Individual at Brixton

Investigation into the circumstances
surrounding the death of
a man at HMP Brixton in June 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2008
This is the report of an investigation into the circumstances surrounding the death of
a remand prisoner at HMP Brixton in June 2006. I extend my condolences to his
family and friends for their sad loss.
The cause of death recorded by the pathologist was lobar pneumonia. Toxicological
examinations were also carried out and a level of 0.55mg/ml of methadone was
detected. This is a relatively high level and raised concern on the part of both the
man’s family and my investigator. The family has asked questions about the issuing,
prescribing and administration of methadone at Brixton, as well as prisoners’ ability
to obtain it illicitly. My investigator explored these and other issues with specialist
healthcare professionals.
The investigation was carried out by two of my colleagues. A doctor from the
Primary Care Trust carried out a clinical review of the man’s medical care and
treatment, for which I am most grateful. I also sought advice from a specialist
consultant in addictions. She has produced a very comprehensive report that
comments on the prescribing of methadone, levels of toxicity, prescribing protocols
and the assessment of the man.
I would also like to thank the Governor of Brixton for making the necessary facilities
available to my investigator. I am particularly indebted to the prison’s liaison officer
for his invaluable help and support.
I must apologise for the very lengthy delay in completion of this report. The
investigation has been extensive and not without its difficulties. I could not issue my
findings until I had seen the final clinical review, and this was not available until
January 2007. The revised draft version of my report would have been issued in
2007, rather than April 2008, if the results of the controlled drug audit commissioned
by the Primary Care Trust had been received more quickly.
Amongst other things, this report raises serious concern about the administration of
methadone at Brixton. I make a total of 14 recommendations, including those from
the clinical review. I am concerned that two of these recommendations have been
made previously, following the self inflicted death of another prisoner at Brixton in
April 2005, and I urge the prison health partnership to address these as a matter of
urgency. I consider it vital that all relevant information about a prisoner is passed
without delay from the police to the Prison Service. I have also identified two areas
of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2008
2
CONTENTS
Summary
Investigative Process
HMP Brixton
Key Events
Issues considered as part of the investigation
Further Investigative work done after the issue of my draft report
Conclusions
Good Practice
Recommendations
3
SUMMARY
The man was a young man who had a complex past. He had used and abused
drugs for a number of years and told prison staff that he drank heavily. He suffered
from asthma and said he had also suffered a recent bout of pneumonia, requiring a
spell in hospital.
On 7 June 2006, the man was remanded by the magistrates’ court to HMP Brixton.
He was in prison for a week before his unexpected death.
It would be usual for a newly received prisoner to be accompanied by any relevant
paper work such as Forensic Medical Examiner (FME) reports. There is no definitive
way of knowing that these reports did accompany the man. All that can be said for
certain is that Brixton did receive these FME reports at some point.
Following his reception into prison, the man was seen by a doctor. The reception
doctor did not physically examine him, but remembered him as being talkative and
agitated. They discussed his drug dependence and the possibility of commencing a
Subutex detoxification. Expert opinion has been given that, even if the reception
doctor had examined him, the signs of drug withdrawal may have masked a
respiratory problem.
The man was also seen by the head of the substance misuse team. She noted that
he was asthmatic and he told her of a recent episode of pneumonia that had resulted
in admission to hospital for treatment. During this assessment it appears that he
changed his mind about starting Subutex, preferring a methadone maintenance
programme.
The man visited the medical hatch once a day from 8 June to 14 June. The last
nurse to administer methadone to the man was identified. She said that there was
nothing untoward or concerning about him on the afternoon of 14 June.
The man was found not to be breathing in his bed by his cellmate during the early
hours of 15 June. The cellmate promptly raised the alarm and staff responded
immediately. Sadly, despite the best efforts of all concerned, they were unable to
resuscitate him.
A post mortem was carried out and concluded that the man died as a result of lobar
pneumonia.
The man’s family has expressed a number of concerns about the management of his
withdrawal from illicit substances. In addition to a clinical review, I commissioned a
specialist review of his care in respect of his substance misuse.
4
INVESTIGATION PROCESS
1. My practice in apparent deaths from natural causes is to conduct an initial
review to determine the extent of the investigation required. My investigator
visited Brixton on 22 June 2006 and spoke to a member of the prison’s
management, who outlined the facts relating to the man’s stay in Brixton.
Notices to staff and prisoners were issued on 19 June. These invited staff
and prisoners to make themselves known to my investigation team if they had
any information they felt relevant. My investigator was also given access to
the man’s records, including his medical record.
2. A family liaison officer from my office contacted the man’s family. Both he and
my investigator met the family on 30 June and explained the purposes of the
investigation and its process. They also listened to the family’s concerns.
The first family liaison officer has since left my office and the family liaison role
has been taken on by another member of my family liaison team.
3. The emerging issues from this investigation required specialist consideration,
particularly concerning reception screening, the cell where the man was
located, the methadone levels prescribed, the prescribing protocols in a
custodial setting, the administering of methadone and whether or not it
followed protocol. The question of whether methadone is available illicitly in
Brixton was also explored. Other more general considerations were given to
the way in which staff responded to finding him, the aftercare available for
prisoners and staff, the staffing levels on G wing and the wing’s regime and
purpose.
4. A general practitioner was appointed by the Primary Care Trust as the clinical
reviewer on 13 July. His role was to carry out a review of the management of
the man’s health needs whilst he was at Brixton. My investigator and the
clinical reviewer interviewed several members of staff. These interviews took
place over several months with many difficulties encountered such as annual
leave, sickness, and union and medical representatives’ availability.
5. A general practitioner with a special interest in the management of substance
misusers was appointed to undertake a specialist review into the clinical
management of the man’s substance misuse. In 1991, the general
practitioner with a special interest in the management of substance misusers
established the Consultancy Liaison Addiction Services in the local area.
From 1996 to 2000, she was senior policy advisor to the Department of Health
(drugs and alcohol), and amongst other things was responsible for drawing
together the national clinical guidelines. Although the general practitioner with
a special interest in the management of substance misusers has never
worked in a prison, she has helped draw together treatment protocols and
guidelines now in use. She has also trained many doctors working in secure
settings and has helped to amend the Certificate in Substance Misuse to
ensure it is relevant to doctors and nurses working in such an environment. In
addition, she has been involved in a number of medico-legal cases. For this
investigation she was asked to comment on the prescribing protocols, the
treatment and assessments of the man and the appropriateness of
5
prescribing methadone. She has also explored the difference between
Subutex and methadone.
6. My investigator also spoke to a number of prisoners who knew the man.
7. Her Majesty’s Coroner was informed of the nature and scope of the
investigation. A copy of the post mortem and toxicology report was
requested, along with medical reports from the man’s GP and an addiction
treatment centre. Further information was requested from and provided by
the addiction treatment centre. Upon completion of this investigation, my
report will be sent to the Coroner to assist with the inquest.
8. A significant amount of additional investigative work was done after I issued
my draft report in March 2007. This additional work was undertaken in
response to detailed observations made by the PPO Liaison Unit at Safer
Custody Group and requests for further clarification and explanation made by
the man’s family and their solicitors. The new material included in response
to these observations and requests can be found in the chapter now inserted
immediately prior to the Conclusions section of this report.
6
HMP BRIXTON
9. Brixton is a local prison holding adult male remand and trial prisoners. It has
five residential wings (A, B, C, D and G). The man was located on G wing,
which is used as the first night induction centre and detoxification wing.
10. HM Chief Inspector of Prisons commented in an unannounced follow-up
inspection report in May 2006 that, “G wing had dedicated counselling,
assessment, referral, advice and throughcare services but required further
psycho-social provision to support the detoxification programmes. Current
mandatory drug testing levels were 15% positive, with a steady downward
trend from a peak of 50% in May 2005.”
11. A recommendation made by HM Chief Inspector of Prisons in her 2004 full
inspection report that, “Primary healthcare staff should receive specialist
training in substance misuse” had not been achieved. The report noted: “This
recommendation had been rejected by the prison. At the time of their
inspection, only two of the three specialist substance misuse nurse posts
were filled and only one of these was a permanent position (the other being
an agency nurse). The permanent substance misuse nurse did not have
specific substance use qualification, although the agency nurse did. There
was no generic training in substance misuse for primary healthcare staff.
Given that primary healthcare staff would have contact with prisoners
experiencing substance related problems, this shortfall diminished the
opportunity to encourage prisoners to access treatment.”
12. Healthcare is commissioned by the local Primary Care Trust (PCT). The
transfer of the responsibility for the delivery of prison healthcare from the
Prison Service to local Primary Care Trusts began in April 2004. The PCT
became formally responsible for the healthcare provision at HMP Brixton in
October 2005. The prison health partnership board has responsibility for
monitoring the delivery of services under the clinical governance
arrangements.
7
KEY EVENTS
13. On Tuesday 6 June at 7.55am, the man was arrested, arriving at the police
station at 8.05am. When he was arrested, the Police National Computer
(PNC) flagged up that he was also wanted on two other warrants. It was for
this reason that he was not bailed. Whilst in police custody, he was examined
by a Forensic Medical Examiner (FME). The FME first saw the man at
9.51am when he recorded the following: “Asthmatic, recent pneumonia, on
amitriptyline 50mgs for depression suicidal attempt two year ago, says not
suicidal now. Opiate dependency on methadone 60mls daily diazepam 40mg
daily from drugs clinic, not apparently had for 48 hours. Early signs of
withdrawal. Given Diazepam 10mg and Dihydrocodeine (DHC) 60mg at
9.50am. Review 4pm if still in custody.” The FME judged the man fit to be
detained.
14. The FME reassessed the man at 3.56pm that day and made the following
observations: “Withdrawal, clear evidence of same. Chest now wheezy.
Given Salbutomol inhaler from stock. Given Diazepam 10mg, DHC 90mg and
Domperidone 10mg at 3.42pm. Please give Diazepam 10mg and DHC 90mg
both at 11pm and at 7am 30 min checks.” Again, the FME considered him fit
to be detained.
15. The following day (Wednesday 7 June), the man appeared before the
magistrates’ court where he was remanded into prison custody and taken to
HMP Brixton.
16. The man arrived at Brixton about teatime and went through the reception
procedures. This included an interview with a healthcare officer. The officer
completes a First Night in Custody questionnaire with the prisoner. This
document considers the prisoner’s current and past health needs.
17. The healthcare officer on reception that evening spoke to the man and
completed the First Reception Health Screen Form. The man gave a history
of drug dependence, saying that he spent £60 a day on heroin, £40 a day on
crack cocaine, and also took benzodiazepines. He also said he was a heavy
drinker and would drink six to seven cans of lager a day. When asked about
any ideas of self harm, he strongly denied any suicidal or self harm thoughts.
