Individual at Manchester

Investigation into the death of
a male prisoner
at HMP Manchester on 5 November 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2006
This is the report of an investigation into the death of a man at HMP Manchester
in November 2005. He died due to inhalation of vomit, which the post mortem
explains was a result of natural causes. He was 38 years old.
The man was a long term user of heroin and had served a number of prison
sentences. His family tell me that it was unusual for him to declare his drug use,
and to be located on a specialist drug wing with a detoxification programme
ahead of him. However, on this occasion he did do all of these things and I was
impressed by the planning and operation of the wing, and especially the links
between officers and healthcare staff. The man was taken ill during his first night
in custody, was helped by healthcare, but deteriorated further in the morning and
then died. Prompt attention was sadly not sufficient to save his life.
My office investigates the deaths of all prisoners. In this case the investigation
was carried out by one of my team leaders, assisted by one of my investigators.
One of my Family Liaison Officers made contact with the man’s family. I hope
that this report addresses their concerns.
The PCT reviewed the healthcare this man received during the short time he was
at the prison. Their assistance is much appreciated.
I would also like to thank the Governor for his help, as well as all the staff who
were involved in the investigation, particularly a certain Principal Officer.
Finally, but most importantly, I take this opportunity to offer my condolences to
the man’s family and friends.
This version of the report has been anonymised for publication on the PPO
website. I have amended two factual inconsistencies in paragraphs 15 and 85.
Stephen Shaw CBE June 2006
Prisons and Probation Ombudsman
2
Contents
Page
Summary 5
Conduct of the Investigation 6
Background 7
The man 7
HMP Manchester 8
Key Findings 9
3 November 9
4 November 9
5 November 13
Information for prisoners 18
Contact with the man’s next of kin 19
Support for staff 20
Issues considered in the investigation 21
Conclusion 24
Recommendations 25
3
Summary
1 The man was arrested on the morning of 3 November 2005 and held in police
custody overnight. He was a long term user of heroin and, though his medical
condition was not described, the police doctor prescribed painkillers.
2 The man appeared at Salford Magistrates’ Court on 4 November, from where
he was remanded to HMP Manchester. No health problems were reported by
the court or by the escorts to the prison.
3 He went through the usual reception processes, including assessment by a
healthcare assistant and doctor, when he disclosed that he used heroin and
was tested positive for heroin and cocaine. Consequently he was located in I
wing, which is a specialist drug and alcohol detoxification wing. Because he
arrived at the prison on a Friday evening, the doctor did not prescribe
Subutex. The doctor prescribed the same painkillers as the man had received
from the police doctor for three days until the next weekday.
4 The opinions of staff and prisoners vary, and some state that the man showed
signs of ill health when he arrived on the wing. There are also different
accounts of his use of the cell bell overnight. Certainly by the early hours of
the next morning, 5 November, he complained of stomach pains, was
assessed by a nurse and given medication. No record was made of his cell
being opened and no contemporaneous record was made of the nurse’s
assessment. However, it does seem that the medication was sufficient for the
man’s needs at the time.
5 When the man’s cell was unlocked in the morning, he told the officer that he
was still unwell and was reminded that he would be seeing the doctor that
morning as part of his prison induction. Shortly afterwards other prisoners
called to staff to come and help as the man was vomiting. Officers and
healthcare attended promptly, but were limited in what they could do as he
continued to vomit copiously and they had difficulty administering oxygen.
6 The paramedics attended, administered emergency assistance and took the
man to hospital where his death was pronounced at 10:00am.
7 The post mortem states that the man’s death was due to inhalation of vomit,
and that he had a severe degree of gastritis. Prior to this conclusion being
drawn, there was a suspicion in the prison that he might have swallowed
drugs before coming into custody. However, he did not disclose that he had
done so and the post mortem finds no evidence of it.
4
Conduct of the Investigation
8 The cause of death was initially unclear and so my investigators opened the
investigation on the premise that it might not be due to natural causes. The
investigation began on 11 November 2005 with a visit to HMP Manchester.
My team leader met the Governor, Deputy Governor, and representatives
from the Independent Monitoring Board and Prison Officers’ Association.
Notices were displayed to announce the investigation and invite prisoners and
staff to contact the investigator. The man’s prison and medical records were
collected.
9 A Clinical Review was commissioned from North Manchester Primary Care
Trust and was carried out by a lady there.
10 Following the initial visit, 14 discipline and medical staff were interviewed on
28 and 29 November and another four staff were interviewed on 14
December. Those interviewed were either responsible for the man’s
reception and induction to the prison, or involved when he was found ill in his
cell during the night and the next morning. The lady from North Manchester
Primary Care Trust accompanied my investigator during some of the
interviews held with healthcare staff. Transcripts of the interviews are
included in the annexes to this report.
11 Informal conversations took place with three of the prisoners who were on I
Wing and knew the man.
