Individual at Whatton

Investigation into the circumstances surrounding
the death of a man at HMP Whatton in August 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2010
This is the report of an investigation into the death of a man who died in August 2009
after collapsing in his cell at HMP Whatton. The post mortem confirmed that the
primary cause of death was an acute myocardial infarction (heart attack), secondary
to ischaemic heart disease (narrowing of the arteries). The man, who had first
suffered a heart attack at the beginning of the decade, was aged 56.
He had been in custody since 2003. He arrived at Whatton on 13 November 2007,
following transfer from HMP Birmingham.
The loss of any family member is acutely painful, but especially so whilst they are in
custody. I offer my sincere condolences to the man’s family and friends.
The investigation was conducted by one of my investigating officers. In addition, I
commissioned a clinical review of the man’s healthcare. I would like to thank the
clinical reviewer who was appointed by the local Primary Care Trust to undertake the
review. I would also like to thank the Governor of Whatton and her Head of
Performance, who acted as liaison with the investigator.
I make two recommendations in this report. I also note as an example of good
practice the location on every wing at Whatton of defibrillator machines.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2010
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CONTENTS
Summary
The Investigation Process
HMP Whatton
Key Findings
Issues Considered during the Investigation
Conclusions
Recommendations
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SUMMARY
The man had suffered a heart attack in 2000, when he was 47 years old. Shortly
afterwards he had an operation to help with blood flow to his heart muscle. He was
a smoker and continued to smoke 30 cigarettes a day.
Following a period of remand commencing in 2003, he was sentenced to ten years
imprisonment in 2004. Held at Birmingham initially, he continued to suffer with chest
pains and was referred to a cardiology department in 2005. When he saw a
consultant cardiologist in 2006, it was noted that he continued to smoke and that he
had severe cardiac disease. He had a further operation to improve blood flow to his
heart in 2006, but this was only partially successful as the arteries of his heart were
found to be damaged.
When the man was transferred from Birmingham to HMP Whatton in late 2007, his
cardiac problems were noted, his medication was reviewed, and plans were made
for up to date investigations. He had cut his smoking down to ten cigarettes a day.
He saw the consultant cardiologist again.
In August 2008, it was noted that his angina (a narrowing of the coronary arteries)
was stable, and there was no mention of any angina when he was reviewed by a
nurse in March 2009. The following month he was found to have a normal pulse,
normal blood pressure and no heart murmurs. Advice was given about future
medical management and no further investigations were planned.
The man did not attend 12 clinic appointments from 26 May, but did collect his
medications from the pharmacy on 11 June and 16 July. He was sent a letter by
healthcare asking if he still wanted to be monitored. He said he did, but although he
was booked in for further appointments he did not attend them. According to a
friend, the man was again smoking around 30 cigarettes a day.
In August 2009, the man collapsed in his cell after suffering another heart attack. He
was found by prisoners who raised the alarm. Two prison officers attended and,
whilst one performed cardiopulmonary resuscitation (CPR), the other asked
healthcare staff to attend. Nurses arrived and an ambulance was requested. A
defibrillator was connected to him and two shocks were given, with CPR continued in
between the shocks. A further eight cycles of CPR were carried out, the defibrillator
advising ‘no shock’ after each two minute cycle of CPR.
After the ambulance arrived, the man was connected to its defibrillator and CPR
continued for a further four minutes. At 12.52pm, with unanimous agreement,
resuscitation was ceased and death was pronounced. He was aged 56.
Two recommendations are made in this report. One concerns the use of radios in
emergency situations, and the second the provision of emergency ambulances. The
ready availability of defibrillators at Whatton is highlighted as good practice.
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THE INVESTIGATION PROCESS
1. My office was notified of the man’s death in August 2009. Notices announcing
the investigation were supplied by my investigator, and displayed by the prison to
staff and prisoners who were invited to contribute relevant information. In the
event, no prisoners or staff made contact.
2. All relevant prison records relating to the man were studied by my investigator.
They included his main prison record, medical records and statements made by
staff. One of my family liaison officers made contact with his mother and his
sister.
3. A clinical review of the man’s healthcare was undertaken by the clinical reviewer
of the local Primary Care Trust. He also made himself readily available to
answer any queries during the investigation, and his assistance is much
appreciated.