He was asked if he had ever received medication for any mental health
problems and confirmed he had. The healthcare officer explored this in more
detail, asking him about when this was, what medications he had received
and at what dose. He said he took benzodiazepines for anxiety and had done
so for 15 years. He said that 30mg a day was on prescription and that the
other 20mg was un-prescribed.
18. In light of the information given during this assessment, the man should have
been referred for further assessment by the mental health team. This did not
occur.
19. The man was then allocated to G wing. Once on the wing, he was seen by
the reception doctor. He was assessed and asked to provide a urine sample,
8
which he eventually did after some difficulty. This tested positive for cocaine,
opiates and benzodiazepines.
20. The reception doctor made a referral for the man to be seen by the Substance
Misuse Team (SMT). The prison doctor wrote in the medical record that he
was very agitated, with flu like illness and sweats. He was apparently anxious
to get “something” to help him through the night. When asked about drug
withdrawal symptoms, he said that he had a runny nose and sweats. The
reception doctor made the decision to prescribe a once only dose of
dihydrocodeine (DF118) at 90mg to help the man with the symptoms of
withdrawal he was experiencing.
21. The FME reports completed at the police station were not available for the
healthcare team to refer to during their consultations with the man.
22. The following day (8 June), the man was seen by the head of the substance
misuse team. The head of the substance misuse team completed a
Substance Misuse Clinical Assessment Form, and explored the man’s history
of drug abuse including his withdrawal symptoms at that stage. He explained
that he was known to two drug addiction centres. She noted that his intention
was to start Subutex, but recorded “prefers methadone maintenance PMH
[past medical history] Asthma and pneumonia in May admitted.” The
information gathered during the assessment was summarised within the
man’s main medical record. The head of the substance misuse team also
made a note that the MO [medical officer] should review in two days.
23. Later that day, the head of the substance misuse team consulted a second
prison doctor about the man. The prison doctor signed a Methadone Titration
Form. The doctor did not see or examine the man before or after signing the
prescription.
24. The titration form begins with two doses of 10mg. The prison doctor changed
the prescription to a single 20mg dose at the request of the substance misuse
nurse. The man’s dose was increased by 10mg a day until he reached
40mgs which occurred on day four of the regime. All the man’s doses were
administered in accordance with the protocol, with two nurses present.
25. According to the note made in the man’s medical record by the head of the
substance misuse team, he should have been seen again by a doctor two
days after her entry of Thursday 8 June. According to the locally agreed
protocol, “Treatment Protocols For Patients With Substance Misuse Problems
Entering Brixton Prison”, there is an on call doctor for Saturdays, Sundays
and Bank Holidays. G wing should be visited by the duty doctor to enable
patients to be discussed and monitored as appropriate. According to his
medical record, the man was not seen; nor was he seen on Monday 12 June.
At 12.21pm on 12 June, the EMIS electronic record system appears to show
that a second healthcare officer made an appointment for him to be seen at a
GP clinic on Tuesday 13 June at 9.05am. However, he did not attend that
appointment and it has not been possible to establish why not. (In interview
the second healthcare officer’s recollection was that the EMIS system had
9
been in operation for about a year at the time of the man’s death and there
were only two or three computer terminals for all the medical staff to use. He
said:
‘’It would be relatively common practice for people , other members of staff
to use that computer because they needed to at the time or they would
maybe ask you to do something for them because they weren’t able to
access it because you yourself were using the computer. So it could have
been me [who booked the appointment for the man], I could have been
doing it on behalf of somebody else or it could have been someone else.’’
The second healthcare officer also explained that an appointment entered on
the electronic record at 12.21pm might relate to an application made by a
prisoner earlier the same day or even on a previous day.)
26. The following day (Wednesday 14 June), the man’s cellmate left the cell early
to attend court. He was not expecting to return to Brixton. The man got up to
say goodbye to him, they shook hands and had a brief conversation before
his cellmate left. There was nothing that struck his cellmate as ‘odd’ about the
man.
27. A prisoner on G wing recalled seeing the man slumped by the medical hatch
at around 4.00pm. The prisoner could not recall if this was association time
(period of time prisoners are allowed to mix with others out of their cells) or if
this was when the man was queuing to receive medication.
28. A second prisoner on G wing said that he visited the man in his cell that
afternoon during the association period at about 4.00pm. He said that the
man was on his bunk, dressed and lying down. The second prisoner asked
him what was wrong and he said words to the effect of: “Nothing, [my
cellmate] kept me up all night talking.” The second prisoner described the
man as looking “out of it”. Neither prisoner felt it their business to alert staff to
him not being his usual self.
29. The Methadone Titration Form shows that the man attended the medical
hatch to receive his methadone that afternoon.
30. The cellmate did in fact return to Brixton and was taken back to the same cell
at around 8.00pm that night. On his return, he said that the man was asleep.
He always breathed heavily and so again there was nothing at that stage to
indicate to his cellmate that anything was amiss with him. The cellmate
settled down to watch a televised football match and eventually fell asleep.
31. The cellmate recalls waking up in the early hours and becoming aware that he
could not hear any sounds coming from the man. He climbed down from his
bunk and checked him. He was cold to touch.
32. The cellmate raised the alarm by pressing his cell bell. This is confirmed by
the printout of the cell bell record. The alarm was raised at 1.25.01am. It was
10
cleared at 1.25.50am when an officer responded to the bell. In order to clear
a cell bell the officer must physically attend the cell.
33. The first officer to arrive at the cell said that he became aware there was an
emergency at approximately 1.22am. He rushed to the threes landing when
he heard a door being banged. When he arrived at cell G3-41, the cellmate
was stood by the door shaking and saying “Gov open the door, it’s like he is
dead. He is not breathing. Open the fucking door.” The officer was not in a
position to open the door as it is only Oscar 1 (the code for the Orderly Officer
– the senior officer in charge of the prison – who is the designated key holder
to respond to emergencies at night) who can open the cells during the night.
The officer put out a call for emergency assistance. He also called for Hotel 6
(the emergency response nurse). The Hotel 6 nurse that night was located in
healthcare. She received the call via telephone by the first officer on scene
and not via the UHF radio.
34. When the Hotel 6 nurse arrived at the cell, Oscar 1 was already in attendance
and the cell door was open. The first officer on scene and Oscar 1 were
inside the cell. Oscar 1 then called a Code 1 emergency over the radio and
checked the man for breathing and a pulse, both were absent. The Hotel 6
nurse was soon accompanied by Hotel 3 who arrived with the resuscitation
equipment.
35. The first officer on scene and the Hotel 6 nurse placed the man on the floor,
positioned him on his back and the Hotel 6 nurse commenced cardio
pulmonary resuscitation (CPR). The Hotel 6 nurse noted in the medical
record that the man was cyanosed (a blue colouring to the skin), face down,
unconscious and his pupils were fixed and dilated.
36. The ambulance arrived at Brixton at 1.44am and at G wing at 1.48am. The
ambulance crew took over the resuscitation attempts, but to no avail. The on-
call doctor for the prison arrived but despite all efforts the man was
pronounced dead at 2.05am. The ambulance crew left the prison at 2.30am.
11
ISSUES CONSIDERED AS PART OF THE INVESTIGATION
Family concerns
37. The man’s family raised a number of questions about the management of his
withdrawal from illicit drugs. Due to the complexity of their questions and the
emerging issues, two separate clinical reviews were commissioned, one by a
specialist in management of drug addiction. I hope that the findings of these
reviews and those of my own investigation provide the answers to some of the
family’s questions.
Was the consultation with the reception doctor thorough and did he recognise
signs of pneumonia or take them to mean drug withdrawal?
38. The consultation on 7 June in G wing lasted about 10 minutes. The man
wanted some medication for his first night in custody. The reception doctor
assessed the man and prescribed a one-off dose of DF118. A urine sample
had been taken and tested positive for morphine, diazepam and cocaine.
39. The reception doctor believes he was not in possession of the Forensic
Medical Examiner’s reports which note that the man’s chest was wheezy and
that he had recently had a bout of pneumonia. He remembered the man and
said that he did not appear unwell in any way. He was not short of breath, but
was described by the reception doctor as being talkative and agitated. The
reception doctor explained that matters regarding his drug withdrawal would
normally be discussed the following day with the substance misuse team. As
far as the reception doctor was concerned following the consultation, the man
would commence a Subutex detoxification and benzodiazepine detoxification.
The reception doctor did note that the man was asthmatic.
40. The specialist in management of drug addiction explains that withdrawal
symptoms may mimic symptoms of severe flu, and says that many people
describe withdrawal as “the worst case of flu they have ever had”. She adds,
“it is likely that had the man been suffering from an acute respiratory infection
at this time then the symptoms would have been masked by his opiate
withdrawal. Only through really careful history taking, together with a high
index of suspicion (of the presence of a concomitant physical illness) would a
coexisting severe chest infection be identified.”
41. The reception doctor did not make a physical examination of the man.
However, he said he would have examined him if he had been in possession
of the FME reports. These FME reports were detailed and highlighted the fact
that the man was an asthmatic and had recently had pneumonia. It was also
noted that, whilst he was in police custody, his chest had become wheezy.
42. My report following the self inflicted death of a prisoner at Brixton in April 2005
referred to uncertainty about when an important FME form, indicating
concerns about the mental health of a prisoner who had recently been
medically examined in a police station, was received at Brixton. The clinical
12
review commissioned for that report made the following recommendation that
has so far not been implemented:
A system should be instituted to record all documents and papers that
arrive in Reception with new prisoners.
The system for assessing newly arrived prisoners at HMP Brixton must
ensure that all relevant documents, such as FME reports, accompany
prisoners as and when they are seen by the GP.
43. The specialist in management of drug addiction considers that, as the man
had been identified as an asthmatic and had previously suffered with
pneumonia severe enough to warrant a hospital admission, it might have
been appropriate to have examined his chest and for the assessing doctor to
have enquired about his breathing. However, she also points out it would be
difficult to ascertain how much the physical signs would have been masked by
the withdrawal and general anxiety around being admitted to prison. The
specialist in management of drug addiction explains that, even if the man had
been found to have a rapid heart rate, high respiratory rate, and moderately
raised temperature, it is likely that these would have been attributed to
withdrawal and anxiety.
Should the prison doctor have seen and examined the man before signing him
up for methadone maintenance?
44. The prison doctor signed the man up for a methadone maintenance
programme that commenced on 8 June. Initially, he was started on 20mls
(according to the titration chart, this is made up of two 10mls doses).
However, the lead of the substance misuse team asked the prison doctor to
change this to one dose of 20mls, which he did. Before the doctor signed the
man up for methadone maintenance, he was informed of his background and
drug use issues by the lead of the substance misuse team. After interviewing
the man, she recorded this information on the substance misuse care plan.
