Individual at Whitemoor

Investigation into the circumstances surrounding the
death of a man at HMP Whitemoor
in March 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2009
This is the report into the circumstances surrounding the death of a man. He died in
his cell at HMP Whitemoor in the early hours of 6 March 2008. The cause of the
man’s death is recorded in the post mortem report as ischaemic heart disease due to
arteriosclerosis. I extend my condolences to the man’s family and friends, almost all
of whom live in Turkey, and I apologise for the delay in publishing this report.
The man developed hypothyroidism whilst he was in prison and he needed to take
medication to stabilise his condition. Unfortunately, he was reluctant to take the
medication, and he became both physically and mentally unwell. He required a short
stay in Rampton high security hospital on two occasions, to help him recover from
mental health crises. I am pleased that prison doctors were able to arrange for the
man to go to hospital and that his condition improved.
The man was a Turkish national serving a lengthy sentence for serious drug crimes.
At the beginning of his time in prison he struggled to communicate because English
was his second language. Towards the end of his life he felt he had served sufficient
time in England, and asked to be repatriated to Turkey (he was due for deportation
at the end of his sentence in any case). The Home Office, however, refused
permission for technical reasons relating to early release schemes in Turkey.
The investigation was carried out by my colleague. A clinical review, for which I am
most grateful, was undertaken by Cambridgeshire Primary Care Trust (PCT). I
included the clinical review as an annex to the draft report.
I am indebted to the Governor of HMP Whitemoor, for his and his staff’s support
throughout this investigation. I would especially like to single out the service and
support given by the Safer Custody Coordinator.
I do not make any recommendations within this report, although I have highlighted
an area of good practice by staff who worked with the man, trying to persuade him to
accept their clinical help. I request that the Governor passes on my observations.
Jane Webb
Deputy Prisons and Probation Ombudsman February 2009
2
CONTENTS
Summary 4
The Investigation Process 5
HMP Whitemoor 6
Rampton Hospital 7
Key Findings 8
Issues
The man’s health 12
Record keeping 13
After the man’s death 13
Good Practice 15
3
SUMMARY
The man was a Turkish national who was arrested and sentenced to 16 years
imprisonment in 1998 for drug related offences. He was held in HMP Belmarsh,
HMP Frankland and HMP Full Sutton before being transferred to Whitemoor in July
2004.
That same month, the man was diagnosed with hypothyroidism, a condition that can
lead to many of the body’s functions slowing down. This can have an effect on a
person’s metabolism, mood, weight, body temperature and skin condition. From this
point on, the man’s behaviour appears to have altered. Prior to this illness, the man
had been physically and mentally well but after it was diagnosed he became
aggressive, depressed, and distrustful. He often refused to comply with requests
from medical staff regarding his medication which resulted in his admission to
Rampton, a high security hospital. In June 2005, and again in August 2006, the man
was sectioned under the Mental Health Act 1983 and admitted to Rampton Hospital
for treatment. On both occasions he got better and returned to the prison, but he
always remained reluctant to take his medication.
In April 2006, the man had an electro cardio graph test (ECG – an electrical trace of
the hearts rhythm) as part of the care being provided to him. It showed that he had a
normal heart rhythm, but indicated that he might have had minor heart attacks in the
past. Repeat ECG’s were done that day which showed more normal rhythms, but no
referral to secondary care services was thought necessary.
On 6 March 2008, the man was discovered by the night patrol officer to be
unresponsive in his cell when she made her early morning checks. Staff assistance
was called and the Night Orderly Officer, together with supporting staff, went into the
man's cell. A nurse checked the man for signs of life, but could find none. An
ambulance was called and staff attempted to resuscitate him. The ambulance crew
found no signs of life and therefore they pronounced life extent for the man at
5.48am.
The post mortem revealed that the man died from ischaemic heart disease and
atherosclerosis, that is to say the blood vessels feeding his heart had hardened and
narrowed, which led to him having a heart attack.
