Individual at The Mount

Investigation into the circumstances surrounding the
death of a man at hospital whilst a prisoner at HMP
The Mount in June 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2008
This is the report into the death of a man who died in June 2007 at hospital,
whilst a prisoner at HMP The Mount. He had been admitted to the hospital on
24 April, following a period of ill health and weight loss. He was 47 years old
at the time of his death.
The man had been sentenced to six years’ imprisonment in April 2005. This
was his first prison sentence.
A post mortem was held at the request of the Coroner. The report noted that
the man’s death was due to natural causes as a result of tuberculosis.
Although suspected, this diagnosis had remained unconfirmed until after his
death. I extend my sincere condolences to his wife, son, family and friends.
The man’s wife was a serving prisoner at the time of her husband’s death.
She has made several complaints about her own care and support which,
unusually, I deal with here.
The investigation was undertaken by one of my investigators. I would like to
thank the Governor of The Mount and his staff for their help and support
during this investigation, and also the Governor of HMP Send for his
assistance. A clinical review of the man’s medical care was undertaken by
the healthcare manager at HMP Littlehey in Cambridgeshire. I am grateful for
his report.
I make one recommendation in relation to the prison’s family liaison after the
man’s death. I also note three instances of good practice, relating to the
prison’s frequent contact with the hospital where he was an inpatient, the
removal of restraints and chaplaincy support for him.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2008
CONTENTS
Summary
Investigation process
HMP The Mount
Key findings
Issues
Recommendations
SUMMARY
The man was sentenced to six years’ imprisonment in April 2005, at the
Crown Court, for assisting in illegal immigration. He was received into HMP
Wormwood Scrubs, then transferred to The Mount. Between 2005 to 2007,
he transferred to Wormwood Scrubs on several occasions to attend court
appearances in the London area. On his last reception into The Mount, on 16
February 2007, he was seen by healthcare staff who completed a first
reception health screen document. He was fit and well on examination and
no health problems were recorded.
On 17 February, the man was seen in the healthcare centre. He complained
of aching across his sternum (chest) which was attributed to his carrying his
property from his transfer. A diagnosis of either a pulled muscle or heartburn
was noted for which he was prescribed Gaviscon and paracetamol. The
following day, he was seen again by medical staff and he was feeling brighter.
The man was next seen in healthcare on 27 February, and treated with
prescribed ibuprofen for low backache and muscular pain. On 19 April, he
again attended healthcare as he was feeling unwell. He was advised to rest
in bed for 24 hours, blood samples were taken for testing and an
electrocardiogram (ECG) was completed. The next day he was seen by a
member of the medical staff with an officer present. The records in respect of
this examination note that his ill health might have been anxiety related and
that he was generally low in mood. The man was advised to discuss his
feelings with the officer.
Two months later, on 24 April, the man was seen by the prison General
Practitioner (GP). The GP noted that he was obviously unwell and had lost
six kilograms in weight since his arrival at The Mount in February. He told her
he had been suffering from headaches, nose bleeds and night sweats for the
past two weeks. He was finding it difficult to walk and in obvious pain. Given
the severity of the symptoms, the GP sent the man to the local as an
emergency admission. He was escorted to the hospital by two officers, under
restraint. The GP wrote in her letter requesting admission that the man had
told her he did not tend to go to the doctors and there was very little in his
medical records. The clinical reviewer comments that this was the first time
he had brought these symptoms to the attention of staff. On 26 April, he was
moved to a separate room in the hospital, following a diagnosis of suspected
tuberculosis. Prison staff escorting him were advised to wear masks,
although the man refused to wear one.
A Governor grade ensured that the man’s wife (who is a serving prisoner at
HMP Send) was made aware of his admission, although the date on which
she was told is unclear. On 30 April, she visited her husband, escorted by
prison staff. A risk assessment carried out on 15 May noted that due to the
man’s continued ill health his handcuffs were removed and the escort was
reduced to one officer. He was placed on a ventilator and a dialysis machine.
On 20 May, the man’s wife again visited her husband, under escort and
stayed with him for four hours. By then he was seriously ill and receiving
treatment in the intensive care unit. During his stay in hospital The Mount
maintained regular contact with hospital staff about his progress. They also
informed Send of any significant deterioration in his health, so they could pass
this information on to him.
An application for his release on temporary licence (ROTL) was considered by
The Mount. On 30 May the Probation Service was asked to provide an
assessment but this was not completed before the man’s death. He was
visited by family members on 4 and 5 June.
On 14 June, the man’s condition deteriorated and he was placed on a
ventilator for a second time. During the evening, hospital staff informed the
escort officer that his condition was serious and his next of kin should be
informed. On receipt of this information, The Mount contacted Send to ask
them to inform the man’s wife. The Mount also contacted his cousin, who had
been named as next of kin by the hospital, but he chose not attend.