The prison doctor did not see him or any of the clinical entries or documents
relating to him. He relied solely on the information provided to him by the lead
of the substance misuse team. The prison doctor said that he would have
wanted to see the man before issuing the prescription for methadone
maintenance if he had been aware of the contents of the FME reports. Whilst
it was not wrong for the prison doctor to sign the man up for methadone
titration, I believe that the doctors should review all available medical
documents, thus making a more informed decision.
Was it appropriate to prescribe methadone to the man?
45. The specialist in management of drug addiction says that it was entirely
appropriate to provide the man with methadone substitution treatment. She
explains that methadone is the most researched treatment for opiate addiction
in the world.
13
Was the amount of methadone prescribed the correct dosage?
46. A report produced for the Coroner by a Consultant Forensic Toxicologist
suggests that the level prescribed (40mgs) was not a particularly high dose.
The maintenance dose for methadone can be from 20mg up to 200mg per
day. The dosage prescribed depends on the individual’s tolerance. The
specialist in management of drug addiction concludes that both the initial dose
and the process of dose induction was in keeping with HMP Brixton, Prison
Health Care Services, National Health Service (NHS) clinical guidelines, and
international guidelines. It is also the specialist’s view that the prescribing of
benzodiazepines alongside methadone was appropriate, given the man’s
addiction history.
Did the man have a methadone intolerance?
47. The report from the man’s GP makes no reference to methadone. A report
obtained by the Coroner from the treatment clinic refers to him having been
prescribed 45mg of methadone mixture by the Maudsley Hospital in January
2006. A month later when he was seen at the treatment clinic, he told them
that he had successfully completed a Drug Treatment Testing Order (DTTO),
but had been unable to come off methadone. The man expressed a wish to
try Subutex. (Subutex is used as an alternative to methadone for
detoxification purposes.) Initially he did very well, but over the next two
months he apparently relapsed and began using heroin on occasions.
Evidence therefore suggests strongly that he was able to tolerate methadone.
48. Had someone unused to opiates taken the 20mgs dose that the man was
prescribed on day one of his methadone maintenance, they would have been
drowsy. Most methadone associated deaths have been reported in
individuals with little or no tolerance to opiates. There are a couple of
discrepancies in the history that he gave to the prison. There is one about
when he last used heroin and methadone, and the other about his reported
use of heroin and methadone. However, it is sadly not unusual for prisoners
to falsify their drug habits in order to obtain more medication. The specialist’s
report (pages 24 and 25) details in depth the clinical examinations, with
attention to signs and symptoms of dependence and biological investigations
(such as urine tests) to ascertain the true physical dependence on illicit
substances.
Were there signs of methadone intoxication before the man’s death?
49. The two prisoners on G wing make reference to “[the man] looking out of it”.
One prisoner talked about the afternoon of 14 June, when he apparently saw
“[the man] slumped outside the medical hatch”, possibly waiting for his
methadone. Neither prisoner raised their concerns with staff, as they thought
it was none of their business. Both prisoners mention the fact that he
breathed heavily and was an asthmatic. They apparently never discussed the
issue of illicit drugs.
14
50. The man’s cellmate was at court for most of the day on 14 June. When he left
that morning, the man got up and shook his hand. They said their goodbyes
as the cellmate was not expecting to return to prison. On his return to the cell
that evening, the man who later died was asleep and the cellmate recalled
him breathing heavily. The cellmate eventually fell asleep but then later woke
up. He was aware that something was wrong as there was no noise coming
from him. The cellmate knew that the man was an asthmatic and that he had
previously suffered with pneumonia. He had filled out an application for the
man to see a doctor a few days prior to his death, although on questioning he
could not remember the reason he put down for his needing to see a doctor.
The cellmate said that although the man who is the subject of this report was
an asthmatic, he smoked heavily and managed the stairs without any
difficulty. The cellmate said it was usual for his inhalers to be left in their cell
and he did not recall the man having to use these on a regular basis.
51. Despite the notices announcing the investigation into the man’s death, no
other prisoners asked to see my investigator. However, my investigator
identified any prisoners who were still in Brixton and had been on G wing on
the threes landing at the time of his death. Twenty other prisoners were
identified. My investigator spoke to them individually. The majority were
unable to add any further information. A couple knew him and spoke about
his general appearance. They said that he did not appear 100 per cent. One
described him as looking yellow and sweating. They also said that they
thought he was recovering from a recent bout of pneumonia and that he still
appeared to have ‘’fluid on his lung’’.
Were staff aware of the man being unwell in the hours preceding his death?
52. The two prisoners on G wing both said that they did not feel it their place to
alert staff to the man’s condition. Neither did they ask him if he had taken any
illegal drugs.
53. The staff identified to my investigator as working on 14 June were either
interviewed by my investigator or spoken to with interview notes taken.
54. The officer on duty from 12.30pm until 9.45pm on 14 June remembers the
man being a quiet man, one who kept himself to himself. When asked to
explain what he meant by quiet, he said “he was not a demanding prisoner”.
He had no recollection of anything significant in relation to him. The officer on
duty was under the impression that procedures for prisoners receiving
methadone have changed recently. He was unclear of the procedures, but
was certain that prisoners were given methadone in a medical room rather
than out on the landing. On being asked about what would happen if a
prisoner was sitting slumped outside the medical hatch, he said “it would be
challenged by a member of staff”. Things can apparently get chaotic by the
medical hatch and for that reason a member of staff is usually in the vicinity to
help maintain order.
55. Another officer had no knowledge of the man, and did not believe that he met
him. In light of what the officer on duty said about the methadone procedure,
15
the second officer was asked if the methadone procedure had changed
recently. He said it had not. He has been on G wing for a year. He explained
that prisoners are taken into a consultation room with two nurses and given a
bottle with methadone in it to drink. He confirmed that it was not acceptable
for a prisoner to be sitting on the floor and it would be challenged. However,
he also said that G wing was chaotic and sometimes the men could be waiting
for an hour or more to receive their medication.
56. A third officer had no recollection of the man at all, and said this was due to
the high turnover of prisoners on G wing. He had no knowledge of
methadone being available illicitly on the wing. My investigator asked if he
had ever been present at a meeting where a Senior Officer had suggested
officers keep an eye out for this. He was vaguely aware that something along
those lines had been mentioned.
57. A fourth officer was working a late shift, mid-day until 9.45pm. He had worked
on G wing for about 18 months. He did not remember the man at all. He was
also asked about prisoners sitting in the medicine queue. His view was that it
would not really be a problem, as the men do have to wait for long periods of
time to receive their medication. He said that ideally the queue would be
more controlled, but there are not enough staff to accommodate this at
present. When asked about the availability of illicit methadone on the wing,
he was not aware that this was or had recently been a problem. However, he
did add that if it was, he would not be surprised. He did not recall attending
any meeting where the subject of methadone and “spit back” was mentioned.
Are staff sufficiently trained in the management of substance misuse and
detoxification?
58. The training records for the healthcare staff at Brixton were obtained and
particular attention was paid to the records of those involved in the man’s
care.
59. The head of substance misuse at the time of the man’s death had received
training in CPR (twice), HIV and Hepatitis C, breakaway training and control
and restraint training. The nurse who administered the last dose of
methadone to the man had been trained in diabetic management three times,
CPR, a further diabetic management course, ACCT (for prisoners on suicide
watch), EMIS (the electronic version of medical record keeping) a further
ACCT course, a diabetic management exam and a course on anaphylaxis.
The Hotel 6 nurse who attempted to resuscitate the man had received training
in EMIS, anaphylaxis, CPR, outreach, ACCT and SMN (substance misuse
nursing).
60. I am rather surprised that more courses are not undertaken with regard to
drug dependence, poly substance misuse, signs of intoxication and
withdrawal. This concern was also raised by HM Chief Inspector of Prisons in
her 2004 inspection report. As noted above, HM Chief Inspector of Prisons
recommended that: “Primary healthcare staff should receive specialist training
in substance misuse.”
16
61. The clinical review identifies that the nurses require more training and
evaluation of their knowledge. I was pleased to hear of the advances in staff
training that had taken place by the time my investigator interviewed a third
doctor in November 2007. I am certain, however, that the potential gains to
be realised from the Integrated Drug Treatment System will only be put in
practice if the relevant managers ensure that staff who deliver the system
receive appropriate initial and refresher training.
The training needs of all the nursing members of the Substance Misuse
Team as well as the primary care nurses on G wing should be
reassessed to ensure that they are all able to assess and monitor the
health needs and clinical problems of prisoners who are drug addicts.
They need to understand fully what they are assessing and monitoring
and the reasons why they are doing this. They also need to be clear
about what to do if any cause for concern arises, including new
information.
What is the relevance of Subutex (buprenorphine)?
62. It appears that the man did consider taking Subutex prior to his imprisonment
and may well have been receiving it. (His family have informed my
investigator that he had been taking Subutex daily since February 2006.) It
was certainly prescribed on 5 June by a doctor from the treatment clinic, as
evidenced on the prescription found by my investigator in the man’s
belongings.
The Substance Misuse Team (SMT) should always attempt to contact
outside drug agencies and GPs to establish the pattern of treatment of
prisoners who are drug addicts or are being considered for treatment by
the SMT. These contacts should be made as soon as possible, and
there may be a need for a standard system for making these contacts
and obtaining the relevant clinical information.
63. The specialist in the management of drug addiction explains in her report that
buprenorphine is a safe, effective medication for use in the treatment of opiate
dependence, and is a valuable addition to the formulary of medications for
treating heroin addiction. It is a partial opiate agonist which appears to be
safer in overdose than methadone. She says that, in her view, even if the
man had been taking Subutex at the time of his admission to prison, this
would not have altered his management plan.
64. Brixton offers both methadone and Subutex to prisoners. During the
consultation between the man and the reception doctor on 7 June, the plan
was for him to commence on a Subutex programme. This is evidenced in his
medical record. However, when he saw the substance misuse nurse the
following day, it appears that he changed his mind. The comment
documented by the nurse is: “Prefers methadone maintenance.”
17
Was it appropriate to locate an asthmatic on the threes?
65. It does not appear from information available that the man suffered too badly
with his asthma. According to his medical records and information provided
by other prisoners, he did not have any problems managing the stairs. In fact,
his cellmate said that the man often left his inhalers in the cell. Prisoners
commented on the fact that he breathed heavily, but at no time did it appear
to be a problem for him. There are no entries within his medical records to
suggest that his asthma was severe or was causing him distress.
When a prisoner with a clinical condition that may affect their physical
abilities is received in prison, they must be individually assessed to
ensure that they are given accommodation suitable to meet their health
and social care needs. This assessment must be documented in their
medical record and their wing history sheet to ensure continuity of care.
Is methadone available illicitly on G wing?
