Individual at Preston

THE CIRCUMSTANCES OF THE DEATH OF
A MAN AT HMP PRESTON ON 10 APRIL 2004
PRISONS AND PROBATION OMBUDSMAN
FOR ENGLAND AND WALES
JUNE 2005
The man died at HMP Preston on 10 April 2004. He was 51 years old. I would like
to express my condolences to his family and friends.
At the time of his death, the man was remanded to HMP Preston and located in the
drug dependency centre. The post mortem report indicates that the cause of death
was peritonitis caused by a perforated duodenal ulcer. In the 24 hours before his
death, he had complained of severe abdominal pain and had been seen by nursing
staff and a doctor. The pain was thought to be caused by withdrawal from drugs.
As Prisons and Probation Ombudsman, I am required to investigate the
circumstances of all deaths of prisoners. This investigation was conducted under
transitional arrangements by a senior investigating officer nominated by the Prison
Service and acting on my behalf. I am grateful to all those who have assisted with
the investigation, including the Head of Healthcare at HMP Garth and Nurse Adviser,
who has conducted a clinical review of the man’s care, and the Governor and staff of
Preston prison.
For reasons the report explains, this has not been an entirely satisfactory
investigation. In particular, the clinical matters raised by the man’s death have not
been fully explored. For that reason, I have ended the report not with a series of
conclusions and recommendations as would be done conventionally. Instead, I have
listed my observations and outstanding issues. I hope these will be of assistance to
the prison and to Prison Health.
STEPHEN SHAW CBE JUNE 2005
PRISONS AND PROBATION OMBUDSMAN
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SUMMARY
The man was arrested on 7 April 2004. He was remanded to Preston prison on 8
April. He died in the drug dependency centre there on 10 April. The pathologist’s
report gives the cause of death as peritonitis as a result of a perforated duodenal
ulcer. The man’s partner says that he was suffering vomiting and pain before he
was arrested.
According to prison medical records, he did not complain of abdominal pain on
admission to prison nor at a clinical assessment the next morning. His first night
cellmate says the man was suffered nausea, vomiting, cramps and stomach-ache
overnight but did not complain to staff. It is likely that the man attributed his
symptoms to withdrawal from drugs.
In the evening of 9 April, the man became breathless and a nurse was called. He
complained of abdominal pain. It was thought the man might have ingested heroin,
though he denied it. The doctor was called. He examined the man, prescribed a
muscle relaxant and documented he should be reviewed in the morning. Overnight,
the man was seen to be restless and in distress. A healthcare officer was called and
he complained of severe stomach pains. In the morning, a nurse discussed the man
with the doctor, who decided not to increase his detoxification medication or to visit.
The man was not examined.
At 12.20pm, the man’s cellmate called for assistance. Officers and a nurse
attended. The man was unsteady and incoherent. He was given oxygen and an
ambulance was called. His condition deteriorated quickly. Cardio-pulmonary
resuscitation (CPR) was stopped at 1.30pm.
The Primary Care Trust was unable to provide a clinical review for this investigation.
Consequently there are outstanding clinical questions about the interpretation of the
man’s symptoms and whether the investigation, care and monitoring of his
symptoms was consistent with reasonable clinical practice. It is also unclear what
medication he was receiving and whether that was an appropriate response to
mitigate the effects of withdrawal from opiates. I also note that the nurse who
attended the man says it was not clear whether prison staff or paramedics were
authorised to stop CPR.
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HMP PRESTON
HMP Preston is a Victorian prison mainly of traditional radial design. Its function is
as a local prison housing prisoners remanded by the courts and those on short
sentences. Operational capacity is 664.
There are five residential wings which are gradually being refurbished. The first
night centre is in D wing. The drug dependency centre where the cells have the
prefix ‘J’ is in C wing.
