with the HM Comptroller. The HM Comptroller took the view that,
whilst the Governor is responsible for the prison, it was impractical to expect
him to deal with everything that occurs. He was satisfied that the Governor has
to devolve responsibility to the most appropriate department. I understand from
the Deputy Governor that the document is to be reviewed.
8. On 11 September, before leaving the prison to return to the United Kingdom,
the investigator and FLO met the Governor and deputy governor to feedback
their initial findings. As part of that feedback, they raised one finding which was
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regarded as urgent and requiring immediate attention. It related to night staff
accessing cells in an emergency. The Governor accepted the feedback and
said he would deal with the matter.
9. At that same meeting, the investigator and FLO discussed the clinical review
which they had received from the doctor who had never previously carried out a
clinical review in a prison environment. They were concerned that the review
did not meet the standard that I expect and that further work would be required.
However, as the doctor had by this time retired, he was not in a position to
reconsider his report. As a result, the investigator suggested that a new review
should be commissioned. It was felt that it would be appropriate to ask a doctor
from the United Kingdom who was experienced in conducting clinical reviews to
undertake a separate review.
10. The investigator discussed the need for a second review with my Deputy
Ombudsman and she in turn contacted a senior public health adviser in the
Department of Health, to see if she was able to recommend a suitable person to
carry out the work. She recommended someone who agreed to assess the
care the man received, and to travel to Guernsey with my investigator for the
purpose of interviewing medical staff.
11. On 22 October, my investigator, FLO, and one of my Assistant Ombudsmen
met the new clinical reviewer at his surgery. The purpose of the meeting was to
brief him and to decide who should be interviewed. It was agreed that he
should not see the report produced by the original appointed doctor. However,
he has had full access to my investigators’ interview transcripts, prison records
including the man’s medical records, and police interview transcripts and files
12. On 28 October, the clinical reviewer and my investigator went to Guernsey
Prison to complete their interviews with medical and prison staff. Unfortunately,
when they arrived at the prison, two of the doctors who the clinical reviewer had
wanted to interview were unavailable as they were awaiting advice from their
medical indemnity provider. The two doctors expressed their willingness to
cooperate fully with my investigation and I accept the delay was not of their
making. However, another doctor did attend for interview along with the
solicitor who had been engaged by his medical indemnity provider.
13. In the afternoon, my investigator, the clinical reviewer, the duty governor , and a
Chief Inspector met the HM Comptroller, at his office in St Peter Port. The
purpose of the meeting was to brief the HM Comptroller on the progress of my
investigation, and to explain the timescales for issuing my draft and final report.
It was expected at that stage that the draft report would be issued in January
2009. The HM Comptroller accepted the timescale and suggested that the
inquest could possibly be held in March 2009.
14. On 29 October, my investigator met the Governor and fed back the findings
from the investigation to that point. The Governor accepted the findings and
also confirmed that the urgent finding referred to earlier had since been dealt
with. My investigator and the clinical reviewer also met the prison’s Healthcare
Manager and fed back the findings relating to prison healthcare.
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15. On 2 December, my investigator returned to the prison with his colleague and to
complete the final interviews and to meet the healthcare staff based in the
prison. The following day, the clinical reviewer joined them to complete his
interviews with the two doctors who had been previously unavailable. The
doctors were accompanied by their legal representative, acting on behalf of the
Medical Defence Union. The clinical reviewer was assisted by my investigator.
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ISLAND OF GUERNSEY ORDINANCE OF THE STATES 1998 (Amended 2002)
16. The Prison Administration (Guernsey) Law, 1949, as amended, is the legislation
governing Guernsey Prison. It addresses the purpose of imprisonment, the
Home Department’s duties in respect of the prison, and the power to make
rules on prison matters by way of Ordinance.
17. The Prison Administration (Guernsey) Ordinance, 1998, and subsequent
amendments, have been approved by the States. Amendments have been
made to respond to changes in prison best practice and the nature and size of
Guernsey Prison.
18. The 1998 Ordinance details how the prison operates on a day-to-day basis, but
says little about how this is to be put into practice. Instead, the prison has its
own Prison Orders which are approved by the Governor.
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GUERNSEY PRISON
19. The current Guernsey Prison is located outside of St Peter Port and was
opened in 1989. The Guernsey Prison Service is accountable to the Guernsey
Home Department.
20. The prison has a series of small two storey wings all of which are fed from a
central corridor. Prisoner movement is mainly confined to the ground floor
level. There are nine residential wings designed to accommodate between six
and 12 prisoners each, and one wing designed to accommodate up to 44
prisoners. In total, there is sufficient cellular accommodation to provide places
for 122 prisoners.
21. Guernsey Prison is unusual in that it is expected under the Prison Ordinance to
provide accommodation for every category of prisoner. It holds adults, young
offenders, and juveniles, convicted and unconvicted, males and females,
vulnerable and mainstream prisoners. Additionally, the prison has been used
occasionally for anything up to 72 hours to hold police prisoners pending their
first court appearance, although my investigators were informed by the Deputy
Governor that this has not occurred for over 12 months.
Police investigations of deaths in custody
22. In Guernsey as in the United Kingdom, every death in prison custody is
reported to the police as soon as it is discovered. In the first instance, the
police treat the area where the person is found as a potential crime scene and,
as part of their investigation, note the names of everyone involved and those
who have been in contact with the body. Additionally, they note the identity of
all those entering and leaving the cordoned area. It is only when the police are
satisfied that the death is not suspicious that my investigators are able to begin
their own investigation.
23. In the case of this man, the Chief Inspector confirmed that he was not treating
the death as suspicious. He agreed to share with my investigator the police
statements that had been taken shortly after the death.
Prison officer grades
24. There are three levels of uniformed officer grades. Prison officers are the front-
line supervisory staff and, in the majority of cases, prisoners have first and most
contact with them.
25. Senior officers (SOs) are the first grade of managers and act as a reference
point for prison officers. SOs are responsible for the day-to-day management of
their area, supervising staff and dealing with issues raised by prisoners.
26. Principal officers (POs) are the highest rank of the uniformed staff. They
supervise other uniformed staff and have operational responsibility for the
prison.
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Prisoner Application Forms
27. Prisoners can make written applications for a variety of things, including asking
to see a doctor. The forms are self copying in triplicate. One copy is kept by
the prisoner whilst the other two go to the prison department to which the
application is addressed.
Radio Communication System
Talk Through
28. The system also allows for the radio net to be placed on “talk through”. This
means that every person with a radio can hear the full transmissions and not
simply the transmission made by the control room radio operator.
Urgent Message”
29. “Urgent message” is a specific radio transmission used in emergencies, usually
associated with a potential or actual breach of security. If used, it should attract
a pre-determined response from the control room. Under normal
circumstances, where medical assistance is required it would not be usual to
announce urgent message.
Gate Override System
30. During normal operating procedures, the prison gates are opened one at a time.
When a vehicle arrives at the gate, one gate is opened and the vehicle drives
in. After the vehicle has entered the vehicle lock, the gate is closed. Once the
gate has closed, the exit gate is opened to allow the vehicle to leave the gate
lock.
31. During an emergency, the officer controlling the gates can “override“ the
system. Overriding the normal operating system allows the officer to open both
gates at the same time, and speeds up the entry or egress of emergency
vehicles. However, before overriding the gates, the officer must ensure there is
another officer sited at the open gates to watch for and prevent escape.
32. At night time, due to the low staffing levels on duty, overriding the gates is not
possible. This is because there are insufficient officers on duty to protect the
vulnerability of a fully open gate. For this reason, emergency vehicles have had
to gain entry or egress in the normal manner of one gate being opened at a
time, thus delaying the vehicle’s movement. Since the man’s death I
understand that the Governor has reviewed the procedures for emergency
access to minimise delays.
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Panel of Visitors
33. The Panel of Visitors are an independent group of local people who, under the
Guernsey Ordinance, are required to oversee the prison. The panel have
access to any part the prison at any time, and access to any prisoner who they
wish to see or who asks to see them.
Her Majesty’s Chief Inspector of Prisons (HMCIP)
34. Her Majesty’s Chief Inspector of Prisons reports on all Prison Service
establishments within the United Kingdom. Although Guernsey Prison does not
fall within the Chief Inspector’s jurisdiction, the Chief Inspector carries out
inspections at the invitation of the Home Department.
35. The majority of inspections are pre-announced and allow the prison to be
inspected time to prepare. On 27 June 2005, the Chief Inspector carried out a
full announced inspection of Guernsey Prison. The inspection was completed
on 1 July, after which the Chief Inspector published her report.
36. In her introduction, the Chief Inspector said the inspection exposed serious
shortcomings in some basic aspects of care for the diverse group of prisoners
held in Guernsey Prison. The inspection found evidence of managers and staff,
“doing their best to deliver decent and appropriate regimes, but doing so
against the odds”. The Chief Inspector went on to say that it was unrealistic to
expect the prison to attain the standards expected elsewhere in the British Isles
while there was such a diverse population living under the same roof.
