Individual at Littlehey

Investigation into the circumstances surrounding the
death of a man
at HMP Littlehey in April 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2010
This is the report of an investigation into the death from natural causes of a man at
HMP Littlehey in April 2009. He was 33 years of age.
I extend my sincere condolences to the man’s family and friends and all those
affected by his loss.
A clinical review of the man’s care and treatment was carried out by the local
Primary Care Trust.
The man died suddenly and unexpectedly. His cause of death was pulmonary
embolus1 secondary to deep vein thrombosis. The possible cause of the
thrombosis was that he had been using a wheelchair for some months past. There
is some evidence that his need for a wheelchair was feigned.
The clinical reviewer found that it would not have been possible to anticipate the
man’s cause of death. He also found that his clinical care was equitable with that
which he would have received in the outside community.
I make one recommendation about the use of translation services at clinical
consultations and brought a similar issue to the Governor’s attention.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in the
investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman February 2010
1Ablood clot obstructing a blood vessel supplying the lung.
2
Summary
The Investigation Process
HMP Littlehey
Key Findings
Issues
Conclusion
Recommendations
Response to draft from the man’s family
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SUMMARY
The man was born in Poland in April 1975. He came to England in around 2000,
with his partner and her young son.
The man was remanded into HMP Bedford in January 2007 to await sentencing
following his conviction of assault occasioning actual bodily harm. He was
subsequently given a five year extended sentence comprising a three year custodial
period followed by a two year period on licence (during which period he could be
recalled to prison if he breached his licence conditions). He spent time at two further
prisons during 2007 before being transferred to Littlehey later that same year.
During reception health screening on arrival in Littlehey, the man was asked whether
he had any physical or mental health problems. The only problem he reported was
that he suffered from epilepsy, although he also reported he was receiving
prescribed Olanzapine (an anti-psychotic medication).
The man’s parole eligibility date (the earliest date he could be released) was July
2008. He applied for parole but his application was unsuccessful. From around this
time onwards he began complaining repeatedly that his sentence had been
miscalculated. He seemed to be under the impression that he was entitled to
release once he had served a set part of his sentence – it seems he thought the two
thirds stage – without the need for approval by the Parole Board.
Not long after this, a number of incidents occurred that might have been related to
the man’s frustration at remaining in prison custody. He began to complain about a
loss of strength in his legs and, from around September 2008, was provided with a
wheelchair. Despite this, he was still considered fit for work, although he disagreed
with this assessment. When told that if he did not go to work he would remain
locked in his cell, he both threatened to harm himself and then did so by cutting his
arms. There is some evidence that his need for a wheelchair was feigned: on a
number of occasions staff saw him both standing, as well as walking, around his cell.
Additionally, on examination he was found not to have suffered any muscle wastage
in his legs.
On an afternoon in April, an officer looked into the man’s cell and saw him lying on
his bed with his bed clothing wrapped around his stomach. The officer went into the
cell to investigate and could not get a responsive from the man. The officer
summoned assistance but despite all efforts to save him, the man was pronounced
dead at 6.15pm. His cause of death was initially unclear but at post mortem he was
found to have suffered a pulmonary embolus secondary to a deep vein thrombosis.
The pathologist has said that his chances of a thrombosis were increased through
his reduced mobility.
The medical care that the man received was reviewed by the local Primary Care
Trust. The clinical reviewer found that the man’s cause of death could not have
been anticipated. Thee reviewer has, however, made one suggestion about how
healthcare services at Littlehey could be improved.
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THE INVESTIGATION PROCESS
1. The Ombudsman’s investigator first visited HMP Littlehey in April 2009 when he
met the prisons governing Governor. The investigator did not conduct any
formal interviews, but he had informal discussion with a number of staff
including the Residential Manager for B wing and one of the prison’s Family
Liaison Officers.
2. The local Primary Care Trust agreed to carry out a review of the man’s clinical
care and treatment at Littlehey prison.
