Individual at Whatton

Circumstances surrounding the death in April 2007 of a
man in hospital whilst a prisoner at HMP Whatton
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2008
1
This is the report of an investigation into the death of a man. The man died in the
hospital, after collapsing in his cell at HMP Whatton in the early hours in April
2007.
A post mortem was held at the request of the Nottingham Coroner and it
revealed that the man’s death was to due to natural causes. The cause of death
was recorded as a myocardial infarction (heart attack).
I extend my sincere condolences to his family and friends.
I would like to thank the Governor at Whatton and his staff for their help and
assistance to my investigator.
I also commissioned a clinical review of the care afforded to the man whilst he
was in Whatton. This was carried out by a doctor on behalf of Nottinghamshire
Primary Care Trust. I am grateful to the doctor for his review.
My report includes one recommendation. I also endorse one made in the clinical
review dealing with medical emergencies at night. One recommendation has
been accepted and the second recommendation has been partially accepted by
the Governor and Head of Healthcare at HMP Whatton. The man’s family
acknowledge the findings of this report but remain dissatisfied with Derbyshire
Probation Service handling of their brother’s case.
This version of my report, published on my website, has been amended to
remove the name of the man who died and those of staff and prisoners involved
in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2008
2
CONTENTS
Summary
The Investigation Process
HMP Whatton
Key Findings
Issues
Recommendations
3
SUMMARY
The man was sentenced to two years imprisonment in June 2005 at Crown
Court. He was released in October 2005 on licence with various conditions. The
man was placed in a hostel in Derbyshire, near to his family. He had learning
difficulties and other mental health problems.
The man was recalled to prison in February 2006 after breaking his licence
conditions. He was re-released by the Parole Board in May to an approved
premises (hostel) in Derby. In August, the man was again re-called to prison for
breaking his licence conditions having entered an exclusion zone detailed on his
licence.
The man was received into HMP Nottingham and later transferred to HMP
Whatton in October 2006. The first reception health screen document noted his
health problems, including hypothyroidism (under-active thyroid), epilepsy,
gastritis, and his learning difficulties. It further noted that the man’s parents had
died of heart disease related illnesses. He was offered advice from healthcare
staff on a healthier lifestyle as a means of preventing heart disease.
In January 2007, at an oral Parole Board hearing at Whatton, it was agreed that
the man could be released once an assessment plan had been re-worked by his
Probation Officer. The hearing was adjourned for six weeks until this happened.
It was also noted by the Parole Board that the man was mentally impaired,
possibly to the extent that he was unable to comprehend the conditions of his
licence.
The man was an offender subject to Multi Agency Public Protection
Arrangements (MAPPA) at level three (offenders who because of the offences
they have committed are considered to pose a risk of serious harm to the public).
Meetings were held to ensure that appropriate arrangements were being
considered for his release, including providing the man with supported housing,
assistance from Social Services and help from the Learning and Disabilities
Team. At the time of the man’s death, his probation officer was trying to ensure
a full support package was in place before the man was released so that his risk
could be safely managed in the community.
In the early morning of 23 April at 3:50am, the man rang his cell bell to tell staff
that he was experiencing pain in his chest. The senior officer on duty was
contacted and attended the man about 20 minutes later in his cell. He then
called the emergency out of hours doctor service and was advised to call an
emergency ambulance so that his heart rate could be monitored. An ambulance
was called at about 4:15am.
Staff kept checking on the man and made enquires about his medical condition.
The prison gates were opened in preparation for the arrival of the ambulance.
4
At around 4.20am, the man was found to be unresponsive in his cell. Staff called
for immediate assistance, and the senior officer and an officer entered the cell.
He did not respond and was sweating and struggling to breathe. The senior
officer collected a defibrillator machine (this sends an electric shock to the heart)
from the nearby healthcare centre and applied this alongside using Cardiac
Pulmonary Resuscitation (CPR).
When the ambulance arrived, paramedics took over the resuscitation attempts.
The man was then transferred to hospital, where he was pronounced dead
shortly after arrival.
5
THE INVESTIGATION PROCESS
One of my investigators visited Whatton on the 3 May 2007. My investigator met
with the deputy governor, and the prison’s Family Liaison Officer. My
investigator reviewed the man’s medical records and prison file, and took copies
of those documents. She then visited a wing and saw the man’s cell.
