Individual at Lewes

The death in custody of a prisoner
HMP Lewes – June 2004
Report by the Prisons and Probation Ombudsman for England
and Wales
September 2004
This is the report of an investigation into the circumstances of the death of
A prisoner in the Royal Sussex County Hospital in June 2004. The prisoner
was in the custody of HM Prison Lewes but had been taken to hospital a few
days earlier. He died after surgery to remove an obstruction in the bowel.
All deaths of prisoners in custody are investigated, including those due to
natural causes. Until recently, the responsibility for carrying out these
investigations fell to the Prison Service, but it has now been passed to the
Prisons and Probation Ombudsman (PPO) to bring independence and greater
consistency to the task.
In this case, two of my investigators carried out the investigation. An
independent review of The prisoner’ clinical care in prison has been
commissioned from the Sussex Downs and Weald Primary Care Trust.
My colleagues and I would like to extend our condolences to those touched by
the prisoner's death. Whatever, the family circumstances, the death of a
close relative is always likely to be bring strong emotions to the surface,
perhaps the more so when there has been a distressing history.
I would like to thank the Governor of HMP Lewes, and his colleagues for their
assistance with the investigation.
Stephen Shaw
Prisons and Probation Ombudsman
September 2004
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Contents
The investigation………………………………………………………4
Summary of findings…………………………………………………..4
The prisoner's medical history…… ……………………………….5
The prisoner's admission to hospital………………………………..5
Security procedures while the prisoner was in hospital……………7
The prisoner's family…………………………………………………..7
Compliance with Prison Service requirements……………………...9
(cid:127) clinical care………………………………………………………….9
(cid:127) communications with the family…………………………………..9
(cid:127) notifying other prisoners………………………………………….11
(cid:127) record management and incident recording………………...…11
Conclusion……………………………………………………………..12
Summary of recommendations……….…………………………..…13
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The investigation
My practice in cases of apparent natural cause deaths is to conduct an initial
review to determine the extent of investigation required.
My investigators visited HMP Lewes in June 2004 to examine documentary
records and to speak informally with staff to outline the facts relating to The
prisoner’ death. They issued notices announcing the investigation and invited
information from staff and prisoners. On a second visit on 9 July 2004 one of
my investigators met individual members of staff to verify key facts.
One of my investigators and a family liaison officer have spoken several times
to members of the prisoner’ family and also visited family members.
With the consent of the Coroner, a copy of this report was sent in draft was
sent to the Prison Service and to members of the prisoner’ family. I have
taken account of their comments in this final version of the report.
Summary of findings
The investigation focuses on three issues: the care of the prisoner by the
prison on the day he went to hospital; the use of security restraints; the
prison’s liaison with family members.
I am satisfied that the prisoner received proper and sympathetic care and that
the limited use of restraints was appropriate. There are lessons to be learned
about communications with family members and about record keeping after a
death.
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The prisoner’ medical history
The head of healthcare at HMP Lewes, formerly practised as a nurse but he is
now a prison governor and no longer retains his nursing registration. He knew
the prisoner because of his extensive contact with healthcare for longstanding
chronic illness. The head of healthcare had read the prisoner’ medical record
and gave my investigators the following summary of his medical history.
While the prisoner was at Maidstone he was under the care of St Thomas’s
Hospital, London. He had two cardiac catheterisations to investigate potential
unblocking of cardiac arteries and shortness of breath. Consideration was
given to a triple bypass but instead it was decided to treat the condition
conservatively by angioplasty. The prisoner became breathless again and
had chest pain and was referred back to St Thomas’s for numerous out
patient appointments.
When the prisoner was transferred to Lewes, a locum doctor immediately
referred him for cardiac consultation at Royal Sussex County Hospital and to
orthopaedic and ENT clinics. He was subsequently seen by the cardiac
department.
The prisoner was admitted to the Sussex County Hospital from Lewes Prison
early in June. He was suffering from a bowel obstruction that required
emergency surgery. However, his overall poor health meant he never
recovered from the anaesthetic. Despite the efforts of the surgical and
intensive care teams he died three days later.
