Individual at Pentonville

Investigation into the circumstances surrounding the
death of a man in hospital, whilst in the custody of
HMP Pentonville on 22 September 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2010
This is the report of an investigation into the death of a man who died in
September 2009 in hospital whilst in the custody of HMP Pentonville. The
man was 66 years old.
The man had had a coronary artery bypass graft operation on 27 August and
returned to Pentonville’s healthcare unit five days later. The following week
he was re-admitted to hospital with low blood pressure. On 21 September,
The man was diagnosed with three bleeding duodenal (stomach) ulcers.
However, for religious reasons he refused a blood transfusion. Her Majesty’s
Coroner for Inner London did not ask for a post mortem examination into the
man’s death. It was noted that his death was from natural causes due to
renal failure.
I extend my sincere condolences to the man’s wife, family and friends.
The investigation was carried out on my behalf by one of my investigators. In
addition, a review of the man’s medical care was commissioned by Islington
Primary Care Trust (PCT). I am grateful to the clinical reviewer for that
review. I would also like to thank the then Governor of Pentonville and his
staff for their assistance with this investigation. I am especially grateful to the
Liaison Officer and Head of Nursing for their support.
I would also like to thank a Judge and the staff at a Crown Court for their help.
I make five recommendations for the attention of the Head of Healthcare
concerning patient care, mental health assessments and medical records.
Furthermore, I acknowledge two further recommendations in the clinical
review relating to multi-disciplinary meetings and the use of the six in-patient
beds for medical use. The support given to the man and his wife as he
neared the end of his life was of a high standard. However, earlier
consideration could have been given to the removal of physical restraints. I
fear this latter issue is one to which I have to return in investigation after
investigation.
In this final report four recommendations have been accepted and one
recommendation partially accepted. The man’s family have not raised any
issues from the draft report.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2010
CONTENTS
Summary
The investigation process
HMP Pentonville
Key findings
Issues
Conclusion
Recommendations
SUMMARY
The man was bailed to appear at Crown Court in June 2009 for alleged sexual
offences. In 24 June 2009, prior to his court appearance, he attended the
accident and emergency department at hospital after taking an overdose of
paracetamol and experiencing chest pain. He told doctors that his overdose
was as a result of anxiety regarding his forthcoming court appearance, but he
denied any intention of self harm. His chest pain was noted and, following
tests, the doctors referred the man to a chest pain clinic.
On 28 June, the man was taken from his home to hospital after complaining of
chest pain. Against medical advice he discharged himself the following day
and went to Crown Court for the first day of his trial, but arriving late. His
failure to attend court on time had already prompted the Judge to issue an
arrest warrant, and the man was remanded into custody at Pentonville.
The man was taken back to court on 30 June and the Judge asked for a
report into his health. A court doctor deemed the man unfit to stand trial and
he was returned to Pentonville. The following day he was seen by a doctor at
the prison who then reported to the Judge that the man was unwell and
waiting for medical investigations for a potential serious heart condition. The
Judge adjourned the trial and remanded The man into custody for pre-
sentencing reports.
The doctor at Pentonville made an urgent referral for the man to be seen at
hospital. However, because of a lack of escort staff an out-patient
appointment was cancelled on 14 July. The man was seen at the hospital on
31July, and the doctor’s diagnosed angina (narrowing of the artery) and
advised the man to remain in hospital for an urgent heart by-pass operation.
The man discharged himself and returned to Pentonville.
Following a discussion with his wife, the man agreed to the surgery and he
was escorted to hospital on 13 August. There his condition was stabilised in
preparation for the by-pass surgery on 27 August.
The man returned to Pentonville on 1 September and was admitted to the
healthcare unit for observation. He was advised on self-administration of
insulin for his diabetes, and to take gentle exercise on the unit to ensure he
did not develop a deep vein thrombosis. Whilst being cared for, nurses also
applied dressings to a seeping wound on his leg.