The man’s family responded to the draft report, which is attached as an annex to the
final report. Amongst other concerns they raised, the difficulty they had in
connection with telephone communication is one that resonates with this office.
There is therefore an additional section added at the end of the ‘Issues’ section of
this report to endeavour to address this issue.
4
THE INVESTIGATION PROCESS
1. My investigator visited HMP Whitemoor on 20 March 2008. He was given
access to the man’s prison records and shown around the prison, including
the wing where the man was resident before his death. Notices of the
investigation for staff and prisoners were sent to the governor in advance of
my investigator’s visit. No prisoners or staff asked to see him as a result of
these notices.
2. Whilst visiting the prison my investigator met a member from the Independent
Monitoring Board (IMB) who gave him the Board’s report on the man’s death.
No matters of concern to the IMB were identified within their report. My
investigator also met committee members from the local branch of the Prison
Officers’ Association.
3. Cambridgeshire Primary Care Trust (PCT) was asked to undertake a clinical
review of the care the man received while in custody. A review was carried
out on their behalf. My investigator asked the clinical reviewer to look at the
entries in the man’s clinical record and determine whether he received an
appropriate level of care whilst in custody, equivalent to what he might have
expected had he been at liberty.
4. One of the Ombudsman’s Family Liaison Officers wrote to the man’s family
via the Turkish Embassy to explain the purpose of the investigation and invite
them to raise any concerns they wished to be considered and addressed as
part of the investigation. At the time of issuing the draft report the family had
not expressed any issues or concerns. They subsequently wrote to me and I
reflected their concerns within the Final report.
5
HMP WHITEMOOR
5. HMP Whitemoor is part of the High Security Estate. It accepts Category A
and B prisoners and those serving four years or more. The maximum number
of prisoners Whitemoor can hold is 458.
6. Healthcare provision is the responsibility of Cambridgeshire Primary Care
Trust (PCT). The healthcare centre is on two floors. The lower floor has the
treatment rooms and in-patient services, and the upper floor has more
treatment rooms and offices. There are x-ray facilities, dentistry, podiatry and
optician services available on this floor. There is one full time doctor
employed and nursing staff provide 24 hour nursing cover to the whole prison.
The “Out of Hours service” is provided by Suffolk Doctors On Call (SUFDOC).
7. The medical records system has recently been updated to an electronic
record system called System 1. This has been slowly introduced since March
2008, and is currently being built up to manage all patients’ health records
electronically, as well as appointments systems and audit processes. There
is a Special Interest Group whose role is to ensure the strategic
implementation of this system across all the prisons in the Eastern region. It
is hoped this will go a long way to improving the quality of prisoner-patient
clinical records.
8. HM Chief Inspector of Prisons, Ms Anne Owers, wrote in her report following
an unannounced follow up visit in June 2008, that the prison showed signs of
difficult relationships between staff and Muslim prisoners. Her report goes on
to say “Staff appeared to have little idea of, and to have been given no
support in, how to relate to this group [Muslim prisoners]”. Ms Owers
described the fundamental problem as being that relationships between staff
and prisoners generally were “distant and distrustful”.
9. In the latest published IMB report of 2006 – 2007, the issue of diversity and
race awareness is highlighted, as is the issue of caring and coping with
mental illness in prison. In respect of black and ethnic minority prisoners, the
Board is critical of the culture that has existed, but recognises that there have
been significant improvements. In regard to mental health services, the Board
are highly critical of the PCT commissioning services, in particular the in-
reach services.
10. There have been nine other deaths at HMP Whitemoor since 2004 when the
Ombudsman became responsible for investigating all deaths in custody.
Apart from the issue of poor medical records, there are no issues identified in
the man’s death that occurred in the other investigations that have been
conducted.
6
RAMPTON HOSPITAL
11. Rampton Hospital is one of three high security hospitals in England. Patients
are admitted to Rampton under the Mental Health Act, 1983, after doctors
certify they need treatment under secure conditions on account of their
“dangerous, violent or criminal tendencies”. The level of security at Rampton
is equivalent to that which can be found in a Category B prison.