37. The Chief Inspector also commented on the application system which she said
needed improving. She went on to say that managers and staff deserved credit
for struggling with a complex mix of prisoners, for which they were not
sufficiently trained or resourced.
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FINDINGS
38. In preparation for the man’s appearance in court, his Probation Officer wrote a
report on 20 June 2008 for Guernsey Magistrates Court. She noted that the
man had told her that he was dependant on alcohol and would drink to excess
on a daily basis, which he said he had been doing over a ten to 15 year period.
The probation officer concluded her report by adding that he was preparing
himself for imprisonment, although she did suggest that a Community Service
Order was an alternative to his being given a custodial sentence.
26 June
39. On 26 June, the man was sentenced to six weeks imprisonment after pleading
guilty to “driving a motor vehicle with excess level of alcohol in breath”. After
receiving his sentence, he was taken to Guernsey Prison. When he arrived
there, he went through the normal procedure for receiving prisoners and his
personal information was recorded by a prison officer. As well as noting his
personal details, he was seen by the healthcare manager, who completed a
First Reception Health Screen (FRHS) document. Again, this is normal
practice.
40. During the FRHS procedure, the healthcare manager noted that the man said
that, prior to being admitted to prison, he had been experiencing chest pain with
exertion. He also told her that he had been an inpatient at an outside hospital
about six years previously in connection with his alcohol problems. (The
outside hospital is part of the Guernsey Mental Health Service.) Whilst there,
he had taken part in an alcohol detoxification programme, but said that he had
since returned to drinking alcohol. He told the nurse that he had a history of
consuming between 14 and 28 units of alcohol daily. However, he added that
he had not consumed alcohol for about one month before going to prison. The
man also said he smoked up to 30 cigarettes per day, but later changed this to
40.
41. At interview, the healthcare manager told my investigators that the man said his
chest pains were present when walking up a hill close to where he worked. He
added that he also felt breathless when doing so. The healthcare manager said
that, from the description, the man’s pains made her think that he had a heart
problem, and that it might possibly be angina. With this in mind, she decided to
carry out an Electro Cardiograph (ECG) straightaway.
42. The ECG’s interpretive report indicated a presence of Left Ventricular
Hypertrophy (LVH) which is an enlargement of the main chamber of the heart.
The healthcare manager also found that his blood pressure was raised at
176/90. She also carried out a Vitalograph spirometry test (a lung function
test). The test indicated mild obstructive airways disease, which the healthcare
manager had anticipated given the man’s history of smoking.
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43. After completing her tests, the healthcare manager decided to telephone the
doctor who was due to attend the prison the next day, to seek her advice.
However, the healthcare manager did not make a record her conversation with
the doctor in the man’s medical notes, nor record that it had taken place. At
interview, she confirmed that she had not mentioned her own thoughts of
possible angina to the doctor, preferring instead to let the doctor make a
diagnosis. She added that the man was not in pain at that time and looked well.
44. The healthcare manager said that the doctor decided there was no need to see
the man urgently, and that she would see him the following day. She said the
doctor told her that the test results were not acute.
45. In her Reception Health Screen notes, the healthcare manager recorded that
the man complained of chest pain in the left thoracic area that the pains
occurred once or twice per day on exertion, but could occur when he was
resting. She wrote that these pains had been occurring for about six to seven
weeks. The healthcare manager also made an entry on the continuation sheet
in the main section of the medical record. This entry includes a sentence to the
effect that the man had been getting left sided chest pain intermittently for
approximately seven weeks, usually on exertion.
46. In her statement to police, the healthcare manager said that “On routine
questioning about any problems related to chest pain he stated that he had
experienced some intermittent chest pain in his left thoracic area on exertion
when sometimes walking up some inclines, but that sometimes the pain could
also be experienced when he was resting. He stated that this sometimes could,
on occasions, be once or twice per day”.
47. The healthcare manager told my investigators that she had discussed smoking
cessation with the man. However, due to his short sentence, he would not have
the opportunity to join the programme (it is a 12 week course and he would
have been released before completing it).
48. As part of the FRHS document, the healthcare manager completed the risk
assessment section. Under one of the headings (“Is there an active risk?”) she
wrote that there was not. After completing the reception procedures, the man
was taken by a prison officer to F wing. When he arrived on the wing he was
allocated to cell F9.
27 June
49. On 27 June, the man was seen by the doctor for the routine Reception Medical.
In her police statement, the doctor said the man had described a cyclical chest
pain lasting between seven and ten minutes during the previous seven weeks
or more. The doctor said they were left sided thoracic pains, which sometimes
occurred when the man was resting and had not been made worse by exercise.
The doctor said she planned to recheck his blood pressure the following week
after he had settled into the prison and, if the readings remained elevated, then
treatment should be started. She said she asked the nurses to begin
monitoring him if the pains returned. Knowing that the prison had its own ECG
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machine, the doctor said she told the man to alert staff if the pain recurred. If
an ECG could be carried out, it would be, otherwise he would need to be taken
to the Accident and Emergency Department. (However, there is no reference to
the need for an ambulance or admission outside nursing hours in his medical
record.) The doctor said she told the man that he might require further tests if
the pains continued. She also gave smoking cessation advice, because his risk
of cardiac problems was significantly raised by continuing to smoke.
50. At interview with my investigators, the doctor said she could not recall receiving
a telephone call from the healthcare manager. However, she later added that
she had a vague recollection of writing the man’s name onto a “post it note”.
Additionally, she remembered a reference being made to alcohol problems,
high blood pressure and LVH. She could not recall any mention of chest pain
and did not believe she had been told of the history of chest pain. She
explained that, had it been discussed, she would have requested far more detail
and would have expected to be able to recall the conversation.
51. The doctor said that, when she was in the prison consultation room, she had
looked at the medical notes made by the healthcare manager. She read that
the man had complained of chest pain. The doctor noted that he smoked 30
cigarettes per day and said he had smoked for 40 years. At the same time as
the doctor was reviewing him and his medical notes, a nurse was present in the
consultation room assisting the doctor.
52. As with her police interview, the doctor told my investigators that the man’s
chest pain was cyclical, lasting between seven and ten minutes. She said it
was a left sided pain and occurred sometimes at rest and was made no worse
by exercise. The man gave the doctor an example of walking to his work place
from the bus stop. He said he was able to walk through the pain and that it
would settle down. (As part of his clinical review, the clinical reviewer has
followed the route that the man would have taken to get to his place of work.
He found that the walk from the bus stop to the workplace is uphill all the way
with a varying degree of incline, and is an ideal test of exercise tolerance for
someone with angina.)
53. In her interview with my investigators, the doctor said the man told her that his
chest pain typically started as he got off the bus, or shortly after, and that the
pain would ease off when he was about half way up the road. At first she
thought the pain was musculoskeletal, but on finding no tenderness to his chest
wall she decided it was atypical chest pain.
54. On the doctors instructions, a doctor’s appointment was made for the following
week. In her notes and statement to police, the doctor noted indicated that the
appointment was for a review of the man’s blood pressure after he had settled
in prison, and for a decision to be made on treatment if his blood pressure was
still raised. This is in line with normal practice. In her interview with the PPO
investigation team, the doctor said that she intended for the duty prison doctor
to review the man after a week and for this to be a general review as well as a
review of his blood pressure.
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55. The doctor said that she had told the nurse that the man should have a series
of blood pressure readings in the meantime. The interim blood pressure
monitoring by nurses is not recorded in her notes or police statement, and the
accompanying nurse arranged for a single reading six days later. She wrote on
the Nursing Handover sheet “Repeat BP next week”, and put his name in the
Nurses’ diary for a blood pressure check on 3.7.08.
56. At interview, the doctor said she recognised that angina remained a possible
diagnosis, notwithstanding the fact that the pain was not typical of angina. The
clinical reviewer says in his report that the pain was atypical, both in its onset as
the man got off the bus, but more significantly in that he could walk through the
pain.
57. In the man’s medical notes, the doctor wrote:
“Repeat BP 1w [meaning repeat blood pressure one week] after settled in
prison and if still elevated then for treatment. Also monitor if further chest
pains occur and consider treadmill/Ix [meaning investigations]. Smoking
advice given.”
At interview, the doctor said that in her experience a patient would have to wait
about six weeks on Guernsey for a treadmill assessment. She said her
intention was that the doctor reviewing the man would check his blood pressure
and undertake a general review of his health. She said that “monitor” was
meant to mean that another ECG should be taken if he had further chest pain.
The doctor explained that her rationale for this was that if an ECG could be
taken during an episode of chest pain it might confirm or refute a diagnosis of
angina.
58. In her police statement, the doctor said she told the man that if the pain
occurred when an ECG could be performed, then it would be done. However, if
the pain occurred when an ECG could not be performed, he would need to go
to hospital by ambulance as an emergency patient. The doctor added that she
told the nurse and the man that in the meantime he was to have a series of
blood pressure readings, although she did not make any entry to that effect in
his medical record. Neither did she record her instructions about the possible
need for transfer to hospital in his medical notes.