4. Her Majesty’s Coroner was contacted by my investigator to inform him of the
nature and scope of my investigation and to request a copy of the post mortem
report. Upon completion, a copy of this report will be sent to the Coroner to
assist his enquiries into the man’s death.
5. My investigator visited HMP Whatton on 24 September to familiarise himself with
the general environment where the man was located when he suffered the heart
failure. He also visited the wing and cell where he was found collapsed, and
spoke with members of staff, including the liaison officer.
6. In October 2009, the family liaison officer was informed by the man’s sister that
her family had received a letter containing a card from a fellow prisoner that
caused them much concern. It suggested that the man had been supplied
medications from other prisoners, and that an unlawful assisted suicide had
taken place. The family were understandably anxious about this and wanted to
know who had written the card and how it had been sent. I hope that this report
helps answer those questions. The family did not raise any other concerns.
7. On 9 November, my investigator returned to Whatton where he interviewed a
prisoner, a prison officer and a nurse. The interviews were recorded and a
transcript was made of each.
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HMP WHATTON
8. HMP Whatton first opened as a detention centre for juveniles, but its role
changed in the early 1990s to that of a prison for vulnerable adult offenders.
During this time, the prison developed as a specialist establishment for adult
male sex offenders to enable them to participate in the Sex Offender Treatment
Programme. Whatton has recently undergone large expansions in 2006 and
2008, increasing capacity by 500 places. On 6 August 2009, there were 839
prisoners in custody.
9. The regime at Whatton includes education, vocational training, industrial
workshops and manufacturing, farms and gardening. There is a large range of
offending behaviour programmes, including both Living Skills and Sex Offender
Treatment Programmes.
10. The local Primary Care Trust is responsible for healthcare provision within the
prison. The healthcare centre is open daily, with healthcare staff on duty
between 7.30am and 7.30pm. Outside of these hours, Nottinghamshire
emergency medical services are used when required.
11. The healthcare department at Whatton runs a walk-in centre and a nurse-led GP
practice. It runs nurse-led triage clinics, blood clinics, specialist clinics and follow
up clinics. From initial consultation the nurse will refer on to the doctors or
arrange appropriate prescriptions to be made up. There are no inpatient
facilities. Nurses take leads in different diseases, so they have various internal
clinical specialists. Occasionally, external specialist nurses come in. These
include diabetic, COPD (chronic obstructive pulmonary disease) and TB
(tuberculosis) nurses.
12. There is a portable automated defibrillator located on each wing. These
machines can analyse the heart rhythm, diagnosing the shockable rhythms and
then charging to treat. Defibrillation consists of delivering a dose of electrical
energy to the affected heart. This halts abnormal electrical activity in the heart
and can allow normal beating to be re-established.
Previous deaths at Whatton
13. There have been 15 deaths at Whatton in the past three years. None of the
circumstances arising from my office’s previous investigations is similar to those
in this case.
Her Majesty’s Chief Inspector of Prisons’ Report
14. HM Chief Inspector of Prisons made a full announced inspection of Whatton in
January 2007. In the report of the inspection the Chief Inspector referred to good
practice in the health services provided. She wrote:
“There had been a comprehensive health needs assessment that had
sought the views of patients, carers and staff as well as reviewing clinical
records, and the results were being used to plan services.”
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Independent Monitoring Board (IMB) Report
15. Each prison is monitored by an Independent Monitoring Board, members of
which are drawn from the local community. They have full access to prisoners
and every aspect of the establishment.
16. In its latest annual report, covering the period 1 June 2007 to 31 May 2008,
Whatton’s IMB said: “Defibrillators are readily accessible for every prisoner with
trained staff available.” The report also said:
“The IMB wish to place on record the proactive work of the Healthcare
Manager and the dedicated staff who are now providing the best level
of care the prison has ever experienced.”
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KEY FINDINGS
Medical history prior to transfer to HMP Whatton
17. On 1 January 2000, the man suffered a heart attack. He was treated at hospital
with a clot-busting injection and told that his heart function had been damaged.