12. The man was transferred to Rampton Hospital under Section 47 of the Mental
Health Act, 1983 (MHA). Section 47 is used to transfer a sentenced prisoner
with a severe and treatable mental illness to a National Health Service
hospital.
7
KEY FINDINGS
13. The man was born in 1964 in Turkey. Little is known about his arrival in the
United Kingdom, until he was arrested on 15 January 1998 for conspiracy to
supply heroin. He was convicted of that offence on 8 December 1998 at
Kingston Crown Court and sentenced to 16 years imprisonment. A
deportation order for his return to Turkey on release from prison was imposed
on 14 February 2000. In 1999, a Confiscation Order was served on him in
respect of assets deemed to have been acquired from supplying drugs. On
29 November 2001, the man was sentenced to a further three years
imprisonment as a punishment for failing to fulfil the Confiscation Order. The
three year additional sentence was to be served at the end of his original
sentence.
14. The man was transferred to HMP Full Sutton from HMP Belmarsh on 21
January 1999, and from Full Sutton to HMP Frankland on 17 August 2000.
There was nothing of significance recorded in either his medical or security
files from Full Sutton or Frankland save that he was a Category A prisoner
(the highest security category) due to the nature of his offence.
15. Whilst at Frankland, the man began to feel depressed and complained of
being unable to sleep properly and that he had ideas of harming himself from
March 2004. He was prescribed an anti-depressant (Cipramil) and underwent
some routine blood tests. He was found to be suffering from a thyroid
condition, hypothyroidism. (This is a condition where the thyroid gland is
underactive and does not produce enough thyroxine. Lack of thyroxine
causes many of the body’s functions to slow down.)
16. In June 2004, the man began to behave in a more aggressive and
unpredictable manner. He believed that the medication he was taking for his
hypothyroidism (Thyroxine) was “messing with his thoughts”. He became
violent and aggressive towards others (there were two assaults on other
prisoners) and he was put into the segregation unit.
17. The following month, on 16 July, the man was transferred to HMP Whitemoor
where he continued to be monitored for depression and feeling low. An
F2052SH document was opened. (The F2052SH system was a process in
place at the time. It was designed to ensure that as much help as possible is
given to a prisoner during a difficult period when they may be at risk of self-
harm or suicide.)
18. The man cut his wrist on 6 August, and required minimal treatment for his
wounds. The staff on his unit increased their level of observations as he
seemed to be depressed, but was unable to explain why he felt like that. On
7 August, another prisoner told staff that the man was depressed because of
“family reasons”. His behaviour is recorded within the F2052SH as being
“odd” in that he spent long periods of time standing and staring, not talking to
anyone who asked him anything. The F2052SH was closed on 13 August
2004.
8
19. Later that month, the man was seen by the mental health in-reach team and
assessed as suffering from depression secondary to his hypothyroidism (in
other words, his hypothyroidism was thought to be partly responsible for his
depression).
20. The man received a letter, dated 20 December 2004, from the Cross Border
Transfer Section of the Home Office regarding his request for repatriation.
The letter told the man that his request had been refused because:
“the Secretary of State is of the opinion that it would not be appropriate
for you to avoid serving any part of the three year sentence imposed in
default of a Confiscation Order solely as a consequence of transferring
to Turkey”.
The Turkish authorities were of the view that the additional three year
sentence was incompatible with Turkish law and they would not therefore
enforce that part of the man’s sentence.
21. The man was sent to the segregation unit again in January 2005, after fighting
with another prisoner. When he arrived there he went on hunger strike for
nine days. He was moved to the healthcare unit in February and it was
reported that he was taking his Thyroxine intermittently. During April he
refused to take his medication at all. He said that “people were playing mind
games” with him. He was hearing voices and messages both on the radio
and through the ventilation system.