Members of The Mount’s chaplaincy team, including the Sikh Minister, arrived
at his bedside by 11.30pm. Prayers were said by the Sikh Minister. At
3.50am, the man’s heart stopped. Attempts at resuscitation were
unsuccessful and his death was pronounced at 4.50am.
It seems that the man’s wife was first told of her husband’s death by his
cousin before staff at Send had the chance to do so. The Mount had made
contact with Send at some point before 5.30am, and at 9.00am the chaplain
and duty governor visited the man’s wife to tell her. She was escorted to the
hospital mortuary on 18 June to see her husband and attended his funeral,
again under escort, on 12 July.
The investigation found that the standard of care given to the man was
comparable to that of someone in the community, however, a
recommendation has been made about family liaison after his death.
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened by one of my
investigators, when she visited The Mount on 25 June 2007,. She met
the Governor and the Deputy Governor. My investigator also visited
Ellis wing, where the man had been located, and spoke to the officer
who had been his personal officer. Notices of the investigation and
terms of reference had already been sent to the prison before her visit.
2. A clinical review was commissioned from the Primary Care Trust (PCT)
to assess the man’s medical care at The Mount. The healthcare
manager at HMP Littlehey, subsequently carried out this review on
behalf of the PCT and I am grateful for his report.
3. On 11 July, my investigator spoke to the personal officer by telephone.
He gave my investigator some background information on the man’s
time in The Mount. On a subsequent visit to The Mount on 16 July, my
investigator spoke to a friend of the man. On 20 July, she spoke to the
Sikh Minister and a member of The Mount chaplaincy department, by
telephone.
4. One of my Family Liaison Officers contacted the man’s wife to inform
her of our investigation. On 22 August, my Family Liaison Officer and
investigator visited her at HMP Send, in the presence of her solicitor.
She raised several questions in relation to her husband’s death which I
hope have been fully addressed in my report.
5. On 24 August, my investigator had a telephone conversation with the
chaplain at HMP Send who had supported the man’s wife before and
after her husband’s death. On 28 August, my investigator also spoke
to the chaplain at The Mount by telephone.
6. Following completion of the investigation, the solicitor representing the
man’s wife sent my investigator some of the letters written by the man
to his wife, and copies of five (undated) Incentives and Earned
Privilege (IEP) warning slips, which his wife had received from The
Mount within his property. The solicitor representing the man’s wife
asked my investigator to investigate these warnings as they might have
been issued during the man’s most recent stay at The Mount. In order
to pursue this, my investigator returned to The Mount on 14 November
and met with the head of residence who carried out the risk
assessment.
7. On 29 December 2007, my investigator wrote to the Governor of HMP
Send to seek his assistance in responding to questions the man’s had
asked about support from the prison during, and following her
husband’s death.
HMP THE MOUNT
8. The Mount is a category C training prison, five miles from Hemel
Hempstead. It opened in 1987 as a young offender institution and
changed role to a male establishment in 1992. The Mount’s
operational capacity is 720 prisoners.
9. Healthcare is open from 7.45am to 5.15pm on weekdays. Prisoners
can report ‘sick’ during these times and be seen by the nurse or the
pharmacist. A range of comprehensive healthcare resources is also
accessible for prisoners, but there is no inpatient facility. Two General
Practitioners (GPs) from a local NHS practice hold clinics every
weekday morning. Another GP visits the prison in the afternoon for
‘special sick’ and new receptions. Out of hours cover is provided by an
on call GP. An in house pharmacist is employed full-time.
10. An unannounced inspection of The Mount, by HM Inspector of Prison
was carried out in September 2006. In relation to GP and nurse
appointments, the report noted:
“The appointment system worked well, although there were some
delays in appointments because of the mass movement system for
prisoners. However, prisoners were seen quickly and without undue
delay. Prisoners who requested appointments with the GP or nurse
were generally seen at the next available appointment, usually the
following day.”
11. The report also noted that The Mount had made very impressive
progress since its last announced inspection in October 2004.
The Annual Report from the Independent Monitoring Board (IMB) for
The Mount concluded, in the section on Primary Healthcare that:
“Overall the Board’s weekly observations indicate a well-regarded
health and mental health facility, which is well integrated, and playing
its full part within the prison organisation.”
12. This was the second death by natural causes my office has
investigated at The Mount, the last one being in 2004.
KEY FINDINGS
13. The man was received in HMP Wormwood Scrubs in April 2005. He
had been sentenced to six years’ imprisonment at the Crown Court for
assisting in illegal immigration. On his initial reception into Wormwood
Scrubs, he had a health screen and his medical history was recorded.
The document recorded that he had no health concerns.
14. He was transferred to The Mount on 27 May, and again no health
concerns were recorded in his medical notes. Between 18 August
2005 and 16 February 2007, the man was escorted to court on eight
occasions and was temporarily transferred to Wormwood Scrubs. On
22 March and 28 September 2006, he was escorted to HMP Send for
inter-prison visits to see his wife.