3. One of the Ombudsman’s Family Liaison Officers contacted the man’s brother.
to inform him of the scope of the investigation and to gave him the opportunity
to ask any questions or to raise any concerns he wished to be considered as
part of the investigation. The man’s brother did not raise any specific issues
that he wished to have explored although he did express an interest in seeing a
copy of the investigation report.
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HMP LITTLEHEY
4. HMP Littlehey is a modern prison in Cambridgeshire holding just over 700 adult
convicted males. The prison has eight residential wings. Health services are
commissioned by the local Primary Care Trust (PCT). A community based
practice provides six GP sessions each week. Nurses provide primary care
during day time hours. After 5.00pm, primary care is available through an out–
of–hours service.
5. The most recent inspection of Littlehey by Her Majesty’s Chief Inspector of
Prisons was a full announced inspection in July 2007. The Chief Inspector’s
findings included:
“… This full announced inspection confirmed [previous inspection findings]
that Littlehey remained an impressively safe prison, with mutually respectful
staff-prisoner relationships, a reasonable amount of purposeful activity and
an appropriate focus on resettlement.
“… Language issues [for foreign national prisoners] were identified on
induction … but although a list was kept about levels of written and spoken
English, this was not always reflected in prisoners’ wing files. Most staff
knew which prisoners on their wings struggled with English, although this
information was not readily available … We were told about a number of
prisoners whose English was very poor, but translations services were
seldom used …
“[We recommend that] information for foreign nationals about … translation
services should be displayed in a range of languages in residential areas.”
6. The only matter contained in Independent Monitoring Board’s report for the year
2008/2009 that is relevant to the man relates to prisoner complaints. Their
report shows that during the previous four years, the number of sentence
related complaints have risen year by year. Only one other of the 14 complaint
categories reflects such a trend.
7. Prior to the man’s death, there had been nine other deaths from natural causes
at Littlehey since April 2004. No matters arising in those cases were of direct
significance to the circumstances surrounding the man’s death.
6
KEY FINDINGS
8. The man was born in Poland in April 1975. After leaving school he started work
as a motor mechanic. Between 1999 and 2003 he had several brain scans
after suffering head injuries. It seems that he first suffered injuries in a motor
accident and subsequently during an assault. At some point around this time
he moved to England with his partner and her young son.
9. In January 2007, the man was remanded into HMP Bedford having been found
guilty of an offence of assault occasioning actual bodily harm. At that time he
was still awaiting sentencing. A month later, he received a five year extended
sentence. This comprised a three year custodial period to be followed by a two
year period on licence. His parole eligibility date (the earliest date he could be
released) was July 2008. His conditional release date (when his time on
licence in the community would start) was January 2010.
10. Having spent time in three other prisons during 2007, the man transferred to
HMP Littlehey in December 2007.
11. During reception health screening on arrival in Littlehey, the man was asked
whether he had any physical or mental health problems. The only problem he
reported was that he suffered from epilepsy which he said had arisen from the
head injuries he had sustained when in Poland. (He was receiving prescribed
medication – Carbamazepine – for this condition.)
12. With the mid point of the prison part of his sentence approaching, the man
made an application for parole. (Had he been successful he would have been
released in July 2008.) In June 2008, the Parole Board wrote to him refusing
his application. The Board explained that the basis of their decision was that:
“[You] committed a violent offence against [your] partner, whilst subject to a
community order for a very similar offence. [You continue] to demonstrate
very little insight into [your] violent behaviour and [have] expressed a clear
wish, in [your] representations, to resume [your] relationship with [your
partner] despite having been informed that this will not be possible or
acceptable. In the absence of firm evidence that the ‘high’ risk of harm to
[your] partner has decreased the Panel is unable to share [your] confidence
that [you are] a changed man …”
13. The Board also explained in their letter that the man would be entitled to a
further review. (If there were to be a further review, it would consider his
eligibility for release in July 2009.)
