Individual at Swaleside

Investigation into the circumstances surrounding the death of a man in
August 2005, while a prisoner at HMP Swaleside
Prisons and Probation Ombudsman for England and Wales
February 2006
This is a report into the circumstances of the death of an 83 year old man,
was found collapsed on the floor of his cell in the Healthcare Centre of HMP
Swaleside. He was taken to hospital and died some hours later.
My colleagues and I would like to extend our condolences to the man’s family
and friends.
I would also like to thank the Governor of Swaleside and his staff for their co-
operation with this investigation.
The investigation was carried out on my behalf of one of my colleagues.
Swale Primary Care Trust, the health care provider, was notified of this
death and a clinical review was requested. We await the reviewer’s report,
but I have judged there would be no merit in delaying this report further on
that account.
In many ways, this is amongst the most straightforward reports I have issued
since taking responsibility for the investigation of all deaths in custody nearly
two years ago. However, the absence of a clinical review is part of a wider
problem that requires the continued attention of Prison Health and other
colleagues in the Department of Health.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2006
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Contents
Summary
Investigative Process
Background
(i) HMP Swaleside
Time in custody from 1998-2005
(i) Blakenhurst 1998-2005
(ii) Swaleside 2001-2005
(iii) January to August 2005
Events of 7 August 2005
Post Mortem and Clinical Review
Conclusions and Recommendation
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Summary
At the age of 78 this man was sentenced to life imprisonment on 16
November 1999 for the murder of his former wife. He suffered ill health from
the time he entered custody on remand a year earlier. He had respiratory
problems and severe chronic bronchitis as well as difficulties with mobility and
back pain.
His health problems meant that he spent the vast majority of his sentence in
prison Healthcare Centres. He lived a socially isolated life as it appears he
was unfriendly and would frequently swear at other prisoners and staff. He
passed his time by lying in bed and resisted attempts to encourage him to
leave his room. Attempts by Healthcare staff to conduct clinical tests and
medical investigations of his ailments were often rebuffed, but his Care Plan
was regularly monitored. He did not co-operate with Life Sentence Plan
Boards.
The health of this man gradually deteriorated, but the day before his death he
refused to see a doctor or have antibiotics. On the day he died, he remained
in bed and did not eat any meals although he had a dietary supplement drink.
He told a nurse who walked past his room at 3:15pm that he was okay. When
she saw him twenty minutes later, he was face down on the floor and
unconscious but breathing. He was taken to hospital by ambulance, but died
later that evening without regaining consciousness.
A post mortem was performed on 11 August. The cause of death was given
as bronchopneumonia due to Chronic Obstructive Pulmonary Disease. The
family of this man has not expressed any concerns about the care he received
while in custody.
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Investigative Process
The Senior Investigator visited Swaleside on 11 August 2005. She was given
access to the man’s prison records including his medical records. My
investigator met with the appointed Liaison Governor, and offered to meet
representatives from the Independent Monitoring Board and the Prison
Officers’ Association to give them the opportunity to raise relevant issues.
She also visited the cell where this man was located and spoke to healthcare
staff who knew him.
Notices to staff and prisoners were displayed around the prison. No
responses were received from staff or prisoners.
One of the man’s sons was contacted by my Family Liaison Officer to offer
him the opportunity to contribute towards the investigation process. He did
not have any issues he wished to raise concerning the care his father
received.
A clinical review of the healthcare given to the man whilst he was in custody
was requested on 18 August 2005. It has not yet been received.
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Background
(i) HMP Swaleside
Swaleside is a medium security prison in Kent which holds 775 prisoners who
are serving sentences of four years or over. It accepts prisoners in the first
stage of a life sentence who do not need the highest conditions of security.
The Healthcare Centre has capacity for 14 prisoners in ten single rooms and
a four-bed ward. It is staffed by a Healthcare Principal Officer, two Healthcare
Senior Officers, three Healthcare Officers, one F grade nurse and one E
grade nurse. The Healthcare Centre also provides in-patient facilities for
HMP Maidstone.
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Time in custody from 1998- 2004
(i) Blakenhurst 1998-2001
This man came into custody on 3 November 1998 and was sent initially to
HMP Blakenhurst. He was seen by a healthcare worker on reception and a
First Reception Health Screen form was completed to find out his medical
history. He said that he was using medication for asthma and that he had
worries about his breathing. He had been discharged that morning as an in-
patient in a local hospital due to a chest infection and possible left heart
failure.