A clinical review was commissioned from Nottinghamshire Primary Care Trust to
assess the man’s medical care whilst in prison. A doctor subsequently carried
out this review and I am grateful to him for his report.
One of my own Family Liaison Officers made contact with the man’s family
informing them of our investigation. The man’s sister-in-law, raised several
points in relation to her brother in law’s recall to prison and to Derbyshire
Probation Area that I have dealt with in this report. The family were appreciative
of the support and assistance from the prison.
On 1 June, my investigator visited Derby and spoke to the man’s probation
officer. On 6 June, my investigator returned to Whatton and interviewed
members of staff and prisoners who knew the man.
On 12 June, my investigator met with a voluntary agency that had been part of
the MAPPA panel. This panel met regularly to discuss his future release plans.
6
HMP WHATTON
Whatton is a category C prison that currently holds 761 adult male prisoners,
primarily sex offenders. It first opened as a detention centre for juveniles, but its
role changed in the early 1990s to that of a prison for vulnerable adult offenders.
During this time, the prison developed as a specialist establishment for adult
male sex offenders to enable them to participate in the Sex Offender Treatment
Programme. Whatton has recently undergone a large expansion programme.
Whatton was last inspected by Her Majesty’s Chief Inspector of Prisons, Ms
Anne Owers, in February 2004. Ms Owers found that: “Whatton … provided a
respectful environment with good standards and cleanliness, food and
healthcare. Staff-prisoner relationships were excellent which … speaks volumes
for the professionalism of the staff.”
Healthcare within the prison is commissioned and provided by Nottinghamshire
County Teaching Primary Care Trust. There is no 24 hour healthcare service in
the prison, therefore no medical staff are on site during the night or weekends.
If staff need a doctor out of normal healthcare unit times, contact is made with
Nottingham Emergency Medical Service (NEMS).
Medication is administered on a weekly and/or monthly basis to those prisoners
who have been risk assessed as suitable to hold it in their own possession. It is
administered on a daily basis to other prisoners, when either they are considered
to be at risk or the medication is considered unsuitable to be held in their
possession.
7
KEY FINDINGS
The man was received into HMP Nottingham on remand in October 2004. He
was sentenced to two years imprisonment in June 2005. The man was later
transferred to HMP Lindholme and released, on licence, in October 2005. In
February 2006, the man was recalled to prison following a breach of his licence
conditions. He returned to Nottingham and was then transferred to HMP
Stocken. In May, the man was released from Stocken following a Parole Board
recommendation. The Board agreed that his recall had been appropriate but
said that the man could be re-released into the community. He was released to a
hostel in Derby, under the supervision of Derbyshire Probation Area.
In August 2006, the man was again recalled to prison following a breach of his
licence conditions. He was received into HMP Nottingham, then transferred to
Whatton in October and located on A wing. He settled well into the regime of the
prison. Throughout the man’s time in prison his mental health issues and
learning difficulties were appropriately identified.
A first reception health screen document was completed. The document noted
his medical conditions of hypothyroidism, epilepsy and gastritis. The document
also noted that the man had suffered from depression associated with his alcohol
use. His learning difficulties were also documented. The man’s family history of
heart disease was recorded; actions were taken in relation to these, and staff
made plans to check his blood lipids and to review this with the GP. Thyroid
function tests and a full blood count were also requested.
In November, a blood sample was taken to test the man’s thyroid levels. In
December, he underwent routine management of his thyroid problem and his
medication levels were maintained.
When the man had first arrived, his medication had been administered to him on
a daily basis due to his history of non-compliance. By the end of the year he was
considered ready to keep his medication in his own possession and staff ensured
he was able to take it correctly.
In January 2007, a Parole Board hearing at Whatton agreed that the man could
be re-released after an assessment plan had been re-developed by his probation
officer. The Parole Board noted that the man had learning difficulties and might
have lacked understanding of his licence conditions. The probation officer was
working with a multi-agency partnership to ensure the man was fully supported
on his release.
In February 2007, following his blood test results, the man was seen in
healthcare to discuss his diet and exercise. He had difficulty in reading so the
nurse used pictorial information to explain the importance of a healthy lifestyle.
The man was advised on a walking regime. He was not interested in smoking
8
cessation sessions. The man’s thyroxin medication was increased to 50mcgs
daily.
