Individual at High Down

Investigation into the death of a man whilst in
the custody of HMP High Down in December 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2010
This is the report of the investigation into the circumstances surrounding the death of
a man who died at HMP High Down. He was a long time alcohol misuser and had
been at High Down for less than 48 hours when he died in the inpatients’ unit of the
prison’s healthcare centre. The post mortem revealed coronary heart disease to be
the cause of his death. He was 46 years old when he died.
The investigation was conducted by one of my investigators. I would like to thank
the Governor of High Down and his staff for their co-operation with the investigation.
Particular thanks go to the prison investigation liaison officer.
I am grateful to Surrey Primary Care Trust (PCT) for commissioning the clinical
reviewer, a substance misuse specialist based at HMP Dorchester, to conduct an
independent review of the clinical care the man received while at High Down.
Thanks are also due to the clinical reviewer for his review.
The man was released from prison on a life licence in 2008, the conditions of which
stipulated that he address his alcohol use. When he failed to do so, his offender
supervisor became concerned about his welfare and requested that he be recalled to
prison. He was arrested by the police on 10 December 2009, arriving at High Down
that evening.
On his arrival, the man was clearly suffering alcohol withdrawal symptoms and felt
very unwell. His pulse and blood pressure were checked and found to be high, but
he complained of no chest pains or shortness of breath. The man was admitted as
an inpatient to the prison’s healthcare centre so that staff could observe him more
closely, and he started an alcohol withdrawal programme. During the night of
11 December, staff could not rouse the man. The paramedics were called and
declared that he had died.
The clinical reviewer concludes that the man received a good standard of care and
was treated with compassion during his brief time at High Down. I do not think the
man’s death could have been foreseen, nor therefore, prevented. I make one
recommendation to the Head of Healthcare concerning checking patients’ blood
pressure and pulse, which was accepted at the draft report stage.
The man was the third prisoner to die of natural causes at High Down since 2004,
when the Ombudsman became responsible for investigating all deaths in prisons.
One more prisoner has died of natural causes since December 2009. I have found
no similarities between the circumstances of the earlier deaths and that of the man.
The 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
Acting Prisons and Probation Ombudsman July 2010
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CONTENTS
Summary
The investigation process
HMP High Down
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
In 1991, the man was convicted of the murder of his father, and sentenced to life
imprisonment. He was released on life licence in 1997 and the conditions ordered
that he address his alcohol misuse. His failure to do so led to his first recall to prison
in 2004. He was released in 2008, again on the condition that he manage his
alcohol use. In late 2009, the man’s offender supervisor became concerned for his
welfare because his alcohol use had increased. She began the process to have him
recalled to prison for the second time.
On 10 December 2009, the man was arrested by the police. While in police custody,
he began to show signs of alcohol withdrawal and was clearly unwell. The police
took him to the local hospital, where he was given medication to ease the withdrawal
symptoms.
At 6.53pm, the man arrived at HMP High Down. Prison reception staff realised that
he was suffering alcohol withdrawal symptoms and alerted the nurse and doctor on
duty in reception. They made a joint assessment of the man’s condition, noting that
he looked and felt very unwell. His pulse rate and blood pressure were checked and
both were slightly high (frequent symptoms of alcohol withdrawal). The man himself
complained of no chest pains or shortness of breath and said he had no concerns.
The man started an alcohol withdrawal programme straight away. He was taken to
the inpatients’ unit in the healthcare centre and placed in a gated cell, where staff
could observe him more closely. The reception nurse asked that his blood pressure
be checked again later (although this did not happen).
As the man continued the detoxification programme, his withdrawal symptoms
lessened. Healthcare staff who had contact with him during the day of 11 December
were not concerned about his health. However he was not examined by a doctor
that day. Early in the evening, it appeared that his withdrawal symptoms had
worsened and he was restless. The man was advised to drink plenty of water and
try to stay in bed.
During the night, the nurse on duty in the inpatients’ unit checked the man every half
an hour. At 12.40pm, she became concerned when she noticed that he had not
altered his position in bed for an hour. She failed to rouse him through the gated
door, so called for help from the officer on duty. When the officer also failed to wake
him, they called for the assist night orderly officer who unlocked the cell. The man
did not have a pulse and was not breathing, so two nurses tried to resuscitate him.
The paramedics arrived and, after carrying out a number of tests, pronounced that
the man had died.
The clinical reviewer concludes that the man’s health was appropriately assessed
and he received a good standard of care at High Down. He finds that staff treated
the man with compassion. I do not think that his death was preventable. He had
abused alcohol for a long time in the community, which had a detrimental effect on
his health, although his death was due to heart disease. I make one
recommendation which would not have altered the outcome.