59. At interview, the nurse who had been present throughout the consultation, said
she remembered the doctor saying that there was an abnormality with the
man’s heart and that it was probably related to blood pressure. She also
remembered he being advised to have an ECG if he had further chest pain
when nursing staff were on duty. However, the nurse said she had no
recollection of the doctor advising the man that he would need to go to hospital
if the nurses were not on duty and did not record such instructions in the
management plan. (Management plans are the doctor’s instructions for what
actions should be taken with individual patients.)
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60. The nurse made an entry on an appointment handover sheet noting the doctor’s
management plan that the man was to have a repeat blood pressure check the
following week. She also made a similar entry in the nurses’ diary for 3 July. At
1.35pm, the Prison Information Management System (PIMS) records the
healthcare manager as having made the man’s appointment on the computer.
61. Although she said she discussed the management plan with the man, the
doctor did not make any record to this effect. She said he told her that, when
the pain eased, it was not because he had stopped walking as he could walk
through the pain. He also said that he had been under a lot of stress at work
and thought it might be linked to his chest pain.
62. The doctor said that her examination showed that the man was mildly
hypertensive on two separate readings, had mildly chronic obstructive
pulmonary disease, and LVH. She said her impression of him was that of a
mildly hypertensive patient, with atypical chest pains and a history of neuralgia
(nerve pain).
63. At the end of the consultation, the doctor prescribed the man with a high dose
Vitamin B Compound and Thiamine tablets. (The clinical reviewer says this is a
normal prescription for treating someone with excessive alcohol use.)
30 June
64. At about 7.45pm, an officer was on evening duty in F wing. At interview, he told
my investigators that the man approached him and told him that he needed to
be taken to healthcare as he had pain across his chest. The officer said he told
him that he was to be taken to healthcare whenever he had chest pains. As the
man appeared to be distressed and was complaining of chest pain, the F wing
officer escorted him to healthcare.
65. When he and the man arrived at the healthcare department, which is on the
upper floor of the building, the nurse was not there. The F wing officer decided
to take the man to the medicines treatment hatch as evening medication was
being issued. (This is an area where medication is dispensed to prisoners by a
nurse.) The F wing officer told my investigators that the man walked “in bursts”
and was “hunched up”. He thought that he might have to get a nurse to him,
rather than him go to the treatment hatch, but in fact he managed to walk to the
hatch.
66. When they arrived at the treatment hatch, the nurse was there dispensing the
evening medication. At interview, the F wing officer said he spoke to the nurse
and told her that the man had chest pain. He said he told her that the man had
said that he was to be placed on a monitor if the chest pains recurred.
67. The F wing officer said the man spoke to the nurse and he heard him say that
he had had chest pains. He said he told the nurse he had been told that, if the
chest pains returned, he needed to be put on a monitor. Additionally, he heard
him telling the nurse that the pains had now gone.
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68. At interview, the nurse said she did not examine the man because he told her
that he felt fine and that he looked well. She said she did not carry out an ECG
because she understood that the test might be useful during chest pain but not
when the pain had gone. The nurse said she did not know whether or not an
ECG would show abnormality after the pain had gone. She added that it was
her recollection that the doctor had said it would be useful if an ECG could be
done during pain. As he did not have chest pain at that time, she thought an
ECG might not have been useful.
69. The nurse noted in the man’s medical record that he had had an episode of
chest pain which had resolved by the time she saw him. She also wrote “see
previous note”. The previous note referred to is one written by the doctor on 27
June, “… Also monitor if further chest pains and consider treadmill/ 1X …”
70. At interview, the F wing officer said he heard the nurse telling the man that it
was awkward at that time for her to see him, as she was about to begin issuing
medication. He also heard her say that, because the pains had passed, there
was no point in doing the ECG. She had added that, should the pains return
later or the following day, he was to go to healthcare where an ECG would be
carried out. The F wing officer said the man accepted the nurses’ instructions.
71. On the way back to the wing, the man told the F wing officer that he knew that
an ECG could only be carried when he had pain. He went on to say that the
pains came and went quickly. The F wing officer told my investigator that the
man walked back to the wing normally and not how he had walked earlier.
72. Soon after returning to the wing, the F wing officer made an entry onto the
PIMS recording his dealings with the man and the nurse. He noted that he had
taken him to healthcare because of chest pain, and that he had told him he
should be placed on an ECG machine. The F wing officer added that, when
they arrived at the treatment room, the man’s pains had passed. He also noted
that the nurse had said she was unable to do anything at that time as she was
issuing medication. If the pain recurred, the nurse had said she should be
called on her radio and that he was to be taken to the healthcare wellness room
where an ECG could be carried out.
3 July
73. At 2.00am on 3 July 2008, the man pressed his in cell emergency call button.
At interview the officer on night duty told my investigators that he was the one
who answered the cell call. When he arrived at the cell he opened the door
observation panel and spoke to the man who complained of having a
headache. When asked if he had mentioned chest pain, the officer on night
duty said he had not. He added that, had he done so, he would have sought
advice from the night manager. Instead, he offered him two paracetamol
tablets, which he accepted. The officer on night duty then went to an office
where he made a note of his actions in the medications issued book (which is
proper procedure at Guernsey Prison). My investigators asked the officer on
night duty if he had gone into the cell. He said he had not as this was not
allowed.
17
74. Later that morning, the man posted an application form into the healthcare
applications box. (The box, which is sealed to protect patient confidentiality, is
only opened by a member of healthcare staff. The applications are then taken
to healthcare where they are date stamped and processed.) On the application
form the man asked to see a doctor. He wrote:
“Could I see doctor Friday? Had to press the red button [this refers to the in
cell emergency cell call button] Thursday 2.00am. Bad chest pain. Took
Paracetamol just in case, but the pain did its usual thing and went within a
couple of minutes. It lasted approx 40 min, - normally 10 min.”
75. During the day the applications box was emptied and the contents taken to
healthcare. That afternoon, the nurse started duty in healthcare. At interview,
she said that when she arrived she found the application form on a desk,
waiting to be actioned. When asked what the purpose of applications was and
the procedures, she described them as an administrative tool. The nurse said
she dealt with the man’s application and wrote on the form “Appointment with
[the duty doctor] – Friday, 4/7/08.”
4 July
76. On 4 July, following the man’s earlier request for him to be seen again by a
doctor, he was seen by the duty doctor. At interview, the duty doctor said he
had been told by the nurse that the man had been seen by the doctor the
previous week. He added that the nurse had told him that his blood pressure
was slightly raised, and that he had had some chest pain. The duty doctor said
he had read the previous doctor’s notes in the man’s medical record, but if he
wanted information from a prisoner’s own doctor he would have to telephone
them.
77. The duty doctor was asked if he had seen the application form written by the
man the previous day. He had not. This is contrary to what the healthcare
manager told my investigators. She said his application would have been
placed before the doctor along with his medical record. Both the doctor and
duty doctor said at interview that, when a prisoner submits an application to see
the doctor, the doctor does not normally see the application form.
78. When the man saw the duty doctor, the nurse was also present in the
consultation room. At interview she said he had described his chest pain as
being identical to that when he had spoken to the previous doctor. He added
that the pain during the night had been “quite bad”, and that it had lasted longer
than usual but then gone away again.
79. The duty doctor noted in the man’s medical record that he had reviewed him.
He also referred to the entry made by the nurse the previous day. He noted
that when the man had mentioned pain on the left side that he was pointing to
left breast. He also noted that he had been woken during the night with chest
pain lasting less than 20 minutes, and that the pain was not related to exertion,
stress, emotion or breathing. The duty doctor could not explain why there was
a discrepancy between his entry of “<20” minutes”, and the man’s own
18
application stating 40 minutes. The doctor added that he said the pain eased
when he sat up.
80. As part of the medical assessment, the duty doctor noted that the man had a
history of smoking. In interview, the duty doctor confirmed that he had not
discussed any family history with the man. He recorded his blood pressure as
174/95, which was raised. The duty doctor also noted that examination of his
heart and lungs showed they were normal, and there was no tenderness of the
chest wall. The duty doctor’s diagnosis was that he had hypertension and
“chest pain ? cause”. He told my investigators that he did not suspect that his
pain was angina, as the way he indicated the site of the pain was not as he
would expect from someone suffering from angina.
81. The duty doctor said the cause of the man’s pain was not obvious. He had
been diagnosed with high blood pressure and was a cigarette smoker, but the
site and nature of the pain was not typical of heart disease. The duty doctor
decided to start him on a course of Amlodipine, a drug prescribed to treat high
blood pressure and angina, although – as noted – the duty doctor said he was
not convinced that the pain was angina. He prescribed 5mg of Amlodipine once
daily and requested a fasting blood test. (In a fasting blood test the patient has
blood taken after a period of not eating or drinking certain liquids.) He added
that the man should be reviewed prior to release from prison. The duty doctor
said the reason for requesting a blood test was that it was a prerequisite for a
treadmill test.
82. At interview, the duty doctor said that he had looked at the man’s medical
record, but did not recall seeing the healthcare manager health screen
document. He said he would normally only read the health screen document
during the reception process and not thereafter. When asked if he had read the
nurses’ entry on 3 July, the duty doctor said he presumed he had. However, he
had not realised that the man had made an application to see a doctor.