In February 2007, the man was transferred to B wing and started work in the
manufacturing workshop. On 23 February, his thyroxin was further increased to
75mcgs daily. In 2 April, his medication was reviewed and it was noted that the
man felt well on his present prescription. Finally, on 16 April, another blood
sample was taken prior to a planned GP review.
On 23 April at 3:50am, the man rang his cell bell on the wing. Operational
Support Grade (OSG) Officers attended his cell. The man told the officers he
had pains in his left arm and centre of his chest, but he did not display other
signs of distress. The officers immediately notified the Night Orderly Officer
(NOO) who was on the wing. The NOO then radioed an officer who was in the
Control Room, to join him on the wing. During night time patrol, two officers
would need to be present to unlock a cell. (The Control Room is away from the
wing.)
At approximately 04:10am, the NOO and the officer visited the man in his cell so
they could observe his physical symptoms and make a decision on what medical
action to take. The man told the NOO he had been having pain for about two
hours and that he had taken medication for his epilepsy the night before. The
man was sitting up on his bed. He was pale in colour and sweating even though
the cell window was open and it was cold. The NOO asked the OSGs to check
on the man every five minutes.
In the meantime, the NNO contacted Nottingham Emergency Medical Services
(NEMS), a doctors out of hours service. He spoke to a doctor who advised him
to call for an emergency ambulance and ask the paramedics to carry out an
Electrocardiograph (ECG) when they reached the man. At about 4:15am, the
NOO ensured an ambulance was requested through the communications room.
He then asked the officer to enquire about family medical history with the man.
He told the officer that both his parents had died as a result of heart conditions.
The man said he felt a little bit better. The officer proceeded to make
arrangements for an escort for the ambulance when it arrived.
About 4:20am, one of the OSGs checked on the man and found he had
collapsed on his bed. His eyes were shut, his skin had a grey colour and he was
struggling to breathe. The OSG immediately called for assistance.
The NOO and the officer returned immediately and entered the man’s cell. They
checked for a pulse and attempted to open his airway. HIs breathing was very
shallow. The NOO left the cell to get the defibrillator machine from the
healthcare centre which was very near to the Wing. He then followed the
instructions on the defibrillator and commenced Cardio Pulmonary Resuscitation
(CPR) until the paramedics arrived at 4:45am.
9
The paramedics continued CPR for around 40 minutes. The man was then
transferred to hospital by emergency ambulance with an officer escort. On
arrival at the hospital, the man was pronounced dead.
The man’s family was informed of his death by Derbyshire Police that morning.
On 24 April, the prison’s Family Liaison Officer visited the man’s family at their
home.
A memorial service for the man was held in the prison’s chapel. The Governor,
attended the man’s funeral. His family told my colleagues that they were
extremely grateful to the staff at Whatton and appreciated their support and
assistance with funeral expenses.
10
ISSUES
Clinical Review of the man’s care at Whatton
Nottinghamshire PCT was commissioned to carry out a review of the man’s
medical care. A doctor carried out this review on behalf of the PCT. He
concluded that the man’s medical care in Whatton was appropriate. A
comprehensive health screen was carried out and plans were made regarding
the man’s ongoing care. His cardiovascular risks were identified and his blood
lipids were checked. With his learning difficulties in mind, Whatton healthcare
staff went to great lengths to educate him to adopt positive lifestyle changes to
prevent death from cardiovascular disease.
The clinical reviewer also commented that there was a 25 minute delay before an
emergency ambulance was called. This time period reflects the procedural
delays involved in alerting the NOO, the arrival of a second officer to open the
man’s cell, and the time taken to seek advice from emergency services and then
acting on it in accordance with local policy.
The NOO needed to enter the man’s cell to be able fully to observe his physical
symptoms. But when the prison is on night patrol status, two officers are
required to be present for a cell to be unlocked and entered. (This is a local
security policy guideline.) The man had complained of chest pain and tingling in
his arms but did not display any signs of distress. The NOO followed correct
local procedure by waiting for the officer. The two officers entered the man’s cell
and observed his physical condition. From their observations, the NOO
contacted the emergency out of hours doctor for advice who, in turn, advised that
an emergency ambulance should attend. This was done and the ambulance was
called at around 4.15am.
The distance from Whatton to the hospital is almost 16 miles by road and the
ambulance took around 30 minutes to arrive. The man suffered a cardio-
respiratory arrest and died of an acute myocardial infarction despite timely
attempts at resuscitation.