66. My investigator explored with a number of prisoners the possibility of
methadone being illicitly available on G wing. The majority of prisoners were
not of the opinion that it was generally available. However, a few did say that
it was possible to obtain methadone illicitly via a method known as “spit back”.
(This is where a prisoner is able to hold the methadone in their throat, spit it
back after leaving the consultation room and then possibly sell it on.)
67. From this investigation, it seems that illicit methadone may sometimes be
available but there is no compelling evidence either way. There was a rumour
that it was available, but the majority of prisoners said that it was not. The
second G wing officer recalled that G wing had had a problem a few months
earlier with “spit back” and the Senior Officer (SO) had told his staff to be
aware and vigilant. This was also recalled by the third officer.
Is there any way of improving the system for issuing methadone?
68. At present, methadone is given by two nurses. The prisoners arrive at the
medical hatch and their identity is confirmed by photograph. Once this has
been done, the prisoner is taken into a side room. One of the nurses
completes the paper work (controlled drugs book and Methadone Titration
Form), while the other talks to the prisoner. If the prisoner is able to
communicate and appears to have no problems, the prescribed methadone is
given. Methadone is a liquid and is given to the patient in a sealed
individually named medicine bottle. The prisoner is required to drink the
methadone whilst in front of a nurse.
69. The lead of the substance misuse team said that, after the methadone has
been drunk, the bottle is filled with water and the prisoner is asked to drink
that too. This is then followed by a short conversation. The process lasts
about two or three minutes. The lead of the substance misuse team was also
asked about the process. She said much the same except she did not
mention any water being given.
18
70. The nurses were questioned about the Methadone Titration Form. On the
form there is a column headed “symptoms assessed by”. Both nurses were of
the opinion that this was not to be filled in unless there was something
significant to record which would indicate that the dose of methadone was to
be withheld. On the man’s form there are no entries recorded, no dose of
methadone was withheld and there was nothing significant to record about
him or his well being. On 14 June, it appears that he received methadone.
The last dose of methadone was administered by the nurse at the medical
hatch. She said that had there been anything untoward with the man she
would have withheld his methadone dose. The nurse at the medical hatch
was asked if she had ever withheld a dose of methadone to which she replied
“not in this prison”. The nurse at the medical hatch was asked what signs and
symptoms she would be looking out for in a prisoner, and what would
determine a dose being withheld. She said: “I would look for smells, speech,
dry mouth, things like sweatiness, him complaining maybe of headache …”
The clinical reviewer further questioned the nurse at the medical hatch about
how confident she would be of noticing if the man had had breathing
difficulties or been short of breath. The nurse at the medical hatch said: “I
would be able to spot it.” Had she done so, she would have explored this
further with him and would have made an entry in his medical record. As no
entry exists in his record, one can assume that she did not have any cause for
concern regarding him receiving his methadone on that afternoon.
71. My investigator asked the nurses and the head of healthcare about the
column headed “symptoms assessed”. My investigator suggested its
meaning is that symptoms are assessed before the methadone is given. She
also suggested that a signature should then appear to indicate that this has
been done. The specialist in the management of drug addiction is of the
same opinion and this is reflected in her report. The clinical reviewer
comments that he is concerned that this practice meant that prisoners, such
as the man who is the subject of this report, were not as fully assessed as
perhaps they should have been.
72. My investigator and the clinical reviewer visited Brixton on 19 September to
observe the administration of methadone. The first two prisoners seen were
managed according to the local policy. Everything was satisfactory: their
identity was checked and the prisoner confirmed his prison number, the
methadone was taken, the bottle was then refilled with water and drunk, a
short conversation was held with the prisoner, and finally the blood pressure
was taken and recorded. This process lasted about three or four minutes.
73. As the morning went on the process changed. The prisoner’s identity was
checked, but some prisoners were unable to confirm their prison number.
The methadone was given to the prisoner and taken in front of the nurses.
Some prisoners then refilled their bottles with water, but the majority did not.
Blood pressures were not taken and little or no conversation was held after
drinking the methadone. The process took as little as 30 to 45 seconds.
Prisoners questioned at random on G wing that morning said that they had
19
never had their blood pressure taken. Some said that they drank water after
methadone, but others did not.
74. The nurses administering methadone that morning were asked by my
investigator and the clinical reviewer if they had ever withheld a dose of
methadone. Both said they had done so. Asked when this was, the reply was
three and five years ago. The “symptoms assessed” column on the
Methadone Titration Form was noted now to contain signatures.
75. The clinical reviewer says in his report: “the experience of observing the
dispensing of drugs such as methadone on G wing caused me significant
concern. Prisoners were sometimes in and out the room so quickly that I
would say it was not possible to assess them adequately in order to identify
significant ill health.”
The administrative systems related to the monitoring of the treatment of
drug addiction need to be reviewed and changed in several ways.
Prisoners who fail to attend for important appointments, such as
reviews of their drug treatment, must be followed up. Important clinical
information about prisoners must be rapidly passed on to members of
the SMT and G wing nurses. Assessment and decision-making must
occur rapidly for prisoners who do not adhere to their agreed
programme.
76. The document “Drug Dependence In The Adult Prison Setting” dictates that
methadone should be administered by a registered nurse or pharmacist.
Before the administration of methadone, the following should be checked: (a)
identity of patient; (b) ensure patient is fully alert, responding appropriately
and there are no signs of drowsiness/collapse, slurred speech, droopy eyelids
or lowering of blood pressure; and (c) consider whether there are any other
reasons to suspect illicit drug use.
The prison health partnership should remind healthcare staff of the
correct procedure for administration of methadone as dictated in the
Drug Dependence guidance.
77. Despite the photographic identity that prisoners carry and the requirement to
verbally check prisoners’ numbers, my investigator was alarmed to hear that
the previous day a man had been admitted to an outside hospital for receiving
the methadone from the nurses on duty that was meant for his brother. This
was confirmed by a manager. Thankfully, after treatment he was well enough
to be returned to the prison. This issue was dealt with at local level.
78. I believe that it would be appropriate to add a further column to the
Methadone Titration Form, requiring the prisoner to sign and print his name,
confirming that he has received his methadone. This process would alert staff
to possible physical impairment, by observing daily consistency in writing. It
would also help with identification of possible fraudulent activity.
20
I recommend that the prison health partnership reviews the existing
systems in place for administering controlled medications, such as
methadone. The new system should make safeguards for the following:
(i) Ensuring prisoners are fit and well prior to receiving medication;
(ii) Ensuring as far as practically possibly that impostors are
prevented from receiving medication.
Did the man die of pneumonia?
79. A Home Office pathologist carried out the post mortem on the man. On
examination, he noted consolidation of most of the left lung with features of
lobar pneumonia. There were also a number of centrally situated abscesses.
The pathologist was made aware of the level of methadone found in the
man’s post mortem blood sample. He agrees that it appears relatively high.
However, he is of the opinion that this does not necessarily mean that the
man was being given an excessive quantity or that he took more than was
prescribed. The pathologist explains that relating methadone levels to the
amount prescribed is not a straightforward exercise and it is beyond his
competence to comment further. He believes the pneumonia and formation of
abscesses was so severe that he is convinced that this was the cause of
death.
80. The man’s family feel he was unwell prior to 14 June, and attach particular
significance to his appearance when he was visited by his niece on 12 June.
During that visit he coughed a lot and, according to his niece, sounded quite
wheezy at times. The clinical reviewer’s report contains his conclusions about
the failure to identify the pneumonia in the man. The clinical reviewer
suggests that the man was probably not unwell until 14 June when he
received his last dose of methadone. The information from prisoners about
his well being suggests it was around this time that he was becoming acutely
ill with lobar pneumonia. Lobar pneumonia is a condition that can develop
extremely rapidly, over a matter of hours or days. The clinical reviewer goes
on to say ”A man such as [this one], who was relatively debilitated as a result
of alcohol and drug misuse, would be more likely to succumb to such an
infection, compared to the average person.” The clinical reviewer further
researched lobar pneumonia with two professors of chest medicine who both
concurred with this view.
The reliability of methadone levels at post mortem?
81. The clinical reviewer and the specialist in management of drug addiction are
both aware that there is much debate about the reliability of post mortem
samples. A paper written by Professor Forrest at the Forensic Pathology
Services in Sheffield states that results “should only be truly relied on if three
samples of post mortem blood are taken and from different parts of the body,
this proving that all three results are subsequently consistent.”
21
82. The specialist in management of drug addiction says that: “It may be that any
concomitant severe respiratory disease altered the metabolism of methadone
resulting in higher plasma methadone levels. It may also have been that if the
man was suffering from severe respiratory problems that methadone and
benzodiazepines (both respiratory depressants) further compromised his
respiratory function. It may also be the case that his plasma methadone level
was within normal range as single post mortem results are notoriously
inaccurate.”
83. The clinical reviewer notes: “Although it is the case that a relatively high
amount of methadone was found in the post mortem sample, this does not
necessarily reflect the level of methadone in his blood before death. It is
therefore not possible to know whether [the man’s] methadone consumption
while in Brixton contributed to his death in any way.”
84. The Coroner’s Officer asked staff in the toxicology unit at Imperial College,
London about the concentration found in the man. A doctor at Imperial
College replied: “After death, drug is released from tissue bound stores and it
then diffuses into adjacent blood vessels. This phenomenon is know as post
mortem redistribution and it means the amount of drug present in post mortem
blood may be higher that the amount of drug present in blood at the time of
death. Because of this, it is not possible to calculate the dose ingested from
the concentration of drug present in post mortem blood.”
Clinical review
85. The clinical reviewer has provided an extremely detailed clinical review. The
aim of his enquiries was to ascertain if the level of care that the man received
in Brixton was comparable to what he would have received in the community.
In doing so, it is important to point out that the prison population is very
different to the general population. These differences, such as challenging
behaviour, drug and alcohol abuse and mental health problems, are part of a
day to day challenge for healthcare professionals working in prisons.
86. The First Reception Health Screen was not completed fully and in accordance
with the local protocol. The man’s answers to the mental health questions
meant that he should have been referred for a mental health assessment, but
it would appear that this did not happen so an opportunity for a further
assessment of his health was missed.
Steps should be taken by healthcare management to ensure that staff
carrying out a First Reception Health Screen do so correctly and fully in
line with the protocol.
87. The clinical reviewer has reached a number of conclusions in relation to the
drug treatment programmes at Brixton. His review covers staff training which
he feels needs to be addressed urgently, given the fact that G wing is the
location for most new arrivals with a drug problem. The clinical reviewer
discusses the possible lack of clarity amongst nurses and doctors about who
22
holds the clinical responsibility for assessing patients prior to decisions being
made on treatment for substance misuse.