83. My investigators asked the duty doctor whether knowing that the man’s pain
had lasted for 40 minutes would have made any difference to his treatment. He
said he was not sure that it would. He was also asked if his decision would
have changed had he seen the application. He said admission to hospital was
not justified as the man looked well.
84. When asked if he was aware of the previous doctor’s management plan, the
duty doctor said she had not been convinced that the man had angina. He
remembered that the nurse had told him that the previous doctor had requested
an ECG during pain. He said the nurse had told him that there were practical
difficulties obtaining an ECG during pain and that it was proving difficult for
nurses to fulfil the previous doctor’s instructions. The duty doctor added that
the nurse had told him that, due to the prison being spread out and the time it
took for nurses to set up the ECG, it was unlikely that they would manage to
record an ECG during pain. The nurse had told him that not all nurses could
use the ECG equipment. My investigators asked the duty doctor if he was
aware of the previous doctor’s instructions advising that an ambulance should
be called if he had chest pain outside of nursing hours. He said he was not.
19
85. The duty doctor said he told the nurse that he wanted nurses to check the
man’s blood pressure each week. However, he did not record this instruction in
his medical notes, nor did he mention it in his statement to police. Furthermore,
the nurse, who had been present throughout, did not record the duty doctor’s
instruction onto the appointment handover sheet. The nurse wrote, “bloods
next week and Amlodipine”.
86. Because of the description the man had given of his chest pain, the duty doctor
said he did not refer him to a specialist. He said the cardiologist in Guernsey
was very busy and that access to him was slow. My investigators asked him if
there was a rapid access facility on Guernsey. The duty doctor said there is a
doctor who can be asked to assess cardiology problems. He added that access
to a treadmill test would take approximately six weeks. He said an urgent
outpatient appointment could be arranged within a few days by discussion with
the duty consultant. Although he had not considered it at the time, the doctor
thought it a good idea to call an ambulance if the man had pain at night.
8 July
87. On 8 July, as per the duty doctor’s earlier request, the nurse took blood from
the man and sent it away for analysis. The results were received on 11 July.
They showed a mildly elevated cholesterol level, and a raised CRP (C reactive
protein) level. The CRP is a measure of inflammation and raised CRP may be
linked to coronary artery disease risk. The red blood cells were enlarged, in
keeping with his history of heavy drinking. (Later, for the post mortem report,
the Pathologist also analysed the blood sample that was taken on 8 July. This
later test showed raised Troponin levels, indicative of heart muscle injury. It is
important to note that this testing is still not available to GPs in Guernsey. It
can only be requested by a specialist.)
9 July
88. On 9 July, the man made a second application to see a doctor. He wrote on the
application form, “wish to see doctor, chest pains back Wed 2.00am for 40 min.”
Rather than placing the form in the healthcare applications box, he handed it to
an officer.
89. During a discussion, the officer that took the form told my investigators that the
man gave him the application form that morning. Having read the application
and realising the nature of what he had written, the officer took it personally to
the dispensary and handed it to a nurse. He said he had decided that the
application was such that it needed to be taken direct to healthcare, rather than
placed into the healthcare applications box. Although he could not remember
the exact time that he took the application form, he was certain it was before
8.15am. He said the dispensary closes at 8.15am and it was still open when he
arrived.
20
90. However, when my investigators examined the application form they saw that it
had been date stamped as received into healthcare on 10 July. As with the 3
July application, there is no signature or time recorded by the member of
healthcare staff receiving the form.
91. My investigators have been unable to explain the discrepancy between the
application date and the date it was stamped as being received into healthcare.
Unfortunately, the officer that took the form has been unable to remember to
which nurse he gave it to. My investigators have looked at the nursing rota for
9 and 10 July and conclude it was either the healthcare manager or another
nurse, as they were in the dispensary on the respective dates.
92. At interview, the healthcare manager said that she had picked up the
application form on 10 July. She said that she had seen the man at the
treatment hatch, but he had not said anything to her about chest pain.
However, at a later interview with my investigators, she changed her account of
events and said she did not deal with the application form and did not know who
had.
11 July
93. At 12.35am, the man pressed his in cell emergency call button, and this was
registered in the prison control room. The night manager went to the cell to see
why the button had been pressed. The control room log shows the time that the
call button was reset by the night manager to acknowledge his arrival at the cell
was 12.37:57am. When he looked into the cell through the observation panel,
he saw the man clutching his chest and said in interview that he looked ill.
94. Using his prison radio, the night manager asked two officers for their
assistance. At interview, the night manager said he asked for the officers’
assistance as there had to be three staff present when opening a cell at night.
95. The night manager told my investigators that he went into the man’s cell along
with one of the officers, whilst the second officer remained outside the cell. He
said the man told him that he had had pain in his chest and difficulty in
breathing, but the pain had eased since pressing the call button. He also said
that the pain had been present about 45 minutes earlier, but that it had had
gone away and then returned. He told the night manager that this was the
reason for pressing the cell call button. He said he was getting repeated chest
pain on a daily basis and had been keeping a note to show to the doctor in the
morning. (I understand that the note is part of the police evidence file prepared
for the Coroner). The night manager said the man had shown him the tablets
that he was taking. He asked him if he wanted a doctor or ambulance, but the
man declined the offer.
96. The second officer told my investigators that she heard the night manager ask
the man if he wanted a doctor or an ambulance and that he had said he did not.
He had said the pain was passing. Additionally, she remembered the manager
telling him to alert staff again if the pains returned.
21
97. After leaving the man’s cell, the night manager decided to speak to the on call
duty manager, and seek his advice. The night manager told the on call duty
manager what had happened and said he planned to carry out hourly
observation checks on the man. The on call duty manager told the night
manager to telephone the duty doctor for advice.
98. At 12.55am, the night manager telephoned the duty doctor based at an outside
hospital. The call was answered by a receptionist employed by an out of hours
service known locally as “Night Owl”. When the receptionist asked the night
manager for the man’s details, he mistakenly believed that she was able to
access his medical information and could see his prison medical details on her
computer screen. He said the reason for presuming this was because, when
she asked him for the man’s name, the receptionist was able to give his home
address. However, he was unaware that she only had access to her own
medical records and not those of the prison, which explains why she was able
to identify his home address details.
99. In her police statement, the receptionist said she advised the night manager to
call an ambulance, but that he said he wanted to speak to a doctor in the first
instance. At interview, the night manager said the receptionist did not advise
him to call an ambulance. However, he later clarified this and said that his
memory was not good enough to recall exactly what was said. He added that,
had he thought the man to be in immediate danger, the correct route for
obtaining medical assistance would have been via the 999 emergency services
and not via the Night Owl.
100. The receptionist took the night manager’s details and arranged for the duty
doctor to telephone him at the prison. At interview, the night owl doctor, told my
investigators that the receptionist had told him she had advised the night
manager to call an ambulance. The night owl doctor added that the receptionist
said the night manager had insisted on speaking to a doctor
101. In the meantime, while waiting for a doctor to telephone him, the night manager
checked the PIMS. He read that the man had been taken to healthcare by the
F wing officer after complaining of chest pain. (Prison officers do not have
access to patient medical notes.)
102. At about 1.00am, the night owl doctor telephoned the prison and spoke to the
night manager. The doctor told my investigators that the night manager said
the man had experienced chest pain for about ten minutes. He added that he
said he had not called an ambulance because the man had said the pain was
settling. The night manager told him that the man had a heart condition and
had had several similar episodes over the previous month, each lasting five to
ten minutes. The doctor said he had no recollection of the night manager telling
him about the PIMS entry which he had read shortly before the doctor
telephoned him.
103. During the interview with the night manager, he said he could not remember if
he had told the doctor about the entry made by the F wing officer on 30 June in
the PIMS. He repeated that he was expecting the doctor to have the man’s
22
medical information on his screen. At interview, the night owl doctor said he
had asked the night manager if any other doctors had seen the man. He had
told him that the man had been seen with similar symptoms. The doctor formed
an understanding that his condition was much the same as previous and that
medical follow up arrangements had been made.
104. Between them, the night owl doctor and the night manager discussed the need
for the man either to be taken to hospital or to remain in the prison. The doctor
concluded that, because the man’s symptoms were the same as during his
previous episodes, it was appropriate for him to remain in prison. He told the
night manager that an ambulance should be called immediately if there were
any further symptoms.
105. In making his decision, the night owl doctor was under the misapprehension
that prison staff would remain with the man and any further symptoms could
immediately be seen. He was unaware that he would be left alone in his cell.
In interview he said that, had he known this to be the case, admission to
hospital would have been appropriate to ensure adequate monitoring.
106. My investigators asked the night owl doctor whether he would have acted
differently had he known of the previous doctors plans to perform an ECG
during an episode of chest pain. He said that, had he been given this
information, he would have arranged an immediate admission to hospital. He
added that, had he known about the PIMS entry made by the F wing officer, his
decision to let the man remain in prison would have changed and he would
have admitted him to hospital.