The man’s death at the age of 30 years was premature, but was from natural
causes. In the doctor’s opinion, the man could not have been saved. His review
said, “This incident occurred in the middle of the night. This is a common time for
heart attacks to occur. There were no healthcare personnel on duty, as Whatton
does not have a 24-hour healthcare facility.”
I appreciate the need for correct unlocking procedures to be adhered to in the
interest of security, particularly at night. However, due to the lack of healthcare
at Whatton at night, there needs to be a level of flexibility to deal with
emergencies promptly. I understand that Whatton is a large prison and it would
have taken some time for the officer to have reached the wing to help unlock the
11
cell. However, considering his own proximity to the man’s cell I consider that it
might have been appropriate for the NOO to have made a cursory check on the
man, and to have spoken to him about his symptoms through the cell door hatch.
In the event, there was a 20 minutes delay before he was seen by the NOO and
the officer and before medical advice was sought. However, I agree with the
clinical reviewer that this would not have affected the ultimate outcome. Once
the NOO reached the man, the response was swift and effective.
The Governor and the Head of Healthcare should ensure that local
procedures allow for medical emergencies at night to be dealt with as soon
as possible.
The clinical reviewer has also commented that prison staff, with their worthy
attempts at resuscitation, did everything they could to keep the man alive
following his heart attack. However, I am concerned by the risks that are
apparent in every prison without 24 hour healthcare if there is any delay in
commencing resuscitation attempts. I endorse the clinical reviewer’s
recommendation:
In the absence of duty healthcare personnel, there should always be on
duty officers trained in Cardio Pulmonary Resuscitation and the use of the
automated defibrillator.
Other clinical issues
The man had been in a number of prisons over the preceding few years. A
review of his previous medical records show no apparent consideration of his
family history of heart disease and therefore his heightened risk.
The man did not have a healthy life-style. He was known to abuse drugs and
alcohol as well as to smoke. There is no documentary evidence to show that, at
any time prior to his final period in Whatton, any health promotion advice was
given to him. Neither does there appear to have been any consideration given to
monitoring the man as part of a chronic disease management programme.
Whilst it is unlikely to have had an effect on the outcome for the man, the
promotion of a healthy life-style and appropriate chronic disease management
may well reduce the risk to others.
Family Issues
The man’s family had a number of questions which I have considered
individually:
12
Why did it take so long for the revised release plan to be completed and
submitted to the Parole Board?
The man was recalled to prison on two occasions following his release from
Lindholme in October 2005. His licence conditions included two specific points.
He was not to make any contact with his ex-wife or her children, and he was not
allowed to enter an area in Derbyshire, where his ex-wife lived with her children.
In August 2006, the man was seen by a community worker in the exclusion area.
This person was aware of the man’s licence conditions and knew he was in the
exclusion zone. The community worker made a statement to the police on his
observation of the man being in that area. The man’s probation officer
immediately applied for a revocation of licence in respect of the man. He was
arrested and received into HMP Nottingham. The man was later transferred to
Whatton.
The man’s family raised issues around his recall to prison. They were concerned
that the recall was unfair. As noted, he was recalled for being in an exclusion
zone detailed in his licence conditions. The man’s family felt that he had gone to
the exclusion zone to find his family, as they had not been able to collect him
from the hostel that day. His family believed that he had no intention of
contacting his ex-wife or her family.
In January 2007, an oral hearing of the Parole Board took place at Whatton. The
Board agreed the recall to prison was appropriate. They accepted that the man
had not entered the exclusion zone with the purpose of contacting his ex-wife,
although they agreed that simply being in the area heightened his risk,
particularly if he were to use alcohol or drugs. Given that he had breached a
core licence condition, there were grounds for believing his risk was increasing.
The man was present at this hearing, along with his solicitor, his sister-in-law
and his probation officer. The Board agreed to the man being released when a
re-worked assessment plan had been completed for him. The Board adjourned
for six weeks to allow that to happen.
The probation officer commenced work on the plan to ensure all the services that
the man would need would be in place on his release, thus to avoid the
possibility of a further recall to prison. The plan involved a multi-agency
partnership of South Derbyshire Learning and Disabilities Team, South
Derbyshire District Council, and Social Services. The identification of suitable
release accommodation tailored to the man’s special needs proved to be difficult.
The man also wanted to live near to his family, and this was supported by them.
He and his family turned down any alternative areas for accommodation.
