Musse, Hamdi

Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Mr Hamdi Musse,
on 13 January 2022, following his
release from HMP Bullingdon
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Hamdi Musse died in hospital from multi-organ failure due to sepsis and acute
autoimmune hepatitis, on 13 January 2022. He had been released on bail from HMP
Bullingdon on 6 January. Mr Musse was 27 years old. I offer my condolences to his family
and friends.
The clinical reviewer concluded that Mr Musse’s clinical care was not equivalent to that
which he could have expected to receive in the community, as healthcare staff did not
follow prescribed clinical practice when he presented with abnormal and deteriorating
symptoms.
My recommendations include the need for timely investigation of symptoms of jaundice
and deteriorating health, with appropriate tests and referrals to specialists. Community
medical records should be obtained for new prisoners; there should be sufficient GP
appointments to meet demand within a reasonable timescale; blood pressure monitoring
should be in line with national guidance; and equipment should be maintained.
I am also concerned that restraints were used, without justification, while Mr Musse was
critically ill and receiving intravenous treatment in the intensive care unit and they were not
removed until 80 minutes after he had been sedated.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman March 2024
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
Summary
Events
1. On 11 December 2021, Mr Hamdi Musse was convicted of supplying drugs and
remanded to HMP Bullingdon to await sentencing.
2. Mr Musse told healthcare staff he had been diagnosed with autoimmune hepatitis, a
condition in which the immune system attacks the liver. During reception health
assessments, they recorded several symptoms, including jaundice, joint pains,
constipation and cramps in Mr Musse’s liver. An appointment with the prison GP
was booked for 29 December.
3. On 18 December, a prison emergency care practitioner examined Mr Musse and
noted jaundice in his eyes, as well as a swollen and painful abdomen. He
considered that Mr Musse should wait for the planned GP appointment, but could
be seen sooner, if necessary.
4. On 19 December, Mr Musse was in considerable pain, his jaundice had worsened
and he persistently vomited. He was examined by the prison GP, who sent him to
hospital. He was diagnosed with sepsis and admitted to the intensive care unit.
5. Mr Musse was initially double handcuffed. This was reduced to an escort chain
during his initial assessments. In the early hours of 20 December, he was sedated
and the prison was told that he might die. The restraints were later removed.
6. On 6 January 2022, Mr Musse was granted bail on condition that he remained in
hospital. He died on 13 January.
Findings
7. The clinical reviewers found several deficiencies in Mr Musse’s clinical care and
concluded that it was not equivalent to that which he could have expected to
receive in the community.
8. Mr Musse’s community medical records were not requested, so healthcare staff did
not know his medical history. His account of the timing of his diagnosis varied in
each discussion and the records might have verified the details of his condition.
9. National clinical guidance recommends that symptoms of jaundice are urgently
investigated. Despite clear signs of jaundice and other abnormalities, healthcare
staff did not request relevant tests, or make appropriate referrals.
10. Although the prison GP planned to review Mr Musse within a week of his arrival,
waiting times were lengthy, so an appointment was not available for 18 days. Given
his symptoms, the clinical reviewers considered he should have been reviewed
sooner.
11. When Mr Musse developed new and significant symptoms, the clinician who
examined him did not refer him to the GP for another opinion.
Prisons and Probation Ombudsman 1
12. At Mr Musse’s initial health screen, a blood pressure reading was outside the
normal range, but was not repeated as recommended in clinical guidance. His
blood pressure was not taken when he was checked on 18 December, as the
monitor was broken. The clinician did not try to use a different machine.
13. Mr Musse remained in restraints while he was in the intensive care unit, seriously ill
and receiving intravenous treatment. They were removed after he was sedated.
Recommendations
• The Head of Healthcare should ensure that healthcare staff obtain community
medical records for newly arrived prisoners, in line with NICE guidance; and that
there is a robust and auditable process to check that they have been received.
• The Head of Healthcare should ensure that healthcare staff follow the assessment
procedures set out in the NICE guidance on assessing patients with jaundice.