15. The man was received back into The Mount on 16 February 2007
following a short transfer to Wormwood Scrubs for a court appearance.
No health problems were recorded in the reception health screen and
his weight was noted as being 71kg.
16. On 17 February, the man attended the healthcare centre where he
complained of aching across his sternum (chest). This was thought to
be due to his carrying his property when he transferred. A diagnosis of
either a pulled muscle or heartburn was noted for which Gaviscon and
paracetamol were prescribed. On 18 February, he was seen again in
healthcare. He was feeling brighter, although he still had some low
backache. Nine days later, he returned to healthcare with low back
ache and some muscular pain. Movement in his spine was noted as
good and he was prescribed ibuprofen.
17. The next time the man attended healthcare was on 19 April, as he was
feeling unwell. Samples of blood were taken for tests, an
electrocardiogram (ECG) was carried out to monitor his heart, and he
was advised to rest in bed for 24 hours. On 20 April, he was seen by a
member of the healthcare staff, in the presence of an officer. The
healthcare worker noted that the man’s symptoms might be anxiety
related and he was in a low mood. He was advised to discuss his
problems with his personal officer.
18. On 24 April, the man was again feeling unwell and seen in the
healthcare centre by the GP. This was the first time the GP had seen
the man. He told her that he had felt fine until two months before.
Since then he had experienced chest pain and in the two weeks before
seeing her he had suffered from severe headaches. In addition, he
had had two nose bleeds in the previous two days as well as general
aches, pains and muscle weakness. On examination, the doctor found
the man to be in pain, his abdomen appeared to be distended, he had
difficulty in walking and an ear infection. He told the doctor he rarely
attended the doctors and his medical record showed very little contact.
The GP arranged for him to be transferred to the local hospital as an
emergency admission. She noted in a referral letter to the hospital
that the man was very ill and dragging himself along the corridor,
obviously in pain.
19. At 11.10am, he was taken to the hospital, under restraint, with a two
officer escort. He was admitted to a ward at 5.05pm with a bed watch
escort of two officers and he remained restrained. The prison arranged
for some of the man’s personal property to be taken to him in the
hospital. The following day, the Governor grade contacted HMP Send
to ensure that the man’s wife was informed of her husband’s admission
to hospital. Throughout the man’s time in hospital, prison staff made
regular contact with the hospital for updates on his health.
20. Two days after his admission (26 April), the man was moved to a side
room, as a precaution, following a diagnosis of a suspected
tuberculosis infection. Escort staff were advised on personal protection
in light of the possible infection. On 28 April, the hospital staff advised
the escorting officers that tuberculosis had still not been ‘ruled out’ and
that prison staff should wear masks. The bed watch officer told the
duty governor about this advice. On 30 April, the man’s wife was
escorted from HMP Send to see her husband for a visit of nearly two
hours.
21. A risk assessment was carried out by the head of residence on 15
May. He noted that the man’s condition had deteriorated and the
escort chain had to be tightened on two occasions due to his weight
loss. The head of residence recommended that the escort be reduced
to one officer and restraints be removed. Further risk assessments
would be reviewed every 48 hours.
22. At 7.20pm, the man was transferred from his side room on the ward to
the Intensive Care Unit (ICU) where he was placed on a ventilator and
a dialysis machine. In the meantime, the head of residence contacted
Send to ensure the man’s wife was fully aware of the situation. She
visited her husband for four hours on 20 May, on escort from Send.
During her visit, she spoke to doctors about her husband’s condition.
23. Although he remained unconscious, the man was taken off the
ventilator on 22 May, but he remained on the dialysis machine. He
was still unconscious. The following day, his breathing tube was
removed at 11.45am, but reinserted at 12.30pm because of breathing
problems. He was given medication to render him unconscious to
assist with his breathing.
24. On 30 May, The Mount began an application for the man to be
released on temporary licence. They contacted the Probation Service
for an assessment, but this was not completed before his death. On 4
and 5 June, his son and other family members visited him in the ITU
where he remained under sedation. On 11 June, his condition had
improved slightly, although he was drifting in and out of consciousness.
25. Medical staff were concerned about the man’s condition on 14 June
and gave him medication to ease his discomfort. At 6.50pm, he was
seen by several doctors as his condition was deteriorating and an hour
later, he was placed on a ventilator. At 7.45pm, hospital staff informed
the escort officer that the man’s condition was serious and the prison
should inform his next of kin. On receipt of this information, the duty
governor at The Mount contacted the Night Orderly Officer at Send, to
ask for the man’s wife to be informed of her husband’s condition. A
second officer then took over from the escort officer. At 9.15pm The
duty governor was again contacted by the second officer following a
request by the hospital for the man’s cousin to be called. The duty
governor authorised staff to contact the man’s cousin to give
permission for him to attend the bedside of the man if he wished to do
so. The man’s cousin chose not to visit that evening.