107. At about 1.45am, the first officer was carrying out his security patrol duties and
whilst in F wing he took the opportunity to check on the man. When he looked
into his cell he saw that he was unwell. At interview, he described him as sitting
slumped in his chair. The first officer said the man’s head was laid back and
that he was gently moving it from side to side. The first officer added that the
man appeared to be alive as his head was moving. He said he was concerned
about him because he looked ill and in need of professional medical treatment.
He did not appear to be conscious and was, at best, semi conscious. The first
officer said he did not speak to the man, and he was unaware that he was so
unwell that there was a threat to his life. He said he knew he was not well, but
was unable to do anything for him until the night manager authorised the cell to
be unlocked. At interview, the first officer confirmed that he had not gone into
the cell.
108. Using his prison radio, the first officer contacted the control room and asked for
assistance. An officer colleague was in the control room and heard the first
officer saying that the man did not look well and asking the night manager to go
to F wing. As the radio system was on “talk through,” the night manager heard
the transmission and replied saying that he was on his way. Additionally, the
first officer telephoned the office where he knew the night manager was located.
The night manager answered the call and told the first officer that he was on his
way.
23
109. My investigators asked the first officer if he was familiar with the “urgent
message” procedure. He said he was, but that it was to be used only in an
escape situation or if there was a threat to an officer. The night manager told
the investigators that “urgent message” could include a medical problem.
110. At interview, the night manager said he was in the centre office when he heard
the first officer’s request for assistance. He said the first officer asked him to
take a look at the man, as he did not appear well. The night manager said he
did not detect any urgency in the officer’s voice, nor had he used the urgent
message procedure.
111. Within the same office there is a bag containing emergency medical equipment.
It is intended that the bag should be taken to the patient in any medical
emergency, to reduce the delay in giving treatment. The bag contains
resuscitation equipment, including an automatic electronic defibrillator. (A
defibrillator can restart the heart in some cases of cardiac arrest by giving an
electric shock. It detects the electrical activity in the heart and gives automated
instructions to the rescuer).
112. Although he knew that it was the man’s cell that he was asked to go to, the
night manager did not take the emergency medical bag with him. At interview,
he said he would have done so had he known the nature of the situation.
113. The officer colleague had earlier been told by the night manager that, should
the man be taken ill again, then an ambulance was to be called. At interview,
the officer colleague told my investigators that he did not call an ambulance
because he did not know whether or not the call from the first officer was a
serious matter.
114. In the meantime, whilst waiting for the night manager to arrive, the first officer
decided to continue with his security patrol checks. Instead of staying with the
man, he left the wing and went on to another.
115. At interview, the night manager said that, when he arrived at the man’s cell, he
first of all looked into it via the observation panel. He said he saw the man lying
back in a chair, with his arms by his side. The night manager unlocked the cell
door and went in alone. At about the same time, the first officer returned to F
wing.
116. When the night manager went into the cell he noticed that the man’s skin
complexion around his neck was becoming darker in colour. The night
manager said he attempted to obtain a response from the man by shouting out
his name and shaking him. As he could not get a response from him, the night
manager began moving him. At this point the first officer arrived and helped
him move the man to the floor. (The purpose of moving him to the floor was to
lay him flat on a hard surface in order to carry out cardio pulmonary
resuscitation (CPR).) The night manager used his radio and called an urgent
message asking the officer colleague to call an ambulance.
24
117. After calling for an ambulance and, knowing that the man was going to be
transferred to hospital, the officer colleague began telephoning off duty prison
officers. This was because he would need to be accompanied by two on duty
officers which would leave the prison short of staff. The purpose of asking for
extra staff to come in to the prison was to replace those escorting him to
hospital.
118. Regrettably, the first two officers he telephoned both declined to attend.
However, the third officer he telephoned did agree to assist and he began
making his way to the prison.
119. At the time when the first officer asked for assistance, the second officer was in
the control room. At interview, she said the officer colleague asked her to go
straight away to F wing, although she was unaware of the nature of the call. On
her way to F wing, the second officer passed the office where the emergency
medical equipment was located. Unaware of why she had been asked to go to
F wing, she did not collect the bag.
120. The second officer told my investigators that, when she arrived at the man’s
cell, she saw the night manager and the first officer moving the man to the floor.
She said she handed the first officer her CPR mask. (CPR masks provide a
protective barrier between the patient’s mouth and the rescuer.) She said the
first officer carried out mouth to mouth resuscitation whilst the night manager
was carrying out chest compressions.
121. The night manager told the second officer to open the doors onto the main
corridor to allow ambulance staff to enter. When she opened the corridor
entrance door the ambulance had already arrived. The ambulance log notes
the time of arrival at the prison gate as 1.52am, having taken approximately
seven minutes to get to the prison from its starting point. It then took
approximately a further seven minutes for the ambulance crew to get to the
man (the main prison gates could not be overridden and had to be opened one
at a time). The ambulance log shows that the ambulance crew were with the
man at 2.00am. My investigators tested the gate system and found that, by not
overriding the gates, there was a difference of about one and half minutes,
before the ambulance could gain entry into the prison grounds.
122. By the time paramedics arrived at the man’s cell, the night manager the first
officer had been administering CPR for about 20 minutes. One paramedic
asked the night manager to move the man from his cell into the wing
association area so they could have more room to continue resuscitation
efforts. In the meantime, the two prison staff were asked by paramedics to
continue CPR which they did.
123. Whilst administering CPR, the paramedics attached a defibrillator to the man
and administered drugs to him. The defibrillator showed that there was no
shockable rhythm detected from his heart and so CPR continued.
25
124. On Guernsey, the paramedic service is operated by the St John Ambulance.
The policy is that once CPR has started all those present have to agree to stop.
Otherwise, CPR must continue. At 2.30am, as the man was not responding to
CPR, paramedics asked if all present were in agreement to stop any further
attempt to resuscitate him. The night manager said he wanted to try one more
CPR cycle, which they did. (A CPR cycle is 30 chest compressions to two
inputs of breath.) At 2.40, approximately 40 minutes after starting CPR, the
decision was taken by all present to stop any further resuscitation attempt.
125. In the meantime, the on call duty manager, who had been told of the
emergency, arrived at the prison. He told my investigators that the paramedics
had complimented the prison staff for their attempts to resuscitate the man.
126. As no more could be done for the man, the paramedics left the prison. In line
with any death in custody, the police were told of the death and arrived to begin
their own investigations. Satisfied that the circumstances were not suspicious,
they allowed his body to be removed from the prison. Before doing so, an on
call doctor attended and confirmed that he had died.
127. Following the man’s death, police officers went to the family home to break the
news. As part of the police procedures, a family liaison officer was appointed to
look after his family and keep them informed.
128. In the meantime, the deputy governor arranged for the staff to be de-briefed
and supported. Additionally, she arranged for a critical incident de-brief to take
place to allow staff to talk about what happened and obtain any necessary
support. As well as caring for staff, the governor ensured that prisoners were
also offered support.
26
ISSUES
26 June 2008
First Reception Health Screening
129. In his report, the clinical reviewer says that the healthcare manager’s
assessment of the man’s medical history was thorough and she obtained a
clear history of exertional chest pain. Additionally, the nurse undertook clinical
tests and discussed the results with a doctor. The clinical reviewer says that
reception health screening assessments can take a considerable time to be
thoroughly completed, and it is important that the need for lengthy assessment
is recognised. The healthcare manager’s actions reflected good practice.
The healthcare manager’s discussion with the doctor
130. My investigation has identified a disparity between the healthcare manager’s
recollection of her telephone conversation with the doctor and that of the doctor
herself. The clinical reviewer argues that the healthcare nurse should have
made a record of the conversation in the man’s medical record, as it is part of
his contemporaneous record of care. She did not. The clinical reviewer says
that it would have been good practice for the doctor to have done the same,
although he says few clinicians would routinely do so.
27 June
131. On 27 June, the doctor met the man as planned. Assisting the doctor in her
surgery was the nurse. In his report the clinical reviewer states that, apart from
omitting to note the character of the man’s pain, or whether he had a family
history of coronary heart disease, the doctor otherwise recorded a detailed
history of his pain. She diagnosed atypical chest pain and considered angina
as a possible cause.
132. At interview, the doctor said that the man’s symptoms did not lead her to
consider that a referral to a cardiologist was appropriate at that time. She said
that the waiting time for a treadmill test was about six weeks. The doctor said
that she believed prison nursing staff could carry out an ECG during pain, and
this was partly the reason why she did not refer him, for treadmill testing.
133. In the clinical reviewer’s view, given the man’s age, smoking history and recent
onset of chest pain, it would have been appropriate to have referred him for a
treadmill test. He says it was not appropriate to delay the referral either
because of the anticipated six week wait or because of the possibility that an
ECG could be carried out if he presented to a nurse with pain.