• The Head of Healthcare should ensure that healthcare staff understand and follow
clinical escalation and referral pathways in the event of abnormal clinical findings, or
when a prisoner presents with significant symptoms.
• The Head of Healthcare should share this report with all the healthcare staff named
and discuss the Ombudsman’s findings.
• The Head of Healthcare should review the arrangements for GP appointments to
ensure that there is sufficient availability to meet demand within a reasonable time;
patients with acute symptoms receive timely appointments; and GPs are aware of
the waiting times so they can designate the level of urgency.
• The Head of Healthcare should ensure that clinical staff are aware of the national
guidance on measuring blood pressure and follow the procedures for abnormal
readings.
• The Head of Healthcare should ensure that blood pressure monitoring equipment is
well maintained. If a device is found to be faulty, staff should use an alternative.
• The Governor should ensure that all staff undertaking risk assessments for
prisoners taken to hospital understand the legal position on the use of restraints and
that in all cases, prison managers regularly review the level of restraints used on
prisoners in hospital.
2 Prisons and Probation Ombudsman
The Investigation Process
14. Notices were issued to staff and prisoners at HMP Bullingdon, informing them of the
investigation and asking anyone with relevant information to contact the PPO. No
one responded.
15. The PPO investigator obtained copies of relevant extracts from Mr Musse’s prison
and medical records. She carried out the initial stages of the investigation and it
was completed by another investigator.
16. NHS England commissioned two clinical reviewers to review Mr Musse’s clinical
care at the prison. One jointly interviewed three healthcare staff with the first PPO
investigator on 19 April 2022, as well as a former member of the healthcare team
on 24 September, with the second PPO investigator.
17. We informed HM Coroner for Oxfordshire of the investigation. The coroner gave us
the cause of death. We have sent the coroner a copy of this report.
18. The Ombudsman’s family liaison officer wrote to Mr Musse’s next of kin, a relative,
to explain the investigation and to ask if he had any matters for us to consider. He
did not reply.
19. We shared our initial report with HM Prison and Probation Service (HMPPS). They
pointed out one minor factual inaccuracy which has been amended in this report.
They provided an action plan which is annexed to this report.
Prisons and Probation Ombudsman 3
Background Information
HMP Bullingdon
20. HMP Bullingdon is a local and resettlement prison, near Bicester, serving the courts
of Oxfordshire and Berkshire. It holds approximately 1100 prisoners. Practice Plus
Group provides healthcare Services and Cotswold Medicare Ltd provides GPs.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Bullingdon was in July 2019. Inspectors
reported that healthcare services were generally good and had improved since the
previous inspection. The service was well led, with positive interaction between
patients and staff. Inspectors noted that learning was now shared with staff and
there had been considerable progress in implementing PPO recommendations on
healthcare practice, which had led to improvements in initial health screens.
22. There was a range of primary care services, with reasonable waiting times. GPs
were available for same-day urgent problems and within eight days for routine
appointments. The management of long-term conditions had improved and
operating procedures and policies for medication were in place.
Independent Monitoring Board
23. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to June 2021, the IMB reported that
the COVID-19 pandemic had affected the prison’s capacity to address health and
wellbeing needs; and the recruitment and retention of healthcare staff had been
difficult. As a result, there had been long waiting lists for both urgent and routine
appointments. Most of the complaints to the IMB were medication-related and an
audit had found some shortcomings. However, the Board was satisfied that prison
doctors followed the guidance relating to safer prescribing in prisons.
Previous deaths at HMP Bullingdon
24. Mr Musse was the twelfth prisoner at Bullingdon to die since January 2020. Seven
of the previous deaths were due to natural causes, two were self-inflicted and two
were drug related. There have since been seven deaths, five from natural causes,
one self-inflicted and one unascertained. We have previously raised with the prison
delays in obtaining community medical records, the management of chronic
illnesses and the use of restraints.
4 Prisons and Probation Ombudsman
Key Events
25. On 11 December 2021, Mr Hamdi Musse, a Somalian national, was convicted of
supplying class A drugs. He was remanded to HMP Bullingdon, to await sentencing.
It was his first time in prison.
