Individual at Hull

Investigation into the circumstances surrounding the
death of a man at Hull Royal Infirmary
while a prisoner at HMP Hull in January 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2008
This is the report of an investigation into the circumstances of the sudden death of a
man while a prisoner at HMP Hull, on 10 January 2008. The man collapsed in the B
wing exercise yard while walking to the visits hall to see his wife and other members
of his family. He was taken by ambulance to Hull Royal Infirmary, but sadly died
there a short time later. He was 77 years old.
I would like to offer my sincere condolences to the man’s family, not least given the
circumstances in which he died.
My colleague conducted the investigation on my behalf. One of my family liaison
officers spoke on a number of occasions with the man’s daughter-in-law. She told
my family liaison officer that the family was happy with the level of care given to the
man who died, and they did not have any specific issues they wished my office to
investigate.
An independent review into the man’s medical care was undertaken by the Clinical
Governance Manager at Hull Teaching Primary Care Trust Provider Services. I am
grateful to her for her valuable contribution. I would also like to thank the Governor
of Hull for his cooperation with the investigation. I am particularly grateful to a
Principal Officer who provided a high standard of prison liaison.
I make one commendation in my report relating to the Principal Officer who
accompanied the man who died in the ambulance to Hull Royal Infirmary. During the
journey to hospital he carried out cardio pulmonary resuscitation (CPR) under the
instruction of the paramedic in an attempt to revive the man. I also make two
recommendations. The first relates to the confusion experienced by staff on hearing
over the radio net about the emergency. The other concerns staff misunderstanding
the codes for calling healthcare assistance.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2008
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CONTENTS
Summary 4
The investigation process 5
The man 6
HMP Hull 7
Key findings 8
Issues 13
Recommendations and good practice 15
Annexes
1. Clinical review
2. Transcript of an interview with an Officer
3. Transcript of an interview with a Principal Officer
4. Notes of debrief dated 11.1.08
5. Extract from Inmate Medical Record
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SUMMARY
The man who died had been remanded in custody at HMP Hull. In August 2007, he
was sentenced to four years’ imprisonment. It was his first conviction. He died at
the age of 77.
The man had a long term heart condition and had been fitted with a pacemaker
around four months prior to his imprisonment. In addition, he had complained of
pains in his feet and had high blood pressure which was poorly controlled. Hull had
thoughtfully located him on the ground floor of I wing where food and medication
hatches were located. This meant he did not have to exert himself unnecessarily in
using stairs and getting his meals. The man also had access to a wheelchair if he
needed it.
In January 2008, he had a cardiac arrest (heart attack) in B wing exercise yard. He
had been making his way from I wing to see family members who were waiting for
him in the visits hall. Staff attempted cardio pulmonary resuscitation and called an
ambulance. The man was taken to Hull Royal Infirmary where staff also tried to
resuscitate him, but he died shortly after his arrival.
I and J wings are designated vulnerable prisoner wings, housing a significant
number of frail and elderly individuals. My investigator noted that it was a
considerable distance to walk from I wing to the visits hall, an issue that had been
previously identified by HM Chief Inspector of Prisons, Ms Anne Owers, in her
Thematic Review of Older Prisoners.
My investigation found that, despite the initial confusion surrounding the location of
the emergency, the response to the man’s collapse was almost immediate. Nursing
staff carried out cardio pulmonary resuscitation in appalling weather conditions.
They were aided by a member of staff who attempted to shelter them with an
umbrella. Other staff thoughtfully fetched blankets to keep the man warm.
Code amber was called over the radio net (code amber is used to indicate a medical
emergency where the individual is collapsed but breathing). The clinical reviewer
has found this to be unsatisfactory as it relies on staff diagnosing between a collapse
and a cardiac arrest. The clinical reviewer has recommended that this policy be
reviewed the better to inform healthcare as to the nature of the emergency. I agree.
I also recommend that the call codes be limited to code red for blood-evident
incidents and code blue for all other medical emergencies. This will ensure staff
bring the correct equipment with them. In this case, the outcome would have not
have been different, but it could well have a bearing on the outcome of emergency
situations in the future.