On 9 September 2009, the man’s health deteriorated and he was admitted to
hospital. Following medical tests he was diagnosed with three bleeding
stomach ulcers. The man refused a blood transfusion on religious grounds,
and was transferred to the intensive care unit. He died on 22 September, with
his wife at his bedside. He was no longer restrained and officers were
respectfully situated away from his bedside.
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened on 5 October 2009
when my investigator visited Pentonville. Notices of the Ombudsman’s
terms of reference and notices to staff and prisoners had been sent to
the prison in advance of her visit. Up to the date of circulation of this
report no members of staff or prisoners have responded to the notices
of investigation.
2. My investigator met with Head of Nursing and the Liaison Officer.
Copies of the man’s medical records and prison files were available for
her to take away. No members of the Independent Monitoring Board
(who monitor the day to day life in prison and ensure standards of care
and decency are maintained) or the Prison Officers’ Association asked
to see my investigator. Pentonville has previous experience of deaths
in custody and both the IMB and the union are aware of the
investigation process.
3. My investigator visited the healthcare unit, and toured the in-patient
facility. On the unit she visited a cell and spoke to a Listener (Listeners
are prisoners trained by the Samaritans to provide confidential support
to other prisoners in times of crisis.)
4. One of my Family Liaison Officers contacted the man’s wife to tell her
about the scope of my inquiries and to offer the family the opportunity
to raise any questions or concerns they would like addressed as part of
the investigation. At the time of issuing this draft report the family had
not raised any concerns directly with my office. However, I hope the
report provides them with an understanding of the man’s time in
custody and the events leading to his death.
5. A review of the man’s medical care was commissioned by Islington
PCT. On 19 October, my investigator telephoned the Crown Court to
make enquiries regarding the man’s appearance at the court in June.
The Judge sent her a full chronology of the man’s court appearances
on 9 November.
6. Also on 9 November, my investigator and the clinical reviewer
interviewed healthcare staff at Pentonville.
HMP PENTONVILLE
7. Pentonville is a local prison, predominately holding prisoners on
remand and serving courts in north east London. At the time of the
investigation, it could hold up to 1,152 prisoners. The accommodation
comprises five residential units, a vulnerable prisoner wing, a
segregation unit, a first night centre, and a healthcare unit with 24 hour
nursing care. Healthcare at Pentonville is provided by the Islington
Primary Care Trust and has beds for up to 22 in-patients.
8. The establishment was last inspected by Her Majesty’s Chief Inspector
of Prisons in June 2006. In her report of that inspection, the Chief
Inspector pointed to improvements in some areas since her previous
visit in 2005 and wrote:
“Progress in healthcare had been slow. A new management
structure had been put in place and the aim was to ensure safety
before developing services. Some good clinical audits were
undertaken. Prisoners were not seen in private in reception but
this was being addressed. GP clinic arrangements had improved
but waiting list management and follow-up arrangements for these
and other clinics were poor. Primary care services were basic
and there were no chronic disease management or formal
discharge clinics and little health promotion work. All healthcare
staff had recently undertaken a drugs assessment but
improvement in administration was needed. The number of in-
patient beds had reduced from 32 to 22 and all in-patients had
care plans. A full-time staff grade psychiatrist was in post. The
mental health in reach team had expanded but saw only patients
with severe and enduring illness and there were no primary
mental health services. A day care service had recently begun.”
9. The 2009 Annual Report of the Independent Monitoring Board at
Pentonville noted that:
“A Health Service provider tender specification was produced and
a new provider was selected. The transfer to the new provider, a
consortium led by Islington PCT, took place on 1st April 2009.
The impact on health care services during the reporting year just
ended before the new contract came into effect was to continue
with the inadequately high levels of nursing and paramedic
vacancies including physiotherapy. It is envisaged that more
nursing staff will be deployed under the new contract. It is hoped
this will reduce the future need for patients to visit outside clinics,
with the resulting added costs of hospital escorts… There were
good examples during the year of the professionalism and
dedication of healthcare staff when faced with emergencies and
acute cases.”
10. There had been four previous deaths due to natural causes at
Pentonville since my office started investigating all deaths in prison
custody in 2004. None of my reports into those deaths raised issues
similar to those arising in respect of the man.