88. The clinical reviewer could not reach a conclusion as to why prisoners are not
adequately assessed by nurses on G wing prior to being given medication
such as methadone. Several possible reasons were considered such as high
workload, with a large number of prisoners to receive medication in a short
period of time. Another possible reason may be lack of training and/or
management supervision.
Staffing levels must be modified to ensure that the drug treatment
protocols can be implemented, if that is a reason for it not happening. It
is not acceptable for there to be insufficient nursing staff to ensure that
the twice daily regime for the initiation of methadone on day 1 cannot
take place.
89. The clinical reviewer identified a number of areas of good practice as well as
a number of shortcomings. He argues: “It is not possible to know for certain
whether the death of the man could have been prevented if these
shortcomings had not occurred.”
90. The clinical reviewer was satisfied that staff attempting to resuscitate the man
did their best and carried out CPR adequately. However, he noted that the
staff were not using the current guidelines of 30 chest compressions to two
rescue breaths, but rather a ratio of 15 to two. He is sure that this variation
would have made no significant difference to the outcome, but felt that staff
would benefit from updating their CPR skills.
Healthcare management at HMP Brixton should ensure that all relevant
nursing and discipline staff receive training so that they carry out
cardiopulmonary resuscitation (CPR) in accord with the current
recommendations.
91. The clinical reviewer noted that there were delays in emergency equipment
arriving at the man’s cell. Staff only collected the equipment when requested
to do so by the Hotel 6 nurse, despite the local protocol making it the
responsibility of the officers to collect the locally available equipment before
the arrival of Hotel 6. The clinical reviewer repeats a recommendation that
has been made in relation to previous clinical enquiries at HMP Brixton. It is a
matter of regret that there still appears to be no reliable system in place.
Healthcare management must look at how to ensure that all the
elements of the response to Code 1 emergencies take place. This
includes ensuring that the wing-based emergency equipment, the
Ambu-Bag equipment, is always brought to the site of the emergency by
the wing staff before the arrival of the nurse on duty.
92. The clinical reviewer was also concerned that there was no systematic review
of the management of events after the man was found. Reviews following
major events are routinely carried out in the primary care setting. They offer
23
the opportunity for all staff to review their practice, identify learning needs,
consider any further training that may be required, and examine systems in
place for emergencies so that if necessary they can be improved. In addition,
it is also an important source of support for staff who have been through a
distressing experience. The following recommendation has been made in
relation to previous clinical enquiries at HMP Brixton, and it is again a matter
of regret that no reliable system is in place.
A process of significant event analysis (SEA) must be introduced for all
major incidents such as deaths or attempted resuscitation. The SEA
process should also be used for all other major medical incidents. The
SEA should help to identify the learning needs of individual members of
staff, as well as the need to develop and refine systems and protocols of
care.
93. The clinical reviewer makes a number of recommendations, each of which I
fully endorse. It is of concern that some of these recommendations have
been made in previous investigations, but do not appear to have been
actioned. I urge the prison health partnership to consider these and previous
recommendations as part of their clinical governance responsibilities and
ensure that an appropriate action plan is developed to address them.
94. The clinical reviewer says that senior members of healthcare management at
Brixton should hold discussions with the GPs who hold clinical responsibility
for the medical follow up of First Reception Health Screens, as well as with
the nurses and healthcare officers who carry out the screening, to clarify what
responsibilities can be appropriately delegated in terms of identifying
important clinical issues and passing them on to the GP. In a similar way,
discussions need to take place between healthcare management, the GPs
and the nurses of the Substance Misuse Team (SMT), about how much
clinical responsibility for assessing the health of prisoners can be
appropriately delegated from the doctors to the nurses on the SMT. The
outcome of these discussions must be absolutely clear, and should be set out
in a formal written policy so that all the staff understand their own level of
clinical responsibility and accountability.
Liaison with the man’s family after his death
95. Liaison with the family in the aftermath of the man’s death was undertaken
by a Reverend. The family and their solicitor were extremely unhappy with
the way in which the Reverend conducted his liaison responsibilities. I have
seen correspondence between the Governor at Brixton, and the man’s mother
and solicitor about the way in which the Reverend performed his duties. My
investigator has not interviewed the Reverend, who no longer works at
Brixton, so I do not comment in detail on these matters. I note that the
Governor has done his very utmost to engage with a range of concerns
expressed by the family and to apologise for some shortcomings, which he
acknowledges. In a letter to the man’s mother, dated 10 August 2006, the
Governor wrote compassionately, non-defensively and apologetically:
24
‘’I would like to take this opportunity to make a further apology to you. It is
clear to me that through this incredibly difficult time for you and your family
and despite our best intentions, we have not managed to satisfy all your
concerns , nor have we supported you as well as I would have liked. I am
very genuinely sorry for that. ‘’
25
FURTHER INVESTIGATIVE WORK DONE AFTER THE ISSUE OF MY DRAFT
REPORT
96. I issued my draft report on the man’s death in March 2007. The following
month I received a response to the draft from the solicitors representing the
man’s family. In May 2007 I received a response to my draft report from the
PPO liaison unit in Safer Custody Group. My investigator began a period of
maternity leave on the day that the Safer Custody response arrived. One of
my Assistant Ombudsmen took over the investigation from my investigator at
that time and he has been responsible for producing this revised draft report.
97. The family’s April 2007 response to my draft report requested that the clinical
reviewer in this case should reach a conclusion as to the reception doctor’s
practice in prescribing inhalers to the man without examining his chest. The
clinical reviewer responded to the request by saying that it was medically
appropriate that the reception doctor did not examine the man’s chest. The
first reason given by the clinical reviewer for his opinion was that the man did
not present any symptoms suggestive of a chest problem to the reception
doctor or to the Healthcare Officer who carried out the first reception health
screen. The clinical reviewer recalled that in interview the reception doctor
had stated, “He (the man) wasn’t complaining of any signs or symptoms, he
wasn’t short of breath, he had no cough, he had been asked constantly about
any other health issues.”
98. The second reason for the clinical reviewer’s opinion was that the reception
doctor clearly remembered seeing the man on the evening of 7 June 2006. In
interview he was able to tell the clinical reviewer that the man had no
observable features to suggest a chest problem requiring examination of his
chest.
99. The third reason advanced by the clinical reviewer in support of his opinion
was that patients with asthma should always have inhalers with them. The
clinical reviewer explained that it is best practice for asthmatics to use an
inhaler on a regular basis, even if they have no symptoms at all. He added
that “this type of inhaled drug is used when the patient is well, to prevent the
development of any symptoms or an acute asthma attack. Therefore, if a new
prisoner inmate with a history of asthma, such as the man, has no inhalers, it
would be good practice to prescribe these inhalers, even if they were
asymptomatic (i.e. well). The prescription of the inhalers is not a reason to
carry out a chest examination.”
100. The fourth reason for the clinical reviewer’s opinion was that although the
FME reports did mention a recent past history of pneumonia, and of asthma
causing wheeziness, the reception doctor was clear that these reports were
not available to him when he saw the man. The clinical reviewer concluded,
therefore, that the reception doctor was not in a position to be guided by the
FME reports in any way.
101. In their response to my draft report, the man’s family supplied a witness
statement made by the man’s niece for HM Coroner. In her witness
26
statement to the coroner the man’s niece described visiting her uncle on 12
June, just three days before his death. In her statement she said that when
the man came into the visits room at Brixton he did not look very well. She
had not seen him for a couple of weeks but now he seemed to her very small
and hunched and his skin looked noticeably yellow. She described his face
as “the colour of a yellowing bruise.”
102. In the eighth paragraph of her witness statement the man’s niece said she
could not remember whether her uncle had been particularly sweaty but he
was coughing a lot, although that was not unusual because he smoked. She
recalled that her uncle had sounded quite wheezy at times during the visit,
both when it first began and after he had had a coughing fit. She said it was
difficult to tell whether her uncle’s coughing sounded any different from
normal. She added that “he sounded phlegmy at times, as if he was trying to
clear his throat.”
103. In the light of the witness statement, the family asked that the clinical reviewer
be requested to review, clarify and if necessary expand upon his view
concerning the man’s likely presentation from the date of his meeting with his
niece.
104. The clinical reviewer responded that he did not think it was possible to provide
a clear answer to the family’s questions. He referred to the possibility that
when the man’s niece saw her uncle on 12 June, he was beginning to
become unwell with what developed into fulminating lobar pneumonia over
the course of the subsequent two days. The clinical reviewer accepted that it
is not at all uncommon for relatives of a person to be able to detect early
changes in their health before this is apparent to a clinician such as a nurse or
a doctor.
105. The clinical reviewer considered the possibility that the man was suffering
from jaundice when visited by his niece on 12 June. The clinical reviewer
would have expected a trained clinician to be able to detect this. He would
have expected jaundice to be detected in the post-mortem examination
carried out by the pathologist, on 15 June. He observed that the post-mortem
examination report referred to “no abnormalities of the colouration of the skin
or, more importantly, no abnormalities of the liver.”
106. The clinical reviewer concluded that the man was probably not suffering from
jaundice on 12 June but that he looked sallow and unwell for other reasons.
The clinical reviewer could not know what those reasons were but it was
certainly a possibility “that they were due to the early stages of the lobar
pneumonia that eventually resulted in the death of the man on 15 June 2006.”
He considered it would be pure speculation as to how those features might
have developed over the next few days and whether they would have been
detectable to personnel who did not really know the man.
107. In response to my draft report the man’s family made one further request, that
the clinical reviewer be asked to perform an audit of the pharmacy records at
Brixton to establish whether methadone stocks were properly controlled and if
27
the entire stock was properly accounted for. The man’s family were very
concerned by the reference in the post-mortem report to a “potentially fatal
dosage” of methadone in the man’s blood after his death. The family
speculated on the seriously deleterious effect on his health that would have
been caused by any over-prescription of methadone.
108. In July 2007, the PCT agreed to an audit of the methadone dispensed around
the time of the man’s death. The PCT informed my investigator that an
independent pharmacy technician would undertake the work with its aims
being
(cid:127) To attempt to ascertain whether there was any methadone which was not
accounted for around the time of the man’s death.
(cid:127) To outline the processes, systems and legislative framework which govern
the management and dispensing of controlled drugs (including
methadone) at HMP Brixton.
109. The work commissioned by the PCT was undertaken by a woman who was
the Chief Pharmacist for the PCT for approximately nine months to March
2007 and is now Chief Pharmacist at another PCT.
110. Despite assurances that the work would be completed by October 2007 my
investigator did not receive a copy of the audit report until March 2008.
111. A response to my draft report was sent to me from the PPO Liaison Unit at
Safer Custody Group in May 2007. My investigator and my then Deputy
Ombudsman discussed this response at a meeting at the PCT Headquarters
in September 2007 attended by senior PCT colleagues and the then Head of
Healthcare at Brixton.