On induction, the man was identified as having mobility and vision
impairments although these were not specified. He was readmitted to the
hospital the next day when his condition appeared to worsen, but was
discharged the same day. In a letter dated 27 May 1999 to the man’s
solicitor, the Senior Medical Officer at Blakenhurst described the man’s health
in the following terms:
“His physical health has remained poor. He has a chronic cough and
wheeze. He is breathless on exertion and spends most of his time in bed.
Mentally, he is irritable but shows no sign of functional or organic mental
illness.
He continues to smoke heavily, so that there is little likelihood of his chest
condition improving and every probability that it will continue to deteriorate
… his health is likely to gradually deteriorate over a period of months or
years, although in the presence of a history of heart disease, he could also
rapidly deteriorate rapidly and without warning.”
In November 1999, this man was sentenced to life imprisonment for the
murder of his former wife. His tariff was 12 years.
On 21 December 2000, the Senior Medical Officer at Blakenhurst wrote to the
Prison Service’s Lifer Unit who were looking for a suitable prison to place the
man.
“His acute respiratory problems quickly settled to reveal that he suffered
from quite severe chronic bronchitis and was subject to attacks of disabling
breathlessness for which oxygen therapy was, at times, required … His
mobility, from the time he entered prison in November 1998 … was always
apparently poor. He walked with the help of walking sticks and soon
became breathless … [His lumbar back pain] recurred with a vengeance
when he injured his back … which is reported to have occurred when he
tried to assault another inmate and fell over in the process. Attempts to
fully assess his injuries failed when he refused to have an x-ray.
“ … He is stubborn, unfriendly, verbally abusive at times, unwilling to co-
operate with attempts to investigate and treat his known ailments …
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Despite the best efforts of health care staff, this man will not be motivated
to try and help himself … [He] will require regular medical and nursing
supervision, if for no other reason than to try and ensure that, despite his
non co-operation, on which you can depend, he does not succumb to
conditions which result from a combination of his advanced age, his chronic
chest problems and his almost complete immobility.”
(ii) Swaleside 2001-2005
The man moved to Swaleside on 26 April 2001. He was seen by a doctor the
next day who noted in his medical record that he was suffering from chronic
respiratory problems. However, as he was “very bad tempered”, it was
difficult to get much information from him. Arrangements were made for
various blood tests to be taken, but he declined to have his blood taken.
A Life Sentence Plan Board was held on 18 July 2001 concerning the man’s
progress. He was not co-operative and the Board was terminated. The
man’s life sentence was reviewed on 28 January 2002. It was recorded that
no targets were set for him to achieve as he would not participate in any
activity offered to him. His personal officer concluded in a lifer report dated 7
March 2003:
“[this man] has some medical problems that restrict his location and
movement but all nursing staff and doctors who have had dealings with him
are in agreement that his mobility and ability to self care are far greater
than he would have anyone believe. His medical condition though serious
is exacerbated by his frequent refusal of medication and neglect of
personal care and hygiene.”
A medical assessment by a doctor was due on 26 June 2003 as part of his life
sentence reports, but he refused to allow the doctor to do so.
His medical record details much of the man’s day-to-day life for the last four
years of his life. Swaleside commenced a Physical Needs Care Plan on 17
February 2003 when it was clear that, due to poor hygiene, his bedding,
clothing and room were not being kept clean. He was described as being
verbally abusive to staff and prisoners, racist, aggressive, intolerant,
sometimes refusing to take medication or consent to medical tests. Whilst he
would collect his meals sometimes, at other times he was unwilling even to
get out of bed. He continued to suffer from poor health including degenerative
spinal disease, back pain, chest pain and respiratory illness. Apart from one
week spent on a residential unit, the rest of his time was spent in the
Healthcare Centre.
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(iii) January to August 2005
On 7 January 2005, a referral was made for this man to be considered for
HMP Norwich’s older persons lifer unit. His Mental Health Needs Plan and
medical record detail his daily life in that his behaviour remained unchanged,
but he had agreed to use a Zimmer frame and had become more mobile. On
20 May, it was noted that he was suffering from low back pain but was
refusing an x-ray and all forms of medication. A lumbar support was ordered.