KEY FINDINGS
11. The man was born in East London in 1946 and was married. He was
unemployed and a Jehovah’s Witness by religion. In December 2008,
he appeared at Magistrates’ Court to face charges of sexual assault
dating back to the 1970s. He was bailed to appear at Crown Court in
June 2009.
12. On 24 June 2009, the man was seen in the accident and emergency
department of a hospital. He had been referred there by his doctor
after telling him he had taken too many paracetamol tablets and was
experiencing chest pain. No treatment was needed for the
paracetamol overdose and the man saw a member of the psychiatric
liaison team. He denied any ideas of self harm, but was anxious about
his forthcoming court appearance and was given written information
about support in the community. However, following a physical
examination and an Electrocardiograph (ECG) some abnormalities
were identified. (An ECG machine traces the heart rate and rhythms.)
The hospital doctor made a referral to The man’s doctor for him to be
seen at the a chest pain clinic on 27 June.
13. The man’s solicitor asked the doctor for a medical report to be
presented to the Crown Court outlining the man’s current medical
condition and whether he would be fit to stand trial. The doctor
completed the report and forwarded this to the solicitor, recommending
that the man’s case be postponed until his heart problems had been
investigated.
14. On 28 June, the man was seen in the emergency unit of a hospital,
having been taken there by an emergency ambulance from his home.
The following day, the man discharged himself from hospital and
signed an irregular discharge certificate. (An irregular discharge
certificate notes that a patient wishes to leave hospital against medical
advice.)
15. At Crown Court at 2.38pm on 29 June, the Judge issued an arrest
warrant for the man for his failure to attend court. In fact, the man
made his way to the court and was taken before the Judge at 3.49pm.
The Judge remanded the man into custody at 4.16pm to appear before
the court the following day.
16. On arrival at HMP Pentonville, The man was seen in reception by a
nurse who noted his present medication and took a verbal medical
history that included type two diabetes. The man told the nurse he had
no thoughts of self harm and he confirmed this when he saw the
doctor. The following day, the man was taken to Crown Court.
17. The Judge asked that the man be examined to ascertain whether he
was fit for trial, and a doctor was called to the court cells. Additionally,
at 11.40am a member of Pentonville’s healthcare staff received a
telephone call from a court officer and asked if the prison doctor could
also confirm that the man was fit for trial. The doctor was unavailable
at that time and said he would contact the court later. The Judge
received a medical report from the court doctor to the effect that The
man was unfit to stand trial. The Judge remanded him back into
custody at 12.33pm and the man returned to Pentonville.
18. On 1 July, the man’s barrister told the Judge that the man was unwell.
The Judge called the escorting officer into the court to confirm that she
had been told that morning by the nurse at Pentonville that the man
had been given all of his medication for angina and diabetes. The trial
was then started with the man present. At the end of the day, the
Judge suggested to the man’s barrister, and their medical advisers,
that they carry out any medical examinations they wished. The man
returned to Pentonville.
19. The man was seen on 2 July by a nurse who recorded his full medical
history. The nurse took his blood pressure (which was 157/82; a
normal reading for blood pressure would be 130/80), measured a pulse
rate of 80 beats per minute (a normal pulse rate would be between 60-
100 beats per minute), and recorded a normal temperature of 36.6
degrees. The nurse noted the man’s recent visit to hospital and
referred him to see the prison doctor.
20. A doctor examined the man and wrote that he had not told the
reception doctor about his chest pain and recent hospital admission
when he had been examined two days previously. Nevertheless, it
was noted that the man had not had any chest pain whilst in prison.
After reviewing medical correspondence, the doctor made a urgent
referral for the man to see a chest specialist and deemed him unfit to
appear in court. A letter was faxed to Crown Court for the attention of
the Judge, outlining the man’s present medical condition and saying
that in the doctor’s opinion he was not fit to stand trial.
21. The Judge reviewed doctor’s medical report the following day,
remanded the man into custody in his absence, and asked for pre-
sentence reports to be prepared. The man was moved to Pentonville’s
vulnerable prisoner unit...