My recommendations aside, I judge that the care the man received before his
collapse and subsequently was entirely appropriate. I also commend the actions of
a Principal Officer who assisted the paramedics with their resuscitation attempts
during the journey to the hospital.
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THE INVESTIGATION PROCESS
1. I was notified of the man’s death on 10 January 2008. Terms of Reference
and notices were issued to staff and prisoners at Hull telling them that an
investigation would be taking place, and inviting those who wished to see the
investigator to make themselves known. My investigator requested copies of
the man’s core record, Inmate Medical Record (IMR), and other records
relevant to his time in custody and his death.
2. My Investigator also contacted the Coroner to ask for a copy of the post
mortem and toxicology reports. A second toxicology report was
commissioned specifically to examine the levels of warfarin. This was to
investigate an allegation made by a prisoner and friend of the man who died
that the man had been given incorrect medication.
3. My investigator visited Hull on 21 and 22 February 2008. She met the
Governor, Head of Residence and the Head of I and J wings, who also acted
as prison liaison for this investigation. My Investigator visited I wing and
spoke informally with staff and prisoners. The Head of I and J wings
accompanied my investigator as she walked a similar journey taken by the
man who died on 10 January. The journey started from I wing and proceeded
to the visits hall via B wing exercise yard where the man had collapsed.
4. A clinical review of the man’s medical care was commissioned from Hull
Primary Care Teaching Trust (PCT). The Clinical Governance Manager
conducted the clinical review which focussed on the medical care the man
who died received at Hull. The review appears as an annex to this report.
5. One of my family liaison officers, contacted the man’s daughter-in-law and
maintained telephone contact with her throughout the investigation. She told
my family liaison officer that the family did not have any concerns regarding
the man’s care at Hull. They were pleased with the care he received.
6. A copy of the draft report has been seen by the family and the prison service.
The family do not have any comments and the prison service has accepted
the recommendations I have made. The prison service response can be
found on page 14 of my report.
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HMP HULL
7. HMP Hull is located around two miles from Hull city centre. It opened in 1870
and was designed to hold both male and female prisoners. In 1939 it was
used as a Military Prison and then as a Civil Defence Depot. In the 1950s it
re-opened as a Closed Male Borstal. Following extensive security
renovations in 1969, the prison became a maximum security dispersal prison.
8. In 1986, Hull ceased to be part of the dispersal system and commenced its
current role as a male local and remand prison. The prison has a maximum
operating capacity of 1,035 prisoners and is rarely below that level.
9. Expansion and refurbishment in 2002 included four new wings, a new
healthcare centre, sports hall and improved kitchen, education and workshop
facilities. There are eight wings in total.
10. Healthcare is provided by Hull Teaching Primary Care Trust Provider
Services. The healthcare department is located on two floors. The first floor
contains consulting rooms for visiting clinics such as psychiatry, dentistry,
chiropody and opticians. The second level has an 18 bed unit that caters for
prisoners with medical and mental health needs who require 24 hour care.
The unit is currently undergoing refurbishment to enable the prison to give
palliative care.
11. The most recent inspection report by HM Chief Inspector of Prisons
acknowledged that Hull had risen to the challenges of a ‘burgeoning
population of often needy prisoners in inadequate conditions’. The prison had
made a number of improvements since the previous inspection in 2004. The
Quality of Prison Life Assessment rated the prison as a three star
establishment indicating that it is a generally safe prison with a commitment to
treating prisoners with decency.
12. The Independent Monitoring Board (IMB) in its latest report for Hull (2005 –
2006) says that overall the prison continues to be well managed. It praises an
organised and dedicated staff. Initial difficulties with Hull Teaching Primary
Care Trust taking over responsibility for healthcare provision were highlighted
at the time of the IMB report.
13. Since 2004, I have been responsible as Ombudsman for investigating all
deaths in custody, approved premises and immigration removal centres. This
includes both deaths from natural causes and those that are self inflicted.
Since 2004, my office has investigated nine deaths through natural causes at
HMP Hull.