22. A Consultant Forensic Psychiatrist from the Norvic Clinic in Norwich,
diagnosed that he was suffering from a paranoid psychosis (that is to say, he
was mentally ill). Due to the seriousness of his offence, and the belief that he
had been involved with a large gang supplying heroin, the Home Office
insisted that the man, should he require treatment at an NHS mental hospital,
would need to go to one of the secure hospitals in the country. He was
assessed and offered a place at Rampton Hospital in June 2005.
23. The man was admitted to Rampton Hospital on 18 June. He had been
refusing his medication and had eaten and drunk very little over the preceding
few weeks. He deteriorated rapidly when he first arrived at Rampton and
continued without food and fluids, until doctors decided that the severity of his
condition warranted emergency treatment. They arranged his admission to
the local hospital (Bassetlaw District General Hospital, Nottingham). Doctors
at Bassetlaw Hospital sedated the man and treated him with intravenous
fluids and Thyroxine. He recovered sufficiently to return to Rampton on 24
June, where he remained until he returned to Whitemoor on 10 October.
24. On 10 November, the psychiatrist requested that blood tests and an ECG
should be carried out. The man started to become unwell again in February
2006, and had to be admitted to the in-patient unit at Whitemoor on 23
February. He believed that staff were conspiring against him and that he
could hear voices again. He was refusing to take his Thyroxine and would not
take any anti-psychotic medication.
9
25. The psychiatrist expressed her concern to staff that they needed to be more
firm in their encouragement of the man to take his medication. He remained
reluctant but was well enough to be discharged from the in-patient unit back to
his own cell on 22 March.
26. There are notes in the continuous medical record that the man refused his
medication, despite staff encouragement, throughout the rest of March and
April. On 13 April, the man was seen by the community psychiatric nurse
together with another prisoner who was a friend. The nurse noted that the
man’s speech was slurred, his complexion was grey and that he refused to
have his pulse checked. The man was adamant that he did not need his
Thyroxine.
27. On 22 April, the man had an ECG which initially showed that he had a normal
heart rhythm, but might have had a recent minor heart attack. A repeat ECG
showed the heart was working normally at that time.
28. Throughout May and June, the man was seen by clinical staff and it was clear
to them that he was becoming increasingly unwell. He was refusing his
medication, which in turn was having a negative impact on his health. He was
grey, his face was getting puffy and he appeared to be putting on weight. He
started to become aggressive, irritable, showed signs of feeling like he was
being persecuted and having auditory hallucinations again. He was
transferred back to Rampton Hospital on 31 August.
29. The man went back to Whitemoor three months later on 20 November, having
been prescribed Thyroxine and Zuclopenthixol. (Zuclopenthixol is an anti-
psychotic medication that was to be given in a long lasting injection. It has a
tranquilizing effect on the patient.)
30. On 16 January, 2007, the man was seen by a second psychiatrist. The man
refused to go to the healthcare centre, so the second psychiatrist went to his
cell. Prison officers on the unit (B wing) told the second psychiatrist that they
believed that the man was over sedated. The second psychiatrist therefore
reduced the frequency of the depot injection from once every three weeks, to
once every four weeks. The next injection was due on 29 January.
31. According to the medical record, the man had the depot injection on 28
January. The next entry in the record reads “prisoner refused to attend
healthcare yesterday for his prescribed injection. Seen in education where he
agreed with [the community psychiatric nurse] to attend healthcare. Agreed to
give prisoner injection”. The entry dated 31 January reads “prisoner stated
that he was well but looked unkempt at this time. He did appear more
cheerful than when I last spoke with him. Zuclopenthixol diconate 300mgs
given. Next due 28 February”.
32. On 6 March at 5.05am, a prison officer was making her morning unlock
checks of prisoners on B wing. Her written report to the Governor said that,
when she looked through the observation panel of the man’s cell, he seemed
an unusual colour. The officer tried to rouse the man by calling to him,
10
switching on the lights and rattling the door, but gained no response. The
officer contacted a principal officer (PO) who was the most senior officer on
duty that night (codenamed Oscar 1). The principal officer and his assistant,
a senior officer (SO), together with the nurse on night duty, went to B wing.