22. The man was referred to the mental health team on 8 July, following an
assessment by a psychiatrist who had visited him at the request of his
solicitors.
23. On 11 July, the man was seen again by a nurse who recorded his
blood pressure as 134/71, a pulse rate of 73 beats per minute and a
temperature of 35.6. The man’s blood glucose level was recorded as
13.8 mmol/l after his breakfast. (Blood glucose levels average at 4 to
7mmol/l before meals, less than 10mmol/l 90 minutes after meals and
around 8mmol/l at bedtime). The nurse noted that the man’s blood
glucose levels would be checked the following day.
24. The man refused his medication from a nurse on 13 July and said he
had not been allowed a telephone call for nearly a week. (There is
nothing noted in the man’s personal file as to why he had not been able
to telephone his wife; it may be that he had no credit left on his
Pinphone.) The nurse tried to persuade him to take his medication and
said that his health would be affected. The man was adamant that he
would not take his medication, and the nurse informed the senior
officer on the wing.
25. The next day, the man’s appointment at a hospital was cancelled by a
charge nurse. At a pre-assessment meeting earlier in the week all the
out-patient appointments had been graded as to their urgency. The
man’s appointment had been assessed as of lower priority than that of
other patients and, because of a shortage in the number of available
escort staff, his appointment was cancelled. Later, he was seen by a
doctor who wrote that the man had pain in his thumb. The doctor
prescribed paracetamol and some cream to rub into the affected area.
26. On 21 July, the man was seen by a member of the mental health care
team. However, there are no notes as to the outcome of that
consultation.
27. The man went to a hospital for an out-patient appointment on 31 July.
As a result of the appointment, the doctor wrote that he had received a
telephone call from the hospital and that the man’s tests confirmed that
he had unstable angina (a narrowing of the coronary artery restricting
blood supply to the heart). The doctor added that he was unhappy that
the previous appointment had been cancelled. The doctor reviewed
the man’s medication and noted that, should the man experience any
chest pain, it should be taken seriously by healthcare staff.
28. An entry in the man’s medical notes said that he had returned a
prescribed medication of Bisoporal (for angina) on 5 August. Two days
later, a nurse wrote that the man had now agreed to take the Bisoporal.
29. On 10 August, the man was escorted to hospital for an angiogram. (An
angiogram is a procedure where a catheter is inserted into an artery or
vein to check the flow of blood to the heart.) Following the result of the
procedure, doctors advised the man that he should stay, as an in
patient, for a coronary by-pass operation. However, the man declined
the operation, saying he wanted to speak to his wife before agreeing to
surgery. He discharged himself from hospital and returned to
Pentonville the following day.
30. On his return to Pentonville, the man saw a doctor whom he told about
his decision regarding the by-pass surgery. He also told the doctor that
he was a Jehovah’s Witness and would not want any blood products,
or transfusions, and that he had told the hospital doctor of this decision.
However, on 12 August the man wrote to the doctors at Pentonvile
agreeing to the by-pass surgery after discussing this procedure with his
wife. On receipt of this information the doctor contacted the hospital to
arrange the man’s admission.
31. The following day it was noted in the man’s medical notes that he had
slept on the floor of his cell rather than his bed. No reason was offered
as to why he had done this.
32. On 3 September, a nurse wrote that the man’s surgical wound
dressings had been changed and he had been assisted with his
personal hygiene. The nurse encouraged the man to take gentle
exercise by walking on the unit during association. (This had been
advised by the duty doctor to prevent a deep vein thrombosis [blood
clot] forming.) The following day, a doctor noted that the man would
need assistance with understanding his diabetes and insulin injections
(medication for diabetes) before he could be sent back to the wing.
33. Four days later, a nurse wrote that the man was now able to check his
own blood glucose levels and would be soon ready for discharge to his
wing. On 8 September, a nurse noted that one of the man’s surgical
wounds was ‘weeping’. A clean dressing was applied and the man
was again encouraged to take more exercise.