134. At interview, the doctor said she thought nurses would be interacting with
prisoners and that the man would have been able to alert them when he had
pain. The clinical reviewer says that, in his opinion, it was unrealistic to expect
that nurses would be interacting sufficiently with prisoners to allow an ECG
during pain to be a realistic possibility. He concludes that the doctor’s plan for
27
nurses to record an ECG during pain was unrealistic and that it was
inappropriate to place any reliance on such an approach.
135. The doctor said that her care plan for the man was that he was to have an ECG
if he had further chest pain and providing a nurse was on duty. However, if
medical care was not available, he was to be taken to hospital by ambulance as
an emergency patient. In her interview, the nurse said she did not hear the
doctor say that the man was to be taken to hospital.
136. The clinical reviewer reports the General Medical Council (GMC) guidance on
professional standards [Good Medical Practice 2006]. In its guidance the GMC
states:
“In providing care you must keep clear, accurate and legible records,
reporting the relevant clinical findings, the decisions made, the information
given to patients, and any drugs prescribed, or other investigation or
treatment.”
The clinical reviewer says that to ensure other doctors and nurses seeing the
man would know of her management plan, the doctor should have made her
plans clear in his medical notes.
137. It is manifest that there is disparity between what the doctor said she told the
man, and the nurses’ account. The clinical reviewer notes in his clinical review
that, even if the doctor did advise the man to tell prison staff if he had chest pain
outside nursing hours, and the officers would then call an ambulance, it was
unsafe to rely on such advice. Undoubtedly, the officers have to exercise
discretion when a prisoner complains of chest pain. In the clinical reviewer’s
opinion, in view of the specific need for action if the man developed chest pain,
the Officers needed to be given specific advice on what to do if he presented
with chest pain, outside nursing hours.
Medical Information Sharing (White Board)
138. Within the centre office, there is wall board which is referred to locally as the
“white board”. It is used to note information of importance including medical
instructions. For example, if a prisoner with a known illness is taken ill at night,
instructions are written onto the white board telling staff what to do. My
investigators found that no entry had been made on the board regarding the
man’s clinical needs.
139. As part of the investigation process, my investigators have considered the
purpose of the white board. They believe it is a useful tool, but somewhat
confusing and not set out in any logical order. It was difficult to determine new
information and almost impossible to assess its contents at a glance. The
doctor said that in her view it was the responsibility of doctors and nurses to
identify healthcare issues that prison officers needed to be aware of, and that
nurses should pass the information onto prison staff. In her interview, the nurse
agreed that nurses should take the initiative in raising concerns. It is possible
28
that events might have gone differently on 11 July if not before, had officers
been alerted to the man’s situation through an entry on the “white board.”
140. Following their first visit to the prison, my investigators brought the Governor’s
attention to the white board and the need for it to display information that could
be readily understood. The Governor accepted this feedback. When my
investigators returned to the prison to continue their investigation a few weeks
later, the white board had been replaced with a well designed, purpose-built
information sharing board. Information is now separated into specific sections,
and clearly identifies any prisoner with a known medical condition and shows
what action prison officers should take if the named person is taken ill. In
addition, the PIMS now has a medical risk element as part of its database. This
ensures that any member of staff accessing the PIMS can see at first glance if
there is any concern relating to a prisoner’s medical care.
141. The clinical reviewer says in his report that the doctor should have told the
nurse to ensure prison staff knew what to do if the man experienced chest pain
when nurses were not on duty. He says prison officers needed to know what
the doctor’s management plans were. My investigators found that the nurse did
not record any details of the doctor’s management plan either in the
appointment/handover notes or the nurses’ diary or on the white board. The
nurse later accepted that she should have done so.
142. The clinical reviewer argues that the white board system should be formalised.
He says the daily updating of the healthcare section of the board should be
made part of the nurses’ timetable. He says that it should be the nurses’
responsibility to add entries to it, and warnings should be explicit about any
actions that officers are expected to take.
The Governor, in partnership with the HSSD should ensure that the
updating of the white board health warnings section is the sole
responsibility of healthcare.
The Governor, in partnership with the HSSD, should ensure that health
warnings are explicit and clearly state what actions prison staff are to
take.
30 June
143. On 30 June 2008, the man had a further episode of chest pain. He told the F
wing officer who took him straightaway to the healthcare treatment dispensary.
When they arrived, the nurse was issuing medication to prisoners. She told the
man that she was busy at that moment in time and that it was not convenient to
see him. As his pain had subsided, he returned to F wing without being
examined.
144. At interview, the doctor said that if the man presented to a nurse with an
episode of chest pain that had just settled she would expect the nurse to log
and note it, also documenting the history of chest pain. Dependent on its
severity, the episode should also be brought to the attention of the on call
29
doctor. The doctor added that, if the pain was mild and transient and the
patient felt it was no different to the pain previously experienced, it would be
reasonable to wait until the next consultation with a doctor.
145. At interview, the nurse said she knew that the doctor wanted the man to have
an ECG during pain. She told my investigators that she should have assessed
him after completing her treatment session, and that she should have contacted
the on call doctor to discuss the further chest pain and that it had not been
possible to record an ECG during pain.
146. In his report, the clinical reviewer confirms that it was reasonable for the nurse
to allow the man to return to F wing because the pain had settled, but that she
should have assessed him after completing her treatment session. She should
then have contacted the on call doctor to advise that further chest pain was
occurring, and that it had not been possible to obtain an ECG during pain.
147. After returning to the wing, the F wing officer made detailed notes on PIMS
about what had occurred. His notes have proved to be extremely helpful in
understanding what happened when the nurse spoke to the man, and are a
good example of the importance of recording information. I regard the F wing
officer’s actions in recording his contact with the man as an example of good
practice. Although I make no formal recommendation, the Governor may wish
to share my comments him and his manager.
Medical Applications
148. On 3 July at 2.00am, the man pressed his in cell emergency call button. The
officer on night duty answered the cell call. He said the man had complained to
him of having a headache, and so he gave him two paracetamol tablets. He
said the man did not mention chest pain. Although I make no criticism of the
officer, his account of events does not appear to agree with what the man wrote
in his application form.
149. The clinical reviewer says in his report that the procedure for administration,
recording and monitoring of paracetamol given outside nursing hours is good
practice.
150. The application form was received by the nurse. Although it was date stamped,
the nurse did not initial it, nor add the time of receipt. She made an entry in the
man’s medical record, noting the date of the application and that he had
complained of chest pain. She told my investigators that she did not discuss
the reported chest pain with anyone.
151. At a later interview, the nurse said she should have acted on the information
given by the man, and that she should have assessed him. She also said that
she should have discussed his symptoms with a doctor, rather than simply
booking an appointment for the following day.
30
152. At interview, the doctor said that she was not made aware of the increase in the
man’s chest pain. Had she been aware of a 40 minute episode of chest pain
during the night, she would have expected the man to have been admitted to
hospital for further investigation.
153. Six days later, on 9 July, the man submitted a further application form.
Although we do not know which member of healthcare staff received his
application, it is clear from healthcare records that nothing was done with it
other than adding a date stamp. There is no evidence on PIMS of any action
being taken by healthcare staff to make an appointment. There is no evidence
of an appointment being made on the appointment handover sheet for the next
doctor’s clinic which would have been the following day. There is no evidence
that anyone went to assess his condition.
154. At interview, the duty doctor told my investigators that his expectation of nursing
staff receiving such an application would be that a nurse would visit the patient,
make a general assessment, check pulse, blood pressure, and perform an ECG
if possible. He would expect a nurse almost certainly to call a doctor. The duty
doctor went on to say that he would expect a Registered General Nurse to
recognise that a 40 minute episode of night time chest pain in a man of this age
is a significant event, and a possible indication of a heart attack.
155. In his report, the clinical reviewer says it was commendable that the officer that
took the man’s application form took account ,and responded by handing it
directly to a nurse. However, it is a matter of great concern that healthcare staff
did not react to the second report of 40 minute chest pain or take any action.
Nurses should have assessed the man, undertaken an ECG, and contacted a
doctor. The clinical reviewer says the history should have raised the possibility
of unstable angina in the mind of a doctor, and thereby prompted urgent
admission to hospital.
11 July
156. The clinical reviewer suggests it is arguable whether or not the night owl doctor
put himself in a position to make an adequate assessment of the man. It could
be argued that the case of a man at this age with chest pains in the night should
always prompt admission for assessment to exclude unstable angina.
However, it is clear that the night owl doctor took care to establish that the pain
had gone within five or ten minutes, and that it was the same in this respect as
previous episodes. The clinical reviewer says the night owl doctor considered
angina as a possible diagnosis, but he did not have a high suspicion of cardiac
disease because of the way the man was being managed by prison doctors.
The night owl doctor established that the man had been seen by a prison doctor
in the previous week when it was felt unnecessary to do an ECG or arrange
urgent secondary care. He mistakenly believed that the man would be watched
by prison officers.
157. In the opinion of the clinical reviewer, the night owl doctor acted reasonably and
appropriately with the information available to him. Unfortunately, he did not
have the full information available to him. In considering this, I note that the
31
night manager apparently did not inform him of the PIMS entry and this was
because he was under the misapprehension that the doctor had access to it.