Funding for a support package, tailored to the man’s special needs, was also
being sought through the multi-agency partnership.
13
The man was subject to MAPPA at level two. Subsequently, meetings at
MAPPA level three were held. It was a priority for MAPPA that those
accommodation arrangements ensured the victim’s safety and were under the
exclusion zone. Additional licence conditions were also under consideration.
Adult services were making an assessment of support services to help the man
following his release.
Due to the complexities of these plans, his release was delayed. Following the
Parole Board hearing, the man’s release unfortunately did not take place before
his death. Whilst I acknowledge his family’s distress that he was still in prison at
the time of his death, I consider that the delay and the reasons for it were
reasonable under the circumstances.
Why were the family excluded from meetings between the man and outside
agencies despite the fact his brother was his legal guardian?
The man’s family felt that his probation officer had failed to engage with them and
had little time for him before his impending release. The family thought that all
communication had broken down with Derbyshire Probation Area.
The man’s family indicated that they had raised the issue regarding the lack of
involvement with their brother’s probation officer with a senior manager at
Derbyshire Probation Area. The family were unhappy at the manager’s
response.
The man’s sister in law spoke about their love and concern for their brother and
their wish to help him. I am unable to comment in this report on the dynamics of
the relationship between Derbyshire Probation Area and the man’s family, but I
highlight their concern. Whilst understanding that his family felt marginalised, it is
also important to point out that the Probation Area was trying to engage with
agencies to ensure the man was offered opportunities on his release that would
be able to support his individual needs. His family were an integral part of his
life, but their home location was also within the location of his victim’s home, and
part of the exclusion zone related to his licence conditions.
It would not have been appropriate for the man to live with his family on release.
He was a MAPPA three level offender. The inclusion of the family at those
meetings would have been inappropriate due to the confidential nature of the
issues for discussion.
The man’s family had attended supervision meetings before his recall to prison
when he had been living in the hostel. According to his probation officer, the
attendance of his family had tailed off. The family disagree with this and maintain
that a member of the family attended every probation appointment when the man
was being seen at the probation office and that they were not always informed of
appointments in Derby.
14
The man’s family felt that the Probation Service did not acknowledge how much
they cared about his future, and the support the family were able to offer. When
the family were not present, the man’s key worker attended the meetings to
support him. The man’s probation officer told my investigator that, after every
supervision session with her client, she repeated his licence conditions and
ensured that he understood what was said to him.
In light of the family’s concerns, I have arranged for a copy of this report to be
sent to Derbyshire Probation for their consideration.
Other Issues
An officer was the man’s personal officer for a short time. She told my
investigator that the man was quiet. He complied with the prison regime and,
despite his obvious learning difficulties, understood prison rules. The man
worked in the manufacturing workshop which he enjoyed.
Two friends of the man, who knew him well whilst at Whatton, told my
investigator that he was ‘buying’ prescription drugs from other prisoners. There
is no other evidence to substantiate this, and the man’s post mortem report did
not indicate that there were any drugs in his system other than those prescribed
to him. The man’s friends indicated to my investigator that he would purchase
the prescribed drugs with tobacco or food items. Following the man’s death, two
prisoners were questioned about these accusations by staff at Whatton. There
was no evidence to substantiate the accusations and no further action was taken
by the prison.
15
RECOMMENDATIONS
1. The Governor and the Head of Healthcare should ensure that local
procedures allow for medical emergencies at night to be dealt with
as soon as possible.
Accepted – The procedures followed by the night staff led by the NOO, as
described in the report, were appropriate. When the man’s condition deteriorated
suddenly, the NOO displayed excellent leadership in commencing CPR. But the
insights offered by the report and the experience of staff that night could properly
be used as the basis for a review of Whatton’s night procedures in partnership
with Nottinghamshire County Teaching PCT. The recommendation will be
placed on the agenda for the Partnership Board which will oversee the review.
2. In the absence of duty healthcare personnel, there should always be
on duty officers trained in Cardio Pulmonary Resuscitation and the
use of the automated defibrillator.
Partially accepted – Nationally all establishments are required to have staff
trained in first aid, including resuscitation, in place. The implications for having
all staff trained in the u se of defibrillators on duty in all prisons will be considered
but at present a risk assessment approach is used at a local level to reflect
population and resources available. Locally this is currently the position, but the
resilience of HMP Whatton’s procedures will be reviewed by February 2008
16