34. Later that day, a nurse noted that the man needed to be prompted to
look after himself and his cell. The nurse further wrote that the man did
not sleep in his bed, preferring to sleep in a chair with his feet on the
ground. This was against the advice of healthcare staff who had told
him to sleep with his legs elevated. The nurse ended her entry by
noting that the man had not taken his evening meal.
35. On 9 September, a nurse recorded that the man’s surgical wound was
still oozing fluid whilst she applied a clean dressing, although he said it
was not painful. The man was now self-administering his insulin but
was slow in taking his exercise.
36. Later, a doctor saw the man and noted that he was pale, tired and
seemed unwell. The doctor spoke to a specialist at a hospital to
discuss the man’s present medical condition. It was agreed that he
should be admitted to hospital. At 2.15pm, the man was taken to
hospital, escorted by two officers and on an escort chain. He was
admitted to a ward for treatment and observation. (A security risk
assessment noted that restraints should be removed for appropriate
medical investigations and any surgical procedures.)
37. Three days later, the man was transferred to the intensive therapy unit
(ITU) as his renal (kidney) function was causing concern. On 14
September, the man was moved to a side room and his wife was
allowed to visit her husband daily.
38. The man was transferred to a high dependency ward on 18
September. At 11.05pm, his condition deteriorated and hospital staff
advised that the man’s wife should be contacted and return to the
hospital. An ECG procedure was carried out and doctor asked the
man if he would agree to a blood transfusion. He refused.
39. The following morning at 00.40am, the man was moved to the intensive
care unit. His wife had arrived at the hospital and remained at her
husband’s beside. An endoscope procedure was undertaken at
00.50am (a tube with a camera attached is passed down the throat to
examine the stomach). The doctors advised that the restraints should
be removed as the man was now seriously ill. The bed watch officers
made contact with the prison and informed them that they had removed
the restraints.
40. The bed watch notes record that a stomach bleed had been controlled
at 3.20am. However, the man was now on a ventilator and his wife
stayed with him until later that morning. A governor agreed that
restraints should not be re-applied unless there was a positive change
in the man’s condition. In addition, the governor gave permission for
the bed watch officers to sit in a side room, away from the man’s
bedside, whilst maintaining observation. On 20 September at 6.45pm,
the bed watch notes record that, for religious reasons, the man again
said he did not want a blood transfusion. The man’s wife told the
escort officers that her husband’s condition was continuing to
deteriorate.
41. Head of Nursing Care visited the ITU on 21 September. He spoke to a
senior doctor and was told that several days previously the endoscope
procedure had indicated that the man had three bleeding duodenal
ulcers which had now been controlled. Nevertheless, the man’s refusal
to accept a blood transfusion meant that his blood levels had dropped
to a dangerously low level. He was now in renal failure and the
prognosis was that he would die within the next 24 hours.
42. At 11.45am, a governor made contact with the bed watch officers to
check on their welfare and that of the man’s visitors. Later, the man’s
wife told the bed watch officers that her husband was in the final hours
of his life and thanked them for their support and help. A governor
visited the hospital at 4.15pm in his role as family liaison officer. He
ensured that officers were on duty at a discreet distance from the
man’s bedside whilst still able to observe him, and that they were
comfortable with the situation. The governor introduced himself to the
man’s wife and offered her any assistance she might need.
43. The man received a visit from his religious minister at 7.30pm. At
11.15pm, the man’s wife left her husband’s bedside and went to the
family rest room. Less than an hour later a nurse asked her to return to
her husband’s bedside. The man’s wife told the escort officer that her
husband had passed away at 00.15am the following day. This was
confirmed by a hospital doctor at 00.40am.
44. A governor remained in contact with the man’s wife and offered her any
support she might need. The prison offered financial assistance for the
man’s funeral.
ISSUES
Clinical Care
45. A review of the man’s medical care was undertaken by an Acting
Director of Nursing in the National Health Service. The clinical
reviewer and my own investigator, interviewed medical staff at
Pentonville as part of the review process. The clinical reviewer noted
the chronology of the man’s interventions with healthcare staff and his
medical care.