Health care at Preston includes in-patient beds, out-patient clinics and a primary
care service. The prison has been unable to recruit a permanent replacement since
the retirement of the Senior Medical Officer and has relied on locums from an
agency. Out of hours cover, including weekends and reception of prisoners in the
evening, is provided through a contract with a local GP partnership.
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THE EVENTS OF 8 TO 10 APRIL 2004
The man was arrested early in the morning of 7 April.
Thursday 8 April
The Prisoner Escort Record states that he was fit and well when received by the
escort service at 8.05am on 8 April. He was considered fit for transfer to Blackburn
magistrates’ court from police custody. The man was remanded to appear before
the magistrates by video link on 16 April. At 2.15pm he was taken by the escort
service to Preston prison where he was registered at 3.13pm.
Health screening on admission to prison
The First Reception Health Screen (revised form F2169) was completed by a nurse
in reception. The nurse recorded that the man said he suffered from lung cancer
that was in remission, sciatica, problems with asthma, and chest pain. He appeared
“tight in chest”. He said he drank 6-8 super strength lagers, smoked four bags of
heroin and took 40ml methadone daily. The form records, “Refer to doctor re
physical health and substance abuse”.
The reception nurse referred him to the doctor, who is one of the GPs providing out
of hours cover. The doctor has initialled the Medical Officer’s reception health
screen noting asthma, no mental health concerns, heroin detox and that the man
was fit for labour and PE. He was prescribed a Ventolin inhaler which was issued to
in possession. No other medication was issued to the man that day.
A nurse conducted a Well Man Assessment. This follows a structured questionnaire,
with questions about Breathing, Diabetes, Heart, Epilepsy, Drugs, Alcohol, and
Mental Health. In response to questions, the man again reported his drug and
alcohol use.
In the mental health section, the man was asked whether in the last six months he
had experienced various symptoms. He said ‘yes’ to sleep problems, lack of energy,
feelings of depression and stomach problems. This reference in the mental health
section of the questionnaire is the only prompt in the questionnaire referring to
‘stomach problems’. Entries in the form indicate that, when invited to say whether he
had any other medical or surgical history, the man complained of sciatica and
soreness of chest related to lung cancer in remission.
The Induction Checklist in the Custody and Care Plan Assessment records that the
man was a heroin/methadone addict, that he had used drugs that week and that he
was suffering severe withdrawal symptoms. In reply to the question “Do you have
any health problems you have not informed medical staff about?” the answer ‘No’ is
recorded.
The man spent Thursday night in the First Night Centre on D wing. No medication
was given that night. In the First Night Centre, he shared a cell. His cellmate says
the man was “withdrawing really badly”, curled up on the bed and experiencing
nausea, vomiting, cramps and stomach-ache. This prisoner says that the man
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attributed his symptoms to withdrawal from drugs and he did not recall the man
pressing his cell bell or asking for help.
Friday 9 April
On Friday, the man saw a nurse for assessment for a detoxification programme.
She noted that urine tests were positive for opiates, methadone and
benzodiazepines. The man described his present drug use as dihydrocodeine 60mg
and methadone 40ml, both of which he said were prescribed, and smoking four to
five bags of heroin daily. He said he had last used drugs two days previously and
the nurse noted he was showing signs of withdrawal. The man was to be located on
J1, the drug dependency centre, and: “commenced on medi 7 (a day) until
methadone confirmed”.
There is a prescription and administration record chart in the Inmate Medical Record
(IMR) and a Detoxification medication chart in the CARATS file (CARATS is a drug
reduction programme). However, I do not know what the ‘Medi 7’ regime is and it is
not clear to me from the prescription and detoxification records what medication the
man received. The nurse concerened has not been interviewed.
In the afternoon, an officer was conducting the induction for new prisoners in the
drug dependency centre. This officer says that during the induction, the man was
feeling unwell and unable to concentrate. The officer helped him back to his cell
where he lay down. The officer assumed that he was poorly because he was
withdrawing from drugs. The man had not complained of any particular symptoms.
