Individual at Ranby

Investigation into the circumstances surrounding the
death of a man at hospital, whilst a prisoner at HMP Ranby,
in October 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 at HMP Ranby in
October 2009. He was 58 years old and had been in custody since 1983. At
8.10am, an alarm bell alerted staff to a problem in billet 3, the living quarters where
he was located. Officers found him sitting on the floor and he informed them that he
was having chest pains. An emergency ambulance took him to hospital and, after
initial treatment, he was moved to the Intensive Treatment Unit (ITU). However, at
12.40am, he had a further cardiac arrest and despite attempts by medical staff to
revive him, he was pronounced dead at 12.55am. I would like to offer my
condolences to the man’s family and friends for their loss.
One of my investigators conducted the investigation. The local Primary Care Trust
was asked to conduct a clinical review into the standard of healthcare the man
received in custody. A Clinical Governance Lead and General Practitioner (GP),
along with the Head of Quality at the PCT carried out this review and their report is
attached in full as an annex.
I would like to thank the Governor of Ranby and her staff for their co-operation and
assistance with the investigation.
The man had a family history of ischaemic heart disease and both his parents had
died at a young age after heart attacks. He had spent over 20 years in prison.
Throughout this time, he made it clear that he had no wish to have contact with
healthcare services despite being encouraged to do so. He had been at Ranby
since September 2008 and during this time the healthcare team had not treated him.
Overall, I consider the treatment afforded to the man to have been appropriate.
However, the clinical review highlights the need for a chronic disease management
clinic at Ranby, as well as concerns that medical information held in paper form is
not lost when copied to new IT systems. Offender Health has commented on this
issue in response to the draft report and their comments have been added to the
relevant section of this report. The review also questioned documents being held
inappropriately with medical records. The Prison Service accepted the
recommendation made in the draft report and their response is highlighted in this
report.
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.
Jane Webb
Deputy Prisons and Probation Ombudsman March 2010
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CONTENTS
Summary
The investigation process
HMP Ranby
Key findings
Issues
Conclusion
Recommendations/Good Practice
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SUMMARY
The man was remanded into custody in April 1983. Later the same year, he was
convicted of murder and sentenced to life imprisonment. When he entered custody,
he highlighted no immediate medical concerns, but told medical staff that he had a
family history of chest problems. Both his parents had died relatively young as a
result of heart problems.
In the first couple of years, the man raised no medical concerns. In August 1986,
while at HMP Gartree, he was admitted to the Infirmary, after complaining of chest
pains. Following examination, he was diagnosed as having had a myocardial
infarction (heart attack) and provided with medication. He was a smoker and,
despite his chest problems, continued to smoke throughout his sentence.
Several years later, the man was diagnosed with angina and given medication to
alleviate the symptoms. However, he had a long history of not complying with his
medication regime. In addition to not taking his medication regularly, he chose to
have little contact with the healthcare department throughout his time in prison. He
reported a phobia of needles and, despite advice to the contrary, he told medical
staff that he had no wish to have blood tests.
The man moved to a number of prisons during his time in custody. On each
occasion, he was seen on his arrival and a record made of previous medical history.
When he transferred to HMP Ranby in September 2008, he was again seen on his
reception and it was noted that he was receiving no medication. He expressed no
concerns and had no further contact with healthcare during his time there.
At 8.10am in October 2009, staff were alerted by an alarm on billet 3, the unit where
the man lived. They found him sitting on the floor complaining of chest pains.
Medical staff and an ambulance were called and attended immediately. A prison
nurse gave him initial first aid before he was taken to hospital by emergency
ambulance. He was admitted to the Intensive Treatment Unit (ITU), where at
12.40pm he had a further cardiac arrest. Despite the efforts of medical staff to revive
him, he was pronounced dead at 12.55pm.
Two recommendations in relation to medical records were made in the draft report,
both of which have been responded to by Offender Health and Prison Service. The
actions of the appointed prison’s Family Liaison Officer (FLO) in trying to trace a next
of kin for the man should also be commended.
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THE INVESTIGATION PROCESS
1. The investigator opened the investigation on 29 October, when he contacted
the prison and spoke with the Governor. He discussed the documentation that
he would require and arrangements were made for this to be forwarded.