12 Prison records, including medical records, were also made available together
with relevant prison policies and procedures.
13 One of my office’s Family Liaison Officers has had telephone contact with the
man’s partner and other members of his family. His partner raised some
concerns:
(cid:127) that his cellmate alleged that the cell bell was rung for about ten hours
without any assistance being provided
(cid:127) when he was seen at the Chapel of Rest, there was a lump on his
forehead which his cellmate said was not present when he left the cell
(cid:127) The man’s clothes were washed before they were returned although she
had not been asked whether this was what she wanted.
My Family Liaison Officer and one of the investigators visited the man’s
brother and sister. They too have asked questions:
(cid:127) what condition was the man in when he was at the police station
(cid:127) what time he arrived at the prison
(cid:127) whether he saw a doctor at the prison
(cid:127) whether he was located on a drug free wing
(cid:127) what happened during the night, whether the bell was rung repeatedly and
how staff responded
(cid:127) how the man came to have a lump on his forehead.
5
Background
14 The man was born in January 1967 and was 38 years old when he died. He
lived in Salford with his partner and her children. He had three children from a
previous relationship. He had a sister and brother who live nearby, and who
met the investigator and Family Liaison Officer. His mother lives in Denmark.
15 This was not the man’s first time in prison. He had a long-standing history of
drug misuse and criminal convictions, which led to him frequently serving
short sentences in prison. On 3 November 2005, he was arrested on
suspicion of driving whilst disqualified and held in police custody until 4
November. Bail was refused due to his previous record, and his solicitor said
that he was held in police custody for such a long period because the papers
were not ready for his court appearance. The man eventually appeared in
court on 4 November, from where he was remanded to HMP Manchester until
11 November.
6
HMP Manchester
16 HMP Manchester is both a local prison that accepts people straight from
courts in Greater Manchester, and a high security prison for prisoners from all
over the country. Following a major disturbance in 1990, the prison was re-
built and the management of the prison was put out to tender. The Prison
Service won the contract and the prison was re-opened in 1994. In early
2003 Manchester became part of the High Security Estate.
17 Accommodation is on two Victorian radial blocks with a mix of single and
double occupancy cells, each with power points and integral sanitation. The
man at the centre of this investigation was located in I wing, which is a drug
treatment unit. Until early 2005, only H wing was used for drug treatment, I
wing being added because of the volume of prisoners needing drug treatment
and in recognition of the special needs of those beginning a detoxification
programme. Staff were recruited and trained to work on the wing. The
training was provided by Manchester Drug Services, who also provide their
own expert staff. Generally the staffing levels are higher than on other wings,
and there are also closer links with healthcare.
18 Healthcare staff are designated to work on I wing. They meet prisoners for
specific reasons, including induction and medication administration, and also
have an open door for prisoners with health concerns. Prisoners remain on
the wing for up to three weeks whilst they receive detoxification medication
and other support. They then move to H wing for four to six weeks’
continuation of their drug treatment programme, and then to another wing.
19 The last full announced inspection of the prison by Her Majesty’s Chief
Inspector of Prisons took place in July 2004. The report states that managers
have taken seriously some of the previous recommendations, and the
inspectors found the prison was a more stable and purposeful environment
than at previous inspections.
20 During the 18 months prior to the man’s death, there were eight deaths at
Manchester, seven of which were self-inflicted. An action plan has been
drawn up resulting from the recommendations made from the investigation
into the death of one of the men, many of which have been achieved. For
example, all staff on I wing are trained by Manchester Drugs Services in drug
awareness and in the use of Subutex, which is used in detoxification
programmes. A further recommendation that all staff involved in an incident
should attend the hot debrief is not always met. In this man’s case, a key
individual who provided healthcare assistance was not present at the debrief.
7
Key Findings
3 November 2005
21 The man was arrested in the morning of 3 November and held in custody at
Swinton police station. His solicitor, who had known him for the previous nine
years, said she thought that his manner and health were unusual. He was
quiet, rather than anxious and agitated, and his pallor was grey. A medical
form was completed at 9:15am. The doctor stated that the man misused
heroin, but that there was no evidence of physical or mental distress. He was
to be observed routinely and no medication was prescribed. At 6:35pm, the
man asked to see the doctor again. The medical form does not include any
details of his condition and states that he “demanded DFs and Diazepam”.
He was prescribed dihydrocodeine, 30mg to be taken every six hours.
Dihydrocodeine (also known as DF118) is provided for the relief of symptoms
associated with the withdrawal from drugs.
4 November 2005
22 The man was taken from the police station to Salford Magistrates’ Court on 4
November. His solicitor explained that the delay was due to problems
completing paperwork in time. From the court he was remanded in custody to
HMP Manchester. He was accompanied by the court’s warrant of
commitment and the records of the escort company, neither of which gave
any indication of health concerns.