He subsequently had an operation to place a stent in his circumflex coronary
artery. (A stent is a small tube inserted inside an artery of the heart to help blood
flow.)
18. The man was first remanded in custody to HMP Birmingham on 18 September
2003. He was suffering from angina (chest pain that occurs when the heart
muscle does not get enough blood), and was taking self administered medication
for his heart complaint. He spent a total of 172 days in custody pending trial, and
on 30 November 2004 was sentenced to ten years imprisonment. He began his
sentence at Birmingham.
19. On 5 August 2005, the man went by ambulance to hospital with non-cardiac
chest pains. Following an overnight stay, he was advised about cardiology
referral, but was not referred to a cardiologist at this time. He returned to the
hospital on 16 August to have a cyst removed from his forehead under local
anaesthetic. Because of increasing chest pains, he was referred to cardiology
on 24 November.
20. On 5 January 2006, following a doctor’s review of his medication and continuing
chest pains, a first consultation was arranged with a consultant cardiologist at
hospital. This took place on 24 February. The doctor noted that the man
continued to smoke and that he had severe cardiac disease. He was listed for a
cardiac catheterisation (a procedure that examines the structures of the heart
and surrounding vessels in detail, allowing an accurate diagnosis of their
condition).
21. At a review by a nurse on 3 March, it was recorded that the man was suffering
anxiety and insomnia regarding his cardiac problems and the planned operation.
Following a cardiology review with the consultant cardiologist on 2 May, he had
an operation on 24 August. He received stents in three arteries during
successful catheterisation, but dilation of the damaged arteries was
unsuccessful.
22. Findings from the procedure were that there was “severe diffuse coronary artery
disease [a condition in which plaque builds up inside the coronary arteries and
reduces blood flow to the heart muscle], with previous left anterior descending
artery occlusion [a blocking of that artery], severe ventricular impairment with
ejection fraction of 18% [this measures the blood pumped out of a ventricle with
each heart beat, typically 50% to 65% for healthy individuals], and diffuse
ischaemic cardiomyopathy [heart muscle disease].”
23. The man continued to have regular hospital appointments at hospital following
the operation. On 21 December, following another cardiology review with the
consultant cardiologist, he was found to have pneumonitis (lung wheezing).
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Further investigations were ordered. He had exercise tolerance tests on 8
February 2007, and respiratory tests on 14 February. A heart scan on 19 April
was followed by an echocardiogram (ECG) on 15 May.
Medical history at Whatton
24. On 13 November 2007, the man was transferred from Birmingham to Whatton.
During his reception health screening the long history of cardiac problems and
current medication was noted. He was smoking 10 cigarettes per day. There
were no problems with his mental state and no allergies were identified. His
vaccination history was up to date, including an annual influenza immunisation.
A referral was made for him to see a doctor.
25. The prison’s general practitioner saw the man on 26 November as a new
reception. Cardiac problems were noted, a medication review performed, and
plans made for up to date investigations to be conducted. His anxieties were
also noted and plans were made to change medication if required.
26. Other cardiology reviews were undertaken by the consultant cardiologist at
hospital on 10 December and 21 December. The man’s diagnosis was diffuse
coronary artery disease, severe left ventricle impairment and worsening
breathlessness.
27. At a review by the prison doctor on 11 January 2008, the man had his medication
changed to mirtazapine (an anti-depressant) to help with his anxiety and sleep
problems. When reviewed by the GP on 22 January and 7 February, it was
noted that he was sleeping better now he was on mirtazapine and was less
anxious. He was also given different medication for high cholesterol
(simvastatin) and acid reflux (lansoprazole).
28. On 3 April, the man’s blood test results showed low haemoglobin (haemoglobin
is a protein found in red blood cells and is responsible for transporting oxygen; it
is measured as part of a blood count) and low blood vessel size. His cholesterol
was satisfactory for someone with cardiac disease. Potential infection with
helicobacter (bacteria) was also found, which is linked to gastric ulcers. On 21
April, following a GP review, he was found to have low ferritin (a protein in which
iron is stored) consistent with iron deficiency.
29. At a further GP review on 9 June, medication changes were made as
recommended by the cardiologist. The man had recently injured his shoulder on
a metal door, so ibuprofen (a pain killer and anti-inflammatory) was prescribed
for his shoulder pains. Lansoprazole (which prevents the stomach from
producing acid) was also prescribed to protect his stomach.