Notices were issued to staff and prisoners informing them of the investigation
process and inviting anyone who had relevant information to come forward. No
responses were received.
2. The local Primary Care Trust (PCT) was asked to conduct a review of the
medical care afforded to the man in custody, particularly at Ranby. A Clinical
Governance Lead and GP, along with the Head of Quality at the PCT,
conducted the review and their report is attached as an annex.
3. The man had nominated no next of kin and none were identified by the prison
despite attempts being made by the prison’s nominated Family Liaison Officer.
The Ombudsman’s Assistant Family Liaison Officer was appointed to deal with
any emerging family issues.
4. The investigator wrote to HM Coroner to inform him of the nature and scope of
the investigation. A copy of the report will be provided to the Coroner to assist
with his enquiries and the inquest process. The post mortem report indicated
that the man died as a result of myocardial infarction as a result of coronary
artery atherosclerosis.
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HMP RANBY
5. HMP Ranby is an adult male training prison located on the outskirts of Ranby,
Nottinghamshire. Holding sentenced category C prisoners it is a large site,
incorporating both new and old accommodation as well as workshops. (On
arrival into prison, prisoners are risk assessed and given a category based on
their offence and the risk that they pose to the public should they escape.
There are four levels of category: A, B, C and D, with category A prisoners
being the most dangerous. Category C prisoners are those who cannot be
trusted in open conditions, but who would not have the ability or resources to
make a determined escape.) The prison also has a large plastics factory where
prisoners are able to work various shifts making a variety of plastic items that
are used across the wider prison estate. All prisons are given quarterly
performance markings and Ranby is currently level 3, which indicates good
performance.
6. Some of the older accommodation at Ranby was used in the prisons former
guise as a military camp. The ‘billet’ style huts provide accommodation for
those prisoners who work in the plastics factory and offer them more
responsibility with fewer officers present.
7. There have been four previous deaths at Ranby since the Ombudsman was
given responsibility for investigating all deaths in custody in 2004. Of these,
two were self-inflicted and two were due to natural causes. Recommendations
following these investigations highlighted concerns with medical record
keeping, which are not repeated in this investigation report.
8. HM Chief Inspector of Prisons completed a full inspection of Ranby in March
2007. She said of healthcare provision at the prison:
“… Healthcare provision at Ranby had developed well, and prisoners
had good access to a wide range of clinical services. Highly qualified
staff delivered a good standard of care and were committed to
progressing the service, but many felt frustrated at the lack of support
at a strategic level for health services. The department was extremely
busy and nurses were employed on non-clinical duties. Wing-based
treatments were in place, but the volume of prisoners who attended
treatment rooms was, in some areas, overwhelming and prisoners
were very demanding. The Primary Care Trust directly commissioned
GP and mental health services, and the prison had an overarching
clinical governance framework with relevant policies. There was good
access to GP clinics. The mental health service was slowly
developing, although there was a lack of structured primary mental
health systems and staff could only deliver primary mental health care
when other pressures permitted. Pharmacy provision had improved
since our last inspection, and there were excellent dental services,
despite major faults in equipment. A large number of prisoners failed
to attend dental appointments …”
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9. The Prisons Act 1952 requires all prisons to be monitored by an independent
board appointed by the Secretary of State for Justice from members of the
community in which the prison is situated. The Independent Monitoring Board
(IMB) at Ranby published their last annual report in March 2009. In relation to
healthcare, the IMB acknowledged that some progress had been made in this
area, with the refurbishment of the healthcare centre providing additional
space. However, the Board also expressed concerns about the lack of 24-hour
healthcare services at the prison. The IMB felt that this was unacceptable in a
prison the size of Ranby, which is one of the largest Category C prisons in the
country.
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KEY FINDINGS
10. The man was received into prison custody at HMP Brixton in April 1983 as a
remand prisoner and sentenced to life imprisonment in October of that year.
This was not his first time in custody. He was 58 years old when he died.
11. When he went into prison, the man reported no significant medical problems
although he spoke about a family history of chest problems, having lost both
parents to heart attacks. After he was sentenced, he moved to HMP Gartree, a
designated prison for life sentenced prisoners. At Gartree, he underwent
assessments to address his offending behaviour with a view to release on
parole.