However, the night manager did tell the night owl doctor of his knowledge of the
man’s history of chest pain whilst in custody. It is worth noting that the night
manager did not have access to the man’s medical record and as I have
already stated, there was no medical information on the white board. The
clinical reviewer comments that if the doctor had more information about the
man’s condition and need for an ECG he would have arranged urgent
admission to hospital. Although I make no formal recommendation, the
Governor might wish to ensure that operational staff are aware that PIMS and
medical records cannot be seen by out-of-hours medical staff.
Urgent Message Procedure
158. It is clear from my investigation that it was not immediately known to prison staff
what the situation was on 11 July when the man was found collapsed.
Although, available, the emergency grab bag was not taken to his cell because
prison staff did not know what the problem was.
The Governor should ensure that prison staff are aware of the correct
radio procedure for raising an urgent message.
Entering a cell at night
159. My investigators found that uniformed staff at all grades did not understand the
routine for entering a cell at night, and that a number were unaware of revised
local instructions updated in March 2008. My investigator raised this and the
first officer’s actions as an immediate urgent finding.
160. In his feedback letter of December 2008, my investigator said:
“It was clear from the uniformed staff interviewed, and a number who we
spoke to on an ad hoc basis, that they believed a cell could not be unlocked
at night, without a minimum of three officers being present. This is an
important factor in [the man’s] case, as clearly he appears to have been
alive when the night patrol officer looked into his cell and realised that
something was wrong. Despite knowing that [he] had been taken ill a little
earlier, he chose not to enter the cell, but did raise the alarm. He then left
[the man] and continued with his pegging duties, in the mistaken belief that
he could not go in.
“As I am sure you will appreciate, this will be a difficult finding for [the man’s]
family to comprehend. Once we were aware of what had occurred I raised
this as an urgent finding and an issue requiring immediate action.”
161. The clinical reviewer says in his report review that, given his description of the
man’s appearance, it is difficult to understand why the first officer left him to
continue with his security patrol. I have to agree.
32
The Governor should remind staff on the correct procedure for entering a
cell at night.
162. In her letter of 2 February 2009, the deputy governor said that every member of
operational staff had been issued with an individual copy of the procedure for
unlocking a cell during the night when there is a potential or actual threat to
safety. Additionally, she said that my investigator’s finding had formed a
significant part of a full staff briefing which had taken place in October 2008 and
that revised night instructions were issued on 16 November. A new notice to
staff had been issued reminding all staff of the correct radio procedures and
what to do in the event of an urgent message.
Resuscitation Attempts
163. Prison officers are not often given public recognition for the work they do. They
deal on a daily basis with sometimes difficult and dangerous people, but are
expected to show a caring attitude towards those in their charge. The man’s
circumstances are a good example of what officers do in trying to care for
prisoners.
164. By the time the St John Ambulance staff arrived at the man’s cell, prison staff
had been administrating CPR for anything up to 20 minutes. Whilst the
ambulance staff set up their emergency equipment, they asked prison staff to
continue with CPR which they did without question. After carrying out their own
checks, and almost 40 minutes from when CPR first started, ambulance staff
asked all present if they were in agreement to stop. The night manager asked
to carry out one further round of CPR, which they did, but unfortunately without
success. I am satisfied that once it was known he had collapsed, prison staff
did everything possible to rescue the man.
165. Given the fact that prison staff had attempted resuscitation for so long and must
have been extremely tired, their efforts to revive the man are worthy of public
commendation. Although I make no formal recommendation, the Governor will
wish to share my comments with those involved.
Communication/Prison Instructions
166. The events of 11 July highlight the issue of communication and the need for
officers to take individual responsibility in keeping up to date with local
instructions and policies. It was evident to my investigator that some officers
and uniformed managers were not routinely using the prison intranet. This was
fed back to the Governor.
167. Following his feedback, my investigator followed the matter up in writing. In his
letter dated 9 December 2008, my investigator wrote:
“We found evidence that although staff knew where information is held, they
did not access it on a regular basis. As an example, none of the uniformed
staff we spoke to knew that your instructions for entering a cell at night (GPI
2.77) had been updated on 19 March 2008.”
33
The Governor should remind all staff of their responsibility to ensure they
are up to date with local instructions and know how to access
information.
Emergency access into the prison at night
168. The gate area is fitted with an override system, enabling both vehicle gates to
open at the same time. However, the facility is only available during daytime
hours. At night time when staffing levels are at the minimum level, the override
system, although still available, is not used because of insufficient staff being on
duty to cover the security risk of both gates being open at once.
169. In this man’s case, the emergency ambulance crew were unable to gain access
into the prison as quickly as they would have done during the day as gates
could not be overridden. Once in the prison grounds, further delay occurred
whilst the inner security fence gate was opened and closed manually, and then
the main corridor unlocked to allow the emergency crew to proceed to the wing.
My investigator raised the delay as an urgent finding.
170. In her letter dated 2 February 2009, the deputy governor said that the night
procedures had been reviewed and updated instructions introduced on 16
November 2008. She said that all senior officers and night teams have
completed refresher training in gate control. She added that all night gate staff
were aware of the gate override system and familiar in its use. Additionally,
with the assistance of the local fire brigade, the override system had been
tested during the day on 4 November with no delays. However, the deputy
governor’s letter does not make it clear whether the override system was tested
under the same conditions as would be in place during the night. She added
that the routine for operating the override system will form a regular part of
testing the prison contingency plans.
The Governor should ensure that the testing of override systems
replicates night time staffing levels and routines.
Doctor’s attendance
171. The current level of doctor cover at the prison is Monday, Wednesday and
Friday. My investigators have been told that in Guernsey, someone wishing to
see a doctor on the day they ring can expect to be seen that day. Their level of
access to a doctor is arguably better than in those in the prison, albeit the
prison nurses can call a doctor in if they are concerned. There is the
opportunity for nurses to ask a doctor to attend if necessary, but it would appear
that this is done rarely. The nurses are expected to triage the patients in the
prison. They did not have triage algorithms despite a previous HMCIP
recommendation to do so.
The Governor in partnership with the Healthcare Group should consider
increasing the frequency of doctor attendance to every weekday and
include Saturdays.
34
Staff/prisoner relationships
172. I have been pleased to learn from my investigator about the positive
relationship between staff and prisoners. He said there was noticeable
interaction and clear evidence of staff taking the time to speak to prisoners,
even if simply to say hello. He reported the atmosphere as relaxed, and that it
made for a pleasant feel about the prison. I invite the Governor to share my
comments with his staff.
35
THE CLINICAL REVIEWER’S CONCLUSIONS AND RECOMMENDATIONS
173. In the report obtained by the Health and Social Services Department (HSSD),
the first clinical reviewer concluded that “It is my opinion, the medical care and
advice he received in prison and from the hospital were of a high standard and
appropriate. From the facts available to me, I do not consider that his
imprisonment, or the medical care he received contributed materially to his
premature death.”
174. On behalf of Her Majesty’s Comptroller,a MD FRCP FACC Consultant
Cardiologist, was asked to prepare a supplementary expert medical report
regarding the man’s death. His report was completed on 6 November 2008. In
his report the clinical reviewer notes that the consultant cardiologist states that:
“… in view of the combination of the documented medical history and the
computer interpreted ECG findings, a presumptive diagnosis of an acute
coronary syndrome could not have reasonably been made. Had it been, I
would have expected that this would have triggered admission to hospital.
There was no further opportunity for medical staff review prior to the patient
suffering the acute ischaemic event on 11 July 2008.
In summary, although the patient did suffer an acute coronary syndrome
proven subsequently at Post Mortem, this could not have been reasonably
recognised from the medical information available at the time from the
expertise of the medical staff and without a clinical diagnosis of an acute
coronary syndrome, it would not have been expected that the patient would
have been admitted to hospital as an emergency admission at the time of
either medical review.”
He adds that:
“…if the acute coronary syndrome had been recognised and the patient
admitted to hospital, it is highly likely that the outcome would have been
different and there would have been an expectation of a good outcome from
medical therapy, combined with either subsequent percutaneous coronary
intervention or coronary bypass surgery”
175. The clinical reviewer has taken into account the expert cardiological opinion of
the consultant cardiologist, and agrees with him that a presumptive diagnosis of
an acute coronary syndrome could not reasonably have been made. However,
the clinical reviewer has approached this investigation and his clinical review
from the perspective of a clinician working in general practice or in primary
medical care. This means forming a judgement about what a doctor in general
practice should reasonably be expected to consider. He has addressed the
question of whether there were occasions when the man’s presentation should
have led to him being referred or admitted to hospital. In the clinical reviewer’ss
opinion, there had been a number of occasions when the man’s symptoms
ought to have raised sufficient concern for further action to have been taken.