30. During a GP medication review on 13 August, it was recorded that the man’s
angina was stable, and he had stopped taking his beta-blocker tablets, bisoprolol
(used to treat cardiovascular diseases). He still complained of shoulder pains
and an x-ray was arranged. This confirmed some irregularities of the left
acromioclavicular joint (a joint at the top of the shoulder).
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31. On 27 August, the man was given reassurance by a nurse after he was found to
be extremely anxious. He described having panic attacks and was concerned
they would bring on another heart attack. They discussed triggers, coping,
distraction techniques, and breathing exercises.
32. At a GP review on 14 November, the man’s medication was altered in respect of
his ongoing left shoulder pains. This was still a problem at the time of a nurse
review on 3 December, and anti-inflammatories were ineffective, making him feel
dizzy and ill. The following day, following earache symptoms, he was prescribed
ear drops and analgesics (pain killers) and told to return if he became concerned.
33. The man did not attend any of his nurse clinic appointments again until he went
for blood pressure monitoring on 13 February 2009. On that occasion, he said
he had had a chest infection for the past few weeks and had been suffering light
headedness for the previous two or three days. He was given blood tests on 18
February. These showed his blood count improving, but that his cholesterol had
increased.
34. At a nurse review on 27 March, the man was noted to be stressed, and
complained again of having shoulder pains. There was no mention of any
angina. The following week, on 3 April, he was reviewed at hospital. Another
ECG was performed showing moderate dilatation [enlargement] and impairment
[loss of function] of the left ventricle. He had a normal pulse, normal blood
pressure, and no heart murmurs. Advice was given about future medical
management and no further investigations were planned.
35. A medication review by a doctor was carried out on 26 May. The man’s shoulder
pains were discussed and mild anaemia, which needed follow up blood tests,
was identified. The doctor increased medications to include dihydrocodeine (an
opioid analgesic), diclofenac (an alternative and stronger anti-inflammatory to
ibuprofen) and paracetamol.
36. He did not attend 12 clinic appointments from 26 May, but did collect his
medications from the pharmacy on 11 June and 16 July. He was sent a letter by
healthcare asking if he still wanted to be monitored. He said he did, but although
he was booked in for further appointments he did not attend them.
Events in August 2009
37. The man spoke to his sister by telephone at about 10.00am. He mentioned that
he had a niggling pain in his back and chest, but did not feel it was anything to
worry about. His sister advised him to speak with a doctor if he was worried.
38. At about 10.30am, he was in his cell with a fellow prisoner who had become a
good friend. They worked together in the servery. Also present was another
prisoner. They were all playing on the man’s games machine (a PlayStation),
whilst waiting to go to work. At this time he complained to both prisoners of
pains in his chest and back. He went to his locker, removed some tablets (which
the second prisoner believed to be paracetamol), took them and then carried on
playing his game.
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39. The first prisoner told the investigator he was aware that the man had previously
had a heart attack and was on medication. He said the man had told him he had
been refusing his blood tests as he was fed up having to travel across the prison
to get them done. The prisoner said the man told him he was getting fed up with
healthcare, as every week they kept on at him to have his blood tests.
40. At about 11.00am, staff called down the servery workers as normal to prepare for
serving lunch. The man did not report any problems to staff that morning. The
first prisoner told the investigator that before they went to work the man looked fit
and well.
41. Just after midday, the man and the first prisoner went back up to their cells.
They went into the man’s cell, sat down and talked for seven or eight minutes.
He then told the prisoner that he needed the toilet, so the prisoner left and went
to see someone else. The man closed his cell door behind the prisoner.
42. The second prisoner has said he was in his cell when he heard a single bang,
which he described as if something heavy had hit the floor. He told the other
prisoner he had heard a bang in the man’s cell. They went to the cell, which still
had its door closed. They looked through the window of the cell door and saw
him lying on the floor. The second prisoner then pressed a cell activation alarm
and waited by the cell, while the other prisoner went to tell officers that the man
had collapsed.