33. The principal officer, senior officer and night duty nurse arrived at
approximately 5.20am and under the principal officer’s instruction, all four staff
entered the man’s cell. The night duty nurse checked for signs of life,
including breathing, pulse and blood pressure, but was unable to find any.
Nevertheless, the principal officer asked for an ambulance to be called and
the night duty nurse began cardiopulmonary resuscitation (CPR).
34. The paramedics arrived at the man’s cell at approximately 5.47am. After a
brief assessment of the man’s condition, the paramedics at 5.48am
pronounced that he had died.
35. The duty governor and the Independent Monitoring Board (IMB), police and
care team were all told of the man’s death. The prison’s death in custody
contingency plans were put into place, and before any staff left the prison they
were seen by the care team and asked to complete statements about what
had happened. The deputy governor, held a hot debrief (a meeting of all
those staff involved in the events surrounding the man’s death) before they
went off duty. The man’s next of kin were informed of his death by the
Turkish Embassy in London.
11
ISSUES
The man’s health
36. The man was sentenced in December 1998 and until early 2004 showed no
signs of any problems either from a custodial or health perspective. His early
days in custody were defined by his security status of a category A prisoner,
whose first language was not English – but aside from those difficulties, it
does not appear the man had any other concerns.
37. In March 2004, the man began to complain of feeling tired, depressed and
having thoughts of harming himself. He was diagnosed with hypothyroidism.
He transferred to Whitemoor the following July.
38. When the man showed signs of being depressed and at risk of self-harm,
Whitemoor instigated the procedure for keeping people safe, using the
F2052SH system. From examination of the F2052SH documents, it appears
that prison staff acted appropriately and caringly on each occasion they
thought the man was approaching a crisis. The only evidence of self harm
appears to have been in August 2004, not long after his arrival at Whitemoor.
39. The man does not seem to have accepted his diagnosis of hypothyroidism, or
at least the need to take medication for his condition. This appears to have
led to behaviour that prison staff found difficult to manage. He was seen and
supported by mental health in-reach services on a regular basis. They
encouraged him to take the medication that he was prescribed.
40. It is difficult to determine whether it was the man’s hypothyroidism or the
mental illness that developed separately to his physical condition, that caused
his feelings of distrust, paranoia and persecution. Either way, there was a
crisis in June 2005 and again in August 2006, such that he had to be
transferred to Rampton Hospital under a MHA Section order. Indeed, in June
2005, he was so ill that he had to be forcibly sedated for his own good whilst
life saving treatment was provided. I believe that the perseverance of staff at
Whitemoor, in particular mental health services, deserves recognition for work
well done.
41. Before the man left Rampton Hospital in October 2005, a multidisciplinary
team meeting was held with the team who had been looking after him. It is
recorded in the notes of that meeting that the man had been seen by a doctor
from Rampton as part of his treatment. In interview the man told the doctor
that he did not like to take Thyroxine “because it was a hormone and [he]
considered that hormones are usually given to women and therefore [he]
considered himself to be less of a man. She [the doctor] considered therefore
that his reluctance to take the Thyroxine was related to cultural issues”. I can
find only this one explicit mention of this belief in the man’s records, yet I
would consider this an important consideration in his care. Although there is
no suggestion in this report that the man was discriminated against on
grounds of race, he thought that staff were “persecuting” him at times. It is
open to debate as to whether the man’s culture led to his belief that his
12
treatment, which contained hormones, affected his sense of his masculinity
and was sufficiently understood.
42. The man had an ECG in April 2006, which initially indicated that he might
have suffered some minor heart attacks in the past. He had repeat ECGs at
the time which showed normal heart rhythms. The abnormal readings were
therefore attributed to what are known as artefacts, that is relating to the
machine, rather than the man’s heart.