26. At 11.00pm, one of the chaplains from The Mount, arrived at the man’s
bedside. He was joined at 11.30pm by the Sikh Minister, and his wife.
The Sikh Minister said prayers at the man’s bedside. A member of
hospital staff had told the reverend that the man’s cousin was listed as
his next of kin. However, the Sikh Minister told the second officer that
in accordance with the man’s faith, his wife was the next of kin for the
purposes of any religious or cultural issues.
27. Early the next morning at 2.30am, the man’s condition was
deteriorating rapidly so he was attached to a cardiac machine. At
3.53am his heart stopped and doctors performed Cardio Pulmonary
Resuscitation (CPR) for 45 minutes, without success. His death was
confirmed by doctors at 4.50am. In the meantime, the duty governor
had been alerted to the situation, and he arrived at the hospital at
4.55am. The second officer had also informed the night orderly officer,
who had begun to put into place the local contingency plan for a death
in custody. This included contacting relevant parties, such as HMP
Send to inform the man’s wife. After speaking to hospital staff, the duty
governor and second officer returned to The Mount at 5.30am.
28. The duty governor confirmed with the night orderly officer that all
relevant parties had been notified of the man’s death and all
documentation completed. By 4.20am, the reverend had received two
calls from the man’s cousin. He told the man’s cousin that he had
been instructed that the man’s wife was next of kin and said he would
contact her to confirm her wishes. After being told this, the man’s
cousin did not call again. The man’s wife was informed of her
husband’s death at 9.00am by the chaplain and the duty governor.
However, it seems that by this time she had already been told. She
received a lot of support from the chaplain during her husband’s illness
and following his death.
29. On 18 June, the man’s wife was taken by escort to see her husband in
the mortuary at the local hospital. Three days later, the Governor of
The Mount sent a letter of condolence to her and offered appropriate
support, including payment for the funeral arrangements.
30. The man’s funeral took place on 12 July and his wife was escorted
there by staff at Send. The Sikh Minister assisted with the
arrangements. Special prayers were said for him during a Sikh service
at the prison.
ISSUES
Clinical Review
31. A clinical review into the man’s medical care at The Mount was
commissioned by the Primary Care Trust (PCT). The healthcare
manager at HMP Littlehey, carried out this review on behalf of the PCT.
32. The healthcare manager reviewed the man’s medical notes. He
outlined the medical history noting that his blood pressure was within
normal range. His mother had died at the age of 42 years from a brain
tumour. Apart from a hernia repair as a baby, no other health problems
were recorded and he was not receiving any prescribed medication.
33. In February 2007, the man was given ibuprofen for chest and clavicle
pain. He was not seen in healthcare again until 19 April when samples
of blood were taken for tests. Elevated liver functions tests indicated
that there might have been a previous history of alcohol abuse. On 20
April, in a consultation with a member of healthcare staff, the man was
noted to be in a low mood. An officer was present during the
discussion, which centred on the physical effects of distress and
elements of loss of life, linked to his imprisonment. The member of
healthcare staff advised that he should spend some time with the
officer looking at these matters. On 24 April, he was admitted to
hospital following an examination by the GP. The clinical reviewer
commented that this was the first time the man had brought these
issues to light.
34. The man’s prison medical records appear to have been regularly
updated following his admission to hospital. The records contained
extensive entries noting communication between The Mount’s
healthcare centre and the hospital. The clinical reviewer does not
comment on the accuracy of what is captured because no information
was received directly from the hospital.
35. The clinical reviewer noted the post mortem report recorded the cause
of death as tuberculosis. The symptoms of tuberculosis include
persistent cough, swollen glands, tiredness, loss of appetite, weight
loss, night sweats and chest pains. Tuberculosis often spreads to the
lymph nodes, and may affect bones, joints, kidneys and resemble a
type of meningitis. He commented that depending upon how quickly
an immune system fights the infection, there might be either no
symptoms, minor symptoms for a few weeks which then go, or some
symptoms for a few days or months later.
36. In his report, the clinical reviewer commented:
“It is clear from the clinical record that [the man] potentially displayed
some of the symptoms of tuberculosis (in particular of 24 April 2007)
leading up to his transfer to secondary care (hospital). I am satisfied
that [his] other consultations were appropriately carried out, given the
presentation at the time. It is of note however, that the Post Mortem
Examination states that the samples sent for possible tuberculosis
returned negative”.
37. The clinical reviewer offered the view that the standard of care the man
received at The Mount was comparable to that of a member of the
public in the community. The clinical record shows that investigations
were carried out in a timely and appropriate manner given his clinical
presentation at the time. When he was seen by the GP on 24 April, his
condition had deteriorated and an appropriate examination and
assessment was undertaken. Following that examination and
assessment, the GP made an urgent referral to hospital.
38. I endorse the clinical reviewers view that the GP’s referral letter was
clear, concise and appropriate, and his recommendation below.
Healthcare staff at The Mount should be commended for their
frequent and robust contact with the local hospital.