43. In a statement, a prison officer said that at approximately 12.11pm he was
starting lock up on landing one in A wing when he heard the cell bell activation.
He discovered that it came from landing two above, and together with a second
officer immediately went upstairs. On arrival they were met by the first prisoner
who told them that the man had collapsed on his cell floor.
44. The first officer went past the prisoners who had gathered outside the man’s cell
and entered with the second officer. He saw that the man was lying on his back
on the floor and looked unconscious. He could not see anything out of place or
anything that looked suspicious. The man’s trousers were undone. The officer
checked his head and face and could not see any injuries.
45. The man was making a gurgling sound and taking sharp inhalations of breath as
he did so. The first officer squeezed his cheek but got no response. The man
then vomited from his mouth and nose. The officers placed him into the recovery
position. The second officer went down to the wing office to telephone for
healthcare to attend (this was despite the fact that he had a radio).
46. Shortly after the second officer left, the first officer saw that the man’s colour had
changed. His face had turned blue and he appeared to have stopped breathing.
The officer rolled him onto his back as the second officer returned. The second
officer gave his face shield (which is used to prevent the transfer of fluids during
resuscitation) to the first officer who then started chest compressions (cardio-
pulmonary resuscitation, CPR).
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47. The second officer returned to the wing office to telephone again for healthcare
staff to attend, but they were already on their way. He returned to the cell and
found that the situation had worsened. The officers agreed that the man had
stopped breathing. The first officer continued with CPR until healthcare staff
arrived within a few minutes.
48. The nurse told the investigator that at approximately 12.15pm healthcare were
alerted to reports that a prisoner had collapsed, and was conscious but
incoherent. She responded to the wing together with a second nurse and a
student nurse, taking the two emergency response bags with them.
49. They were met on A wing by the first prisoner who escorted them up to the man’s
cell. The nurse saw that the two officers were performing CPR on him and
immediately called out to a third officer to call for an ambulance, to ask other
healthcare staff to attend, and to bring the wing’s defibrillator.
50. The nurse opened the response bag, removed a valve mask, connected it to the
oxygen and handed it to the second officer to use instead of a face shield. She
then got out a guedel airway (a device used to maintain a person’s airway by
preventing the tongue from covering the epiglottis, a piece of cartilege at the
back of the tongue), but did not have time to put it in before the defibrillator
arrived. She cut away the man’s T-shirt and connected the defibrillator, asking
the student nurse to make a note of the number of cycles and shocks given.
51. As she applied the defibrillator pads, she noticed that they had expired in March
2008. As there were no other pads available, she elected to use them rather
than not defibrillate. The defibrillator began to analyse and advised that a shock
be given. The first defibrillation (electric shock) was given at 12.22pm. Two
minutes of CPR followed, and the guedel airway was introduced. Despite this,
air was still not getting into the man’s lungs as his chest was not rising. The
nurse proceeded to suction using a hand suction pump to ensure that his airway
was clear of fluid.
52. A further shock was given as instructed by the defibrillator at 12.25pm. CPR
then recommenced. A further eight defibrillator cycles were completed, each
advising “no shock”. CPR was continuous in between defibrillator cycles, and
eventually they were able to get air into the man’s lungs. He vomited on at least
two occasions, after which suction was used to clear his airway.
53. An ambulance was dispatched at 12.25pm and arrived at the prison gate at
12.40pm. It arrived, with two crew members, at the man’s cell at 12.48pm. The
nurses continued CPR while the ambulance crew attached him to their
defibrillator.
54. CPR was continued for a further four minutes after which time it was agreed by
all present to cease resuscitation attempts. Death was pronounced by the
technician at 12.52pm. Residual pulseless electrical activity (PEA, where there
is electrical activity in the heart, but this is not producing a pulse) was present on
the ECG but it was not a rhythm conducive to life. PEA finally ceased at 1.11pm.
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55. Shortly after the man’s death, the prison activated its death in custody
contingency plan. Nottinghamshire Police, the Governor, the Independent
Monitoring Board, and the Ombudsman were informed. A prison family liaison
officer was appointed. The police visited the prison at 2.20pm, interviewed staff
and prisoners and took several statements, copies of which were given to my
investigator.