Mental Health
46. The man was referred to the mental health team on 8 July following an
assessment by a psychiatrist acting on behalf of the man’s solicitor.
He was seen by a member of the mental health care team on 21 July.
Notes from that consultation were absent and the clinician who
undertook the assessment was unavailable for interview. The Deputy
Manager of the Mental Health Team described the outcome of the
assessment, noting that it was not felt that the man had either a
depressive or a psychotic illness and he was not suicidal. Any
symptoms were due to anxiety about being in custody. They planned
to follow up with the psychiatrist, but there is no record of this
happening and no interventions were made available to help the man
manage his anxiety.
47. The clinical reviewer was concerned over the length of time from
referral to assessment and the lack of documentation available to other
clinicians regarding the outcome of this assessment. In his review he
comments:
“In the recent inspection by the Chief Inspector of Prisons the
report noted that primary mental health needs were clearly not
well served. This case would appear to confirm that view.”
I endorse the following recommendations from the clinical review:
The mental health team should review access to Primary Mental
Health Care Services.
The mental health team should review its policies for recording
assessments and interventions in the primary healthcare record
(EMIS) to ensure availability of information for clinicians.
Cancelled out-patient appointment
48. The man’s first appointment at a chest pain clinic was scheduled for 14
July. This was cancelled due to a lack of escorts being available. The
nurse who cancelled the hospital appointment described to my
investigator the system for cancelling hospital appointments based on
risk. High risk appointments are graded red, medium amber, and low
green. The decision to cancel the man’s appointment clearly annoyed
a doctor who noted on 31 July that he was unhappy that the out-patient
appointment on 14 July had not gone ahead. The doctor judged the
man’s referral as urgent. The clinical reviewer comments:
“The recent prison inspectorate report describes the management
of external hospital appointments as exemplary, and noted that no
appointments had been cancelled due to a lack of escorts. This
case is an exception to this and the panel would urge the
healthcare services to look in some detail as to the reasons why it
happened. “
I endorse this further recommendation from the clinical review:
The Head of Healthcare should review the cancelled appointment
in this case to understand why this slipped through what was
recently described as an exemplary system.
Care plans
49. On the man’s return to Pentonville on 1 September, he was admitted to
the healthcare unit for post-operative care and observation. He was
seen by a doctor, and further medical reviews were held on 3 and 4
September, and then again three days later. However, while a care
plan was supplied to the clinical reviewer on the day of the interviews,
this gives little guidance to nursing staff on what was required. The
clinical reviewer writes:
“Daily entries make no reference to it and it would also appear
that the man preferred to sleep either on the floor or in his chair at
night. No attempt seems to have been made to understand this or
any implications of this explored, rather each evening the relevant
nurse was left to find the best solution for him.”
I endorse these recommendations from the clinical review:
The Head of Healthcare should ensure that in-patients have clear
plans of care that are referred to by individual nurses on a day to
day basis.
In-patient notes should be subject to regular audit and
recommendations made and acted upon. As a minimum this
should be three monthly.
50. The inpatient unit has 22 beds, nominally split between 16 beds for
mental health patients and six for people with physical healthcare
needs. Nursing staff are predominately from Camden and Islington
Foundation Trust and mental health nurses. The clinical reviewer
comments:
“It is understood that there are currently a number of vacancies
within the nursing team. The GP input is via a weekly rota with
each of the GPs offering input for a week at a time. Thus there is
little continuity of care or consistent oversight of formulation of
treatment and care plans and implantation of the same. The
panel were of the view that the input both medical and nursing into
the in-patient unit and specifically the beds for those patients with
physical healthcare needs should be reviewed.”
I note the recommendation in the clinical review relating to the six
physical healthcare beds.
Primary care
51. In interview a number of those spoken to during this investigation
referred to the meetings held between the wing staff, mental health
team and primary care nursing staff. It was noted that there were
mixed views about the purpose of these meetings and their function.