12. On 17 August 1986, the man was admitted to the Infirmary after complaining of
chest pains. It was recorded that he smoked around 30 cigarettes a day and
had a family history of ischaemic heart disease (ischaemic refers to a reduced
blood supply.) He was recorded as having suffered a myocardial infarction
(heart attack) and following treatment, he made a good recovery. He was given
glyceryl trinitrate (GTN) spray, which is used to alleviate the symptoms of
angina.
13. Over the next 14 years, the man moved to various prisons. During this time, he
had little contact with prison healthcare departments. His progress with his
sentence was not without problems. In March 1993, he absconded from
custody at HMP Erlestoke, which resulted in any possible parole release being
delayed. Each time he moved to another prison, medical staff assessed him as
part of the reception process and his recorded history. It was also noted that
he continued to smoke. On some occasions, he declined to be seen by a
doctor saying that he did not feel it necessary. Apart from initial health
screenings, his interaction with medical staff was minimal.
14. On 13 May 2000, at HMP Featherstone, the man again complained of chest
pains. He told medical staff that he had not used his GTN spray as it gave him
headaches. He was given a new spray and, after being assessed by the prison
doctor, he was admitted to hospital. Following an examination, he was
diagnosed as having unstable angina and prescribed further medication to
relieve the symptoms before being discharged. He continued to transfer to
various prisons in order to complete offending behaviour work.
15. While at HMP Dovegate in April 2002, a doctor who assessed the man
recorded that since being admitted to hospital in 2000, he had not had any
further chest problems. He told the doctor that he had been taking medication
for angina but had stopped taking it of his own accord. He provided no clear
reason for not wishing to take the medication and the doctor explained to him
the consequences of not doing so. Following the assessment, further
appointments were arranged for him to attend the healthcare department at
various times in order for his cholesterol to be checked, but he declined to
attend on each occasion.
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16. The man transferred to HMP Risley in October 2003, and again was seen on
his reception by medical staff. Due to his history of heart problems, staff
arranged for him to have regular blood tests and the importance of them was
explained to him. However, he told nursing staff that he had a phobia of
needles and had no wish to attend in the future. He also said that he would not
take any medication other than his GTN spray and signed a disclaimer to this
effect. There was little contact with healthcare services at Risley after this.
17. In March 2005, the man reported sick at Risley and was spoken to by a nurse.
He explained that he had been experiencing chest pain and pains down his
arm for around eight days but this had eased off. He told the nurse that he had
not taken any medication for “months” and had a fear of needles. It was
recorded that he continued to smoke and his diet was good. At the time, he
was working in the prison kitchens. He agreed to begin taking aspirin again, his
GTN spray, and a follow up appointment was made with the GP. No further
problems were recorded at Risley.
18. A transfer to HMP Sudbury took place in September 2006. Again, all past
medical history was recorded as well as the fact that the man had not
previously taken his medication. It was recorded that he had very little contact
with the healthcare department at Sudbury, but would occasionally attend to
collect medication. In June 2007, he escaped from Sudbury and after returning
to custody the same month, was taken to HMP Birmingham. As in other
prisons, at Birmingham he had minimal interaction with healthcare staff and
reported no chest problems. He remained at Birmingham until 12 September
2008 when he transferred to HMP Ranby.
19. At Ranby, the man’s medical screening recorded his past history and that he
was not taking any prescribed medication. He was not considered high risk of
serious illness and highlighted no medical concerns. He had no further contact
with healthcare staff. He worked on the night shift in the plastics factory located
within the prison and his general behaviour was considered good.
October 2009
20. On a morning in October at 8.10am, two officers responded to an emergency
alarm call in ‘billet 3’. When the officers went into the billet, they found the man
sitting on the floor. He told them that he had pains in his chest and arm and
thought that he was having a heart attack. The second officer immediately
radioed for medical assistance informing the control room that a prisoner was
having a suspected heart attack.