56. At the time of the man’s death his current prescribed medication was aspirin,
paracetamol, diclofenac sodium, dihydrocodeine (all of which are painkillers),
lansoprazole (to stop the stomach producing gastric acid), mirtazapine (an anti-
depressant), ramipril (for hypertension and congestive heart failure), simvastatin
(to control elevated cholesterol levels), miconazole (an antifungal cream) and a
glyceryl trinitrate pump spray (for relief of chest pain). No other medicines were
found in his cell by police.
57. At 3.00pm, a debriefing about the man’s death took place at the prison. Support
and counselling were offered by the prison to those healthcare staff, prison
officers and prisoners who had either been directly involved or who had been
affected by the death. Notices to inform prisoners and staff of the man’s passing
were issued throughout the prison. Prisoners on A wing were informed
individually.
58. The prison family liaison officer and the Deputy Governor drove over to the
man’s family home in Coventry and informed his mother at about 4.30pm of his
death. His mother became distraught and the FLO called her GP to attend.
The FLO then spoke to the man’s sister by telephone. They stayed at the house
for around two hours.
59. At approximately 6.00pm, undertakers were instructed to collect the man and
take him to the Infirmary. They arrived at the prison at 7.15pm and left at
7.35pm.
60. At 8.35pm the same day, a post mortem examination was carried out at the
Infirmary by a Consultant in Forensic Pathology and a Home Office Registered
Forensic Pathologist. At the external examination, she found that there were no
injuries present that caused or contributed to the man’s death.
61. On internal examination she identified severe coronary arteriosclerosis (a
degenerative process in which fatty material is deposited in the walls of the
coronary arteries, leading to obstruction of the blood flow to the heart muscle),
with a metal stent (tube) and a fresh thrombus (blood clot) in the left anterior
descending branch (coronary artery). An old myocardial infarction (heart attack)
with fresh areas was present to the anterior wall of the heart. In her opinion, this
resulted in a natural death.
62. Forensic toxicological samples were sent to the Forensic Toxicology Service of
the Infirmary. The toxicological examination yielded no evidence of an
intoxication that could have caused or contributed to the man’s death. His cause
of death was from an acute myocardial infarction, secondary to ischaemic heart
disease.
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63. A memorial service was held at the prison. Prisoners collected a large sum of
money. Flowers were bought and placed on top of the man’s coffin at his
funeral. Together with the man’s personal money, the rest was given to his
mother to be used to engrave his name on the family gravestone. Prisoners also
recorded messages in a book of condolence that was passed onto the family
who will forward it to the man’s brother in Australia.
64. Funeral expenses were properly offered by the prison. The Deputy Governor
and the prison family liaison officer attended the funeral in Coventry. The man’s
family donated his foodstuffs, electrical items and games to the prison for use by
others.
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ISSUES CONSIDERED DURING THE INVESTIGATION
Clinical care
65. A heart attack resulting in disturbance of cardiac rhythm may be better survived
in a prison than in the community. Assuming the prisoner is found in time, CPR
and defibrillation, and the attendance of medical staff, may all be available much
more quickly than if someone is in their own home.
66. The man had severe cardiac disease and his life expectancy was not surprisingly
reduced. According to the clinical reviewer, his premature death at the age of 56
was understandable. However, while he had severe disease, he did not suffer
frequent angina attacks and did not require repeat prescriptions of his angina-
relieving medication. He was never given standard angina medication with beta-
blocking tablets (bisoprolol) because of side effects. Targets for cholesterol
lowering were also not reached.
67. The clinical reviewer has found that the man’s blood count was slightly low, and
there was evidence of an iron deficiency anaemia which can be caused by
chronic blood loss from the gastrointestinal system. This is commonly attributed
to aspirin medication but, although the low haemoglobin was noted and repeat
checks were made, continued prescriptions of aspirin together with anti-
inflammatories were made. According to the clinical reviewer, this increased the
risk of significant gastrointestinal haemorrhage (a loss of blood in the intestine).
68. In addition, despite a positive test result for helicobacter antigen there was no
record of an antibiotic prescription being considered or made. However, the man
was started on lansoprazole, to protect against blood loss from the stomach
69. These matters aside, the clinical reviewer has not found any significant
shortcomings in the way the man was managed whilst serving his sentence at
Whatton. He also judges that the medical care of the man was satisfactory.