112. The man’s family asked for a further meeting with my investigator, which was
held at the solicitor’s office in October 2007. At this meeting the man’s family
requested that additional investigative work be undertaken. Later that month,
my investigator met with the then Deputy Governor at Brixton. In November,
he returned to Brixton to interview the third doctor and to re-interview the
prison doctor, as the man’s family had requested. My investigator duly
provided documents which had been sought by the solicitor at the October
meeting.
113. The May 2007 response from Brixton, channelled through Safer Custody
Group, to my draft report challenged many of the recommendations made in
that report. The Safer Custody response noted that the bulk of the
recommendations referred to prison specific processes and questioned
“whether the clinical reviewer had the necessary experience of prisons to
adequately comment.’’ The Safer Custody response also referred to
significant factual inaccuracy and “apparent confusion regarding the process
for review of patients on opioid replacement.” The response suggested that
this confusion could have been cleared up with a call to the third doctor.
28
114. After my investigator’s meeting with the deputy governor, he was sent a note
explaining that the third doctor had written a lengthy response to the clinical
review conducted by the clinical reviewer. “This was intended as a discussion
document for the senior clinicians at HMP Brixton who would later edit and
refine the response.’’ It appeared that the response had left the prison before
the anticipated editing and refining had taken place.
115. In response to my revised draft report, issued in April 2008, I received an
explanatory note on 4 July from the Casework and Learning Section of Safer
Custody and Offender Policy Group (SCOP). Safer Custody was merged with
Offender Policy in April 2008. The note indicated that part of the Safer
Custody response to the draft report I published in March 2007 was based on
a document entitled ‘’Response from Senior Clinicians HMP Brixton to the
Draft Report into the Investigation into the Circumstances surrounding the
death of the man at HMP Brixton on 15th June 2006’’. That document was
emailed to Safer Custody Group on 4 May 2007 by the then deputy governor
at Brixton. Its purpose, according to the July 2008 note from SCOP, was to
‘’contribute to the Safer Custody reply to the Ombudsman’s draft report and it
was presented as a response from all the senior clinicians, not just the third
doctor.’’ The wording of the senior clinicians’ response is indeed almost
identical to that of the last four pages of the response to my draft report issued
by Safer Custody Group on 10 May 2007.
116. My investigator interviewed the third doctor at Brixton on 15 November 2007
so that any factual inaccuracies could be reduced to a minimum and so that
he could comment, if he wished, on the recommendations mainly made by the
clinical reviewer and endorsed in my draft report.
117. In interview the third doctor explained that he and four GP colleagues from a
family practice have, since 2005, held the contract for the delivery of primary
healthcare and substance misuse services at Brixton. He explained that the
senior clinicians at Brixton had come together in the past in order to review
ways of working together to improve the safety of healthcare in the prison.
They had set up a committee which would review all critical incidents and
design appropriate policy. The doctors responded to any reports as a group
and he wrote an e-mail to his colleagues on the committee about the draft
report on the man as he was about to go on holiday. He added that his e-mail
was for internal purposes only and for consideration by his fellow doctors at
Brixton. In response to a question, the third doctor confirmed that his e-mail
was written for discussion with his clinical peers alone and “it was not even
intended to go to the PPO Liaison Unit.” During the interview the third doctor
spoke of his determination to help improve the clinical service at Brixton and
to make the major changes which he and his colleagues felt were necessary.
He commented on most of the recommendations in the draft report and also
spoke about a number of clinical developments at Brixton in the 18 months
which had elapsed since the man’s death.
118. The first two recommendations in the draft report were that a system should
be instituted to record all documents and papers that arrive in reception and
that all relevant documents, such as FME reports (reports by the Forensic
29
Medical Examiner/police doctor), must accompany prisoners as and when
they are seen by the GP. In response, the third doctor said that recording all
the documents as they arrive would not guarantee that “the proper person”
sees them and he observed that GPs must receive as much of the information
accompanying a new prisoner as possible. In a later response he added that
it is essential for such information to be available to the doctor on the first
night because “the second day is too late.” He was aware that quite often
prisoners go straight out to court on the following day and the doctors need to
know as much about them as possible to make an assessment of safety and
risk on the first night.
119. The third doctor was asked about the route followed by documents (such as
FME reports or concerns about possible suicide risk, raised by the escort
company) when a prisoner arrives at Brixton. He referred to a deficit in
information getting to the GP, depending on how chaotic the reception is, how
late the vans arrive and whatever else might be going on in the prison. His
experience was that the PER (Prisoner Escort Records) and IMRs (clinical
records) did not arrive together and “we are still frequently seeing patients
without the PERs.” My investigator asked the third doctor how the information
deficit might be closed and he spoke of the enormous pressure on nurses
who screen new receptions at Brixton. He feared that some errors were
bound to occur “when 30 or 40 people are arriving within an hour and we
expect them all to be fully screened and all documentation read.” He
suggested that an alternative might be to do the necessary screening at court
but I suspect that proposal would be even more costly and resource intensive
than the existing arrangements at Brixton.
120. The third recommendation in my draft report was for a reassessment of
training needs. In a detailed response the third doctor explained that the
Substance Misuse Team were not highly trained in November 2005. They
were not trained specifically in how to assess patients with substance misuse
problems but by June 2006 two dedicated nurses were undergoing training.
He recalled that the treatment for people at Brixton with drug problems prior to
his arrival was hydrocodeine and valium, which were completely against the
national guidelines. He and his colleagues introduced substitute prescribing
with methadone in March 2006. Brixton received funding, through the
Integrated Drug Treatment System (IDTS), to establish a more
comprehensive substance misuse team, which by November 2007 was being
built up to a team of five. The third doctor spoke of the difficulty of moving a
prisoner from Brixton, which has IDTS, to another prison which does not.
121. The Ministry of Justice issued a Prison Policy Update Briefing Paper in
January 2008 which announced that by April 2008 29 prisons would have
introduced IDTS “and with the Department of Health we would be extending
the scheme to a further 20 prisons over the next 12 months.” The briefing
paper explains that IDTS provides better clinical services funded by the
Department of Health, such as improved detoxification programmes and
greater continuity of care between the community and prisons, between
prisons, and on release into the community, as well as helping offenders to
address some of the deeper roots of their drug abuse. The third doctor told
30
my investigator that by November 2007 most of the staff on the Substance
Misuse Team at Brixton had been employed already trained. An extensive
programme of training had been provided to the previous staff and, as a
result, at the time when he was speaking, all prisoners at Brixton were
assessed on the morning following their arrival by a well-trained substance
misuse nurse. The lead of the substance misuse team had become a nurse
prescriber who is able to prescribe methadone and systematic relief in her
own right.
122. In response to the fourth recommendation, that the Substance Misuse Team
should always attempt to contact outside drug agencies and GPs, the third
doctor agreed and said, “That is something that we are always trying to do.”
123. As to recommendation number five, the third doctor thought that any
expectation to locate people with asthma on the ground floor would meet a lot
of opposition from the prison authorities. He referred to Brixton having a lot of
people with significant physical infirmities who need the ground floor
accommodation.
124. In relation to the sixth recommendation, about prisoners who fail to attend
follow-up appointments, the third doctor recalled that under the previous
system “people would be put onto a nine day detox and would never be seen
again unless they were requesting it, unless they actually requested
themselves to see a GP.” He explained that the current system is that one of
the two GPs particularly trained in substance misuse (himself or his
colleague) will see any substance misuser within a week of arrival and being
put on methadone or Subutex. He recalled that there was no formal system
to “go after” (follow-up) prisoners who failed to attend follow-up appointments
at the time of the man’s death. The system now, as explained by the third
doctor, is much more proactive because all the prisoners on methadone or
Subutex are held on G wing “and I now go to the wing after my morning
surgery, if there is a problem with any of them I would see them. [My
colleague] on a Tuesday afternoon at 4 o’clock will go to the wing as well so
that he can assess anybody who might have been missed and we are shortly
hoping that we will have an observation unit opened.”
125. In relation to the seventh recommendation (correct procedure for the
administration of methadone) the third doctor said that all staff dispensing
methadone at Brixton are trained in the correct procedures “and we are
constantly updating them and the pharmacy is heavily involved as well in
monitoring and knows what goes on and we believe that we have very robust
systems in place.”
126. The eighth recommendation was that a review should take place of systems
for administering controlled medications such as methadone. The report from
the PCT following such an audit was still awaited at the time of my
investigator’s interview with the third doctor.
127. In relation to the ninth recommendation, that staff carrying out a First
Reception Health Screen should do so correctly, the third doctor accepted
31
that the screening process should be completed in the way that is intended
although he expressed a view that tasks in prisons are liable to be completed
for themselves rather than for the outcome that is expected from that task.
128. In response to the tenth recommendation, about the possibility of two
separate methadone doses on a prisoner’s first day of treatment, the third
doctor referred to the long period of time that a prisoner would have to spend
queuing on his first day if methadone was administered in two separate
doses. He said that such prisoners would miss being involved in other
activities such as making phone calls or taking showers and he was confident
that “20mls of methadone is still a very low dose and we believe that it is safe
at that dose.” (the man was given a 20mls dose of methadone on 8 June
2006, his first day of treatment at Brixton.) The specialist’s report confirms at
paragraph 110 that “[the man was provided with a dose induction regime (at
Brixton) that was in keeping with prison and national policy and congruent
with most other relevant countries’ regimes.”
129. In relation to recommendations 11 and 12, the third doctor said they were not
within his remit and he added that within the healthcare team there is a
significant amount of analysis that is used internally for all incidents.
130. The prison doctor was re-interviewed in November 2007. He explained that
he usually works at Brixton on Thursdays but is on-call every sixth weekend.
For six to eight days each year he supplies cover for colleagues who are on
holiday. On Tuesday 13 June 2006, he supplied cover for a clinic that would
normally have been undertaken by his colleague. The prison doctor was
asked about the current system (in November 2007) for reviewing prisoners
who are receiving opiate replacement medication. He replied that the current
system was that the third doctor and his colleague are responsible for the
policy of substance misuse and drug dependency work. He added that they
also do the vast majority of reviewing patients and sorting out their
requirements. The Assistant Ombudsman asked the prison doctor about
arrangements, both in June 2006 and November 2007, for following up
prisoners who did not attend at clinic but a much more detailed discussion of
that issue is contained in the remarks made by the third doctor in his response
to the sixth recommendation (“prisoners who fail to attend for important
appointments, such as reviews of their drug treatment, must be followed up”)
in my draft report.
131. On 10 March 2008, the Assistant Director of Service Strategy and Adult
Commissioning at the PCT wrote to my investigator. He enclosed a report on
the methadone audit undertaken by the Chief Pharmacist and apologised for
the delay in supplying the report. He referred to a number of factors, including
the fact that the Healthcare Service at Brixton had recently been tendered
through a competitive process which had been very resource intensive. He
added that although the report outlined a number of issues regarding the
management of controlled drugs at Brixton, these had been or were in the
process of being dealt with through the Drugs and Therapeutic Committee.