The induction officer was aware that the nurses saw the man a few times during the
day.
Sometime after 4.00pm, officers searched the cell occupied by the man and his cell-
mate and found a quantity of heroin and burnt foil.
That evening, a nurse was called to see the man in his cell at 6.20pm. He was
breathless, rocking back and forth and complaining of abdominal pain. The entry in
the medical record comments that he was withdrawing from opiates. The nurse
administered oxygen. The man’s pulse was elevated to 149 beats per minute. He
was helped to use an inhaler. The entry in the medical record notes:
“Becoming more and more anxious due to abdominal pain so his breathing
problems were exacerbated.
“DHC [dihydrocodeine] 60 mg given as prescribed....”
The nurse checked the man again at 6.30pm. His blood pressure was 160/90 and
pulse reduced to 120. The entry in the continuous medical record says that the
nurse was told that the man had taken some heroin. He was suspected of having
swallowed heroin in foil and then to have excreted the foil parcel but with the
possibility that some heroin had leaked into his stomach. At this point, the nurse
contacted the duty doctor.
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The next (untimed) entry in the medical record says that the man said it was not true
that he had swallowed heroin. His pulse at this point was 145.
The duty doctor examined the man at 7.00pm. He notes that the abdomen was firm.
The man had opened his bowels that morning, had passed urine, had no haematuria
or vomiting but was coughing. The doctor prescribed Buscopan 10mg (a muscle
relaxant) and made a note that the man was to be reviewed in the morning.
Overnight Friday/Saturday
The man’s cell-mate says the man behaved bizarrely during the night. He seemed
to be hallucinating, was constantly spitting on the floor and banged on the door and
rang the bell several times. The cell-mate says that, all the time he was with the
man, he was shaking violently and complaining of bad stomach pains.
An entry in the medical record timed at 12.30am says:
“Called to J1 @ 00:30. C/o [complained of] severe stomach pains. Generally
inconsistent history. Advised.”
The signature is hard to read but is probably that of a Healthcare Officer Senior. He
has not been interviewed.
The night orderly officer, in charge of the prison overnight, says that the night duty
officer brought to his attention during the night his concerns about the man. His
behaviour was very erratic, he was curled in a foetal position and complaining of
stomach pains. That was why the healthcare officer visited at 12.30am. The night
orderly officer said it was not unusual for prisoners coming off drugs to complain of
stomach cramps and to curl up in a foetal position. The night orderly officer said that
the officer had told him that the man had rung his bell quite a lot during the night but
had been quite happy when he had been spoken to. The night orderly officer said he
had asked the officer to monitor the situation and he assumed that the man would be
put down to see the doctor in the morning. In contrast with the wings at Preston that
have recently been refurbished, there is no electronic record of when cell bells are
rung on C wing.
The night orderly officer also said that the man had been monitored on the cameras
that permanently monitor the detox unit cells. He said that the man was not
continuously in a foetal position but between the times when he rang the bell he was
sitting on the chair having a drink or smoking.
Before going off duty, the night officer made an entry in the wing occurrence book
recording that the man had been restless all night, seemed to be hallucinating, and
might need to see a doctor when the main staff came on duty. The officer coming on
duty for the day shift, signed to accept the handover. These officers have not been
interviewed.
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Saturday morning, 10 April
Another officer told the investigation that the man came out of his cell for breakfast.
The prescription chart indicates that he received Buscopan 10mg. Later in the
morning, his cellmate had rung the cell bell because the man was vomiting into the
bucket or trying to drink from the bucket and staff had removed it. The officer had
been watching the monitoring screen and had not entered the cell himself. His cell-
mate says that during the morning the officer came and told him that the man would
be moved to the hospital wing.
An entry in the medical record timed at 9.30am says: “Discussed with [doctor]
concerning review, or increasing detox to medi 2(12 day), declined to review or
increase detox.”