21. A nurse was on duty in the healthcare centre when he heard the call for
medical assistance. He immediately went to billet 3, taking with him a
defibrillator and other emergency equipment. A defibrillator is a machine that
can restart the heart by giving an electric shock in some cases of cardiac
arrest. An ambulance had been called which the nurse was aware of. He said
that when he arrived the man was conscious and in obvious pain. The man
described having central chest pain, which also went down his left arm. He told
the nurse that he had felt the pain for about five hours but had not asked for
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any help. The nurse gave him oxygen and checked his pulse. He said that at
this point the man vomited and, almost at the same time, the ambulance staff
arrived. It was now 8.20am. The nurse helped ambulance staff to get the man
into a chair so that he could be moved to the ambulance. Once in the
ambulance, paramedics continued to treat him. Two members of staff were
instructed to go in the ambulance with him, no restraints were used and the
ambulance left the prison at 8.30am.
22. The man arrived at hospital at 9.00am. He was given treatment to stabilise his
condition before being moved to the Intensive Treatment Unit (ITU). His
condition remained serious and at 12.40pm, he suffered a further cardiac
arrest. Despite the best efforts of the medical staff he was pronounced dead at
12.55pm.
23. Following notification of the man’s death, Ranby appointed a Family Liaison
Officer. She liaised with the police, Public Protection Casework Team and the
man’s solicitor and offender supervisor in trying to trace his next of kin. Over
the following few weeks it became evident, that his contact with the outside
community had been severed some years earlier.
24. In addition to her attempts to trace a next of kin, the Family Liaison Officer
liaised with the Coroner’s office, and spoke with other prisoners that had known
the man. A celebration of the man’s life was held at the prison on 29 October
also organised by the Family Liaison Officer, and a book of condolence was
opened.
25. When it became apparent that no next of kin were likely to be identified or
traced, the Family Liaison Officer made all the necessary arrangements for the
man’s funeral, organising a wreath to be sent on behalf of the prison. The
funeral took place on 19 November, attended by a number of staff from Ranby,
of all grades.
26. While sorting the man’s property, the Family Liaison Officer discovered
correspondence to him from other prisoner’s that were located at other prisons
around the country. Although not a task that she was expected to carryout, she
wrote to the prisoners and notified them of his death.
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ISSUES
Medical records
27. Due to the length of time that the man had been in custody his medical record
was quite extensive, in spite of the limited contact with healthcare staff. There
were various notes from all of the prisons in which he had served. These were
difficult to read as they had become mixed up and there appeared to be little
chronology. In addition to his medical notes, his record contained a large
number of psychological reports. Given they appear to have no medical
significance and describe the details of an individual’s offence in graphic detail,
I question the propriety of them being stored within the medical record. The
clinical review team also makes reference to this in their report:
“… The medical records reviewed were a combination of previous
handwritten medical notes, computer generated notes and the notes
made on the day of death by both hospitals. There were also many
psychological reports prepared, for parole boards. It is questionable on
confidentiality grounds as to whether these should have been held with
his medical record …”
28. The clinical review team made the following recommendation, which I have
slightly recast.
The Head of Healthcare should review the policy on inclusion of
psychological assessments in medical records.
29. Nationally, prison healthcare services are in the process of removing paper
medical records in favour of a computerised system used in community health
practices. This requires information held in paper records to be input into the
new system. This is a time consuming task and the investigator was told that
this cannot be given priority at Ranby. It is possible that prisons that do not yet
operate the new systems could receive a prisoner with a long medical history,
but miss some of this information as they still rely on paper records. The
clinical review team refer to this in their report:
“… Ranby reported that some prisons are now removing paper records
from use entirely, and not forwarding them on when a prisoner is
transferred. If the prisoner’s computerised records are inadequate, it
then may be a self-reported history that becomes the entire medical
history. In the man’s case there were no medical records regarding
him at all from October 2007 until his arrival at Ranby in September
2008 …”
Although the clinical review team found that prisons within the region had set
up a process for sharing information, I am unaware of a similar national
initiative. Availability of clinical records is particularly important as the prisoner
population is ageing as is the number on life or indeterminate sentences. The
clinical review team have recommended that “prisons [and healthcare] work
collaboratively to transfer key information held in paper records on to the new
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computer systems to ensure that information is not lost when prisoners are
transferred”. I appreciate that this would require a huge investment in
resources. I draw the matter to the attention of the National Offender
Management Service and to Offender Health.