The Assistant Director of Service Strategy and Adult Commissioning wrote
that progress was being monitored by the Prison and PCT Partnership Board.
32
132. When the Assistant Ombudsman first wrote to the Assistant Director of
Service Strategy and Adult Commissioning, he relayed the request by the
family solicitors that an audit of the pharmacy records at Brixton be performed
to establish whether methadone stocks were properly controlled and if the
entire stock was properly accounted for.
133. The introduction to the Chief Pharmacist’s report, received on 10 March,
states that the Primary Care Trust commissioned an independent review by a
pharmaceutical adviser of the governance arrangements relating to controlled
drugs at Brixton in order to address the following three questions asked by the
solicitors for the man’s family:
(cid:127) Was any methadone reported lost/missing during the time of the man’s
death?
(cid:127) Would it be possible for methadone to be diverted in the prison?
(cid:127) Did an error in the recording in the controlled drugs register occur?
134. In response to a number of questions posed by the Assistant Ombudsman
after receiving her report, the Chief Pharmacist set out as follows the ten
methods constituting her methodology:
1. Consultation of the literature: Using the search criteria of “prison
pharmacy”, “controlled drugs” and “controlled drugs in prisons” A
selection was made from these searches.
2. Reference to legal framework for controlled drugs (references sourced
from the RPSGB, HealthCare Commission, Department of Health)
3. I contacted the East & South East England Specialist Pharmacy
Services, which were known to have given the processes some thought
and requested documentation of their audit tools, policies and processes
4. I adapted the controlled drugs audit tool produced by the East & South
East England Specialist Pharmacy Services to answer the questions
posed by the solicitors.
5. I met and discussed the issues/ concerns and the processes utilised by
various stakeholders (lead nurse, principal pharmacist, prison
pharmacist, specialist nurse for substance misuse, Chief Pharmacist the
PCT, Commissioner)
6. I observed the substance misuse clinic on the wing
7. I reviewed controlled drugs registers (wing & pharmacy), including the
one for the man, drug charts and SOPs
8. I observed and examined clinic locations/ consultation areas. I
questioned a variety of staff as to the procedures used in those areas.
9. Consultation with the leading UK academic on the subject of NHS
rationing, resources and ethics and consulted his books.
10. Analysis of the research, procedures/ charts collected and
recommendations followed.
135. The stated aims of the report are to provide responses to the questions raised
by the solicitors and to assess the governance arrangements relating to the
33
management of controlled drugs at Brixton that may have contributed to any
system failures.
136. The Chief Pharmacist’s report indicates that over the 18 months to February
2008 there were significant changes in legislation and good practice
arrangements regarding the management of controlled drugs. She refers to a
review of the current management of controlled drugs (CDs) instigated by the
Department of Health following a previous inquiry. She indicates that several
pieces of legislation and guidance have been issued to further strengthen the
governance arrangements around the prescribing and use of controlled drugs.
The statutory framework now requires all health and social care organisations
to be accountable for ensuring the safe management of CDs. Primary care
trusts ‘must ensure robust monitoring arrangements are in place for the use
and management of CDs by all healthcare providers who they employ or
contract with’.
137. The Chief Pharmacist’s report then turns to the questions raised by the family
solicitors. In response to the question about whether any methadone was
reported lost or missing at the time of the man’s death, she says:
“On questioning, the lead nurse and Principal Pharmacist (who were both
working at Brixton at the time of the death) reported that there was no
methadone that was reported lost or missing. Adverse incident forms did
not highlight that any methadone was missing.”
138. In response to the question about whether it would be possible for methadone
to be diverted in the prison, the Chief Pharmacist’s report reveals that the
system of supplying methadone on a named prisoner basis made it difficult to
reconcile the contents of the register with the cupboard with ease. The report
continues:
“This system is no longer in use. The use of a variety of drug charts in a
variety of locations, poor implementation of processes (observed during
the audit) relating to the supervised consumption of medication and the
workload and working environment issues means that it may be possible
for methadone to be diverted in the prison.”
139. In response to the question about whether an error occurred in the recording
in the controlled drugs register, the Chief Pharmacist’s report says the
following:
“On checking the controlled drugs register for the wing where [the man]
was an inmate there were no discrepancies or miscalculations relating to
entries for methadone in the controlled drugs register for [him]. The
remainder of this register was checked and assessed for quality or
recording. In June 2006, methadone was supplied on a named prisoner
basis with a maximum of one week. This made it exceptionally difficult to
track the stock and correlate it with the entry in the registers, as more than
one register could have been in use. The recording of methadone in the
CD register was noted to have many errors and was generally poor.
34
Where it was possible to check the pages of the CD register there were no
discrepancies in calculations noted. It should be noted on assessment of
current CD registers on the wings there has NOT been a significant
improvement in the recording of controlled drugs.”
140. In the section of her report entitled ‘Key Findings’ the Chief Pharmacist lists
12 issues identified in the assessment which are relevant to the questions
posed by the solicitors. I reproduce verbatim the 12 bullet points made at this
section of her report:
a. Development of appropriate governance processes needs to occur to
ensure that prisoners receiving opiates are clinically assessed regularly by
nursing/healthcare staff
b. Review of the workflow during the supervised consumption within clinical
areas should be carried out
c. Appropriate performance management structures for staff that consistently
poorly perform relating to CDs is needed
d. Capacity assessment of nurses to undertake supervised consumption for
the number of clients within HMP Brixton
e. Development of a consistent single record for prescribing and monitoring
healthcare, including rationalisation of drug charts, is needed
f. Development/review of clinical guidelines relating to substance misuse is
needed
g. Better records management needed and management of controlled drugs
stationery needs to be tightened. Consistency and cross referencing
between EMIS prescribing and written drug charts is needed.
h. Completion of Standard Operating Procedures within an appropriate
timescale
i. Checking anaphylaxis drugs and naloxone are available in clinical areas
as appropriate
j. Rapid escalation of medicines related errors and issues to the governor,
healthcare manager and chief pharmacist
k. Education and training programme for all staff (CDs, anaphylaxis,
medicines management, incident reporting etc) needed
l. Monthly audits of all CD registers in all locations needed
141. The last section of the Chief Pharmacist’s report is entitled ‘Summary of
Findings’ and announces that the governance processes related to the
management of controlled drugs have been strengthened in Brixton over the
last 12 months as a result of the implementation of a previous review and
under the leadership of the principal pharmacist. She writes that her report
identifies areas where there may have been factors that affected optimal safe
systems of managing controlled drugs. Her belief, however, is that ‘it is not
possible to make inferences or relate any of the suggestions as contributing
directly to the death of the man’.
142. The Chief Pharmacist’s opinion is that a matrix approach to the management
of controlled drugs and medicines would benefit processes. She
recommends that professional and managerial accountability needs to be
more tightly managed and a focused plan should be developed by the Head
35
of Medicines Management, the Healthcare Manager and the principal
pharmacist to deliver the identified changes required within (appropriate)
timescales.
143. Her final observation is that ‘the accountability arrangements for controlled
drugs and all medicines need to be better understood by all healthcare staff
and managers within HMP Brixton’.
36
CONCLUSIONS
144. The opinion of the clinical reviewer and the pathologist is that the man died as
a result of lobar pneumonia. This condition is quite rare and is described by
the clinical reviewer as a very rapidly developing illness. The illness can come
on over a period of one to two days or as little as 24 hours. The abscesses
found in the man’s lungs suggest that he had an extremely aggressive form of
bacteria which rapidly damaged the lung tissue.
145. The specialist in the management of drug addiction has concluded that the
man was appropriately assessed as a substance misuser over a long period
of time and in recent days prior to his incarceration. How much he used, and
when he last did so, is open to question but unlikely to be of great
significance. The specialist concludes it was entirely appropriate to prescribe
and administer methadone treatment. She says that it may have been that
severe respiratory problems were also present, but she is of the opinion that
these would have been largely masked by withdrawal symptoms. She adds:
“It is unlikely that the man was acutely respiratory compromised, with rapid
respiratory rate, cyanosis, shortness of breath and so forth as these clinical
signs would (should) have been identified by the large number of clinical and
non clinical staff that he came into contact with over the course of the nine
days he was in prison and police custody.” It is also of significance that she
says: “it may also have been that if the man was suffering from severe
respiratory problems that methadone and benziodiazepines (both respiratory
depressants) further compromised his respiratory function.”
146. The man was seen by the reception doctor, who did not physically examine
him. They did discuss his drug dependence and the possibility of
commencing a Subutex detoxification. Expert opinion has been given that,
even if the reception doctor had examined him, the signs of drug withdrawal
may have masked a respiratory problem. Be that as it may, it would be far
more satisfactory if the reception doctor were to give new arrivals a physical
examination. I am fully aware of the constraints, time available, and the
numbers of prisoners arriving through reception. But even if this physical
examination were to take place within 48 hours of arrival, it would be better
than none at all.
147. The man was also seen by the lead of the substance misuse team. She
noted that he was asthmatic and he told her of a recent episode of pneumonia
when he was admitted to hospital. During this assessment, it appears that he
changed his mind about starting Subutex. She wrote that the man preferred
methadone maintenance. The lead of the substance misuse team discussed
the man and the possibility of methadone maintenance with the prison doctor.
He signed the man up for methadone maintenance, but he did not see or talk
to him about this. Apparently this is the norm. However, it is noteworthy that
the prison doctor said that had he been aware of the man’s history he would
have wanted to see him. This is an area of concern and I suggest it would be
beneficial for a prescribing doctor to at least read the papers in a prisoner’s
medical record before signing a methadone maintenance. That is not to say
37
that this would have altered the outcome in the case of this man, but doctors
need to be fully aware of all the medical information available to them.
148. The man visited the medical hatch once a day from 8 June to 14 June. Each
time, there would have been two nurses involved in giving him his methadone.
In effect, this means that during this period there would have been 14
separate nursing observations of him, although it is likely that some nurses
may have seen him more than once.
149. The nurse at the medical hatch on 14 June was identified as being the last
nurse to administer methadone to the man. She said that there was nothing
untoward or concerning about him that afternoon. She was asked about this
and said that if she had any concerns about a prisoner she would withhold
medication and refer to the doctor.
150. The man was found dead in his cell by his cellmate who promptly raised the
alarm. Staff responded immediately as evidenced by all of the official logs
(prison, police and London Ambulance Service). The Hotel 6 nurse attempted
CPR despite the indications that the man was already dead. I do not believe
it is respectful if staff are required to commence CPR on those who are clearly
beyond resuscitation. However, in the particular circumstances, I believe the
actions of the nurse reflect very well and have drawn attention to them as an
example of good practice.