This entry contradicts the doctor’s records of the previous evening when following an
examination of the man he recorded he was to be reviewed. It also comes before
the entry for 00:30 which was written at the top of a fresh page. It is not clear
whether the nurse and doctor were aware that a health care officer had been called
to the man during the night or of the man’s restlessness overnight as noted by the
night officer. The doctor and nurse have not been interviewed
The episode leading to the man’s death
The man’s cellmate says that at 12.20pm the man collapsed on the floor and he
pressed the cell bell for help.
An officer answered the bell at about 12.25pm closely followed by two other officers.
They called for assistance from a healthcare officer. When the nurse arrived, at
about 12.35pm, the man was alternating between staggering about, sitting on the
floor and sitting on a chair. The nurse took a reading of blood pressure at 70/30 and
pulse 67 to 69. The man was becoming ashen. An officer radioed the
communications room to call for an ambulance. The man was given oxygen. His
breathing became shallower and stopped. Two officers laid him on the floor and the
nurse and another officer attempted cardio pulmonary resuscitation. Another nurse
brought a defibrillator and attached it to the man. The paramedics arrived. One
nurse and an officer assisted the paramedics. At 1.15pm the paramedics ceased
attempts to revive the man. The officer says that the paramedics looked to the
prison staff to make the decision to cease CPR but they had said that it was not their
place to do so and left it to the paramedics. The nurse says that the decision to
cease attempts to revive was made jointly by the whole team.
Videotape
Eleven cells in the drug dependency centre are constantly monitored by a closed
circuit television system. These are used for newly admitted prisoners and included
the cell occupied by the man. My Assistant Ombudsman has watched the videotape
covering the period from 4.20pm on Friday 9 April to 1.25pm on Saturday 10 April. It
confirms that the man appeared to be in considerable discomfort overnight,
constantly shifting from one place or position to another between the bed, the chair
and the floor.
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An officer, presumed to be a Healthcare Officer Senior, entered the cell at about
12.25am and spent about five minutes with the man. After the officer left, the man
continued to be restless but from about 1.00am mainly stayed in bed, lying first one
way up, then the other. From about 3.30am the screen is dark with no image visible
until about 8.45am when the man was up and about. He was sitting at the door then
appears to be standing on something at the door. He went out of the cell and
returned. During the morning he appears to be in distress. He moves from the floor
to the bed to the chair and back again repeatedly. At 10.00am he is kneeling on all
fours on the floor. He takes his sweatshirt off. At 10.54am he appears to be
scrabbling in a bucket. A prisoner and an officer come in then leave again. An
officer is in the cell briefly at 11.05am.
At 11.28am the man is on the floor. At 11.39am he is curled up on all fours. His
cellmate leaves the cell and returns. He appears to be in distress too, as if he does
not know what to do for the man, and is in discomfort himself. At 12.13pm the
cellmate goes out of the cell then returns. At 12.27pm two officers enter. The nurse
comes at 12.39pm. The paramedics are present from 12.58pm.
Contact with the man’s family
On 10 April, the Governor and a chaplain visited the man’s partner and other
relatives to tell them of his death. They had already learned of it from another
relative who was on the same landing as the man in the prison and who had
telephoned the family.
My Assistant Ombudsman spoke to the man’s partner on 16 April, wrote to her on 20
April and provisionally arranged to visit her at home. However, before the planned
visit, the man’s partner said that she had sufficient support from the police and the
Coroner’s officer and chose not have a further visit.
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OBSERVATIONS AND OUTSTANDING ISSUES
The investigation
I regret to say that this investigation has not yet been satisfactorily completed. There
are outstanding questions about clinical matters.
The Preston Primary Care Trust was asked to undertake a clinical review of the
man’s healthcare but in the event did not nominate anyone to do so.