What is clear is that the man was discussed on three occasions: 23
July, 6 and 13 August, with notes as follows:
Date Clinical record
23rd No concerns from staff on the wings. No meds
July
6th No nurse from G1, no officers present, therefore unable
Aug to update
13th Not known to nursing staff on main G wing nor known to
Aug officer.
52. Whilst the clinical reviewer views this as a model of localised primary
care for discussing patients, he would like the function of these
meetings to be specified and a renewed commitment from all partners
ensuring that they attend, have the right information available, and that
the meetings have the right membership. The Head of Healthcare
should clearly define the purpose of the wing based clinical meetings
and ensure that staff are committed to ensuring that they function as
intended.
Bed watch
53. Officers escorting the man on 19 September were told by hospital staff
that restraints were inappropriate when the man’s condition
deteriorated following the diagnosis of three bleeding duodenal ulcers.
The officers immediately removed the restraints and notified the prison
of their actions. Risk assessments had indicated that restraints should
be removed for appropriate medical investigations and at the request of
hospital consultants. However, I believe an earlier risk assessment for
removal of restraints should have been considered.
54. A governor went to the hospital later on 19 September. He asked the
escorting officers to sit away from the man’s bedside, thereby offering
him and his family privacy and dignity. On 21 September, a governor
spoke to the bed watch officers to check that they were comfortable
with the situation and that the man’s wife and his visitors were being
cared for.
55. During the afternoon, a governor again visited the hospital and spoke
to the man’s wife. He introduced himself as the family liaison officer
and offered support any assistance she might need. This support
continued following her husband’s death. She was noted as thanking
the bed watch officers for their support shortly before her husband
died.
56. The help and care shown by the staff who visited the hospital, or acted
as bed watch escort, was of a high professional standard. I note the
good practice of discipline officers and managers in supporting the man
and his family during this very difficult time.
CONCLUSION
57. The man was promptly referred to hospital when the doctor at
Pentonville became aware of his potentially serious heart condition.
However, because of a shortage of escort staff, the man’s first
appointment was cancelled. When he did attend the hospital and
doctors advised him to have urgent heart surgery, he refused until he
had spoken to his wife. When he made the decision to have the
surgery he was immediately admitted to hospital.
58. The man’s health deteriorated whilst being cared for in the healthcare
unit. On grounds of his religious beliefs, the man refused a blood
transfusion when he was admitted to hospital.
59. The clinical reviewer has made recommendations for the attention of
the Head of Healthcare that I endorse. However, I do not feel the
man’s death could have been prevented by clinical or uniformed staff.
60. Managers and escort staff were supportive in their care of the man
whilst he was an in-patient. Indeed, I have identified this as an
example of good practice. However, an earlier removal of restraints
should have been considered.
RECOMMENDATIONS
Head of Healthcare
1. The mental health team should review access to Primary Mental Health
Care Services.
Accepted – “Reviews currently in progress, taking elements of inter
disciplinary coordination to improve referral process, and timeline
delivery on appropriate actions. The head of healthcare leading
review.”
2. The mental health team should review its policies for recording
assessments and interventions in the primary healthcare record (EMIS)
to ensure availability of information for clinicians.
Accepted – “Regular audit of record keeping standards 3 monthly. To
be led by MH in line with FT policy.”
3. The Head of Healthcare should review the cancelled appointment in
this case to understand why this slipped through what was recently
described as an exemplary system.
Partially Accepted – “Work with the prison in partnership to ensure
the appropriate availability of escorts to secondary care services.
Agree new working protocol at Safer Custody/Governance.”
4. The Head of Healthcare should ensure that in-patients have clear plans
of care that are referred to by individual nurses on a day to day basis.
Accepted – “Review as part of the Record Keeping Audit. Expectation
of FT, all patients will have individual care plans that are used to
assess, implement and monitor patient care. These to be
utilised/monitored during the weekly ward round.”
5. In-patient notes should be subject to regular audit and
recommendations made and acted upon. As a minimum this should be
three monthly.
Accepted – “As above, regular audits to be carried out at 3 monthly
intervals, utilising recommendations and timelined.”