The prisoner’ admission to hospital
The prisoner's cellmate had shared with him for about six weeks. He told my
investigators that, during the night before he was taken to hospital, the
prisoner was ill with "sickness and diarrhoea". The cellmate said he knew the
prisoner had a weak heart and lungs but the illness in the night had nothing to
do with that. The prisoner did not seek any help from staff and he and his
cellmate discussed what he had eaten that might have caused it. In the
morning, the prisoner saw the nurse on F wing at about 0800 and in the
afternoon he was taken to the healthcare centre. The cellmate arrived back
from work at 1600 on that afternoon and the prisoner had gone. The cellmate
heard first from another prisoner that his cellmate had died, and then asked
an officer, who confirmed it.
A nurse saw the prisoner when she was giving out treatments on F wing
between about 0800 and 0830. When the prisoner came to the hatch he said
he had been suffering from abdominal pain since the previous evening and
felt unwell. He did not look acutely unwell but, because of his age and chronic
illness, the nurse thought it appropriate he should see the doctor that day.
The healthcare centre called the wing to ask for the prisoner to be brought
over that afternoon and he was escorted to healthcare by an officer. When
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the prisoner came to the healthcare centre that afternoon he still did not
appear acutely ill, but was sufficiently unwell to warrant cause for concern.
The system is that registered nurses exercise their professional judgment to
decide whether a patient needs to see a doctor that day or can wait for an
appointment. The doctors hold surgeries in the mornings, the lists are
generally filled in advance by appointments. In the afternoons the doctors
come back to see anyone else who needs to see them.
A Doctor saw the prisoner on the examination couch in the health care centre
in the afternoon of a day in early June. He had thought he was suffering from
an adhesion or other obstruction in the bowel and arranged for an emergency
admission to the Royal Sussex County Hospital. There is no time of day
entered for the record on that day; the doctor usually arrives at the prison at 2
pm on Thursdays.
The Prisoner Escort Record indicates that the prisoner was taken from the
healthcare centre to an ambulance at 1600 and left the prison at 1610. He
was accompanied by two members of prison staff and arrived at the Royal
Sussex County Hospital in Brighton at 1640 where he was admitted for an
acute obstruction to the bowel.
Subsequent entries in the medical record indicate that at 0100 on the day
after he entered hospital, a message was received to say the prisoner’
handcuffs were removed as he was undergoing invasive investigations.
On Friday morning, healthcare staff telephoned the hospital and were told that
the prisoner would be going to the operating theatre for removal of a bowel
obstruction and was expected to go straight to the Intensive Therapy Unit
(ITU). The hospital considered the prognosis poor because the prisoner had
a ‘bad chest’. They requested that the prisoner’ next of kin be informed.
However, at 1210, the medical record says that Security had received a call to
say the prisoner did not want friends or family informed of his condition or the
fact he was in custody.
On Saturday morning, the healthcare staff telephoned the hospital and were
told the prisoner was now on the ITU. He had been sedated and was being
ventilated. His condition was considered to be critical
On Sunday morning the hospital reported that the prisoner had been unstable
overnight and oxygen use increased. He had gone into renal failure and the
doctors would review his condition. Later, the hospital telephoned to say the
decision had been made to withdraw treatment. The prisoner died peacefully
at lunch time on a day in June.
The post mortem records the cause of death as being ischaemic heart
disease subsequent to major surgery for a small bowel abscess and
perforation. The surgery itself is not thought to have contributed to his death.
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Security procedures while the prisoner was in hospital
The prison remained responsible for the prisoner while he was in hospital.
Two officers accompanied him to hospital and remained there as escorts.
A risk assessment prepared by a Senior Officer says that the prisoner was
handcuffed to an escort chain when he went out in the ambulance because of
the nature of the medical emergency. This meant he would have worn a
handcuff on one wrist attached to a chain about two metres long which was
attached to a single handcuff worn by an escorting officer.
The prisoner was seen by members of the hospital staff in Accident and
Emergency and then he was transferred to a ward later that evening.