It was agreed in June 2004 that the Area Health Care Adviser for the Prison Service
North West Area would assist the investigator with interviews with the relevant
clinical staff. Unfortunately, she then left the Service. The investigator obtained the
assistance of the Head of Healthcare at HMP Garth who reviewed the medical
records. However, the doctor, a nurse and the Healthcare Officer Senior, all key
players, have not been interviewed.
Outstanding questions
The Home Office pathologist’s report indicates that the man died of peritonitis
caused by a perforated duodenal ulcer and that he was likely to have experienced
abdominal pain in life.
The response to the man’s abdominal pain
The man’s partner says he was already suffering from severe stomach pains before
his arrest on 7 April. I do not know whether the police have any record of this. His
first night cellmate says the man experienced severe stomach pains during the night
of 8/9 April. He was seen to be unwell during Friday 9 April. The medical record
indicates that he expressly complained of abdominal pain at 6.20pm on 9 April and
of severe stomach pain at 00.30am on 10 April. He was observed to be in distress
overnight. It appears that he was not examined in the morning of Saturday 10 April
despite the doctor’s decision the previous evening that the man should be reviewed
in the morning, and the events of the night.
By his own account, the man was withdrawing from drugs. He also said that he was
suffering from lung cancer in remission (the pathologist’s report contains no evidence
of this), sciatica and asthma. The man’s pain was apparently attributed to
withdrawal symptoms perhaps coupled with his general poor health.
From the autopsy report it appears that this judgment may have been wrong. I am
not qualified to say whether it was a reasonable judgment in the circumstances and
whether the investigation and monitoring of his symptoms was in accordance with
reasonable clinical practice but, on the face of it, there are issues that should be
considered further.
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The detoxification regime
I am also concerned that it is not clear from the prescription charts exactly what
medication the man was receiving in the drug dependency centre. That should be
manifestly clear from the records but is not. Moreover, if the pain that the man was
undoubtedly suffering as a result of a perforating ulcer could reasonably be mistaken
for the pain routinely suffered by prisoners withdrawing from drugs, that raises
questions about whether the medication prescribed for detoxification is adequate and
appropriate, and the safety of prisoners in those circumstances.
In the report of an announced inspection of Preston prison from 26 to 30 June 2004,
HM Chief Inspector of Prisons commends the commitment of staff working on the
drug dependency unit but comments that facilities there were poor.1 Overall, the
inspectorate comments:
“There were shortfalls in the clinical management of prisoners with substance-
related problems; in particular first night medication was given out
inconsistently; the only regime on offer for opiate users consisted of
symptomatic relief; there was an absence of specialist, dedicated nursing staff
and a lack of care planning and joint working.”
HM Chief Inspector recommends:
“8.60 First night symptom relief should be administered consistently and the
process closely monitored.
8.61 A dedicated team of specialist nurses should be appointed to undertake
assessments, care planning and follow-ups for all substance-dependent
prisoners requiring clinical treatment….”
“8.63 The new clinical protocol; for substance misuse services should be
introduced as soon as possible and prescribing brought in line with national
clinical guidance.”
The decision to stop Cardio-Pulmonary Resuscitation
A nurse says that it was not clear whether the prison staff or the paramedics were
authorised to make the decision to stop the attempts to resuscitate the man.
The well man assessment
I was surprised that the only prompt for stomach problems in the well man
assessment appeared in the mental health section and wonder whether this is
appropriate and sufficient.
1HMCIP: Report on an announced inspection of Preston Prison 26-30 June 2004
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RECOMMENDATIONS
The clinical issues surrounding the death of the man, I do not believe have been fully
explored. I recommend that a further investigation is commissioned to consider
clinical care afforded to the man with specific reference to:
(cid:127) The doctor declining to see the man after having documented he would review
him in the morning.
(cid:127) The apparent failure of staff to recognise the symptoms of an acute abdomen and
treat appropriately.
(cid:127) The assumptions by healthcare staff that he was withdrawing from drugs.
(cid:127) That considering his history of lung cancer and the man’s complaints of a tight
chest no further clinical examination was undertaken.
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