Chronic disease management
30. The man had been diagnosed with chest problems for a number of years. It is
clear that he chose not to have contact with the healthcare services in prison
and seldom took his prescribed medication. During the investigation, it became
apparent that HMP Ranby does not have a Well Man clinic. When asked about
this, the Head of Healthcare said that a Well Man clinic is scheduled as part of
the healthcare programme at Ranby. This would highlight prisoners with
perceived chronic illness and they would be invited to attend. However, he told
the investigator that the clinic had been suspended due to staff shortages and
priorities elsewhere. He also said that while priority in this clinic would be given
to those suffering from chronic illness, the man did not fall into this category.
The clinical review team comment on this in their report:
“… While the reviewers do recognise that there are strong competing
priorities within the prison health services, chronic disease
management clinics should be established, based on the commonly
understood read codes. A basic framework for this is held within the
GMS contract Quality and Outcome Framework. Given his history of
non-compliance, it is possible that attempts to engage this particular
individual would not have been successful in changing this outcome,
but it should have been tried …”
31. I make no recommendations in relation to this, as it is clear that the services
are scheduled to be delivered. However, I urge the prison and local PCT to
work together to find a way for this important service to be delivered regularly.
Medical response in October 2009
32. The clinical review team concluded that as soon as staff at Ranby were aware
the man was suffering from a suspected heart attack he was dealt with quickly
and appropriately by all concerned. I agree with their conclusion.
Family Liaison
33. The man for reasons known only to himself and his family had severed all ties
some years ago. This made it difficult for the prison and particularly the Family
Liaison Officer to trace them after his death. It would have been easy for her to
conclude early on that attempts to trace the family were unlikely to be
successful and give up. However, it is clear that this was not the case and her
actions in making tireless attempts to find a next of kin and ensuring that those
friends that were identified were notified, should be commended. Her actions
are I believe a demonstration of good practice and I urge the Governor to share
my comments with her.
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CONCLUSION
34. The man had been aware of his medical problems since suffering a suspected
heart attack in 1986. Prior to this, he knew of his family history of chest
problems and that this put him at greater risk. His medical history clearly
shows that he took little responsibility in alleviating the potential risks. Even
after subsequent chest problems he continued to smoke, and was reluctant to
have health checks. At Ranby, he had no contact with healthcare apart from
his initial health screen and reported no problems of any kind whilst there.
35. Given his previous refusal to attend clinics in other prisons, it is likely that even
if offered at Ranby, he would have declined. I am satisfied that the care he
received in prison was appropriate.
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RECOMMENDATIONS
1. The Head of Healthcare should review the policy on inclusion of psychological
assessments in medical records.
In response to the draft report, the Prison Service accepted this
recommendation and said:
‘… A policy has been implemented that all medical records of prisoners coming
into Ranby will have any psychological assessments removed and guidance
sought from the healthcare managers as to its appropriateness for inclusion in
this medical file …’
2. The National Offender Management Service should develop a policy and
process to ensure that prisons across the service work collaboratively to
transfers key information held in prisoner’s paper medical records to new
computer systems. This is to ensure that information is not lost on any
subsequent transfers.
In response to the draft report, Offender health responded and said:
‘… Offender Health and the Prison Health IT programme have considered the
important issue of summarising paper based primary care clinical records,
which would include inmate medical records currently held in a prison and
those received as part of a prisoner transfer. It would also include GP records
received in paper format from the community. This issue is important to support
continuity of care.
There are established standards of summarising Primary Care records, which
have applied in the community for many years as GP clinical records have
become almost universally computerised. As such, the quality expected is firstly
that paper based, clinical records should be transferred to the prison health
care clinical IT system. The standard and approach should be decided and
agreed by the local prison/PCT Partnership Board and there should be a
clinical governance approach to assure the quality of the work. Who does the
work, admin staff, nurses, medical students, doctors, will be determined by
these discussions and relate to local capacity and resources …’
GOOD PRACTICE
1. The actions of the Prison Family Liaison Officer should be commended and
highlighted as good practice.
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