Family Issues
39. On 22 August, my family liaison officer and investigator visited Send to
see the man’s wife. Her solicitor was also present at this meeting. The
man’s wife gave my family liaison officer and investigator a copy of a
statement dated 15 August that she had made to her solicitor in
relation to issues surrounding her husband’s diagnosis, illness and
healthcare treatment at The Mount and the local hospital. She also
raised questions about her support and treatment at Send during her
husband’s illness and after his death.
40. Following the meeting, my investigator wrote to the solicitor confirming
the issues and questions this report could address and those which
were out of our remit, for example those relating to the man’s hospital
treatment. The solicitor referred the man’s wife to organisations who
could deal with her other concerns. Below I address two of the
questions raised in her statement. The remainder are dealt with in the
body of this report.
Why was my husband not treated earlier for his illness when at
HMP The Mount?
Why did the healthcare department at HMP The Mount fail to
provide my husband with adequate medical treatment at an
earlier stage of his illness?
41. The man was treated in the healthcare centre at The Mount the day
after his reception, on 17 February. He had complained of chest pain,
which was diagnosed as either a pulled muscle or indigestion.
Painkillers and indigestion medication were prescribed.
42. He was seen the next day and reported to feel better. On 27 February,
he attended healthcare again, with muscular and back pain. He was
advised to rest in bed and prescribed more painkillers.
43. The man did not attend healthcare again until 19 April, five days before
he was admitted to hospital. He felt unwell and was seen by the GP
who ordered blood tests and advised him to rest. The next day, he
was seen by a member of the healthcare staff as he was feeling
depressed and they discussed possible anxiety related illnesses. On
24 April, he saw the GP who made an emergency admission to
hospital.
44. A fellow prisoner and friend of the man, told my investigator that the
man had been unwell since his return from Wormwood Scrubs in
February. He had told his friend that healthcare staff seemed
disinterested in his healthcare needs and he had only been prescribed
painkillers. The man’s personal officer, told my investigator that he
was looking unwell shortly before he was admitted to hospital, but at no
time did he complain to him of feeling unwell. There is no evidence to
suggest that healthcare staff were not treating the man appropriately,
given his symptoms.
45. In an entry in the man’s history sheet dated 23 April, a third officer
described a conversation he had with the man following his
appointment with a member of the healthcare staff. The officer said:
”Spoke with [the man] at length. He has recently had chest pain, but
don’t think this is a heart problem. What healthcare thought was that
[he] had a few problems not major problems, but his wife is serving a
custodial sentence his son lives in Pakistan and a few other problems
which are making [him] having (what healthcare think) is anxiety
attacks. Told [the man] to speak to staff to which [he] agreed.”
46. It is possible that the man thought that healthcare staff had not taken
his symptoms seriously as they did not diagnose a heart condition.
However, tests were carried out and he was then assessed again.
47. In his wife’s statement she says her husband had told her that he had
approached healthcare on numerous occasions but only given
paracetamol for his illness. She said he had requested a chest x-ray
but nothing had been done. She also said that he had been told by
healthcare that he was abusing the healthcare system because of the
number of complaints he was making. I can find no evidence that this
was the case. The man’s medical notes do not record any reference to
abuse of the system. It appears that he approached healthcare only
twice in February and then not again until two months later. His
concerns appear to have been taken seriously as blood tests and other
observations were carried out. Medical and discipline staff also
discussed his concerns with him. Five days later he was immediately
transferred to hospital when it became clear that his condition had
deteriorated. The GP noted in her referral letter that the man had said
he tended not to see the doctor and his clinical records confirm this.
48. The confirmation of tuberculosis as a cause of the man’s death was
made at the post mortem, although the hospital had been treating
some of his symptoms as possible tuberculosis. He had an emergency
admission to hospital following a consultation with the GP in which she
noted his serious ill health. I am unable to judge whether an earlier
referral would have changed the outcome, particularly as the hospital
was unable to diagnose the man’s illness when he became an
inpatient.
49. The clinical reviewer was satisfied that the consultations (including
those in February) were carried out appropriately, given the man’s
presentation at the time. He had been prescribed painkillers and blood
tests were carried out on 19 April, two months after his return to The
Mount. The results of the blood tests and his visible deterioration led to
him being admitted to hospital. The clinical reviewer concluded that,
given the timeframe leading up to the emergency transfer, it is difficult
to clearly link an earlier diagnosis with a greater chance of survival.
50. On 1 November, the solicitor sent copies of four letters dated 4 and 25
January, 29 March and 15 April 2007, written by the man to his wife.
The letters contain personal details and some sentences referring to
him feeling unwell are underlined. The letters of 4 and 25 January
would have been written whilst he was in Wormwood Scrubs. He said
in one letter he had not been to work (in education) because of a cold
but was taking paracetamol. The second letter indicated that he was
not sleeping as he was having problems with his arthritis. He makes
no reference to attending healthcare or being refused health
interventions.