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THE INVESTIGATION PROCESS
1. The Ombudsman was notified of the man’s death. The investigation was
allocated to one of my investigators.
2. My investigator issued notices inviting staff and prisoners to contact her with any
information they thought might be relevant to the investigation. There was no
response to these notices. My investigator was provided with copies of the
prison records relating to the man’s short time at High Down, including his
medical record.
3. Surrey PCT commissioned the clinical reviewer, a specialist in substance misuse
at HMP Dorchester, to conduct an independent review of the clinical care the
man received at High Down. The Quality and Clinical Governance Manager at
Surrey PCT, and my investigator conducted joint interviews with healthcare staff
at High Down. In compiling his review, the clinical reviewer had access to the
transcripts of those interviews, the results of the post mortem and the man’s
medical record. The clinical review is attached as annex 1.
4. HM Coroner for Surrey was notified of the investigation and provided the results
of the post mortem. The Coroner will receive a copy of the report to assist his
enquiries.
5. The Ombudsman’s family liaison officer invited the man’s friend, his nominated
next of kin, to be involved in the investigation. She provided some information
about the man’s life, but chose not to be involved any further in the investigation.
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HMP HIGH DOWN
6. HMP High Down is a local category B prison for adult and young adult men on
the outskirts of London, serving courts in the surrounding areas. As of July 2009,
the prison can hold up to 1,103 prisoners.
7. Healthcare services at the prison are commissioned by Surrey NHS and
provided by Surrey Community Health. There is a 23 bed inpatient unit, plus a
12 bed “step down” unit (for prisoners requiring a less intensive level of care)
which is located on one of the house blocks. The prison also offers an integrated
substance misuse service and employs a doctor who specialises in substance
misuse treatment.
8. The National Offender Management Service (NOMS) publishes quarterly
performance ratings for all prisons in England and Wales. The ratings are based
on a set framework and prisons can be rated from one to four (with four
indicating ‘exceptional’ performance). High Down has achieved a rating of three
(‘good’ performance) for the last two published quarters.
HM Chief Inspector of Prisons (HMCIP)
9. The prison was last inspected by HMCIP in an unannounced inspection in May
2009. The inspection report noted that the prison’s size had increased by 50 per
cent since the last inspection in 2006. The most recent inspection found that the
prison had taken forward previous recommendations and progress had been
made in improving the safety of prisoners there.
10. HMCIP found the healthcare centre to be “large, clean and well-maintained”.
Prisoners had good access to primary care and access to doctors was
“satisfactory”.
Independent Monitoring Board (IMB)
11. Each prison in England and Wales is also monitored by an IMB, consisting of
volunteers from the local community. Members of the IMB have access to every
part of the prison and each prisoner held there. Boards produce annual reports
for the Secretary of State, with the latest available for High Down covering the
period November 2008 to December 2009.
12. The Board noted the damaging impact of budget cuts on provision for prisoners
and staff morale. However, the IMB otherwise judged the prison to be “well run”,
with staff committed to providing a “secure and fair” environment for prisoners.
The Board also recognised the work that had gone into maintaining and
improving the healthcare service.
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KEY FINDINGS
13. In August 2008, the man was released from HMP Standford Hill on life licence.
As part of the conditions of his licence, he was required to address his
problematic alcohol use and engage with his offender supervisor. In December
2009, his offender supervisor began proceedings to get the man recalled to
prison for breaching those conditions. As a result, Margate Police arrested him
on 10 December.
14. At 6.50am that day, police officers in the custody suite noted that the man was
shaking uncontrollably, due to alcohol withdrawal. Seven minutes later, he was
given medication in his cell as he was shaking too much to leave it. Officers
decided that the man should be constantly observed because he was unwell.
They wrote in the custody log that the man had been sick.
15. The man was given food and a drink at about 8.00am and told officers he was
feeling better. However, half an hour later he was sick again and said he felt
“quite unwell”. At 8.57am, police staff decided that he should be taken to Queen
Elizabeth the Queen Mother Hospital (QEQM) for treatment. At 11.45am,
hospital staff gave him anti-sickness medication and ten milligrams (mg) of
diazepam (a drug with sedative properties) to combat his alcohol withdrawal
symptoms. The doctor at QEQM advised that he could be prescribed up to 30
mg of diazepam per day. While in hospital his blood was tested and the results
showed his liver was not working properly.
16. Following his hospital treatment, he returned to Margate Police Station at
midday, still being constantly watched by police officers. At 3.20pm, the police
doctor assessed him in his cell and concluded that he was showing no clinical
signs of alcohol withdrawal and was fit to be detained. Just over an hour later,
he left the police station for HMP High Down.