The officer in charge of the overnight bedwatch on Thursday night, said that
hospital staff were attending the prisoner continuously conducting various
interventions. It was evident to him from the prisoner’ frailty and his medical
condition that he posed no risk of escape. To facilitate his medical treatment,
the officer removed the restraint, probably at about 2200. This was later
confirmed to the prison at 0135 when the House Officer formally requested
that the prisoner not be restrained. Officers have confirmed that the restraints
were not reinstated. It was necessary to balance the requirements of security
with the need for sensitivity and common sense. The prisoner was a
Category B prisoner serving a long sentence for a serious offence, but his
medical condition was such as to allow restraint not to be used.
Communications with the prisoner’ family
The prisoner's inmate medical record (IMR) states that at 10:10 on the
morning after he entered the hospital, hospital staff asked the prison to inform
his next of kin of his condition. However, a later entry at 12:10 that day says
that Security had received a call to say the prisoner did not want friends or
family informed of his condition or the fact he was in custody.
Hospital staff contacted the prison on Saturday to say the prisoner was dying
and had requested the prison to contact a Prison Visitor who was known to
him. The Prison Visitor was not an authorised visitor for Lewes Prison but
prison staff identified her telephone number on the prisoner’ list of authorised
phone numbers. The communications staff tried to telephone but were unable
to get through to her.
Having been unable to contact the Prison Visitor, staff identified a name and
address for next of kin in the prisoner’ local records. This was his former wife.
They contacted the local police in his former wife's area who found that she
had moved twice since that address. However, they were able to locate her
and told her that her ex husband was dying. A Principal Officer understood
from the police that the prisoner's former wife indicated that she no longer had
any interest in the prisoner and did not wanted to make any contact.
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When the prison was told that the prisoner had died, communications staff
again contacted the police. Staff had not dealt with any particular individual in
the police, and gave no contact details of the prison, as they understood the
family was not interested.
A few days after the man’s death, the Prison Visitor telephoned my office on
behalf of one of the prisoner’ daughters. The daughter had received her
father’s property from the prison and amongst this she had found a letter
addressed to the Prison Visitor. She had contacted her to find out more about
her father’s recent life, the circumstances of his death and what would happen
about the funeral and to his estate.
The prisoner's daughter told my investigators that the police went to a
neighbour's house who directed them to her address and was given a
message to ask her mother, to phone the police. This message was passed
onto her mother who indeed, did phone the police. They gave her the phone
number of the hospital. The daughter then phoned the hospital and they
discussed her father's condition. It was the hospital who then phoned her on
the Sunday to inform her of her father's death. Although the daughter felt very
torn in her feelings towards her father, she felt a need to know what had
happened. One of my investigators spoke to the prison and was given the
name of an officer who would act as liaison for the family and with my
investigation.
Two members of my staff visited the prisoner's ex wife and daughter. They
gave a more detailed account of their contacts with the police and the prison.
The police had come to the house next door to the prisoner's daughter in
search of her mother and had spoken to her neighbour. An unclear message
was passed to the daughter who asked her mother to call the police. When
she did so and was told that the prisoner was dying and which hospital he was
in. The prisoner's daughter phoned directory enquiries to obtain the hospital
number and rang the hospital, who asked her how she felt about turning off
the life support machine.
The prisoner's daughter wanted to contact the prison. She did not know her
father was in Lewes. She rang HMP Maidstone as she knew he had been
there and they informed her of the move to Lewes.
She then phoned HMP Lewes and asked to speak with the Governor. The
prison does not have a dedicated switchboard but uses a telephone switching
centre. The person who answered the telephone asked her the nature of her
call and she explained her father had been in Lewes and had died. She told
my colleagues that the telephonist replied, "Do you want to inform the
governor?" and that she did not get put through. The prisoner's ex wife says
that when she tried later, she was told she would have to write to the
Governor.
The prisoner's family felt they had received mixed messages from the prison
and this had caused distress. They felt prison staff had been hesitant to
provide information on the basis that they were uncertain who was next of kin.