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KEY FINDINGS
14. The man who died was remanded into custody at Hull in 2007. He was
convicted of serious offences following a trial at the Crown Court and later in
2007 a sentence of four years imprisonment was imposed. He was located in
the vulnerable prisoner wing. There is very little information within wing
records regarding the man’s behaviour but his fellow prisoners and staff
speak well of him as a pleasant, polite individual. Although he was retired
from work in the prison, the man attended education classes. He complied
with his sentence plan and was willing to be assessed for a place on an
Offending Behaviour course specific to his offence.
15. There is a well documented medical history covering his period in custody and
this is examined more fully in the clinical review. A note dated 18 May 2007 in
his clinical records acknowledges that he was fitted with a pacemaker prior to
imprisonment. He was prescribed warfarin (for the treatment and prevention
of abnormal blood clotting) and digoxin (for irregular heartbeat).
16. A further entry on the same day records states that the man who died told the
healthcare professional that he felt well with no problems. He said that he
was awaiting surgery at a local hospital to ‘clear the veins in his neck out as
they are both blocked’. On 16 August, a telephone call was made by an
unspecified member of healthcare staff to the hospital to check that there
were follow up appointments at the hospital. The member of staff was
informed that there were no follow up appointments for the man at that
hospital. A subsequent letter dated early December 2007 from the hospital to
the prison said that an appointment had been made for the man for early
January 2008. A handwritten note on the letter stated that the man was to be
referred to hospital by the local hospital. The referral was made because two
days before the man’s death, the prison was notified of a pacemaker check-
up appointment. This appointment was due to be at the Cardiac Investigation
Unit in February 2008. Sadly, the man died before the date of the
appointment.
17. Medical records indicate that, in addition to his heart condition, the man said
he had difficulty walking and complained of pain in both feet. He suffered
from high blood pressure that prison medical professionals noted was poorly
controlled.
18. The prison had placed the man on the ground floor of I wing. This enabled
him to obtain his meals and medication from the ground level without
unnecessary exertion. My investigator spoke to his friend who was permitted
to assist him in everyday tasks. My investigator walked the distance from I
wing to B wing exercise yard where the man who died collapsed and then
onward to the visits hall. She noted the distance was considerable and
unpleasant in poor weather as was the case on the day the man died. The
frailty of a number of the prisoners on I and J wings, including the man, would
have made the walk particularly difficult although wheelchairs were available.
HM Chief Inspector of Prisons, Ms Anne Owers, had also raised a concern
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regarding the distance between the vulnerable prisoner units and the visits
hall in her Thematic Review of Elderly Prisoners published in 2004.
19. A fellow prisoner and friend of the man who died was with him when he
collapsed on the exercise yard. The man’s friend raised a concern to staff
and my investigator that the man informed him that he had been given the
wrong medication the day before he died. The friend stated that the man was
very clear about the medication he should receive. On a number of occasions
in the past he had complained to his friend that he was dealt with by different
nursing staff who were not aware of his needs. Nursing staff had often sent
the man back from the medication hatch on the wing. They told him that he
was not due to receive medication and he should return either in the evening
or on the following day.
20. In the light of concerns raised by the man’s friend, a toxicology report was
requested by the Coroner. The report did not show any adverse results that
would indicate the wrong amount of medication had been administered.
However, the clinical reviewer has identified that the drug which might have
been administered incorrectly was warfarin. Accordingly, a further toxicology
report has been requested with specific emphasis on levels of warfarin. The
clinical reviewer investigated this matter in the light of the friend’s concerns.
She found that the man had been receiving the same dose of warfarin since
mid-November 2007 and concludes that this was entirely in keeping with his
needs. The toxicology report supports the clinical reviewer’s findings as it
concluded that, ‘The Warfarin is at a level expected with low therapeutic range
use.’
Events on 10 January 2008
21. An Operational Support Grade (OSG) member of staff, was standing by the
gate on B wing exercise yard as part of a team of staff monitoring prisoner
movements from the wing to the visits hall.
22. At approximately 1.50pm, the man who died, along with other prisoners, was
walking to the visits centre for an afternoon visit with his wife and daughter-in-
law. They passed through a gate supervised by the OSG. They had nearly
reached the visits centre when the man suddenly collapsed in the exercise
yard.