51. The two letters written by the man whilst he was at The Mount, dated
29 March and 15 April, again include some reference to his health
problems. In the letter of 29 March, he wrote that he was feeling
better, medicine was not helping but orange juice was. He said he was
going to work regularly. The letter dated 15 April said that he was still
feeling a bit rough and weak but should be better when he got back to
education to give his brain some exercise and stimulation. Neither of
these dates correspond to him being seen in healthcare. In these
letters, the man makes no reference to a lack of healthcare resources,
being refused medication or an appointment to see a nurse or doctor.
52. The solicitor also forwarded copies of five IEP warning slips given to
the man. His wife had found these slips in her husband’s property,
which she had received from The Mount following his death. Her
solicitor said these warnings referred to the man not attending work,
because he felt so unwell, and the prison (The Mount) ignored his
requests for assistance and chose to punish him. Her solicitor said
these warnings were issued during the period between being received
into The Mount on 16 February and his admission to hospital on 24
April.
53. On 14 November, my investigator met the head of residence at The
Mount to investigate these matters further. My investigator received a
copy of The Mount’s Incentives and Earned Privileges (IEP) Policy.
The section on dealing with work within the IEP policy notes:
“The policy of The Mount is one of a three warning system. Warnings
are issued arising out of a failure to adhere to the above standards of
behaviour or performance. Warning notices are coloured green,
amber and red. These warnings may be issued by any member of
prison staff. All of the following warnings remain in force for a period
of three months from the date of issue. Green - This is the first
warning issued and requires the issuing member of staff to address
the issues with the prisoner and record that this has taken place.
Amber -The second warning is dealt with in the same manner with the
exception that the wing senior officer will interview the prisoner and
clearly identifies what is and is not acceptable. Red - When a red
warning is issued the matter will be referred to the wing senior officer
who will convene a board to consider the subjects continued
suitability for the given regime at that point. If demotion to basic
(lowest level privileges) is awarded this decision must be endorsed by
least senior officer rank. The wing senior and principal officers
(unless witnessing unacceptable behaviour) are not required by rank
to issue amber or red notifications. Their responsibility is to interview
the prisoner and deal with the emerging issues. The traffic light forms
are spilt into two sectors one being issued to the prisoner and the
other being placed in the wing history file.”
54. The IEP warning slips sent to my investigator comprised of two green,
two amber and one red. There were no dates on any of these slips.
One green slip was from H wing, an induction unit. The man had only
been on H wing for two days, 16 and 17 February. As he had
previously been in The Mount he was moved to E Wing, a residential
block, on 18 February. The slip said, ‘to go to your work place when
requested to do so’. The second green slip issued on E wing said, ‘to
get out of bed in the morning and attend work’. Of the two amber slips,
one was issued on E wing and said, ‘to attend work every day when
required’, and the other on which there was no location said, ‘to attend
workshops’. The red slip marked E wing, was hard to decipher.
55. From the E wing history sheet, there is only one referral to an
incentives review board for the man. Only prisoners receiving red
warnings go to a board and his board took place on 4 March 2007.
The reason for the red warning was, ‘You threw a stone at a window on
Bristol wing’. The man is noted as replying, ‘I was only trying to get my
mate’s attention I did not mean any harm’. Following the board it was
concluded that he would remain at his incentive level of standard. His
improvement objective was not to throw stones. It was further noted at
the review board that he did not request an IEP appeal form.
Therefore the red warning did not relate to attending work. There are
no other references or records on the wing history sheet to other
warnings.
56. It is the practice at The Mount to photocopy the upper part of the slip
which is filed on the wing history sheet and give it to the prisoner with
the lower part. My investigator was not given copies of the upper parts
of any of the IEP slips issued to the man, nor were they on his wing
history sheets. The Mount was unable to shed light on where these
might be.
57. Without any dates or further evidence, I am unable to correlate any of
these IEP warnings to the assertion by the solicitor that the wing staff
at The Mount ignored the man’s ill health and his requests for
assistance. The only IEP board, during the period of 16 February to 24
April related to the man being reviewed for throwing stones. Whilst I
accept that these warnings refer to him not attending work or getting
out of bed, it is also possible that they could have been historical from
his previous time in The Mount when he had stayed on both H and E
wings.
58. The man’s wife said that her husband had told her he had made
complaints regarding his lack of healthcare and he would, ‘be put on
report’ by the prison if he continued to do so. I am unable to find any
evidence of this. He does not refer to this in his letters to his wife. His
prison file contains no copies of any complaints, neither were any
complaints lodged with the IMB clerk. The head of residence was also
unaware of this issue.
59. Entries in the man’s personal record from 16 February to 10 June 2007
make mention of him being demanding. However, they do not tell of
health concerns, until an entry on 23 April, by the third officer, the day
before the man’s admission to hospital. His demands were about his
property coming from Wormwood Scrubs, moving cell and requesting a
mirror. There are no other records relating to his requests. The head
of residence informed my investigator that he has checked E wing
history and there are no records regarding any warnings.