It arrived on 24 May but was too small and he did not want another one to be
provided. On 25 May the man’s breathing was observed to have improved
since walking upright with a frame rather than being in a wheelchair.
On 6 June he was given Feldene gel for back ache. On 11 July, he was seen
by an in-reach mental health care worker but no symptoms of mental health
problems were detected. As he was verbally aggressive and appeared
unwilling to participate, no further action was taken.
On 5 August the man had a shower after being doubly incontinent during the
night. On 6 August, it was noted in his medical record, “feels unwell, cough
and expectoration, refuses to have his temp checked. Chest - basal creps.
Amoxycillin. Refuses antibiotics.” His health was noted to have been poor
that day, but he refused to see a doctor.
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Events of 7 August 2005
On 7 August, the day of his death, it was noted in the man’s Care Plan
Evaluation at 2:00pm that he had remained in bed all morning and had not
eaten breakfast or lunch. He had not been locked in his room except for the
patrol period at lunchtime. A staff nurse told my investigator that she had
offered the man a drink of Fortisip supplement earlier in the day, which he had
taken. He was later offered a Complan drink, but declined it.
The staff nurse walked past his room at about 3:15pm and saw him lying in
bed. She had asked him if he was okay and he said he was. At 3:35pm, she
saw him face down on the floor. She was unable to rouse him. With the help
of a Healthcare Officer the man was lifted onto his bed, and the staff nurse
telephoned the Healthcare Senior Officer (HCSO) who was in an office
upstairs.
The HCSO told my investigator that he went downstairs immediately and saw
that the man was breathing, but unconscious. He looked as though he might
have had a stroke as one side of his face seemed to have slumped. The man
then regained consciousness, but was breathing with difficulty. The HCSO
conducted a set of clinical observations on the man which took a couple of
minutes. His blood pressure was 100/60. The HCSO could not recall
exactly, but thought that he had asked another member of staff to contact the
Principal Officer in charge of responding to incidents to ask for an emergency
ambulance to be sent.
Kent Ambulance NHS Trust have confirmed that they received a request for
an ambulance from Swaleside at 3:46pm. An ambulance was despatched at
3:48pm and arrived at the prison at 3:59pm. It left the prison at 4:30pm and
arrived at hospital at 5:16pm. The man’s death, from severe pneumonia, was
confirmed by the hospital at 10:05pm on 7 August.
The police were asked to trace any family as the man had not provided
Swaleside with next of kin details. The man’s son, was contacted and told of
his father’s death.
In compliance with its contingency plans relating to the deaths of prisoners,
HMP Swaleside notified the Coroner, the IMB and other official parties of the
death.
My investigator visited Swaleside on 11 August and asked several staff about
life in the Healthcare Centre. The HCSO told my investigator that the man
had been suffering from a chest infection the week before his death, but did
not want antibiotics so the medication was not ordered. The man had been
prone to chest infections but his deterioration had seemed sudden.
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My investigator asked staff to describe a typical day. She was told that he
would just stay in bed, smoke and read a newspaper. He would not take
exercise outside and always bought ½ oz tobacco, a packet of cigarette
papers and a packet of toffees once a week.
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Post Mortem and Clinical Review
A post mortem examination of the man took place on 11 August. It concluded
that the cause of death was bronchopneumonia due to Chronic Obstructive
Pulmonary Disease.
A clinical review of the man’s healthcare whilst in custody was requested from
Swale Primary Care Trust on 18 August 2005. I am disappointed that I have
been unable to include its findings in this report, as I have not yet received a
copy of the review.
As in a number of cases, I have judged there to be no benefit in delaying my
report further. To do so, would not be advantageous to the family, the Prison
Service or the Coroner. Nor would it be respectful to the man’s memory.
However, the absence or late delivery of a clinical review is part of a wider
problem that I have encountered in far too many of my office’s investigations.
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Conclusions and Recommendation
This man suffered from ill health from the time he entered custody in 1998.
He was an elderly man who smoked and did not engage well with medical
staff. More detailed comment on the quality of healthcare he received in
custody is a matter for the Primary Care Trust, whose review has not yet been
received.
I recommend that a copy of this report is sent to the Head of Prison
Health, drawing his attention to my comments on p.12.
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