23. Movement is supervised by officers posted at various stages of the route
prisoners take while moving together from one location to another. This was
the case on the day the man collapsed. The OSG heard two prisoners call
out to him that the man had collapsed. Officer A was present and was also
supervising the line of prisoners on B wing exercise yard. He told my
investigator that a prisoner collapsed in front of him. He thought at first that
the man had slipped because of the wet conditions. Officer A approached the
man and found him unconscious. He said that he put the man in the recovery
position, at the same time calling a ‘code amber’ for healthcare assistance.
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24. The OSG also radioed for assistance using the call sign ‘code amber’ to
indicate to healthcare nursing staff that there was a medical emergency. The
Orderly Officer, the senior uniformed officer in charge of the prison, was also
supervising the line route when she heard the call over the radio net. She
was one of the first on the scene, arriving with the OSG and Officer B. The
Orderly Officer noted that the man had been placed in the recovery position
and that he was ‘turning blue’. She then asked the main Control Room to
immediately cease all prisoner movement.
25. A Staff Nurse was detailed as Hotel 5 (Hotel 5 is the call sign given to the
healthcare staff member who carries a radio and is detailed to attend all
medical emergencies in the prison). She told my investigator that at 1.59pm
she had received an unclear message over the radio net for Hotel 5 to attend
D wing. On receipt of the message, she asked for confirmation of the area
and was informed it was B wing exercise yard. The Staff Nurse attended with
a Senior Staff Nurse. Using the radio net, the Senior Staff Nurse immediately
requested a paramedic ambulance.
26. At the time the man collapsed, the Principal Officer was in the Stores
selecting suitable clothing for the poor weather conditions. He was not
wearing a radio but heard the code amber called over the storeman’s radio.
His initial understanding was that the incident was located on C or D wing as
the phonetic alphabet had not been used. (In other words, in the first instance
he misunderstood the location.) In interview, the Principal Officer confirmed
that nursing staff were on the scene by 1.58pm when he arrived.
27. Hull operates a colour coded radio net call system to give medical staff an
indication of the nature of the emergency. Code red is used if blood is
evident; code amber is used if the person is collapsed but breathing; code
blue is used if the individual is not breathing. My investigator found that
medical staff considered the ‘code amber’ call unclear. The system is reliant
upon an assessment by officers as to whether an individual is breathing or
not. The OSG called ‘code amber’ over the radio net when asking for
assistance from healthcare. However, my investigator found a lack of
understanding of requirements between healthcare and prison staff. The
Head of Healthcare, informed my investigator that her nursing staff needed to
be accurately advised as to the nature of the emergency so that they could
prepare for it and take the necessary equipment. In the man’s case,
healthcare staff arrived very swiftly to administer medical assistance.
28. The phonetic alphabet should be used by staff when using the radio net. It
was evident from the Principal Officer’s account and the notes of the debrief
held at Hull on 11 January, that staff initially misheard attendance at B wing
exercise yard as B or D wing. The Staff Nurse said she was initially unsure
whether the call was for D or B wing. The notes of the debrief record as an
action point: ‘K D to brief control room staff to use phonetic alphabet.’ It would
be good practice to implement this immediately. While not critical in this case,
as staff reached the man very swiftly, it might be so in future emergencies.
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29. The Principal Officer said that the Senior Nurse confirmed that an ambulance
had been called. She asked him to go to B wing for the emergency medical
bag (staff refer to it as the ‘grab bag’) as she specifically wanted the oxygen
bottle with a mask that would be in the bag. The Principal Officer said he
went on to B wing and asked an officer to collect the grab bag as he did not
know where it was on B wing.
30. The OSG said that the Orderly Officer arrived with Officer B. Officer B
instructed the OSG to go to B wing and fetch blankets to keep the man warm.
Around the time the man collapsed, the weather had deteriorated significantly.
Resuscitation attempts had to be conducted in high winds and torrential rain.
Officer B held an umbrella over the man while the Staff Nurse and the Senior
Nurse carried out cardio pulmonary resuscitation (CPR). Upon his return, the
OSG saw two healthcare nurses attending the man.
31. The Staff Nurse examined the man and noted no signs of life. She could not
detect a pulse, and observed that the man’s pupils were fixed and dilated, his
lips were blue and his heart had stopped. The Senior Nurse applied CPR for
approximately 12 to 15 minutes but the man did not respond.
32. The communications room log noted that at 1.59pm there was a call for an
emergency ambulance. At 2.03pm, Senior Staff Nurse 2 arrived, having been
asked to attend the incident to assist the Staff Nurse and Senior Staff Nurse
with CPR. The ambulance arrived at 2.10pm and went to the exercise yard.
The paramedics took over care of the man. They assessed the gravity of the
situation and immediately placed the man on a stretcher and into the
ambulance.
33. The Principal Officer asked Officer C if he would travel in the ambulance with
the man. The Principal Officer said that at the point the ambulance set off, the
paramedic asked him to assist in giving CPR. The Principal Officer said that
he knew the procedure but he had not used it since training some 20 years
before. The paramedic quickly instructed the Principal Officer in the method
of CPR and then asked him to continue for as long as possible. The Principal
Officer described to my investigator how, under the paramedic’s instruction,
he and the paramedic carried out CPR while being ‘thrown about at the back
of the ambulance’ as it was travelling at great speed.
34. The Principal Officer and Officer C went with the man into the resuscitation
area at the hospital. The Principal Officer described strenuous attempts by
medical staff at the hospital to save the man. Sadly, he was pronounced
dead at 2.30pm. The Principal Officer confirmed that the time between the
man’s collapse and the pronouncement of his death in hospital was
approximately 35 minutes.
35. Poignantly, at the time of his collapse, the man’s wife and daughter-in-law had
already arrived in the prison visits hall. At that point, the Head of
Resettlement received a radio message for him to attend B wing exercise
yard. The Head of Resettlement arrived at 1.59pm where he witnessed the
man lying on the ground and two members of healthcare attempting to
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resuscitate him. The Head of Resettlement told my investigator that, when
the ambulance arrived, he telephoned the wing principal officer and asked for
the man’s cell to be secured. He further asked for copies of the man’s prison
records to be sent to the Command Suite. When the Head of Resettlement
arrived at the Command Suite, he was told that the man’s family had arrived
for their visit. The Head of Resettlement went downstairs to meet the family.
He took them to the Care Suite where he told them what had happened.
36. The Principal Officer telephoned from the hospital to say that the man had
died. The Deputy Governor together with a member each of the chaplaincy
team and of the Independent Monitoring Board, went to the Care Suite. The
chaplain informed the family of the sad news. The family were very
distressed and the prison ordered a taxi to take them to the hospital. Staff
and the chaplain remained with the family until the taxi arrived.
11
ISSUES
Clinical Review
37. The Clinical Review was undertaken by the Clinical Governance Manager,
Hull Teaching Primary Care Trust (PCT). She concludes that the care the
man received was broadly similar to that which he would have received in the
community.
38. The man was due to attend an outpatient appointment at local hospital.
However, he died before the date of his appointment on 21 February. The
clinical reviewer consulted the Consultant Cardiologist, who originally treated
the man who died. They discussed whether, if the appointment had been
brought forward, it would have made a difference to the outcome. In the
consultant’s opinion, it would have made no difference as appointments are
set at six-monthly and sometimes annual intervals.
39. The reviewer considers that the response to the man’s collapse was in line
with local and European resuscitation policy. The initial confusion over the
location of the incident did not result in a significant delay that would have
affected the final outcome. The response of nursing staff to the incident was
very swift and the time from collapse to pronouncement of death was around
30 minutes. The clinical reviewer has reiterated my investigator’s finding that
the phonetic alphabet should be used to reduce the risk of misunderstanding
over the radio net.
40. The reviewer and my investigator spoke to the Head of Healthcare, regarding
the use of the red, blue and amber colour coding system to indicate the type
of medical emergency. As noted, ‘code red’ is used when blood is evident,
and ‘code blue’ is used when it is clear that a prisoner is not breathing. Code
amber is used to indicate that a prisoner is unconscious but breathing. The
Head of Healthcare was of the view that the ‘code amber’ is of little value to
nursing staff as it is not specific in advising nursing staff as to the type of
emergency they are called to attend. It also relies upon prison staff being
equipped to diagnose whether a person is breathing or not. The OSG used
the ‘code amber’ call sign as did the Orderly Officer. This did not truly reflect
the circumstances as the man had stopped breathing in the very short time it
took staff to reach him. Had a code blue been called, medical staff might
have had the opportunity to gain access to emergency medical bags before
arriving. In the man’s case, not carrying the correct medical equipment may
not have altered the outcome, but it might be a crucial factor in another
emergency in the future.
41. The reviewer has also highlighted the need for clarity regarding the use of
code amber. She says it is probable that the member of staff using the code
will not be healthcare trained. As a result, they may be unable to diagnose
the difference between collapse and a cardiac arrest. The reviewer’s
recommendation is for Healthcare to respond to both code blue and code
amber with the same urgency and equipment.
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I recommend that the Governor and the Primary Care Trust review the
coding policy with a view to restricting the use of Code Red for blood-
evident incidents and Code Blue for all other medical emergencies, to
provide medical staff with accurate information regarding the nature of
the emergency.
The radio net
42. Staff initially misunderstood the location where the man collapsed. The
Principal Officer was in the stores when he heard the Storeman’s radio. He
thought he heard that the incident occurred on either C or D wing. He quickly
found the location because, ‘I could see the incident occurring in front of me.’
The Senior Nurse was located on A wing when she heard the radio call for
nursing assistance. It was not immediately clear to her whether the call was
for B or D wing although this was quickly clarified. In the staff debrief held on
11 January 2008, it was noted that ‘several other members of staff also
commented on this’. It is good practice for staff to use the phonetic alphabet
over the radio net. This serves to reduce the likelihood of misunderstandings
and ensure effective communication and prompt action if necessary.
I recommend that the Governor reviews the policy and procedures
governing the use of the radio net and reminds all staff equipped with
radios to use the phonetic alphabet when directing other staff to
locations.
43. The Principal Officer is to be commended for his actions in assisting the
paramedic with CPR. The Principal Officer had not practised this procedure
since his training around 20 years before. On the paramedic’s instructions, he
assisted with medical procedures in extremely difficult circumstances.
Although the outcome was unsuccessful, the Principal Officer’s behaviour was
exemplary.
The Governor should commend the Principal Officer by way of a letter
for his actions in assisting with first aid under particularly difficult
circumstances.
Conclusion
44. The man’s death was sudden and unexpected. It occurred in particularly
poignant circumstances as his family were actually in the prison awaiting a
visit. In adverse conditions, every effort was made to save his life, but sadly
without success.
45. The investigation has found that the man received regular and appropriate
healthcare comparable to that in the community, with up to date records and
appropriate referrals to secondary care. Although I have made
recommendations concerning the use of call signs and coding, I have
concluded that the shortcomings identified would have made no difference to
the man’s chances of survival.
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RECOMMENDATIONS AND GOOD PRACTICE
1. I recommend that the Governor and the Primary Care Trust review the
coding policy with a view to restricting the use of Code Red for blood
evident incidents and Code Blue for all other medical emergencies, to
provide medical staff with accurate information regarding the nature of
the emergency.
Accepted. The prison service action plan response states ‘completed and
implemented 30th April 2008’.
2. I recommend that the Governor reviews the policy and procedures
governing the use of the radio net and reminds all staff equipped with
radios to use the phonetic alphabet when directing other staff to
locations.
Accepted. The prison service action plan response says that ‘ An email has
been sent to all control room operators regarding the use of phonetic
alphabet, and an email has been sent to all staff regarding the use of the
phonetic alphabet’.
3. The Governor should commend the Principal Officer by way of a letter
for his actions in assisting with first aid under particularly difficult
circumstances.
Accepted. The prison service action plan response has said that ‘Letter to be
drafted’ to the Principal Officer.
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