26. A nurse carried out an initial health screen. Mr Musse told her that he had been
diagnosed with autoimmune hepatitis two weeks before and was under
investigation but had not been prescribed medication. (Autoimmune hepatitis is a
rare and chronic condition in which the immune system attacks the liver.) He also
reported joint pains, constipation and cramps in his liver which he thought had
caused jaundice in his eyes and he gave the contact details of his community
medical practice. The nurse referred Mr Musse to the prison GP.
27. In line with the COVID-19 policy at that time, Mr Musse was required to self-isolate
away from the main prison population for up to 14 days (known as reverse
cohorting) and he was allocated to a dedicated unit. No concerns were recorded
during his first night interview and the next day he was noted to have settled. (There
were no further substantive entries by operational staff until 6 January 2022.)
28. At a secondary health assessment on 12 December, a nurse noted that Mr Musse
had been diagnosed with autoimmune hepatitis (abroad) a week before and that he
was jaundiced. Tests for hepatitis B and C were negative, which indicated that
neither of these conditions had caused the jaundice.
29. A prison GP reviewed Mr Musse on the same day and recorded that he claimed to
have been diagnosed with autoimmune hepatitis by a specialist abroad, three
months before. The GP planned to see him again within a week.
30. A member of the healthcare team conducted a personal wellbeing check on 16
December. She noted that Mr Musse had no issues or concerns; was comfortable
with the regime, staff and available support; and had telephoned his family.
31. On 18 December, a nurse examined Mr Musse and recorded that he had ‘yellowish’
eyes as well as dry and pale skin. She noted that although the GP had planned to
see him within a week of his arrival, the appointment had been booked for 29
December. The nurse asked a Supervising Officer (SO) to arrange food more suited
to Mr Musse’s dietary needs and discussed Mr Musse during the handover between
healthcare staff.
32. After the staff handover, Mr Musse was assessed by an emergency care
practitioner and qualified paramedic employed by the prison. Mr Musse told him that
he had been diagnosed with idiopathic hepatitis in Africa and had seen bright red
blood in his faeces. The paramedic noted obvious jaundice in Mr Musse’s eyes as
well as a painful and swollen abdomen, with a build-up of fluid. He reassured Mr
Musse and decided that he should wait for the planned GP appointment, but could
be seen sooner, if necessary.
Prisons and Probation Ombudsman 5
Events of 19 December
33. On 19 December, a wing officer informed a nurse that he was concerned about Mr
Musse’s health and the prison GP reviewed him at around 10.00am. The doctor
noted that Mr Musse had vomited over forty times since the previous day, his
jaundice had worsened, his stomach was swollen and he had pain in his liver. (At
this appointment, Mr Musse said that his condition had been diagnosed eight weeks
before.)
34. Mr Musse was tearful due to the severity of the pain, which he described as ten, on
a scale of one to ten. The GP concluded that he was definitely jaundiced and in
considerable pain, possibly due to untreated autoimmune hepatitis and that he
needed to be treated in hospital.
35. Paramedics took Mr Musse to John Radcliffe Hospital, Oxford, arriving at 12.42pm.
He was escorted by two prison officers and double handcuffed with a pair of single
handcuffs and an escort chain.
36. Mr Musse’s handcuffs were removed for a few minutes at 1.31pm to allow hospital
staff to start intravenous medication and at 2.50pm to take a CT scan. At 3.15pm, a
prison manager instructed the escort officers to use an escort chain only, as Mr
Musse was “very ill” and to re-apply double handcuffs if he started to move around.
37. Between 9.00pm and 11.00pm, there were several clinical assessments and the
escort staff were told that Mr Musse might be moved to the intensive care unit
(ICU). At 11.00pm, a doctor confirmed a diagnosis of sepsis and Mr Musse
transferred to the ICU at 11.55pm. An SO, one of the escort staff, noted in the
escort log that despite severe discomfort, he was cooperating well.
38. In the early hours of 20 December, the SO again noted Mr Musse was cooperative,
despite his considerable pain and that staff were considering sedation to limit his
movement. At 5.45am, Mr Musse was sedated.