Informing the man’s wife of her husband’s death
60. As soon as the man became ill and was admitted to hospital, The
Mount ensured his wife was informed promptly of this and the
subsequent deterioration in his condition. Once in hospital, his wife
had contact with the hospital by telephone. Although being a prisoner
herself this would have been more difficult than if she had been in the
community. The prison kept a daily record of contact with the hospital.
61. Although the hospital care provided to the man is outside my remit, in
response to his wife’s question I can clarify that a life support machine
was not switched off and staff attempted to resuscitate him when he
went into cardiac arrest.
62. At 8.10pm, on the evening before his death, the duty governor
contacted the Night Orderly Officer at Send, to inform the man’s wife of
her husband’s serious condition. A little later at around 9.15pm, she
was taken to the chapel where she was supported by the duty chaplain
and allowed to call the hospital. Hospital staff also informed the bed
watch officer that the man’s cousin should be told of his deteriorating
condition. The man’s cousin declined to attend the hospital. It is not
clear whether the man had given the hospital staff his cousin’s contact
details or whether his cousin had given this information himself.
63. On the man’s prison record his family were noted as next of kin, but he
may have changed this when he was taken into hospital. When the
Sikh Minister visited on the evening of 14 June, he told the bed watch
officer that the man’s wife would be next of kin if any decision needed
to be made in terms of any medical intervention as there were no
cultural or religious issues that would impede her rights to do so.
64. At some time before 5.30am, following notification of the man’s death,
The Mount’s night orderly officer asked the Night Orderly Officer at
Send to notify the man’s wife of the sad news. She was officially told of
her husband’s death by the chaplain and duty governor at about
9.00am that morning. However, it is understood that by this time she
had already spoken to the man’s cousin, who had informed her of her
husband’s death.
65. Staff from The Mount did not visit the man’s wife at Send following her
husband’s death. In most circumstances, the family liaison officer
(FLO) from the prison where a death had occurred would visit the next
of kin, at their home to inform them of the death of a relative. If there is
a long distance to travel, the FLO might ask staff from a nearby prison
to carry out the visit. As the man’s wife was a serving prisoner and
already being supported by the chaplaincy, it was appropriate that she
was informed of her husband’s death by the chaplain and duty
governor at Send, with whom she was more familiar.
66. I recognise there was a delay informing the man’s wife of her
husband’s death, but understand that Send were waiting for
appropriate staff to come on duty to convey the news to her in a
sensitive and fitting manner. However, Prison Service Order (PSO)
2710 and the corresponding Family Liaison Officer guidelines are clear
that where face to face notification is not possible, there should be
personal follow up by a representative of the prison where the death
occurred. The PSO also notes ‘the prison should demonstrate its duty
of care and show that it is taking the death seriously by making a
personal visit’. Although a letter of condolence was sent, no personal
visit was made. I therefore recommend that:
The Governor should ensure that The Mount’s local contingency
plan for a death in custody makes provision that, where face to
face notification of the next of kin is not possible, and the prison
have used alternative means, this should be followed up as soon
as possible with a visit by an appropriately appointed Family
Liaison Officer from the establishment.
Questions raised by the man’s wife in relation to support from HMP
Send
67. The man’s wife raised 57 questions in her statement to her solicitor.
My investigator and family liaison officer met with the solicitor and the
man’s wife and agreed those questions to be dealt with in this report. I
hope they have been fully addressed. The majority of the questions
are outside my remit as they related to the man’s medical condition
following his admission to hospital. However, seven questions focus
on issues pertinent to her support during and following her husband’s
death. With the assistance of the Governor of Send my investigator
has been able to obtain a response to the questions raised, which are
listed below.
Why was the man’s wife not allowed to visit her husband in the
weeks leading up to his death?
68. The man’s wife was allowed to visit her husband on 30 April and 20
May 2007, prior to his death. A third visit was planned but her husband
passed away before this could take place. The Governor of Send said
that although it is always difficult to view these things after such a sad
event, he considered the prison’s action in facilitating these visits –
which were some distance – not unreasonable, given the many other
priorities on staff resource. He also pointed out that the man’s wife
was allowed to undertake three visits to the Chapel of Rest, and also
attended the funeral and the spreading of her husband’s ashes in line
with her religious observance. I am satisfied with the prison’s response.
Why did HMP Send refuse to update the man’s wife on the status
of her husband’s health?
69. The Governor of Send believes that all the staff involved with the man’s
wife were extremely helpful towards her and assisted wherever
possible. Numerous calls about her husband’s condition were made to
the Deputy Governor and other Governors at The Mount by several
members of the Senior Management Team at Send. However, limited
information was available owing to The Mount, having trouble with
obtaining information from the hospital. (It was noted in the clinical
review that there was limited information from the hospital). The
Governor said his managers ensured that the man’s wife was
personally informed of any information passed to them even if this was
limited and I am satisfied with the prison’s response
Why did the Governor at HMP Send not respond to the
complaints/correspondence requesting action on 25 and 28 May
and 7 and 14 June 2007?