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The prison had sent the prisoner’s property in two Parcelforce boxes with no
accompanying letter; they had not sent the prisoner’ bank-books but had not
explained why. The Governor informed my investigators that the prisoner’s
accounts contained substantial sums and the prison wanted to be sure that
the bank-books were released to the appropriate representative of the
prisoner’s estate. The family have now instructed solicitors to deal with the
estate and they are in correspondence with the prison.
The victims of the prisoner’s offences were family members. The prisoner's
daughter was struggling with the fact that her father had never acknowledged
or apologised for what he had done, and was hoping to find someone that he
might have spoken to about his offence. To this end she had contacted the
Prison Visitor. She also contacted the prison Chaplain. She spoke to one
Chaplain who said an officer knew about the case and he would get them to
call her but she does not know who the officer is and has not heard from
them.
My investigator spoke to the Victims Unit of the National Probation Service in
the area where the family live. A Senior Probation Officer, said that the field
probation officer was aware that the prisoner was ill but it was his daughter
who contacted the Victims Unit to say that he had died. The Senior Probation
officer considered that there might properly be a role for NPS in
communicating with the family in these circumstances.
Compliance with Prison Service requirements
Clinical care
Standards of healthcare in the prison are intended to mirror those available in
the outside community. I am satisfied that this was achieved.
Communications with the family
PSO 2710, which is currently being revised, advises prisons about what
actions must be completed after a death in custody. Much of the advice is
directed to the circumstances when a prisoner dies within the prison, but the
PSO makes clear that it applies to the death of anyone whilst in prison
custody. Although the prisoner died in hospital, he remained in the custody of
the prison.
The Order recognises that it will sometimes be necessary to notify next of kin
via the police, but provides as a mandatory requirement that:
“where the police are used it is important to gain confirmation and
ensure that a member of staff is in contact with the next of kin at the
first available opportunity to ascertain whether they wish to receive a
visit or visit the establishment. Give next of kin as much factual
information as possible at this stage and who the family can contact for
outside support...A note describing the arrangements to inform the next
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of kin…should be retained by the governor for possible inclusion in
reports to Headquarters. Where the police are used a note describing
the follow-up contact with the next of kin should be retained.”
(paragraph 3.2.5)
The Order contains further detailed guidance about follow-up support for
families. Notably:
“A senior member of staff should be appointed as the named point of
contact for the family and a second person named as available in the
first person’s absence.” (paragraph 6.2.3)
“The handing over of personal effects including all monies held on
behalf of the deceased needs to be done with care and sensitivity."
(paragraph 6.2.10)
The sequence of events in this case as relayed by the family show the
wisdom of the guidance. It seems that reliance was placed on conversations
with the police, and a fixed impression of the family’s feelings was formed
prematurely on the basis what was said to have been their reaction to the
sudden news of the prisoner’ illness and death. Some of the family’s
confusion and distress might have been averted if the prison had made
contact directly to offer information and named contact points.
As noted, Prison Service guidance on action following a death in custody is at
present under review. I recommend that the revised version of Prison
Service guidance pays particular attention to the following lessons, which can
be drawn from this case:
(cid:1) The guidance on supporting families applies to all deaths of prisoners,
including occasions when a prisoner dies in hospital of natural causes.
(cid:1) Prisons should always ensure that the next of kin is informed how to get in
touch with a named member of staff (and deputy in their absence) who will
act as liaison point and who knows all aspects of the case, even if the
initial response has been apparent indifference.
(cid:1) The liaison person should hold all information and as far as possible be the
only one to deal with the next of kin and other family members.
(cid:1) Operators answering the phone should be notified of prisoners’ deaths,
trained in dealing with bereaved family members sensitively, and briefed
as to who should deal with their calls.
(cid:1) When property is sent it should be presented sensitively and the family
member should be informed of when to expect to receive it.
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(cid:1) Where family members are also victims, consideration should be given to
engaging the Probation Service’s assistance in accordance with the
Victims’ Charter.
Notifying other prisoners
It is a mandatory requirement to notify other prisoners, especially friends or
associates in the establishment. (PSO 2710 3.2.18)
The prisoner's cellmate told my investigators that he heard of the prisoner’
death first from a prisoner then spoke to an officer who confirmed it.