39. At 6.50am, the SO informed the orderly officer (responsible for the running of the
prison) that Mr Musse had rapidly declined and a nurse had asked for his family to
be informed that he might die. The SO also asked for the restraints to be removed,
but was told that the request had to be approved by the duty governor. This was
authorised at 7.05am. At 3.05pm, the escort was reduced to one officer.
40. Prison healthcare staff received updates. Mr Musse remained seriously unwell and
sedated and doctors thought he was likely to need a liver transplant. On 4 January
2022, he was transferred to the Royal Free Hospital, London.
41. On 6 January, Mr Musse was granted bail, on condition that he remained in hospital
and that the court was notified if he was moved, or discharged. The remaining
escort officer was withdrawn.
Contact with Mr Musse’s family
42. The prison assigned a family liaison officer on 20 December. At around 8.30am,
she informed Mr Musse’s uncle that his nephew was in hospital. He did not seem
surprised and asked if it was due to Mr Musse’s autoimmune condition. Later that
6 Prisons and Probation Ombudsman
day, the family liaison officer gave him the contact details of the hospital and
confirmed that family members were allowed to visit. She kept in touch and helped
with liaison between the hospital and Mr Musse’s family.
43. On 6 January, a member of the safer custody team informed Mr Musse’s uncle of
Mr Musse’s bail and conditions, as well as the requirement to inform the court if his
circumstances changed.
44. On 14 January, Mr Musse’s solicitors notified the family liaison officer that Mr
Musse had died the previous day. The family liaison officer telephoned to offer
condolences and support. She also arranged for Mr Musse’s property and money to
be sent to his family.
Cause of death
45. No post-mortem examination was carried out. The coroner accepted certification by
a hospital doctor that Mr Musse’s death was due to multi-organ failure, as result of
sepsis caused by acute autoimmune hepatitis.
46. The Coroner did not hold an inquest into Mr Musse’s death.
Prisons and Probation Ombudsman 7
Findings
Clinical Findings
47. The clinical reviewers concluded that Mr Musse’s care at Bullingdon was not
equivalent to that which he could have expected to receive in the community. Their
overriding concern was that there had been no action to investigate and identify the
cause of Mr Musse’s significant symptoms.
48. Full details of the clinical reviewers’ findings are in the clinical review report. We
reflect the weaknesses identified and recommendations below.
Obtaining community medical records
49. National Institute for Health and Care Excellence (NICE) Guidance 57 Physical
health of people in prison advises that reception healthcare staff should ask the
prisoner for consent to transfer their GP records. Although Mr Musse gave details of
his community practice, there is no evidence that staff asked for consent for his
records to be shared.
50. During his initial health screen and other clinical assessments, Mr Musse said that
he had been diagnosed with autoimmune hepatitis, but his account of when he was
diagnosed varied each time. If untreated, this illness can lead to cirrhosis of the liver
and/or liver failure. Minimal information was recorded about the nature of Mr
Musse’s condition and community records might well have clarified aspects of this.
We recommend:
The Head of Healthcare should ensure that healthcare staff obtain community
medical records for newly arrived prisoners, in line with NICE guidance; and
that there is a robust and auditable process to check that they have been
received.
Assessment of Mr Musse’s jaundice, abnormal symptoms and deteriorating health
51. NICE clinical knowledge guidance states that jaundice “usually indicates a serious
underlying condition and requires urgent investigation.” It lists several questions that
patients should be asked when assessing jaundice.
52. The clinical reviewers found that although Mr Musse had clear signs of jaundice, as
well as other significant physical symptoms, healthcare staff did not ask pertinent
questions about his diagnosis and any previous plans for treatment.
53. At an interview during the investigation, the prison GP acknowledged that Mr
Musse’s symptoms would have been investigated urgently in the community and
that was the reason he had planned a review within a week. However, the
reviewers noted that he had recorded no plan of action and thought that he should
have at least requested blood tests after immediately assessing Mr Musse on 12
December.