14. In July, the man was visited by a consultant psychiatrist who wrote that:
“[The man] remains very distressed and upset, principally now about the
separation from his ex-partner and [step son]. He also seems to be poorly
occupied at present. He is approaching the halfway point of his sentence
and tells me he is seeking a hearing in relation to the Parole Board decision
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that he should not be released. He threatened to cut himself if he is not
successful.”
15. The man had a mental health review with a community psychiatric nurse (CPN)
in July which again explored the stress he was feeling about his young step son
now that his parole application had failed. The CPN noted that he was being
monitored through the ACCT2 process at that time although he denied to her
having any thoughts of suicide or self-harm.
16. From around this time onwards the man had very frequent healthcare
consultations. The main problems he reported were fits or epileptic seizures
and the loss of strength in his legs. The latter problem ultimately led to him
being provided with a wheelchair. He continued to be prescribed medication for
his epilepsy although he remained in a single cell.
17. In August, one of Littlehey’s doctors wrote a letter of referral to a consultant
neurologist at a nearby NHS hospital. The doctor mentioned in his letter that
the man had reported recurrent epileptic fits but that none of these had been
witnessed by staff. The doctor also noted that he had denied experiencing any
of the symptoms that can sometimes follow an epileptic fit, such as confusion or
incontinence. The doctor listed his current anti-epileptic medication and asked
the consultant neurologist to advise.
18. The man’s records over the following weeks and months contain repeated
references to his complaints about the lack, or absence, of strength in his legs.
His clinical records show that he was examined by a physiotherapist in
September. She noted that on returning to his cell after collecting some
analgesia for him she saw him standing completely unaided. She gave him a
programme of exercises.
19. It has not been possible to establish the precise date, but at some time in
September, the man was supplied with a wheelchair for his exclusive use. His
records nevertheless contain frequent references to staff witnessing him
standing or walking around his cell at times when he did not realise he was
being observed.
20. Towards the end of October, the man was examined by the consultant
neurologist at the NHS hospital following the referral from Littlehey six weeks
earlier. The neurologist noted that there appeared to be no change in the
frequency of the man’s seizures and she recommended that there be no
change to his medication regime. However, the neurologist also remarked that
the man was not accompanied by a Polish translator which made it difficult for
her to obtain a clear history from him.
21. As a convicted prisoner, the man was required to do some work or to attend
education. Prisoners may, however, be excused if a prison doctor finds them to
be medically unfit. If a prisoner is not able to go to work he will usually remain
2ACCT (Assessment, Care in Custody and Teamwork) is the process used for monitoring and
supporting prisoners at risk of self-harm or suicide.
8
locked in his cell. In January 2009, wing staff called for a nurse to examine the
man as he was claiming to be unwell. The nurse assessed that he was fit for
work and that he did not require medical intervention. A member of the wing
staff then made the following note:
“[The man] appeared to become unwell when not opened up this morning.
Seen by [healthcare who] said nothing wrong with him and [that he was] not
medically unfit for work so is to stay locked in [in] the day time. When told
he was not coming out this afternoon, he stated he would cut his wrists.
ACCT opened.”
22. The ACCT form was closed three days later.
23. In February, an officer made the following entry in the man’s records:
“[An officer] had counted the [first] landing at tea time lock up … I went to
check the landing not knowing it had been done – so [the man] wasn’t
expecting another check. [The man ] was standing by the sink (for a while)
he then walked perfectly to the window and then looked out then when he
turned round l knocked and said “You can walk”. [The man] looked
surprised I had seen him he immediately sat on the bed and said “No I’m not
walking.” This inmate is supposedly “Wheelchair bound.” [Healthcare]
informed.”
24. Towards the end of March, an officer noted that the man claimed to be unfit for
work but he was told that healthcare considered that he was fit. He responded
by inflicting some shallow cuts to his arm. The officer opened another ACCT
form. The levels of observations were set at once per hour until he had been
assessed.
25. At an ACCT assessment interview later that same afternoon the man said that
he cut himself as an expression of his frustration. It seems he was frustrated
that he was still in prison when he believed that he should have been released
once he had served two thirds of the custodial part of his sentence. He was
also frustrated that he had been deemed to be fit for work. Observations were
maintained at once per hour during the day time with a reduction to once every
two hours during the night and during periods such as lunch time when
prisoners are locked in their cells.
26. At just before 9.00pm on 2 April, Littlehey called for an ambulance as the man
was complaining about chest pain. When the ambulance paramedics
examined him they found that he was hyperventilating (breathing rapidly). He
was advised to slow his breathing but he would not do so. As well as
complaining about chest pain, he also complained to the paramedics that he
wanted help for the problem with his legs. The paramedics left the prison
having advised the man to take up his issues with the prison doctor.
27. The man continued to complain about his sentence calculation and in April,
Littlehey’s Head of Discipline spent around half an hour trying to explain his
9
sentence to him. She ended the meeting as he would no longer listen and
started calling her a liar.
28. On a morning in April, the man was visited in his cell by a doctor. In a report
about the visit and in a separate entry in the man’s clinical records, the doctor
wrote that the main reasons for visiting him were to review his chest symptoms
and his continuing use of a wheelchair. The man said that he had received
some penicillin from another prisoner and his chest was now feeling better. On
examination, the doctor found no problems with the man’s breathing. The
doctor examined his legs and found no evidence of muscle wastage or other
changes expected in a person who was wheelchair bound. The doctor asked
the man to lift his legs and he did so by using both hands – indicating that he
had no strength in his legs. The doctor noted that he asked the man how, in
the circumstances, he was managing to use the toilet and to transfer in and out
of bed. The man said that he was managing without any problems. The doctor
told the man that he was concerned for his safety by remaining in a single cell
so would be moved to a double cell.
29. The next morning the Clinical Nurse Manager (CNM) made the following entry
in the man’s clinical records:
“Medication taken to [the man] this morning as usual, however he said he
had suffered a seizure last night and was concerned no one was available to
watch him. I advised him that this was one of the reasons along with his
limited mobility and chest pain that the [doctor] felt it advisable to move [him]
to shared accommodation.”
30. Early one afternoon in April, the Senior Officer (SO) noted that the man had
been told that he was to be moved to a double cell on E wing in accordance
with medical instructions. The SO noted that the man was not happy and was
refusing to move. An hour later, the CNM, attempted to explain to the man why
it was in his best interests to move into a double cell. He was noted to have
responded with abusive words. She noted she would discuss options with the
doctor the following week.
31. Entries were made in the man’s ACCT form at 4.30pm and again at 4.45pm.
On both occasions it was noted that he appeared to be asleep. At about
5.30pm, an officer checked him again and saw him lying on his bed with the
bed clothes around his stomach. This seemed unusual to the officer so he
went into the cell. He called the man’s name and then shook him. The man did
not move so the officer asked two of the prisoner cleaners to call for assistance.
32. The officer checked the man for a pulse but found none. The SO and another
officer arrived. The SO also checked, unsuccessfully, for a pulse and then
radioed the communications room to ask for further assistance. The second
officer examined the man before moving him onto his back and starting cardio
pulmonary resuscitation (CPR). Another SO arrived very soon afterwards and
he helped give CPR along with another officer who responded to the
emergency call. Staff continued with their efforts until the ambulance
10
paramedics arrived at 5.50pm. All efforts to try to resuscitate the man proved
unsuccessful and he was pronounced dead at 6.15pm.
After the man’s death
33. A hot debrief3 was held for staff and they were made aware of the support
available from the prison care team. The prisoner cleaners were also offered
support.
34. A prison Family Liaison Officer, in company with the Deputy Governor, visited
the man’s nominated next-of-kin, his brother, to break the news. They arrived
at the home at around 7.45pm. The man’s mother, who was visiting from her
home in Australia, was also present. The prison Family Liaison Officer told the
Ombudsman’s investigator that he and his colleague spent around 45 minutes
with the family. They invited the family to visit the prison and the family took up
that offer. The family were informed that Littlehey would contribute to the costs
of the funeral in accordance with national policy instructions.
The man’s cause of death
35. The man’s cause of death was initially unclear. However, in his post mortem
report the examining pathologist found that:
“This man died suddenly in prison. He had recently been immobile within a
wheelchair. He had been found to be tachycardic recently … Post mortem
examination reveals a massive pulmonary embolus with underlying deep
vein thrombosis. His risk of thrombosis would have been increased by his
immobility. Small emboli more distally (distant) suggesting early episodes
which may have been the cause of his underlying tachycardia are also
identified. There is nothing at post mortem examination to suggest death is
due to anything other than natural causes.”
36. The pathologist recorded the cause of death to be pulmonary embolus
secondary to a deep vein thrombosis.
3Ahot debrief meeting is a meeting held immediately after a significant event to give those involved
the opportunity to discuss the event while the experience is still very fresh in peoples minds.
11
ISSUES
Clinical care
37. The main findings from the clinical review included that appropriate healthcare
referrals for assessment and treatment were made for the man throughout his
time in Littlehey. The reviewer found that his care and treatment in prison was
equitable to that which he would have received in the outside community. The
reviewer also found that it would not have been possible for health staff to have
anticipated the man’s death, although the risks of that happening were
heightened due to his immobility.
38. The clinical reviewer raised as a learning point the need, where necessary, to
make use of translation services to assist during clinical consultations. He went
on to say that in the case of external consultations (such as the man’s
neurological consultation in October 2008), it is important that interpretation
services are utilised to ensure that the maximum benefit is obtained from the
consultation. In the case of an outside clinical consultation, the outside hospital
would be expected to provide interpretation services. But could only do so if
informed beforehand in the referral letter that translation services are likely to
be needed.
(Her Majesty’s Chief Inspector of Prisons also commented on the limited use of
translation services at Littlehey following her last inspection of the prison.)
I recommend that the PCT and Head of Healthcare ensure that translation
services are used, where appropriate, to aid clinical consultations both
inside and outside the prison.
The man’s sentence
39. The Criminal Justice Act 2003 introduced a number of changes to prison
sentencing for offences committed on or after 4 April 2005. Information about
the changes was included in Prison Service Instruction 11/2005. The change
that became relevant in the man’s case was that:
“Dangerous offenders convicted of a … violent offence specified in the Act
which carries a maximum penalty of less than 10 years, will be sentenced to
an [Extended Sentence for Public Protection]. This sentence comprises two
parts: a custodial period of at least 12 months; and an extended licence
period. Release is at the discretion of the Parole Board at any time between
the half way point of the custodial period and the custodial end date …”
40. The man had been given an extended five year sentence comprising a three
year custodial period followed by two years on licence. He seems to have been
under the impression that he would be released automatically once he had
served two thirds of the custodial element of his sentence. This was a mistaken
belief. He was in fact able to apply for parole at the mid point of the custodial
period and he did, indeed, apply at that stage. Had his application been
successful he would have been released on 21 July 2008. However, the Parole
12
Board did not consider him suitable for release and wrote to inform him of the
reasons for their decision. He could next have applied for release in July 2009,
but if that application failed he would have to serve the full three years ending in
January 2010.
41. It is not exactly clear to me why the man should have been confused about his
position. But he undoubtedly was confused and his records show that staff
made many attempts to explain. Unfortunately, no one seemed able to satisfy
him on this matter. It is not clear to me the extent to which his knowledge of
English might have impeded his understanding. As I have said, the Governor
may wish to satisfy himself that sufficient use is made of interpretation services
to explain potentially complex matters which in the man’s case also include
sentencing decisions.
Opening of the ACCT forms
42. An ACCT form was briefly opened for the man in the middle of January 2009
when he threatened to cut his wrists following a dispute with an officer about
work. He claimed to be unwell on a morning in January even though a nurse
examined him and found him to be fit for work. He threatened to harm himself
when he was told that if he did not go to work he would not be unlocked from
his cell. He did not carry out his threat and the ACCT form was closed a few
days later.
43. The man had a similar dispute with staff two months later. This time, when he
was told that healthcare deemed him fit for work, he responded by cutting his
arm. Staff opened an ACCT form and during his assessment interview he
explained that his actions were a manifestation of his frustration. He told the
assessor that he had reached the point in his sentence when he should be
released. He also disputed the assessment that he was fit for work. A further
attempt was made to explain the sentence to him but once again without
success. The ACCT form was still open when he died two weeks later.
44. The evidence indicates that the man’s threats, and actual acts, of self-harm
were not driven by a true desire to harm himself, as is most usually the case.
Instead, his actions were driven by his frustration at still being in prison.
Despite his motives, it was appropriate for staff to open an ACCT form given his
actions and the procedures governing the ACCT process were followed
correctly.
The man’s use of a wheelchair
45. From some time around September 2008, the man started to use a wheelchair.
He was still using the chair by the time of his death around seven months later.
His records contain a number of references to him being observed by officers
either standing or mobilising around his cell. And when physically examined by
the doctor on the day before his death, the doctor found no evidence of muscle
wastage or constricture in his legs. The Ombudsman’s investigator was told by
staff at Littlehey that their belief was that the man was feigning his need for a
wheelchair.
13
The decision to move the man to a double cell
46. The man had further disputes with staff in April when told that he was to be
moved to a double (shared) cell. He was told that the reason for moving him
was concern for his safety given his claims that he was wheelchair bound and
that he had suffered fits in his cell. He was unhappy about having to share a
cell, insisting that he was able to manage by himself. The plan to transfer him
was postponed pending further advice from the doctor the following week. This
seemed a reasonable decision by the staff team to take, given the man’s strong
feelings on the matter.
The man’s cause of death
47. At post mortem examination, the man’s cause of death was found to have been
caused by a pulmonary embolus. The pathologist described a massive
embolus with underlying deep vein thrombosis. Both the pathologist and the
clinical reviewer commented that the man’s risk of a thrombosis would have
been increased by his immobility. The clinical reviewer has said that it would
not have been possible for staff to have anticipated the man’s death. The
clinical reviewer also commented that the clinical care provided to the man was
equal to that which he would have received in the outside community.
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CONCLUSION
48. The man was convinced that he was entitled to automatic release once he had
served a set portion of the three year custodial part of his sentence: two thirds
of the period it would seem. He was mistaken. He was in fact eligible for
release at the mid point of the custodial period, but only if agreed by the Parole
Board. The man did indeed apply for parole at that stage, but the Board
rejected his application. The Board wrote to him explaining their decision.
Despite the explanation, the man remained dissatisfied. It was from this time
onwards that the man began to complain of lost strength in his legs. He also
complained about suffering fits at night time, that healthcare deemed him fit for
work and that he would remain locked in his cell if he did not go to work. On a
number of occasions the man was observed by staff to be standing or walking
around his cell. They were convinced that the man was feigning disability. The
fact that the man lost no muscle tone in his legs would support that view. The
relevance of his use of a wheelchair – whether feigned or otherwise – was that
this might have been the cause of the deep vein thrombosis that in turn resulted
in the pulmonary embolus that caused his death. Both the pathologist and
clinical reviewer confirmed the possibility of this.
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RECOMMENDATIONS
1. I recommend that the PCT and Head of Healthcare ensure that translation
services are used, where appropriate, to aid clinical consultations both inside
and outside the prison.
16
RESPONSE TO DRAFT REPORT FROM THE MAN’S FAMILY
49. Before the final version of this report was issued, a version was sent in draft
form to all relevant parties seeking their comments. The man’s mother replied
raising a number of matters about which she remained concerned. Her main
concerns focussed on her son’s health care needs. She pointed out that her
son had been complaining about his health for some time and she questioned
why he was not hospitalised. She also questioned why certain examinations
were not carried out and why her son’s clinical records from Poland, which were
copied to Littlehey, appeared to have been disregarded.
17