70. The Governor of Send advised that complaints reference 313/07 (25
May 2007) and 321/07 (28 May 2007, made by the man’s wife, were
replied to by a governor grade and a second governor grade replied to
complaint reference 363/07 (14 June 2007). There was no record of
any complaint dated 7 June 2007 and I am satisfied with the prison’s
response
The man’s wife felt that the inconsistent information that she
was given by staff at the hospital and HMP Send was unfair,
unprofessional and in breach of the prison’s duty of care to
provide her with support and information during this difficult
time. She would like to know why she was not appointed a
family liaison officer at this time from within the prison to help
her obtain information and support.
71. The prison was unable to comment on information imparted to the
man’s wife by hospital staff. However, the Governor of Send
confirmed that staff informed her of all available information as soon as
it was received at HMP Send. He did not consider that HMP Send
failed in its duty of care towards her and every assistance was offered
to her in trying to obtain information so she could be kept fully informed
of all developments. It is not prison policy to allocate a formal family
liaison officer in these circumstances to prisoners in her situation, prior
to a family member’s death. That said, the man’s wife was advised by
numerous individual members of staff within the establishment who
undertook all reasonable steps to assist her wherever possible at all
times. The appointment of a specific liaison officer at Send would not
have provided any assistance over and above that given to her by the
managers at the time.
I am satisfied with the prison’s response and understand from members
of Send’s chaplaincy team, that she was offered appropriate support.
On what basis was the man’s wife informed by hospital and
prison staff, specifically the PO, that her husband’s condition
was better?
72. The PO spoke to the man’s wife about her husband and was involved
in assisting her to visit him at the beginning of the illness. The PO
contacted the hospital on her behalf. The PO was informed by a doctor
that although the man had been seriously ill, there seemed to be some
improvement as he was cooperating with the staff wearing his oxygen
mask, which had not been the case previously. The PO advised the
man’s wife at the time about her conversation with the hospital. I am
satisfied that the prison responded appropriately.
Why was the man’s wife only allowed one Release on Temporary
Licence (ROTL) other than the funeral to see her husband?
73. The man’s wife was not granted ROTL to visit her husband as, in line
with PSO 6300 and the substantial confiscation order against her, she
was ineligible for any form of temporary release. She was made fully
aware of this and therefore attended the hospital and subsequent
funeral under escort as per the required risk assessment. I am
satisfied with the prison’s response to her request for ROTL.
Why did the man’s wife have to be handcuffed at her husband’s
funeral?
74. The wearing of handcuffs is standard operating practice for anyone
leaving an establishment under escort having been risk assessed as
not suitable for release on temporary licence or accompanied. I am
satisfied that the prison used restraints appropriately.
75. I am unable to comment further on the questions the man’s wife raised
in terms of her support at HMP Send, and acknowledge the responses
from the Governor of Send. I have therefore advised her that she may
pursue Send’s internal complaints procedure should she not be fully
satisfied with the response in the report. The remainder of her
questions have been dealt with in the body of this report.
Removal of Restraints
76. Whilst an in-patient at the local hospital, the man was under the escort
of two officers and was restrained until 15 May. The head of residence
visited the man in hospital and noted the serious deterioration in his
health. A risk assessment was undertaken, the escort was reduced to
one officer, and the restraints were removed. From this time, until the
man’s death, the security measures remained as a one-officer escort
with no restraints.
I commend the head of residence for his timely risk assessment
and the removal of restraints, allowing the man some dignity
before his death.
Spiritual support offered to the man
77. The man was supported by members of the chaplaincy department at
The Mount. Chaplaincy staff visited the man regularly in hospital.
They offered him spiritual and practical support during their visits. On
the evening before his death the reverend and the Sikh minister went
to his bedside, late at night. The Sikh minister said religious prayers
for him as his condition deteriorated.
78. Following the news of the man’s death, the reverend arrived at The
Mount at 4.20am. He spoke to the man’s cousin on the telephone on
two occasions and offered support to the escort on his return to the
prison from bed watch duty.
I commend the support and dedication of the chaplaincy team in
their care of the man.
RECOMMENDATIONS
1. The Governor should ensure that HMP The Mount’s local
contingency plan for a death in custody makes provision that,
where face to face notification of the next of kin is not possible,
and the prison have used alternative means, this should be
followed up as soon as possible with a visit by an appropriately
appointed Family Liaison Officer from the establishment.
GOOD PRACTICE
1. The Healthcare staff at The Mount be commended for their
frequent and robust contact with the local hospital
2. I commend the head of residence for his timely risk assessment
and the removal of restraints, allowing the man some dignity up to
his death.
3. I commend the support and dedication of the chaplaincy team in
their care of the man.