17. The man arrived at High Down at 6.53pm. A reception officer took him through
the induction paperwork (which provides a brief overview of the important
aspects of prison life). The officer recorded that the man was given a smokers’
pack. She noted that he had been in prison before but, as he had not been at
High Down within the last six months, he needed a full induction. The man said
he had no immediate worries. The officer completed the first section of the Cell
Sharing Risk Assessment (CSRA). (This assesses the risk the prisoner poses to
other prisoners and whether they are suitable to share a cell.) She recorded that
the man was dependent on alcohol but had no concerns about sharing a cell.
The officer assessed the man as being a low risk to other prisoners.
18. While in reception, the man was sick. Reception staff told the nurse and the first
prison doctor on duty that he was unable to control his bowels and was clearly
unwell. As a result, at 8.00pm, the nurse and the doctor (a substance misuse
doctor covering reception that day) carried out the first reception healthscreen
together. (The purpose of the healthscreen is to identify any immediate physical
or mental health needs requiring referral to the doctor or other specialist service.)
The nurse was interviewed as part of this investigation and the doctor provided a
written report of her contact with the man.
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19. The man told the staff he was not registered with a doctor in the community, had
no outstanding medical appointments and was not currently being prescribed any
medication. He said he had not received any physical injuries in the few days
prior to coming to prison and denied having any physical health problems.
20. The reception nurse asked him how much alcohol he usually drank and he told
her that he consumed about two bottles of vodka and several cans of strong
lager each day. He denied using any drugs in the past month. The nurse
recorded that the man had received ten mg of diazepam while in police custody,
but that he currently felt “terrible”. The man said he had suffered with depression
about ten years ago and had been prescribed anti-depressants. He said he had
no thoughts of harming himself.
21. The nurse wrote that the man was nauseous and had been sick on his arrival at
High Down. She noted that he was clearly withdrawing from alcohol and had
tremors in both hands, was visibly shaking and felt hot and sweaty.
22. In interview, the nurse described the man as physically very unwell. She
remembered that he was quite distressed during the healthscreen interview,
particularly when he talked about the death of his father. The man told the two
healthcare staff that he drank alcohol because he was unable to come to terms
with his offence. The man said he began drinking in the morning and would
continue to drink throughout the day.
23. The nurse explained to the investigator that she took the man’s blood pressure,
which was “slightly high” and his pulse rate was fast. She said that patients
withdrawing from alcohol often have high blood pressure and that, in fact, the
man’s was lower than she might have expected. She was a little concerned
about his pulse rate but thought this might be due to the stress of being recalled
to prison. She and the doctor concluded that he did not need to be taken to
hospital for treatment but should be admitted to the prison inpatients’ unit, where
he could be checked by nurses during the night.
24. The doctor and the nurse agreed that the man needed to begin an alcohol
detoxification programme and he was given 30 mg of chlordiazepoxide while in
reception. Chlordiazepoxide is a benzodiazepine, commonly used to help
alleviate the effects of alcohol withdrawal. It is a sedative drug, which helps to
reduce anxiety. At High Down, the alcohol detoxification programme involves the
prisoner being prescribed a reducing dose of chlordiazepoxide over a ten day
period. The man was also prescribed thiamine and vitamin B. (Heavy alcohol
users are commonly prescribed these as part of their alcohol detoxification
programme.) The nurse remembered that she helped the man to drink two
glasses of water, and encouraged him to drink plenty during the night. The nurse
was asked whether the man complained of any chest pain or appeared short of
breath during her assessment, and she said that he had not.
25. Following the healthscreen, the nurse completed the healthcare section of the
CSRA. She concluded that the man posed a low risk to other prisoners but that
he would have a single cell in the inpatients’ unit anyway.
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26. The nurse told the investigators that she took the man to the inpatients unit
herself. Although she could not remember which nurse she had handed his care
over to, she remembered that she asked that he be placed in a gated cell (when
the cell is secured with a gate, rather than a solid door) so that staff could check
him more easily during the night. She also asked nursing staff to check his blood
pressure later. There is no note of her handover in the man’s medical record and
no mention of his blood pressure being read again. The nurse explained that,
whilst she could ask the nurses on duty to carry out such checks, it is for them to
decide when to do so. However, the nursing staff interviewed agreed that it was
difficult to make these checks during the night, when prisoners were locked in
their cells, as the nursing staff do not carry cell keys.