54. By 18 December, Mr Musse had developed several physical abnormalities,
including a painful and swollen abdomen and blood in his faeces. The prison
8 Prisons and Probation Ombudsman
paramedic took no further action but noted that he could be seen sooner than the
planned GP appointment on 29 December, if he needed to. The clinical reviewers
considered that, given these new symptoms, as well as a raised pulse rate, should
have been escalated to the GP or a hospital.
55. The clinical reviewers concluded that Mr Musse’s jaundice was not properly
investigated and that healthcare staff would benefit from structured learning on
handling abnormal clinical findings. We recommend:
The Head of Healthcare should ensure that healthcare staff follow the
assessment procedures set out in the NICE guidance on assessing patients
with jaundice.
The Head of Healthcare should ensure that healthcare staff understand and
follow clinical escalation and referral pathways in the event of abnormal
clinical findings, or when a prisoner presents with significant symptoms.
The Head of Healthcare should share this report with all the healthcare staff
named and discuss the Ombudsman’s findings.
Availability of GP appointments
56. Although the prison GP intended to review Mr Musse within a week of his remand,
no priority was recorded and the appointment was scheduled for 29 December.
During the investigation, healthcare staff said that, at the time, there were lengthy
waiting times for GP appointments. We share the clinical reviewers’ concern that
someone with Mr Musse’s symptoms was expected to wait over two weeks to be
seen. We recommend:
The Head of Healthcare should review the arrangements for GP appointments
to ensure that there is sufficient availability to meet demand within a
reasonable time; patients with acute symptoms receive timely appointments;
and GPs are aware of the waiting times so they can designate the level of
urgency.
Blood pressure checks
57. NICE guideline (NG136) Hypertension in adults: diagnosis and management states
that if a blood pressure reading is 140/90 or higher, a second reading should be
taken. A reading of 141/78 during Mr Musse’s initial health screen was not
repeated.
58. When Mr Musse’s health worsened on 18 December, clinical observations were
taken, but his blood pressure was not checked as the monitor was faulty. There is
no evidence that the clinician tried to use another machine. We recommend:
The Head of Healthcare should ensure that clinical staff are aware of the
national guidance on measuring blood pressure and follow the procedures
for abnormal readings.
Prisons and Probation Ombudsman 9
The Head of Healthcare should ensure that blood pressure monitoring
equipment is well maintained. If a device is found to be faulty, staff should
use an alternative.
Security risk assessments and the use of restraints
59. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility.
60. A judgment in the High Court in 2007 made it clear that prison staff need to
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when they have a serious medical
condition. The judgment indicated that medical opinion about the prisoner’s ability to
escape must be considered as part of the assessment process and kept under
review as circumstances change.
61. These requirements are reflected in HMPPS’ Prevention of Escape – External
Escorts Policy framework, on the use of restraints. The policy encourages sensitive
handling to ensure that the needs of security are balanced against the clinical
needs of a seriously ill prisoner. It also states that restraints should not be used
during life-saving treatment or if the prisoner’s medical condition, or a physical
impairment renders restraints inappropriate.
62. The security risk assessment for Mr Musse’s journey and admission to hospital
concluded that he was a medium risk to the public and low risk on all the other
factors of concern, such as the risk of escape and the likelihood of outside
assistance to escape. The assessment also noted that he was very unwell and
there had been no adverse behaviour in prison. Subsequent escort logs indicated
that he had been fully compliant in hospital.
63. We are not critical of the decision to use restraints for the journey to hospital and
initial clinical assessments, given Mr Musse was young, alert and mobile. However,
no justification was recorded for their continued use once it became clear that he
was seriously ill. It is unacceptable that Mr Musse was still in restraints almost 18
hours after starting intravenous treatment; while seriously ill in the intensive care
unit; and under sedation. As escort staff had frequently updated prison managers
about his condition and treatment, there was ample opportunity to formally review
his risk and remove them. We recommend:
The Governor should ensure that all staff undertaking risk assessments for
prisoners taken to hospital understand the legal position on the use of
restraints and that in all cases, prison managers regularly review the level of
restraints used on prisoners in hospital.
10 Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk