Individual at Leeds

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Leeds,
on 7 January 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
This is the report of an investigation into the death of a man, a prisoner at
HMP Leeds. The man died in his cell on 7 January 2009, shortly after having
been found collapsed by his cell mate. He was 68 years old. The cause of
death was found to be ischaemic heart disease (a lack of oxygen to the heart
muscle) and cardiomegaly (an enlarged heart) with a secondary condition of
fibrosing lung disease and bronchopneumonia.
I offer my sincere sympathy and condolences to the man’s family and all who
have been affected by his loss. I must, however, apologise to his family for
the delay to issuing this report.
The investigation was carried out by my colleague. An independent review of
the man’s medical care in prison was carried out by the local Primary Care
Trust. I am most grateful to the clinical reviewer for his assistance.
I would also like to thank the Governor and staff of Leeds for their co-
operation during the course of the investigation. My particular thanks go to
the safer custody team for their work in liaising with the investigator.
My investigation found that the man who died received a high standard of
medical care whilst at Leeds. However, it is apparent that there were
occasions in which his medication was not available to collect when he
needed it. Although this would not have adversely affected his health whilst in
prison, I recommend that a review of dispensing is undertaken. I make one
further recommendation, regarding the appointment of family liaison officers at
Leeds.
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 my investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman January 2010
2
CONTENTS
Summary 4
The investigation process 5
HMP Leeds 7
Key findings 8
Issues 14
Conclusion 19
Recommendations 20
3
SUMMARY
The man who died was remanded into custody at HMP Leeds on 7 July 2008.
He had several long standing health problems affecting his heart and lungs,
for which he took various types of medication. On account of these problems,
he spent his first two months in prison living in the healthcare inpatients’ wing
for observation and assessment.
Following an exacerbation of his symptoms, the man was admitted to the local
hospital for a week in mid August. In the month after discharge his condition
stabilised and, by mid September, he was well enough to move to a ground
floor cell on A wing.
The man’s first three months on A wing were largely uneventful. However, he
found it difficult to walk the long distance from A wing to healthcare and
became out of breath quickly. Both the man and his personal officer spoke to
healthcare staff in December to enquire whether he could be seen in his cell
rather than in healthcare, to spare him the walk. However, prison doctors
thought it was better for his heart and lung conditions that he continue to
exercise where possible.
On 17 December, the man submitted a complaint form in which he said that
his warfarin (medication he took to prevent blood clots) was never ready to
collect when he needed it. He therefore missed a day of medication when he
was due a new batch of warfarin. The healthcare manager asked a member
of staff to investigate this complaint. However, due to an apparent breakdown
in communication, the complaint never reached the assigned investigator.
The man’s records indicate that there were some occasions in which he did
not receive new warfarin until a day or two after his previous batch was due to
expire. My report recommends that the arrangements for dispensing
medications are reviewed.
Shortly after 8.00am on 7 January 2009, the man was found collapsed by his
cell mate. Over the next 20 minutes, staff attempted to resuscitate him.
Sadly, their efforts were unsuccessful and he was pronounced dead by a
prison doctor at 8.22am. The main cause of death was later established as
ischaemic heart disease and cardiomegaly.
In the weeks following his death, one of the man’s daughters complained to
the prison about the conduct of the appointed family liaison officer, Senior
Officer (SO) A. She said that SO A was not returning her calls and had made
several promises to contact her that she had not kept. In order to protect
relations with the man’s family, a new family liaison officer was appointed by
the prison in April 2009. SO A’s usual place of work at the prison is reception,
a very busy and demanding environment in a large local prison such as
Leeds. I recommend that the Governor consider appointing family liaison
officers who work in areas in which they can contact the bereaved family more
easily.
4
THE INVESTIGATION PROCESS
1. The investigation was opened on 7 January 2009 when the investigator,
issued notices announcing the investigation to staff and prisoners. The
notices included an invitation to those who wished to submit information
relating to the man’s death to make themselves known to the investigator.
No prisoners or staff came forward as a result.
2. The investigator was given access to the man’s prison files, including the
medical record. He visited Leeds on 21 April and 28 April, interviewing
four members of staff and one prisoner during the course of the
investigation.
3. An independent clinical review of the man’s health care whilst he was in
custody was carried out by a doctor on behalf of the local Primary Care
Trust. A doctor accompanied the investigator on 28 April, a visit which
included an interview with a prison doctor.
4. One of the Ombudsman’s family liaison officers contacted three of the
man’s daughters to inform them of the investigation and give them the
opportunity to raise any questions or concerns they had about their
father’s death. The family liaison officer spoke to the first of the man’s
daughters on 3 February 2009. She told the family liaison officer that she
had seen her father just before Christmas recalled that he was “fine” but
had lost some weight.
5. The family liaison officer spoke to another of the man’s daughters on 4
February. She raised the following issues with the family liaison officer:
(cid:127) Her sister had visited their father in December 2008. During the
visit, the man said that he had collapsed on 11 December and had
to be resuscitated.
(cid:127) She had heard several different versions of the events of the
morning of 7 January 2009, when her father died. The man’s
daughter asked that the report tells her what happened that
morning, including how her father was discovered and the timings
of events.
6. The family liaison officer spoke to the third daughter on 6 February. She
raised the following issues that she wished the investigation to address:
(cid:127) Her father wrote to her in December 2008 and said he had
collapsed on a Thursday on the way to hospital. He had keeled
over on the way to the ambulance and had to be resuscitated
before he got there.
(cid:127) On a visit in December, the man was “visibly puffing and panting”.
He used a spray more than once on the visit. His daughter asked
5
what the spray was used for and stressed that the investigation
should look at the standard of healthcare received by the man.
(cid:127) Her father had received a threat from his sister’s husband. This
may have added to his stress levels.
(cid:127) She had been told by the prison’s family liaison officer that she
would contact her after her father’s funeral to arrange a visit to the
prison. This never happened. She also said that she had left
messages for the prison’s family liaison officer but had received no
response. The man’s daughter contacted the Ombudsman’s family
liaison officer again several weeks later and said that she was still
having problems with the prison’s family liaison officer not returning
her calls.
7. I hope that this report helps to clarify any issues that might remain unclear
for the man’s children and helps them to better understand what
happened in the time leading to his death.
6
HMP LEEDS
8. HMP Leeds is a category B local prison serving courts in West Yorkshire.
At the time of the man’s death, the prison had an operating capacity of
1,004 across six wings. The man lived on A wing, the vulnerable
prisoners’ unit (VPU, a wing for those who request to be separated from
other prisoners for their own safety), for most of his time at Leeds.
9. During his first two months at Leeds, he lived as an inpatient in the
prison’s healthcare centre. There are 24 beds in the healthcare centre,
with provision for those with both physical and mental health needs.
Healthcare at Leeds is provided by the local Primary Care Trust.
10. Leeds was last inspected by HM Chief Inspector of Prisons, in December
2007. She found that Leeds had some significant problems and was
underperforming in several key areas. However, there had been progress
in all areas and managers were seeking to introduce further
improvements.
11. Half of those prisoners surveyed by the Inspectorate felt that health
services at Leeds were either good or very good. However HM Chief
Inspector of Prisons identified several areas for improvement. Among
these, she felt that waiting times to see a prison doctor were too long. She
also noted that not all healthcare staff had received resuscitation training
in the last 12 months.
12. In their annual report for 2009, the prison’s Independent Monitoring Board
commented that the healthcare team had improved the service provided to
prisoners over the course of the previous year. They reported that
healthcare was a “well managed and forward thinking department”.
13. The Ombudsman investigated four deaths in custody at Leeds in 2008, of
which three were due to natural causes. There have been a further three
deaths at the prison since the man died, one of which was due to natural
causes. One of the investigations in 2008 involved a man who collapsed
and died suddenly whilst living on A wing. The clinical review in that case
was also conducted by Dr J. He recommended that prisoners identified as
being at high risk of cardiovascular disease should be managed in line
with nationally agreed standards of care. This recommendation was
accepted by the Prison Service, to be taken forward as an element of the
prison’s chronic disease management plan.
7
KEY FINDINGS
14. At the time of his imprisonment, the man had an extensive medical
history. This included a condition known as congestive cardiac failure,
whereby the heart struggles to cope with any strain put on in (caused by
an insufficient oxygen supply to the heart), which usually leads to
shortness of breath on exercise. The man was taking the medications
frusemide and spironolactone to treat this condition.
15. As a result of the lack of oxygen to his heart, the man also suffered
frequent angina pains. He therefore carried GTN spray (glyceryl trinitrate
spray) with him, which is used by angina sufferers to relieve pain. As well
as this he suffered from an irregular heartbeat (a condition known as atrial
fibrillation). This particular condition can lead to the formation of a blood
clot in the heart and therefore increase the risk of a stroke. As a result of
this the man took warfarin. Other medications taken by the man in
relation to his heart disease were digoxin (to control the heart rate) and
simvastatin (to reduce cholesterol).
16. The man also suffered from chronic obstructive pulmonary disease
(COPD, a disease of the lungs in which the airways are narrowed), as a
result of which he regularly used inhalers and a nebuliser (a device similar
to an inhaler whereby medication is breathed in as a mist through a
mouthpiece or mask. Nebulisers are used to treat more severe symptoms
than an inhaler). Additionally, the man had previously been exposed to
asbestos, which also affected his lungs and led to increased shortness of
breath.
17. Following his arrival at HMP Leeds on 7 July 2008, the man was assessed
by a nurse for a first reception health screen (a routine health screen for
all new arrivals into prison). His medical history, as outlined in paragraphs
14-16, was recorded. The nurse also recorded that he had reduced
mobility and had previously used a scooter to travel. On account of his
numerous health problems, the nurse arranged for him to be admitted to
the healthcare centre’s inpatients’ wing for observation and assessment.
18. The man who died attended court the following day. In his absence, his
medication was confirmed with his pharmacist in the community and the
prescription chart was written and signed by a prison doctor. He remained
on the inpatients’ wing following his return from court. Various blood tests
were carried out on 9 July, none of which showed anything unusual.
19. On 11 July, the man was reviewed by a prison doctor. His International
Normalised Ratio (INR, a blood test used to check the effectiveness of
warfarin) was taken and found to be slightly lower than the normal range.
As a result the prison doctor increased the dose of warfarin from 5mg to
5.5mg.
20. A week later, the man was sick in his cell and said that he felt dizzy. The
following day he had to use a nebuliser to help him breathe. It was also
8
noted that minimal exertion left him breathless. On 24 July, he had to use
the nebuliser twice to help him breathe. It was reported on the same day
that he was able to walk around by himself and could care for himself
without assistance. The following day, the man’s INR was higher than the
normal range. The prison doctor therefore reduced his dose of warfarin to
4.5mg.
21. Towards the end of the month the man developed oedema (swollen legs
due to fluid retention), a condition that often develops in patients with
congestive cardiac failure. As a result the prison doctor increased the
man’s dose of frusemide, the medication he took to control oedema. The
swelling in his legs caused him difficulty walking so it was decided that he
should remain an inpatient for the time being.
22. The man continued to experience swollen legs in early August. He asked
for a wheelchair to move about the wing, but was advised by healthcare
staff that it was better for him to try to keep walking as much as he could.
His warfarin dose was reduced further, to 4mg, on 8 August.
23. In the early hours of the morning of 12 August, the man experienced chest
pain for several hours. He used his GTN spray, but this had no effect.
Later that morning he was reviewed by a prison doctor, who queried
whether he may have suffered a heart attack. She arranged for the man
to be admitted to the local hospital for investigation and monitoring.
24. The man was discharged from hospital on 18 August. He had been
diagnosed with an exacerbation of his heart and lung disease. The
discharge letter sent to the prison reported that he had “responded to
standard treatment”. His warfarin prescription was increased to 5mg by
the consultant cardiologist (heart specialist).
25. In the month following his discharge from hospital, the man’s health
stabilised. He still experienced some breathlessness and was advised to
stop smoking and walk round the exercise yard during association. He
started to use nicotine patches on 7 September, and occasionally used his
nebuliser if he was feeling breathless.
26. By 16 September, his condition had stabilised to the extent that he was
able to move out of healthcare to a cell on A wing. He was allocated a cell
on the ground floor of the wing and staff were advised that he did not need
any assistance to care for himself. A risk assessment was carried out
which concluded that he would be given his medication on a weekly basis
to keep in his possession and use as prescribed.
27. The man attended education classes during his time on A wing. He was
reported by the tutor to co-operate very well in class, work hard and
communicate well with the group. His cell mate said that the man got on
well with other people on the wing and would usually come out during
association and either sit and chat or play pool.
9
28. After ten days on A wing, the man’s INR reading was higher than
previously. His warfarin prescription was therefore reduced to 4mg by the
prison doctor. Over the following weeks, his INR was checked regularly.
Each reading was within normal limits and the prescription therefore
remained at 4mg.
29. He attended an asthma clinic on 25 November, at which the nurse
observed that he had a poor technique with his inhaler. She advised him
how to use it properly. A week later, he refused to attend for an INR
reading. The reason for this refusal is not recorded.
30. On 12 December, Officer A spoke to a prison nurse, about the man’s
mobility. Officer A was his personal officer on A wing. (Each prisoner is
assigned an officer on their wing who they can approach first with any
problems.) He told the prison nurse that the man became very breathless
when he walked back from healthcare, and asked if there was any other
way he could be seen. The prison nurse said that she would discuss this
further with her colleagues.
31. Officer A described to the investigator the route that the man who died
took to healthcare. It involved walking up three flights of stairs to the top
floor of A wing, across to C wing, down three flights of stairs on C wing
and then a walk of around 250 yards to the healthcare centre. He recalled
that on one occasion he was “really, really struggling … he was really
gasping” on his return from healthcare. It was this that prompted Officer A
to speak to the nurse.
32. The man submitted a complaint form on 17 December. He complained
that his warfarin was never ready to collect when he needed a new batch.
This meant, he said, that he always missed a day of treatment when his
warfarin ran out. He said this had been going on throughout his time at
Leeds.
33. The following day, he spoke to the prison nurse to follow up Officer A’s
query of 12 December. He asked if he would be allowed to have medical
staff visit him in his cell, rather than having to walk to healthcare and back
for appointments. He was told that the situation had been discussed with
the prison doctor, whose view was that it would “do him good” to walk over
to healthcare. The man queried this and said he was becoming
breathless and dizzy on the walk to and from healthcare. The prison
nurse said she would discuss the situation further with the prison doctor.
34. Later that morning, the prison nurse spoke to the prison doctor and
another prison doctor. They both agreed that, in view of his COPD, the
man should continue exercising, but should be encouraged to go at his
own pace. At interview with the investigator, the prison doctor explained
the reasons behind his decision:
“We try to encourage people to come to us if it’s at all possible because
there’s good evidence in the long term management of obstructive lung
10
disease that exercise is good for you, prolongs life and maintains
respiratory function. It’s also well documented in cases of heart
disease to get regular exercise … We felt that [walking to healthcare
and back from A wing] was overall beneficial for him, certainly having
seen him on his arrival in healthcare he didn’t seem to be performing
too badly.”
35. On 22 December, the healthcare manager replied to the man’s complaint
form submitted five days previously. His reply consisted of the following:
“I feel that this situation does need to be reviewed and you should be
given an explanation as to why this apparently keeps happening.
Therefore I have asked the matron to investigate this complaint and
offer you an explanation.”
The investigator spoke to the matron about the man’s complaint. She said
she had no recollection of being asked to carry out an investigation.
36. At an appointment with the prison doctor on 24 December, the man
repeated his complaint that he did not get warfarin every day. The
previous day, his INR reading had been lower than usual although he told
the doctor that he did not want to increase his warfarin dosage. The
prison doctor noted that they would try to get warfarin to him every day
and check this in a week. (There is no record of any check taking place,
nor of the man making any further complaints about missing medication.)
37. The next INR reading was taken on 6 January 2009. The level was
normal and no change was made to his prescription. At around 4.30pm
that afternoon, an officer unlocked the man’s cell for the evening meal.
He told the officer that he did not feel very well and was not hungry. He
did not say what symptoms he had. The officer told the investigator that
he looked the same as usual and was able to hold a normal conversation.
She added that she had no concerns about his health and did not think it
was necessary to call healthcare. It does not appear as though the man
raised any further concerns about his health during the night.
38. At around 7.30am the following morning, Officer A unlocked the man’s cell
so that his cell mate could collect his own medication before going to
work. Officer A spoke briefly to the man’s cellmate and added that he did
not see the man, but had no reason to be concerned about him.
39. Around half an hour later, Officer B returned to the cell to let the man’s
cellmate out to go to work. He shouted to the man’s cellmate that it was
time to go to work and moved onto the next cell. Officer B told the
investigator that he did not open the door and therefore did not see the
man.
40. The man was sitting in the cell toilet when his cell mate got up. His
cellmate went in and realised that the man was not moving. He told the
investigator that he touched him and thought that he was dead. The
11
man’s cellmate left the cell and shouted to the nearest member of staff,
Officer C, that the man was “sat on the toilet dead”.
41. Officer C went into the cell, followed by Officer A, and shook and spoke to
the man. He got no response and therefore left the cell and shouted to
Nurse A to assist. The nurse was on duty on A wing that morning to
distribute medication to prisoners. She went to the cell immediately.
42. The two officers moved the man to the floor and Nurse A made a ‘code
blue’ call for assistance on her radio. (Code blue is an emergency code
used in several prisons to indicate that urgent assistance is required for a
prisoner who is having severe breathing difficulties or who has stopped
breathing.) The control room log records that this call was made at
8.05am.
43. Nurse A then checked the man for a pulse, but could not find one. She
also observed that he was not breathing. Nurse A immediately began
cardio pulmonary resuscitation (CPR) with the assistance of Officer Y,
who had arrived at the cell shortly after her. At the same time, she asked
the other officers present to request an ambulance. Officer A made the
call. The control room log records that an ambulance was called at
8.08am.
44. Shortly afterwards, Nurse B arrived at the cell in response to the earlier
‘code blue’ call for assistance. After assessing the situation, she left to go
to the centre (a central area from which the main wings lead off) to collect
the emergency bag, containing resuscitation equipment and a defibrillator.
On her return, Nurse B took over CPR from Nurse A, who attached the
defibrillator to the man. The defibrillator advised that they should continue
with CPR and give no shock, as there was no electrical activity in the
heart.
45. At around 8.12am, another officer and two prison doctors arrived at the
cell. The officer took over CPR and applied an oxygen bag and mask.
The nurses took turns to give chest compressions. The prison doctor
administered adrenaline and, shortly afterwards, atropine (medications
used to try to start the heart beating).
46. The defibrillator was attached again and, as previously, the advice was
that no shock could be given. After concluding that their resuscitation
attempts were going to be unsuccessful, the prison doctor pronounced the
man’s death at 8.22am. The paramedics arrived in the cell around one
minute later and confirmed this. A post mortem report later found the
cause of death to be ischaemic heart disease (a lack of oxygen to the
heart muscle) and cardiomegaly (an enlarged heart) with a secondary
condition of fibrosing lung disease and bronchopneumonia.
47. As the man had not provided details of his next of kin to reception staff,
his visits record was used to establish to whom the news of his death
should be broken. His most recent visitor was one of his daughters, who
12
had visited on 22 December 2008. The appointed family liaison officer,
Senior Officer (SO) A, along with the deputy family liaison officer, SO B,
and their manager, Governor A visited the man’s daughter around three
hours after his death. His daughter broke the news of his death to other
family members. His sister was informed over the telephone by SO A the
following morning.
48. The man’s funeral was held on 28 January and was attended by SO A
and SO B. The investigator found that the prison’s contribution to the
funeral costs was in accordance with PSO 2710 (the Prison Service Order
that sets out the actions to be taken following a death in custody).
49. As well as not naming any next of kin, the man did not leave a will. As
such, it was for the Probate Service to determine who the executor of his
estate should be, by issuing a letter of administration. Until this process is
complete, the prison cannot hand over any of his money or property. At
the time of writing this report a letter of administration had yet to be
issued.
50. In April 2009, SO A was replaced as family liaison officer by Governor A.
One of the man’s daughter’s had written to the prison to express her
unhappiness at the contact she had had with SO A. She told the
Ombudsman’s family liaison officer that SO A had not returned her calls
and had made promises to contact her which she did not keep.
51. Governor A told the investigator that the prison understood the complaint
to be that SO A had been speaking to other members of the family and
given out property inappropriately. She also thought that some members
of the family wanted SO A to apply for the letter of administration, which
was not her role. Although she supported SO A and did not think she had
acted inappropriately, they felt that it was best to make a fresh start and
appoint a new family liaison officer.
13
ISSUES
Warfarin prescription
52. On account of his heart condition, the man who died had been taking
warfarin for some time prior to coming into prison. The medication was
used to thin his blood and stop clots forming. During his time in custody,
his INR reading was taken regularly. When this reading fell outside
acceptable ranges, his warfarin dose was adjusted accordingly.
53. In December 2008, the man submitted a complaint form in which he said
that his prescription was never ready to collect when he needed it. This
meant that he missed a day’s medication with each batch of warfarin
received. He was told that a member of healthcare staff would be asked
to investigate. However, due to an apparent breakdown in
communication, the identified nurse was never asked to take this forward.
54. The man’s dispensing records show that he was given a 14 day supply of
warfarin on 1 December 2008. He was next dispensed warfarin on 17
December, the same day that he submitted his complaint form, some 16
days since his previous batch was received. There are similar
discrepancies between the supply of warfarin dispensed to the man and
the time until he collected his next batch in both October and November
2008. After he submitted his complaint form, he collected his warfarin
every week with no further discrepancies.
55. The prison doctor told the investigator that it was a “very common
problem” for prescriptions to go missing in prison. He explained the
impact of missing a day of warfarin as follows:
“I think if you miss a day of warfarin it probably won’t make very much
difference because it’s quite a long acting drug … [missing] a day or
maybe even two is probably not going to have a massive impact
clinically. Although clearly it’s undesirable that anyone should miss any
medication it’s very, very difficult to legislate for all the things that seem
to go wrong in prison practice. Due to a shortage of nursing staff who
were competent to deal with warfarin I did dramatically reduce the
numbers of patients who were maintained on it at some point last year.
But the man, having been well established on warfarin, we kept him on
it.”
56. The clinical reviewer considers the man’s missing warfarin:
“I do not consider this to have been a serious problem or contributing
adversely in any way to the man’s health whilst in prison. I base this
on the fact that he had very regular INR blood tests to monitor the
effectiveness of the warfarin therapy and these results ranged between
2 and 4 – the usual acceptable standard … The last INR dose test was
entirely satisfactory at 3.2. This was measured the day before his
death. My opinion is that his warfarin therapy was managed
14
appropriately and except for the occasional missed dose this was to a
high and acceptable standard.”
57. However, the clinical reviewer goes on to make the following
recommendation, which I support:
A review should be held of medicines management and the
dispensing of important medications, such as warfarin, so that any
missed doses are immediately recognised and that the likelihood of
this happening is reduced.
58. Following the death of the man, NHS local Community Healthcare carried
out an internal serious incident investigation. They made the following
comment on the Ombudsman’s draft report:
“Whilst agreeing with the [Ombudsman’s] findings that the man did not
always receive his medication on the date that it was due, [our]
investigation found that this was due to a ‘mixture of patient and
system factors’. Patient factors identified the patient had on occasions
willingly not engaged with healthcare staff to pre-order a repeat
prescription as per the local renewal of in possession medication
process.”
Mobility
59. One of the man’s daughters told the Ombudsman’s family liaison officer
that her father had said during a visit that he had collapsed on 11
December 2008 and had to be resuscitated. Another daughter told the
Ombudsman’s family liaison officer that her father had written to her in
December 2008 and said he had collapsed on a Thursday on the way to
hospital. (11 December 2008 was a Thursday.) He wrote that he had
“keeled over” on the way to the ambulance and had to be resuscitated
before he got there.
60. The man’s medical record does not show any hospital appointments or
emergency admissions in December 2008, nor is there any indication that
he had to be resuscitated at any time before 7 January 2009. None of the
staff to whom the investigator spoke were aware of him collapsing and
needing resuscitation in December 2008.
61. It is likely that the events raised by the man’s daughters are linked to the
request made to healthcare by Officer A on 12 December. Officer A
advised that the man became very breathless on the walk from healthcare
to A wing, and asked whether there was any other way that he could be
seen, such as in his cell. The issue was discussed by the prison doctors,
who agreed that it would be beneficial for the man to continue exercising.
The prison doctor’s reasons for this decision are outlined in paragraph 34.
It was not felt to be in his best interests for him to have his medical
appointments in his cell.
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62. The clinical reviewer makes the following comments in the clinical review,
with which I agree:
“The clinical care of the man during his time in custody was to a high
standard and certainly equivalent if not better to the care that could
have taken place in a community setting. I have no reason to believe
that anything could have been done differently prior to [his death] in
terms of care of his long term conditions that would have prevented the
unfortunate outcome.”
The man’s health during a visit in December 2008
63. One of the man’s daughters told the Ombudsman’s family liaison officer
that he was “visibly puffing and panting” during a visit in December and
used a spray on more than one occasion. She asked what the spray was
used for and requested that the investigation explore the standard of
healthcare received by the man at Leeds. His daughter also said that he
mentioned during a visit that he had been threatened by his sister’s
husband. She wondered whether this might have added to his stress
levels.
64. On account of his COPD, the man regularly used inhalers and nebulisers.
Given his daughter’s description of him “puffing and panting”, it is probable
that it was one of these devices that he used during the visit.
65. His daughter also questioned whether a threat he had allegedly received
may have contributed to his stress. There is no evidence of him reporting
any threat to prison staff, nor of him saying he felt stressed for this reason.
66. The clinical reviewer comments on the standard of medical care received
by the man at Leeds. He considers that he was “well assessed and cared
for” during his first two months in prison, when he was an inpatient in the
healthcare centre. He goes on to say that, following his move to A wing,
he received “appropriate” care for his medical conditions. As I have noted
in paragraph 62, the clinical reviewer concludes that the medical care
received by the man at Leeds was to a “high standard”.
Collapse on 7 January 2009
67. The post mortem report found that the main cause of the man’s death was
a lack of oxygen to the heart and an enlarged heart. The clinical reviewer
describes the events as follows:
“The man appears to have suffered a sudden and complete loss of
cardiac [heart] output causing a collapse and unconsciousness.
Irreversible damage to major organs leading to death would have
occurred within a few minutes of this collapse. Unless the heart can be
restarted within the first few minutes, and then sufficient cardiac output
maintained by further medical intervention, death is an inevitable
outcome.”
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68. Staff were alerted to the man’s collapse by his cell mate, shortly after
8.00am on 7 January. A nurse was on the wing at the time and went
immediately to his cell. On her arrival, the nurse made an emergency
coded radio call for medical assistance. She then began to try to
resuscitate him. Whilst it might also have been appropriate to request an
ambulance at this stage, there was just a short delay of around three
minutes until the nurse did so. In any case, the prison doctors arrived at
his cell at around 8.12am, around ten minutes before the paramedics, and
administered drugs to try to restart his heart. A defibrillator was also
applied but indicated that no shock could be given at any time.
69. The clinical reviewer makes the following comments on the resuscitation
attempt, with which I agree:
“It is my opinion that the procedures for dealing with a medical
emergency on A wing appear to have been followed correctly and there
was an adequate response in terms of appropriate numbers of the
trained personnel arriving in a timely fashion to try to resuscitate the
man. The manner of resuscitation was clearly appropriate and of a
sufficiently high standard.”
Contact with the man’s family following his death
70. It is unfortunate that I have to report that relations between the prison and
some members of the man’s family were strained following his death.
One of his daughters told the Ombudsman’s family liaison officer that the
prison’s family liaison officer, SO A, had made promises to contact her
which she did not keep. She said SO A had said she would telephone her
after the man’s funeral to arrange a visit to the prison, but had not. She
also said that she had left messages for SO A but her calls had not been
returned.
71. SO A told the investigator that she did not recall agreeing to telephone his
daughter after the funeral, nor did she think she had failed to return any
calls. The prison’s family liaison manager, Governor A, told the
investigator that they understood the complaint to be related to SO A
speaking to other members of the family and handing over property. The
disagreement was apparently resolved in April 2009, when Governor A
appointed a new family liaison officer. She told the investigator that she
supported SO A and did not think she had acted inappropriately, but
thought it was best to make a fresh start.
72. This was not an easy case for SO A to work on. She found herself
dealing with a divided family and was therefore required to keep in contact
with several family members. At times she found herself speaking with up
to half a dozen different relatives about the same information.
73. I am unable to determine whether there were any instances when SO A
failed to return calls or messages to the family. Her usual role at the
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prison is as a senior officer in reception. In a large local prison such as
Leeds, this can be a very busy and demanding environment. SO A does
not have her own telephone and messages have to be left with other
members of staff. Although I am unable to say whether this did happen,
given the nature of her place of work, it would not be surprising if some
messages did fail to reach their intended recipient.
74. In several prisons at which the Ombudsman has undertaken
investigations, the family liaison officer carries a mobile telephone. This
enables the bereaved family to contact them quickly and efficiently. For
security reasons, this would not be practical in all areas of a prison. At the
very least, however, I would expect a family liaison officer to have their
own direct dial telephone, with voicemail service. Whilst I do not intend
any personal criticism of SO A, I am not persuaded that a busy reception
area is a suitable place for a family liaison officer to work.
The Governor should ensure that family liaison officers work in an
environment in which they can be easily and directly contacted by
the bereaved family.
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CONCLUSION
75. The man who died was an older prisoner with several long standing health
problems. On account of these conditions, he spent his first two months
at Leeds living on the healthcare inpatients’ wing. Once his health
improved, he was able to take a cell on the ground floor of the vulnerable
prisoners’ unit (VPU). He raised two concerns about his health whilst
living on the VPU. Firstly, that the walk to healthcare left him very
breathless and, secondly, that his warfarin prescription was never ready to
collect when he needed it.
76. My investigation found that the man received a high standard of medical
care whilst in prison and that the decision of the prison doctors to continue
to ask him to attend healthcare when he had an appointment was
reasonable. However, it appears that there were indeed some occasions
in which he went without warfarin for a day or two. Although the clinical
reviewer considers that this did not adversely affect his health, he
recommends that a review of medicines management is held at Leeds.
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RECOMMENDATIONS
1. A review should be held of medicines management and the dispensing of
important medications, such as warfarin, so that any missed doses are
immediately recognised and that the likelihood of this happening is
reduced.
Accepted – from a wider view of medicines management implemented by
healthcare, three initiatives have been implemented that have improved
access to medication services for patients:
(cid:127) All prescription repeat requests are now sent to pharmacy at least 72
hours prior to the due date for renewal. This reduces the risk of the
medication not being back on the wings by the date required.
(cid:127) The skills mix of staff delivering the medication administration services
has been reviewed with pharmacy technicians now managing
treatments on the wings. This improves governance through; clearer
clinical communication pathways from treatments to pharmacy,
pharmacy technicians expertise and competence in medication
administration and through introducing community pharmacy systems
and standard operating procedures.
(cid:127) A daily check of prescriptions not collected at the end of treatments is
now carried out by pharmacy technicians, who follow up patients to
ascertain the reason for non collection and initiate any clinical
corrective action required.
2. The Governor should ensure that family liaison officers work in an
environment in which they can be easily and directly contacted by the
bereaved family.
Accepted – family liaison officers are not always on duty but there is a
dedicated telephone line on which families can leave a message for the
family liaison officer. This is given by the family liaison officer to the family
during their first contact along with their work extension number.
Messages are checked daily then passed onto the family liaison officer.
Every family liaison officer now has a deputy to cover if they have to be
absent for any reason.
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