27. The man was given a further 30 mg of chlordiazepoxide at 9.00pm. At 7.00am
the following day, a nurse working on the inpatients’ unit noted that he was
“pleasant and talkative”, had slept soundly and that there were “no problems”. A
few hours later a second inpatients’ nurse recorded that the man was “generally
settled”. This nurse recorded that he was showing signs of alcohol withdrawal
and the doctor would examine him that afternoon. However, there is no record of
any examination taking place. A second prison doctor a substance misuse
specialist doctor at the prison, was also interviewed during the investigation. She
said that she had reviewed the man’s file and confirmed that he was not
assessed by a doctor on 11 December.
28. During the day, the man received four 30mg doses of chlordiazepoxide – once in
the morning, at noon, in the afternoon and evening. He also received another
dose of thiamine and vitamin B. The reception nurse said that she saw the man
smoking in the prison garden that day. She described him as “fine and smiling”
and said she was surprised to see that he was no longer shaking (indicating that
he was being prescribed the correct dose of chlordiazepoxide). The man
thanked the nurse for her help the previous day. She said she had no reason to
have any concerns about him.
29. At 7.50pm, a third inpatients’ unit nurse made an entry in the man’s medical
records noting that he was showing clear signs of withdrawing from alcohol. The
nurse advised him to remain in bed, but recorded that he was “very restless and
fidgety”. The investigator spoke to this nurse by telephone during the course of
the investigation. The man told her he was thirsty so she got a cup of water for
him. She said that he did not mention feeling unwell or having any other
concerns. The nurse said that staff on the inpatients’ unit are used to treating
patients who are withdrawing from alcohol. She asked the nurse who had made
the 7.00am entry, who was on duty that night, to check him overnight. She
agreed to check him every half an hour.
30. During a routine check the nurse became concerned about the man. She
noticed that he had been in the same position in bed for more than an hour. She
tried calling his name and splashing him with water through the cell gate but he
did not wake. The nurse asked an officer, who was also working on inpatients
that night, for his opinion. The officer also tried calling to the man through the
observation hatch in the cell door, but he did not respond. At this point, they
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used a radio and asked the assist orderly officer (who was second in charge of
the prison that night) to attend.
31. The assist orderly officer also tried to rouse the man by calling through the gate.
When he still did not respond, she unlocked the cell and the nurse and officer
went in. The nurse checked the man for a pulse or signs of breathing, but found
neither. The assist orderly officer used her radio to alert the prison to a “Code
Red” (the call sign used to indicate a medical emergency) and to ask that an
ambulance be called. Another nurse who was working in the outpatients’
department that night, arrived and the two nurses began delivering cardio
pulmonary resuscitation (CPR).
32. The nurse working on the inpatients’ unit that night has since left her employment
at High Down and attempts to contact her by telephone have been unsuccessful.
However, the outpatients’ nurse was interviewed. He explained that the nurses
on duty at night do not carry cell keys. A governor grade member of staff said
that officers working on the inpatients’ unit carry a sealed pouch containing a cell
key. In an emergency, the officer should break the sealed pouch and open the
cell door. If it is not an emergency, staff should call for the night orderly officer
(in charge of the prison) or the assist orderly officer to unlock the cell for them.
33. The outpatients’ nurse said that, on going into the cell and although the
inpatients’ nurse had already done so, he too checked the man for a pulse or any
signs of breathing. On finding none, he and the inpatients’ nurse began CPR.
The nurse said that healthcare staff at High Down have refresher heart start
training annually, but that he last received the training in December 2008.
34. The paramedics arrived at 1.03am. They checked the man for signs of life and
took a reading of the electrical output of his heart. At 1.14am, they pronounced
that he had died.
35. Following the man’s death, prison staff travelled to the address he had provided
for his next of kin, a friend. There was no response at the address, but later that
day, staff managed to speak to the friend and inform her of the man’s death.
Attempts by the prison and the Coroner’s office to trace members of the man’s
family have, to date, been unsuccessful. Prison staff arranged the man’s funeral.
36. On 12 December, the duty governor, issued a notice to prisoners informing them
of the man’s death. They were reminded that the Listeners (prisoners trained
and supported by the Samaritans to offer a confidential listening service) and
Samaritans’ telephone were available. Prisoners were encouraged to talk to staff
if they required any support.
37. In the early hours of the morning of 12 December, the deputy governor held a hot
debrief. (This is a meeting for all members of staff involved in a serious incident
to share their experiences. It is a requirement of Prison Service Order 2710.)
38. The post mortem concluded that the man died of coronary heart disease, as a
result of significant narrowing of the coronary arteries. There was no evidence to
suggest that withdrawing from alcohol was a factor in his death.