Some cellmates will be close friends, some reluctant acquaintances. As a
matter of good practice, however, I recommend:
(cid:127) that staff should make a point of telling cellmates in person at the earliest
opportunity when if someone with whom they have lived recently in such
close proximity has died.
Record management and Incident recording
My investigators were given copies of the prisoner’ Inmate Medical Record,
Sentence Management, Security and Main Records. These did not include
his recent history sheets in which staff record significant events. Various
members of staff searched for the papers to no avail. My investigators were
told that there are several boxes of unfiled records, which are generally stored
alphabetically. A search as far as the ‘Es’ produced nothing for the prisoner.
There were no statements, special logs or debrief report, as we would usually
find in the case of a prisoner’s death. This is probably because what occurred
was that the prisoner became ill and was admitted to outside hospital. There
would have been no reason at that stage to implement the contingency plans
for action following death in custody.
However, the prisoner remained in the custody of the prison even though he
was in hospital. It is regrettable that his recent wing history sheets could not
be found. These, with the medical and other records might have provided a
sufficient contemporary record of events immediately before his admission to
hospital. After The prisoner’ death, I consider that it would have been good
practice for those members of staff who were in contact with the prisoner on
the day he became ill to have been asked to prepare brief statements of their
contact with him that day. I recommend that:
(cid:127) in the event of a death, it is good practice for Prison Service staff who have
been involved in the episode to prepare a written statement promptly after
the event. This would have been helpful to my investigation. It would also
assist the inquest at which staff might be required to give evidence, as well
as enabling the Prison Service to demonstrate accurately the care
provided to a prisoner who has died.
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Conclusion
From my enquiries it seems to me that the prisoner was treated by prison staff
with care and humanity and that he received appropriate medical care at least
as quickly as he would have received it in the community.
That a sick and elderly man should be taken to hospital secured by a chain for
what proved to be his final illness is not a comfortable idea. But it is part of
the necessary paraphernalia of security outside the prison walls. Staff used
the least oppressive form of restraint and an officer took the initiative to
remove it once the extent of the prisoner’ illness became clear, even though
medical staff had made no express request at that stage. I consider that
prison staff acted properly and considerately.
I have made recommendations that I hope may help the Prison Service to
respond more effectively to the needs of bereaved families, and to provide a
full account of their care when a prisoner dies in custody.
In commenting on the draft of this report, the Prison Service told me that HMP
Lewes is taking action to apply the lessons of this investigation. The Suicide
Prevention Co-ordinator is developing a protocol for managing the follow-up
process when a prisoner dies in a hospital outside the prison. I welcome this
constructive response.
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SUMMARY OF RECOMMENDATIONS
Communications with families
I recommend that the revised version of Prison Service guidance pays
particular attention to the following lessons which can be drawn from this
case:
(cid:1) The guidance on supporting families applies to all deaths of prisoners,
including occasions when a prisoner dies in hospital of natural causes.
(cid:1) Prisons should always ensure that the next of kin is informed how to get in
touch with a named member of staff (and deputy in their absence) who will
act as liaison point and who knows all aspects of the case, even if the
initial response has been apparent indifference.
(cid:1) The liaison should hold all information and as far as possible be the only
one to deal with the next of kin and other family members.
(cid:1) Operators answering the phone should be notified of prisoners’ deaths,
trained in dealing with bereaved family members sensitively, and briefed
as to who should deal with their calls.
(cid:1) When property is sent it should be presented sensitively and the family
member should be informed of when to expect to receive it.
(cid:1) Where family members are also victims, consideration should be given to
engaging the Probation Service’s assistance in accordance with the
Victims’ Charter.
Notifying other prisoners
I recommend:
(cid:127) that staff should make a point of telling cellmates in person at the earliest
opportunity when if someone with whom they have lived recently in such
close proximity has died.
Recording incidents
I recommend
(cid:127) that in the event of a death, it is good practice for Prison Service staff who
have been involved in the episode to prepare a written statement promptly
after the event. This would have been helpful to my investigation. It would
also assist the inquest at which staff might be required to give evidence, as
well as enabling the Prison Service to demonstrate accurately the care
provided to a prisoner who has died.
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