36
176. The clinical reviewer comments that, notwithstanding the consultant
cardiologist’s expert opinion, it is his opinion that there were sufficient grounds
for concern to expect that referral to a cardiologist should have been made on
27 June, and the man’s presentation on 4 July indicated the need for admission
to hospital or urgent referral. Nurses should have responded on 30 June, 3 July
and 10 July by discussing his symptoms with the duty doctor. Had they done
so, a referral for treadmill testing would have been the appropriate response to
the episode of chest pain on 30 June. The clinical reviewer goes on to say that
urgent admission to hospital was the appropriate response to the two episodes
of 40 minutes of chest pains, described in each of the applications made on 3
and 9 July.
177. The clinical reviewer argues that had a referral been made, and the discipline
officers made aware that an ambulance should be called if the man had chest
pain outside nursing hours, it is likely that the night manager would have
arranged admission when the man first pressed his cell call button on 11 July.
Additionally, the clinical reviewer is satisfied that the out-of-hours doctor would
almost certainly have arranged hospital admission for him, had he known about
the management plan. In the opinion of the clinical reviewer, it is possible that
the outcome on the night of 11 July would have been better had admission to
hospital occurred before the man had his heart attack and cardiac arrest.
178. The clinical reviewer says the investigation has found significant deficiencies in
communication within the healthcare department, within the discipline staff of
the prison, and also between these two professional groups. He adds that
clinical decisions, and systemic and individual communication deficiencies, are
relevant in assessing the care that the man received.
179. In addition to the recommendations already identified, the clinical reviewer
makes the following additional recommendations, which I support:
(cid:127) The HSSD should undertake a review of the use of the
Appointments/Handover sheets, and any necessary training should be
given, to ensure good communication between members of the healthcare
team based in the prison.
(cid:127) The HSSD should undertake a review, and any necessary training should be
given, of the procedures for nursing staff to raise healthcare warnings about
patients/prisoners to discipline staff. This should include, but not be limited
to, the morning management meetings.
(cid:127) The Governor, in partnership with HSSD, should consider delivering
appropriate training in the recognition and response to medical
emergencies, including some of the indications for an immediate ambulance
call.
(cid:127) The HSSD should ensure that Triage Algorithms are obtained and used by
all nurses to ensure consistency and best management. (Repeat
recommendation from the Chief Inspector of Prisons’ Report 2005. Triage
37
Algorithms are a decision making tool used by nurses to assess and
determine the best route to keep a patient safe.)
(cid:127) The Governor, in partnership with the HSSD, should consider redesigning
the reception health screening document to include the question: “Is there a
need to raise a health warning with discipline staff?” This should follow
through to the healthcare section of the wing and cell allocation risk
assessment form.
(cid:127) The Governor, in partnership with the HSSD, should redesign the medical
application and request forms for healthcare, so that the date and time of
receipt and the name of member of staff receiving the form can be recorded.
(cid:127) The Governor, in partnership with the HSSD, should ensure that all entries
in the prisoner medical record are dated and timed, in accordance with NMC
(Nursing and Midwifery Council) standards.
(cid:127) The Governor, in partnership with the HSSD, should ensure that medical
applications or request forms are made available to the doctor during
consultations with the applicant prisoner.
(cid:127) The Governor, in partnership with Healthcare Group, should ensure that a
contract or Service Level Agreement for GP services is completed.
38
RESPONSE BY THE HEALTH AND SOCIAL SERVICES DEPARTMENT (HSSD) TO
FEEDBACK
180. As a result of feedback given during the course of my investigation, a member
of the HSSD has implemented a Performance Management Plan setting out the
following objectives to the nursing team in prison healthcare. The plan has
been fully endorsed by the clinical reviewer:
(cid:127) To involve the Clinical Nurse Specialist with responsibility for cardiac
rehabilitation with the aim of providing cardiac awareness training sessions
for the Prison Healthcare Team. Target date January 2009.
(cid:127) To introduce a service user information leaflet specifically for prisoners in
relation to the management of chest pain. This will involve making minor
adjustments to HSSD leaflet 391 so that it reflects the security measures
required within a prison setting. Target date January 2009.
(cid:127) To bridge the theory practice gap by attending accredited training/updates in
the following areas:
o ECG up-date workshop
o Acute medical emergencies
o All staff to attend during 2009.
(cid:127) To invite the Royal College of Nursing to review Prison Healthcare service
delivery as part of a wider prison service review. This has been agreed to
take place in February 2009.
39
CONCLUSION
181. I have considered carefully the workings of Guernsey Prison. I am conscious of
the dangers of unthinkingly applying a direct comparison with what is required
in England and Wales. Having said that, it would be quite wrong were I not to
expect Guernsey Prison to treat prisoners decently and properly.
182. My investigator found aspects of the prison that on the mainland would be
considered old fashioned. Because they have always done things in the same
way, some staff were unaware of changes in procedure and did not know what
would now be expected of them. I am aware that the deputy governor has
identified a number of issues since her arrival in Guernsey, and is driving
forward the necessary changes. However, it would appear that some staff may
be resistant to change.
183. As an example of outdated practices, although not connected to the man’s
death, my investigator noted that all staff on duty at night carried security keys
and some could not see a reason not to do so. This is not a practice that would
be acceptable to HM Prison Service in England and Wales and is something
the deputy governor has now addressed. On the other hand, the PIMS system
is far superior to what is used in prisons on the mainland. PIMS is informative
and well used.
184. I am satisfied that when the man first arrived into prison he was assessed
correctly by the reception nurse. His medical history was obtained, with the
result that an ECG was carried out which noted a problem with his heart.
185. However, from then on there were aspects of the man’s medical care that could
not be regarded as satisfactory. There were deficiencies in the recording of the
doctor’s management plans. There was insufficient account and action taken in
response to the reporting of prolonged night time chest pain. From the
consultant cardiologist’s report, and the clinical reviewer’s report, it is quite clear
that if admission to hospital hade occurred before 10 July 2008 it is highly likely
that the outcome would have been different. In the clinical reviewer’s opinion,
“it is possible that the outcome on the night of 11 July would have been better
had admission to hospital occurred before the man had his heart attack and
cardiac arrest.”
186. I have also considered carefully the first officer’s actions in leaving the man
when clearly ill, and continuing with other duties in the mistaken belief that he
could not enter the cell. His actions reinforce my view that some staff may rely
far too much on how things have always been done rather than keeping up with
new practices and procedures. What the outcome might have been had the
first officer gone into the cell cannot be known, but I find his conduct very
difficult to understand.
187. Once it was realised that the man had collapsed, prison staff did everything
possible to resuscitate him. CPR continued for a considerable time. Even
when the opportunity came to stop, the night manager wanted to try one more
40
time to rescue the man. I am satisfied that the resuscitation attempts were
appropriate; indeed, that they were admirable.
41
RECOMMENDATIONS
1. The Governor should remind all staff of their responsibility to ensure they are up
to date with local instructions and know how to access information.
2. The Governor should remind staff on the correct procedure for entering a cell at
night.
3. The Governor should ensure that the testing of override systems replicates night
time staffing levels and routines.
4. The Governor, in partnership with the HSSD, should ensure that the updating of
the white board section relating to healthcare is the sole responsibility of
healthcare.
5. The Governor, in partnership with the HSSD, should ensure that health
warnings are explicit and clearly state what actions prison staff are to take.
6. The Governor, in partnership with Healthcare Group, should consider increasing
the frequency of doctor attendance to every weekday and include Saturdays.
7. The Governor should ensure that prison staff are aware of the correct radio
procedure for raising an urgent message.
8. The HSSD should undertake a review the use of the Appointments/Handover
sheets, and any necessary training should be given, to ensure good
communication between members of the healthcare team based in the prison.
9. The HSSD should undertake a review, and any necessary training should be
given, of the procedures for healthcare professionals to raise healthcare
warnings about patients/prisoners to discipline staff. This should include, but
not be limited to, the morning management meetings.
10. The Governor, in partnership with HSSD, should consider delivering appropriate
training in the recognition and response to medical emergencies, including some
of the indications for an immediate ambulance call.
11. The HSSD should ensure that Triage Algorithms are obtained and used by all
nurses to ensure consistency and best management.
12. The Governor, in partnership with the HSSD, should consider redesigning the
reception health screening document to include the question: “Is there a need to
raise a health warning with discipline staff?” This should follow through to the
healthcare section of the wing and cell allocation risk assessment form.
13. The Governor, in partnership with the HSSD, should redesign the medical
application and request forms for healthcare, so that the date and time of receipt
and the name of member of staff receiving the form can be recorded.
42
14. The Governor, in partnership with the HSSD, should ensure that all entries in
the prisoner medical record are dated and timed, in accordance with NMC
(Nursing and Midwifery Council) standards.
15. The Governor, in partnership with the HSSD, should ensure that medical
applications or request forms are made available to the doctor during
consultations with the applicant prisoner.
16. The Governor, in partnership with the Healthcare Group, should ensure that a
contract or SLA for doctor’s services is completed.
GOOD PRACTICE
1. The reception health screen carried by the healthcare manager was very
thorough. The recording of an ECG and contacting the doctor was good
practice.
2. The clinical reviewer says in his report that the procedure for administration,
recording and monitoring of Paracetamol given outside nursing hours is good
practice.
3. The F wing officer’s action in recording in the PIMS his contact with the man
was good practice.
43