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ISSUES
Clinical care
39. In his review, the clinical reviewer considers how staff at High Down assessed
and treated the man’s alcohol withdrawal symptoms on his arrival at the prison
on 10 December. He concludes that the reception doctor and the reception
nurse’s examination of the man was comprehensive and the man was swiftly
placed on an alcohol detoxification programme. The clinical reviewer notes that
the doses of chlordiazepoxide were appropriate, as was the man’s admittance to
the inpatients’ unit.
40. During the first reception healthscreen, the man’s general physical health was
assessed. The reception nurse said that he did not mention experiencing any
chest pains (which might have indicated heart disease). However, the second
prison doctor explained that the symptoms of alcohol withdrawal might have
masked any other physical health problems. Both the reception nurse and the
third inpatients’ nurse talked to the man on 11 December, when his withdrawal
symptoms were being controlled by chlordiazepoxide. The man did not mention
pains in his chest or other symptoms which might have revealed his underlying
heart problem.
41. According to the clinical reviewer, the medical records are well completed and
indicate that the man was appropriately observed. However, when the reception
nurse measured the man’s blood pressure and pulse in reception, both were
high. She said that, during her handover to inpatients’ staff, she suggested that
the man’s blood pressure be checked again. There is no evidence that further
readings were taken. No handover notes were made in the man’s medical
record.
The Head of Healthcare should ensure that inpatients’ blood pressure and
pulse rate are checked, and the appropriate notes made in the medical
records
42. The medical record also indicates that nursing staff believed that the man would
be examined by a doctor on 11 December. There is no record of an examination
taking place and the prison was not able to confirm whether he was assessed by
a doctor. The introduction of an electronic medical records system (expected to
take place shortly) should lessen the likelihood of this uncertainty.
43. The Quality and Clinical Governance Manager explained that the PCT expects
prisoners admitted to healthcare to be examined by a doctor within 24 hours of
admission, which is what happened to the man. I do not believe it likely that, had
the man been assessed by a doctor on 11 December, his death would have
been prevented. Nevertheless it is unsatisfactory that he was not followed up.
The emergency response
44. The inpatients’ nurse checked the man at half hourly intervals during the night of
11 December. She became concerned when she noticed that he had been in
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the same position in bed for an hour. She attempted to rouse him, and being
unable to do so, asked the officer working on the inpatients’ unit to help her. The
officer was carrying a cell key in a sealed pouch. However, the two staff chose
to call for assistance from the assist night orderly officer rather than open the cell
immediately. When the assist night orderly officer arrived, and the man was still
not roused, she unlocked and went into the cell.
The man had been admitted to healthcare as an inpatient because he was
experiencing severe alcohol withdrawal symptoms, which can be fatal. The staff
interviewed as part of the investigation explained that the nurses working on the
inpatients’ unit are experienced at managing patients withdrawing from alcohol.
I do not think that the decision to wait for the assist night orderly officer to arrive
before unlocking the man’s cell caused a particular delay in providing treatment
to the man. However, the Governor and Head of Healthcare might wish to
remind staff of the circumstances in which the cell key contained in the sealed
pouch should be used.
45. Overall, however, the clinical reviewer concludes that the healthcare staff
involved in assessing the man and caring for him as an inpatient showed a
commendable level of care and compassion. I am pleased to endorse that
finding. I do not think the man’s death could have been foreseen or prevented.
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CONCLUSION
46. The man had a long history of serious alcohol abuse. On 10 December 2009, he
was recalled to High Down under the terms of his life licence because of his
problematic drinking. On his arrival at the prison, he was already experiencing
alcohol withdrawal symptoms and felt very unwell. His blood pressure and pulse
readings were taken and found to be high, both common symptoms of alcohol
withdrawal. However, he complained of no chest pains or shortness of breath.
He was placed on an alcohol detoxification programme and was admitted to the
prison inpatients’ unit for close observation.
47. During the night of 11 December, he was found unresponsive in bed. Staff went
into his cell and, finding no pulse or signs of breathing, commenced CPR until
the paramedics arrived. They confirmed that the man had died. The post
mortem revealed coronary heart disease to be the cause of his death.
48. The investigation has found that generally, the man received a good standard of
care and was treated with compassion during his short time at High Down. I
conclude that his death was not foreseeable. Although I make one
recommendation, I do not believe that the omission was a factor in his death.
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RECOMMENDATIONS
1. The Head of Healthcare should ensure that inpatients’ blood pressure and pulse
rate are checked, and the appropriate notes made in the medical records
The Prison Service accepted the recommendation at the draft report stage, noting
that:
“Baseline observations should be recorded for anyone being admitted with a
physical illness and this is standard procedure. The medical records are now
electronic and this makes follow-up on patients easier and not reliant on
verbal prompts.”
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