70. As noted earlier, the nurses at Whatton lead on different diseases. The first
nurse is the clinical lead for cardiovascular disease and the man was on her
clinic list. When interviewed by my investigator, she said that he regularly did not
attend clinic and blood appointments, and was very uncooperative. She did not
know why he was refusing his blood tests and thus had sent him a letter asking if
he still wanted to be monitored. He had replied that he did and she had started
booking him in for appointments again. However, he never kept them.
71. When she was told that a prisoner on A wing had collapsed, she immediately
went to the wing with two other nurses, taking two emergency response bags.
One contains an assessment kit, with items such as blood pressure equipment,
stethoscope, glucose gel, and pulse oximeter. The other contains an oxygen
barrel bag, nebuliser mask, airways etc. Healthcare has a defibrillator, as does
each wing. However, as the nurses had been told the prisoner was conscious,
they did not take their own defibrillator with them.
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72. On the way to A wing, the nurse thought the patient might have had a stroke, but
at that stage she did not know it was the man who had collapsed. On arrival,
seeing who it was, she immediately shouted for the wing’s defibrillator, for an
ambulance to be called urgently, and for more healthcare staff to assist her.
73. As she applied the defibrillator’s pads to the man she saw that their expiry date
was March 2008. The clinical reviewer has said that the out of date gel pads
would still have been effective (as they proved to be). However, it is self-evident
that in future they should always be kept in date. I am pleased to report that this
has already been addressed by Whatton and all defibrillators are now checked
weekly. On that basis, I need make no further recommendation about this.
74. As I have recorded earlier, the nurse connected the defibrillator and delivered a
shock when indicated by the machine. CPR was continued for two minutes until
another shock was indicated and given. A further eight cycles of CPR for two
minutes, without prompts to further shock, took place prior to the ambulance staff
arriving. Oxygen was given, the man’s airway was checked, and when he
vomited it was suctioned away. I judge that both the nurse and, earlier, the first
officer, carried out CPR most professionally. Sadly, their efforts were not enough
to save the man.
75. I would like formally to acknowledge as good practice the location of defibrillators
on each wing.
Use of radios in emergency situations
76. When interviewed by my investigator, the second officer said he was aware that
the man suffered from angina but did not know he had previously had a heart
attack. Asked why he used the telephone to call healthcare and not his radio, he
said that he never thought to use his radio and did not think it was warranted on
this occasion. Upon returning to the cell and finding the man’s condition had
deteriorated, he again telephoned healthcare. While the delay is unlikely to have
made a difference to the chances of success in resuscitating the man, on other
occasions the outcome might be different. It is important that staff recognise
emergency situations and use the most effective method of communication that
they have at their disposal.
The Governor should remind all staff to obtain prompt emergency
assistance via radio communication when someone is found collapsed,
giving the prisoner’s name and updating any changes in condition.
The arrival of the ambulance
77. The communication log shows that an ambulance was called at 12.20pm. The
ambulance log confirms dispatch at 12.25pm. The gate log shows the
ambulance arrived at Whatton at 12.40pm. The ambulance crew then took eight
minutes to reach the man. The investigator was concerned that there might have
been a delay in getting the ambulance crew from the front gate to the cell.
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78. The ambulance crew consisted of a technician and an emergency care worker.
The nurse said she was somewhat concerned by this as they could do no more
than the nurses were already doing for the man. She had hoped for a paramedic
(the Ambulance Service’s ambulances are currently split between technician-led
crews and paramedic-led crews) as they are able to attempt drug resuscitation,
such as adrenaline, atropine or other drugs, depending on their observations.
79. Category A (life threatening) calls should receive an emergency response within
eight minutes, with category B (serious but not life threatening) having a 19
minute call target. According to prison and ambulance logs it took the
ambulance 15 to 20 minutes to arrive at the prison and between 23 and 28
minutes to reach the man.