Record keeping
43. The man was discharged from Rampton Hopsital on an anti-psychotic
medication, Zuclopenthixol. He was initially supposed to have this injection
every three weeks but the second psychiatrist, decided that this dose was too
high for him. Arrangements were made to reduce the frequency this was
given to once every four weeks.
44. On 31 January, the medical record says that the man was given his injection.
There then follows an entry that says 28 January “Depot given this am. Next
due 27 March 2008”. The clinical reviewer says “It is possible that the wrong
month has been recorded but I am unable to comment further as I cannot find
any evidence to say one way or other”. It does seem logical that the entry
dated 28 January, should indeed read 28 February. It does, after all, appear
in the clinical record after the entry made 31 January.
45. However, this highlights an issue that is not peculiar to this man’s record, but
is a feature of other investigation reports by the Ombudsman. The clinical
reviewer found it extraordinarily difficult to complete his report because of the
poor state of the clinical record held by Whitemoor. He had some initial
difficulty following the content of the clinical record because there was no
summary of medical conditions, some records were missing and there were
poorly written entries in the medical notes. The missing records were
eventually resolved, but had resulted in a time delay for the clinical reviewer.
This may, in part be due to the fact that most of it is in handwritten format
rather than electronically recorded. It may, in part be due to the fact that the
man had recently been a patient at Rampton, and transferring records around
the health system can have its effect on them. Nevertheless, the clinical
reviewer records in the clinical review in a number of different ways that he
could not comment about matters because “a considerable part of the inmate
medical record was missing”. I trust, with the introduction of a computerised
medical records system, that this will not be an issue in future clinical reviews
relating to Whitemoor.
Telephone communications with the man’s family
46. Foreign National Prisoners (FNP) often do not receive visits whilst they are in
prison. The Prison Service therefore makes arrangements for foreign national
prisoners to receive additional phone calls so that they can maintain family
ties. Whitemoor has a process whereby they give extra money to a prisoners
13
pin phone account to facilitate this. They also have a means for cheaper
overseas phone calls to be made.
47. There is also a need to consider protection of victims in foreign countries.
Whitemoor has a policy of speaking first with a prisoner’s nominated
telephone contact using the services of a translator. This is to ensure that the
person at the other end of the telephone call is a bone fide contact of the
prisoner. This is only done the first time a prisoner makes contact with the
nominated person. It is a way of preventing potential harm to innocent third
parties (it gives the recipient of the call the opportunity to say ‘no, I do not
want to receive calls from this person’). I believe this to be an appropriate
safeguard to have in place, but understand the difficulties this might on
occasions cause for genuine family contacts.
After the man’s death
48. After the man’s death, the principal officer instigated the death in custody
protocol in line with Whitemoor’s local instructions. It seems clear from the
records that much was done to ensure staff were properly supported.
Whitemoor’s local contingency plan structures seemed to work well and the
hot debrief identified some useful learning for the establishment.
49. The clinical review concludes that the man died of natural causes. The
clinical reviewer says that:
“Post mortem shows that his arteries were 80 percent occluded and
this would clinically indicate that the heart had difficulty pumping
oxygenated blood around the system. This would have resulted in the
heart becoming over worked and ultimately resulted in the man’s heart
stopping. There is a high incidence of fatal heart attacks in men under
50 years of age who have occlusions of this nature; often the first sign
of such atherosclerosis in young men is their death”.
14
GOOD PRACTICE
50. I commend the work of staff at HMP Whitemoor, particularly mental health
staff, in their tireless efforts to manage the man’s physical and mental health
condition. To encourage a man who is ill and remains reluctant to receive
medicines that will help him is a difficult task. It would have been all too easy
for staff to consider the man’s decision not to take medication as his own
choice and take no further action. Instead, they chose to persevere and were
determined to ensure, as best they could, that the man should receive the
care and medication he needed.
15