151. A good deal of further investigative work has been undertaken by the
Assistant Ombudsman in response to a number of questions raised by the
man’s family and their solicitors. The family asked that the clinical reviewer
should reach a conclusion as to the reception doctor’s practice in prescribing
inhalers to the man without examining his chest. His response to this
question was that it was medically appropriate that the reception doctor did
not examine the man’s chest. Reasons cited by the clinical reviewer were
that the man did not present any symptoms suggestive of a chest problem to
the doctor, that the doctor clearly remembered seeing him on the evening of
7 June and that (in the clinical reviewer’s opinion) patients with asthma should
always have inhalers with them. The clinical reviewer acknowledged that the
reports from the Forensic Medical Examiner, who saw the man in police
custody before his arrival at Brixton, did mention a recent past history of
pneumonia and of asthma causing wheeziness. The reception doctor was not
in a position to be guided by the FME reports as they were not available to
him when he saw the man who is the subject of this report.
152. The man’s family supplied a witness statement made by his niece for HM
Coroner. She visited him at Brixton on 12 June, just three days before his
death. The clinical reviewer was asked by the family to review, clarify and if
necessary expand upon his view concerning the man’s likely presentation
from the date of his meeting with his niece. The clinical reviewer has
responded that it is not possible for him to provide a clear answer to the
family’s question. He has referred to the possibility that when his niece saw
her uncle on 12 June, he was beginning to become unwell with what
developed into fulminating lobar pneumonia over the course of the
38
subsequent two days. The clinical reviewer considered the possibility that the
man was suffering from jaundice when his niece visited. The clinical reviewer
would have expected jaundice to be detected in the post mortem examination
carried out by the pathologist, on 15 June. The pathologist’s post mortem
examination report referred to no abnormalities of the liver and the clinical
reviewer therefore concluded that the man was probably not suffering from
jaundice on 12 June.
153. The May 2007 response from Safer Custody Group to my draft report
challenged many of the recommendations made in that report. The response
was particularly critical of the clinical reviewer’s role, questioning whether he
had the necessary experience or training to make recommendations referring
to prison specific processes. I have little doubt that he will be able to defend
his reputation robustly but I wish to place on record my thanks to him for
supplying a detailed, wide ranging and impressively evidenced report on the
circumstances of the man’s death.
154. The Safer Custody Group response referred to apparent confusion regarding
the process for review of patients on opioid replacement and suggested that
this confusion could have been cleared up with a call to the third doctor.
155. After the Assistant Ombudsman met in October 2007 with the then deputy
governor of Brixton, he was sent a note explaining that the third doctor had
written a lengthy response to the clinical review. He referred in his note (to
the healthcare manager at Brixton) to the ‘unfortunate distribution of my
previous comments’. They were intended as a ‘discussion document for the
senior clinicians at Brixton who would later edit and refine the response. My
comments therefore were taken out of context’.
156. The wording of the last four pages of the response I received from Safer
Custody Group on 10 May 2007 is almost identical to the Response from
Senior Clinicians at HMP Brixton which was sent to Safer Custody Group six
days before. In view of his remarks in the previous paragraph, I judge that the
third doctor contributed significantly to the Response from Senior Clinicians
document. My investigator gave him an opportunity to comment in detail,
almost 18 months after the man’s death, on all the recommendations
contained in the previous version of this report. I fully accept the third doctor’s
assertion that he and his GP colleagues at Brixton ‘are all trying to ensure that
the service we provide is not just equivalent but superior to that received in
the community’.
157. In his interview with the Assistant Ombudsman, the third doctor explained that
he and his colleagues had introduced substitute prescribing with methadone
as recently as March 2006. I note with pleasure the increasing sophistication
of the treatment available for substance misusers at Brixton. The recent
introduction of the Integrated Drug Treatment System (IDTS) has enabled the
substance misuse team to build up to a strength of five staff members. I
observe in passing that IDTS has not yet been introduced to many other
prisons, with the inevitable consequence that the sophisticated treatment
39
already available to a prisoner at the likes of Brixton is not yet reproduced
throughout the prison estate.
158. In interview, the third doctor confirmed that at the time of the man’s death
there was no formal system to “go after” (follow up) prisoners who failed to
attend their medical appointments. The current system is that one of the two
GPs particularly trained in substance misuse will see any substance misuser
within a week of him arriving at Brixton and being put on methadone or
subutex. Now, but not at the time of the man’s death, the system is much
more pro-active because all the prisoners on methadone or subutex are held
on G wing and the third doctor is able to see them on that wing after his
morning surgery.
159. I am grateful to the PCT for supplying the document headed “HMP Brixton –
Findings from a Review of Controlled Drugs” though my investigator was
informed that the report would be available several months before it
eventually materialised. The Chief Pharmacist’s report says, according to
information supplied by the lead nurse and Principal Pharmacist, that no
methadone was reported lost or missing at the time of the man’s death. The
report concedes that it might have been possible for methadone to be diverted
within the prison because the system of supplying methadone on a named
prisoner basis made it difficult to reconcile the contents of the (controlled
drug) register with the cupboard.
160. The Chief Pharmacist reports that the controlled drug register was scrutinised
to establish whether there were any discrepancies or miscalculations relating
to the man. None were found but the Chief Pharmacist adds that the system
for supplying methadone in June 2006 made it “exceptionally difficult to track
the stock and correlate it with the entry in the registers”. She highlights her
worrying finding that “there has NOT (capital letters in her report) been a
significant improvement in the recording of controlled drugs in current CD
registers on the wings”.
161. The Chief Pharmacist says that her report identifies areas where there may
have been factors that affected optimal safe systems of managing controlled
drugs. She argues that “it is not possible to make inferences or relate any of
the suggestions as contributing directly to the death of the man”.
162. I am well aware that the opinion of both the clinical reviewer and the
pathologist is that the man died as a result of lobar pneumonia. Nevertheless
I believe that the Chief Pharmacist’s findings in relation to the management of
controlled drugs at Brixton are important and timely. In the concluding
paragraphs of her report the Chief Pharmacist suggests that a number of
changes are required. She observes that a matrix approach to the
management of controlled drugs (and medicines) would benefit processes.
Her opinion is that dual accountability (professional and managerial) needs to
be more tightly managed. The Chief Pharmacist’s last paragraph refers to the
need for accountability arrangements for controlled drugs (and all medicines)
to be better understood by all healthcare staff and managers within Brixton. I
40
therefore endorse the following recommendation made by the Chief
Pharmacist and include a suggested timescale.
Working in conjunction with the Governor and the PCT, a focused plan should
be developed to deliver the changes to the management of controlled drugs at
Brixton identified as being required in the Chief Pharmacist’s report of
February 2008. The Head of Medicines Management, Healthcare Manager and
Principal Pharmacist should devise a focused plan, with timescales, within 3
months of receiving my revised draft report.
41
RECOMMENDATIONS
I make the following recommendations. The majority of these arise from the clinical
reviewer’s clinical review. Recommendations 5, 7 and 8 are my own.
1. A system should be instituted to record all documents and papers that
arrive in Reception with new prisoners.
2. The system for assessing newly arrived prisoners at HMP Brixton must
ensure that all relevant documents, such as FME reports, accompany
prisoners as and when they are seen by the GP.
3. The training needs of all the nursing members of the Substance Misuse
Team as well as the primary care nurses on G wing should be
reassessed to ensure that they are all able to assess and monitor the
health needs and clinical problems of prisoners who are drug addicts.
They need to understand fully what they are assessing and monitoring
and the reasons why they are doing this. They also need to be clear
about what to do if any cause for concern arises, including new
information
4. The Substance Misuse Team (SMT) should always attempt to contact
outside drug agencies and GPs to establish the pattern of treatment of
prisoners who are drug addicts or are being considered for treatment by
the SMT. These contacts should be made as soon as possible, and
there may be a need for a standard system for making these contacts
and obtaining the relevant clinical information.
5. When a prisoner with a clinical condition that may affect their physical
abilities is received in prison, they must be individually assessed to
ensure that they are given accommodation suitable to meet their health
and social care needs. This assessment must be documented in their
medical record and their wing history sheet to ensure continuity of care.
6. The administrative systems related to the monitoring of the treatment of
drug addiction need to be reviewed and changed in several ways.
Prisoners who fail to attend for important appointments, such as
reviews of their drug treatment, must be followed up. Important clinical
information about prisoners must be rapidly passed on to members of
the SMT and G wing nurses. Assessment and decision-making must
occur rapidly for prisoners who do not adhere to their agreed
programme.
7. The prison health partnership should remind healthcare staff of the
correct procedure for administration of methadone as dictated in the
Drug Dependence guidance.
8. I recommend that the prison health partnership reviews the existing
systems in place for administering controlled medications such as
methadone. The new system should make safeguards for the following:
42
(i) Ensuring prisoners are fit and well prior to receiving
medication;
(ii) Ensuring as far as practically possibly that impostors are
prevented from receiving medication.
9. Steps should be taken by healthcare management to ensure that staff
carrying out a First Reception Health Screen (FRHS) do so correctly and
fully in line with the protocol on the FRHS form.
10. Staffing levels must be modified to ensure that the drug treatment
protocols can be implemented, if that is a reason for it not happening. It
is not acceptable for there to be insufficient nursing staff to ensure that
the twice daily regime for the initiation of methadone on day 1 can take
place.
11. Working in conjunction with the Governor and the PCT, a focused plan
should be developed to deliver the changes to the management of
controlled drugs at Brixton identified as being required in the Chief
Pharmacist’s report of February 2008. The Head of Medicines
Management, Healthcare Manager and Principal Pharmacist should
devise a focused plan, with timescales, within 3 months of receiving my
revised draft report.
12. Healthcare management at HMP Brixton should ensure that all relevant
nursing and discipline staff receive training so that they carry out
cardiopulmonary resuscitation (CPR) in accord with the current
recommendations.
13. Healthcare management must look at how to ensure that all the
elements of the response to Code 1 emergencies takes place. This
includes ensuring that the wing-based emergency equipment, the
Ambu-Bag equipment, is always brought to the site of the emergency by
the wing staff before the arrival of the nurse on duty.
14. A process of significant event analysis (SEA) must be introduced for all
major incidents such as deaths or attempted resuscitation. The SEA
process should also be used for all other major medical incidents. The
SEA should help to identify the learning needs of individual members of
staff, as well as the need to develop and refine systems and protocols of
care.
GOOD PRACTICE
(cid:127) I commend the actions of the Hotel 6 nurse in attempting resuscitation
despite the fact that the man displayed physical signs of death.
(cid:127) I note that since my investigator expressed concern about the
“symptom assessed” column on the Methadone Titration Form, it is now
being completed and I urge the prison health partnership to ensure this
continues.
43