80. Ambulances are positioned to respond to the greater population centres and so
anyone who lives in a remote location (such as Whatton) may wait longer than
those in an urban environment. That said, given the size and age of Whatton’s
population, the availability of ambulances in that part of the county may be an
issue. In order that the Governor can assure herself that the ambulance service
is aware of the needs of the prison, I make the following recommendation:
The Governor should share this report with the Ambulance Service and
jointly consider if Whatton’s needs are properly provided for.
Actions of the two prisoners
81. As I have reported, the man was found collapsed in his cell by fellow prisoners.
One immediately pressed a cell activation bell to alert staff, whilst the other went
to tell staff that it was the man who required assistance. Their prompt actions
gave staff the best chance of saving their friend’s life, and I hope the Governor
will pass on my appreciation of their efforts.
Letter received by the man’s family
82. As I have reported earlier, a letter containing a card was received from the prison
by the man’s family, the contents of which they found extremely distressing. On
one half, the card suggested that he was being supplied with controlled drugs
and that an unlawful assisted suicide had taken place. Written beneath this half
was a name. The other side the card said how very kind, happy and bubbly the
man was. This had a name beneath it. The whole of the card was written in the
same handwriting.
83. My investigator interviewed the first prisoner. As noted, he had found the man
collapsed in his cell and described himself as a very good friend. When he was
shown the card he was surprised by what had been written, and understood why
the family were distressed by it. He explained that he had received a letter of
thanks from the man’s family, following a collection he had made from other
prisoners. He wanted to write to the family and share his condolences.
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84. He said that, as he could not write very well, he asked another prisoner to write
the card for him. This prisoner wrote on the right hand side of the card as
dictated by the first prisoner and told him he would also post it. Without the first
prisoner’s knowledge, the other prisoner added his own words to the other side
of the card, placed it in an envelope and posted it to the man’s family. My
investigator checked this prisoner’s writing and confirmed that he had written the
whole card.
85. This prisoner was on the same wing and landing as the man and the first
prisoner, and he worked with them in the servery. Since these events took
place, he has moved from Whatton and the investigator was unable to interview
him. However, from speaking to staff, the investigator is aware that he may have
been unwell at the time and that this may have contributed to the comments he
made on the card.
86. I hope that this information helps explain to the man’s family how they came to
receive the distressing card. This was clearly not the first prisoner’s intention
and I believe that he is innocent of any malicious intent. During interview, he
asked for his condolences to be passed to the man’s family.
87. It is not possible nor desirable to read all the mail that goes in and out of a prison
like Whatton. While I very much regret the distress caused to the man’s family, I
do not think there are any recommendations that I can sensibly make regarding
this most hurtful and unfortunate incident.
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CONCLUSIONS
88. Upon entering the prison system, the man had already survived a heart attack,
was in poor health, and was smoking 30 cigarettes a day. He managed to
reduce this to 10 a day at one point, but it would appear that he subsequently
returned to smoking about 30 roll-up cigarettes on a daily basis.
89. He regularly refused to attend appointments for blood tests and clinic reviews.
He did, however, continue to collect his medication. When he collapsed after
suffering another heart attack, he was speedily attended to by two prison officers
who knew how to perform CPR, and by healthcare staff (including the clinical
lead nurse for cardiovascular disease) who knew how to use the defibrillator.
They, and an emergency response ambulance crew, all acted appropriately and
in accordance with the information available to them. They made extensive
efforts to save his life.
90. The toxicological examination yielded no evidence of an intoxication that could
have caused or contributed to the man’s death. I conclude, therefore, that the
allegations that he was supplied with medications by other prisoners were
unfounded.
91. In light of the findings of the clinical review and my own investigation, I conclude
that the man’s medical care was – with minor exceptions – both appropriate and
satisfactory.
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RECOMMENDATIONS
1. The Governor should remind all staff to obtain prompt emergency assistance
via radio communication when someone is found collapsed, giving the
prisoner’s name and updating any changes in condition
The Prison Service has accepted this recommendation. The Governor will
issue a notice to staff reminding them of the requirements and procedures for
summoning medical assistance.
2. The Governor should share this report with the Ambulance Service and jointly
consider if Whatton’s needs are properly provided for.
The Prison Service has accepted this recommendation and has shared the
report with the local Primary Care Trust to take forward on their behalf.
Good Practice
Having defibrillator machines available on each wing is good practice
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