23 The first person he met at the prison was a Senior Officer (SO). The standard
reception processes were explained by a second SO, although he was not on
duty when the man arrived. The role of an SO involves identifying each
prisoner and recording their basic information and establishing whether they
are convicted or on remand. Whilst these procedures are carried out, the
second SO said that any prisoners who appear to be injured or unwell are
referred immediately to healthcare. Property and cash are then noted and
prisoners are searched. The search procedure includes a wand and rub
down search, full strip search and shoes and outer garments are x-rayed.
The prison’s drug sniffer dogs are not used in the reception area.
24 Although the second SO did not meet the man on 4 November, he
remembered him from previous periods at the prison, when he worked as a
Drugs Co-ordinator and dealt with mandatory and voluntary drug testing. He
described him as generally looking thin, gaunt and in need of help when he
arrived, and that he always looked healthier when he was released. The
second SO said that during previous periods in the prison, the man had not
signed up for voluntary drug testing and was not subject to mandatory drug
testing either.
25 After the initial interview with the SO, the Cell Sharing Risk Assessment
(CSRA) was begun by a reception officer. In this man’s case, he was
interviewed by a female officer. When she was interviewed for this
investigation, she said that it was her job to make sure that the man was
8
suitable to share a cell. The form enquires whether prisoners have abused
drugs and the female officer confirmed that the man told her that he did. She
had met him on previous admissions and said that, as usual, he was quiet
when he was interviewed. She thought that he was relaxed, and answered
her questions honestly. The female officer did not recall any concerns about
his health, and said that he seemed to be the same as usual and was pale
and quiet. If she had had any concerns, she said that she would have
informed the healthcare staff on duty in reception.
26 After the CSRA interview, prisoners are interviewed by healthcare staff. The
man was seen by a healthcare assistant who does not hold a nursing
qualification. He was working under the supervision of a qualified nurse. The
healthcare assistant recalled meeting the man, and said that the interview
lasted approximately 15 minutes. He said that the man’s main concern was
that he had been held in police custody for two days and was beginning to
experience withdrawal symptoms. The healthcare assistant said that the man
did not say where his pain was coming from, and the healthcare assistant
could not tell from his own observations. He described the man as having
understood what was happening, and that he was co-operative throughout.
He thought that the man had experienced withdrawal symptoms and
detoxification previously, and so would be aware of the symptoms which he
would experience. The CSRA interview does not include enquiries as to
whether prisoners have any drugs on their person, and the healthcare
assistant said that this would only be known if a prisoner disclosed that they
had.
27 The man asked him whether he would be given any medication, and the
healthcare assistant said he told him that he would first have a urine test. The
test result would decide whether he would see a doctor later that day and be
given what is referred to as a “detox welcome dose of medication”. The
healthcare assistant said that the man had difficulty producing a urine sample.
After several attempts, what he produced was insufficient to test so the
healthcare assistant handed him on to another colleague. The specimen he
provided was larger in volume, lighter in colour and clear, which indicated to
the nurses that water had been added to it. The sample tested positive for
heroin and cocaine. The urine test was carried out on 4 November when the
man arrived at the prison, and recorded on the correct urine analysis form.
The information was transferred to his medical record the following day and
the test was dated as 5 November.
28 The healthcare assistant could not recall any other concerns, but said that, as
is his usual practice, he spoke to a qualified member of staff about the
interview. He recorded on the Modified First Reception Healthscreen that the
man had not seen a doctor in the last few months, had no outstanding
medical appointments and was not receiving any prescribed medication. He
noted that the only health related observations of the man’s physical
appearance were that he had “pain due to withdrawal”. The man told the
healthcare assistant that he used heroin and crack cocaine, which was
confirmed by the urine test. The final part of the health screen noted that the
9
man should be referred for detoxification and be admitted to the detoxification
unit (I wing).
29 When my interviewer met the man’s brother and sister, one of their questions
was whether he had gone to a drugs wing. They said that he did not usually
disclose that he used drugs, and so did not usually undergo a detoxification
programme when he was in custody. This is confirmed by the medical
records from a previous sentence. In July 2004, the man denied using any
drugs and was not referred for detoxification. On that occasion he told the
interviewer that there was a family history of heart disease, but he did not
mention it when he spoke to the healthcare assistant.
30 After the interview with the healthcare assistant, the man was interviewed by
a doctor. The medical records note that he felt rough because of the effects
of withdrawal and that detoxification should start. He was prescribed 120mg
of dihydrocodeine elixor for three days. Dihydrocodeine is not a detoxification
but, as noted in paragraph 21 above, is used for symptomatic relief in patients
withdrawing from drugs.
31 Following the doctor’s assessment, the man was interviewed by another
officer who completed the reception procedures by giving him a prison
number, taking photographs and fingerprints and allowing a telephone call.
32 The man was escorted from reception to I wing by the Movements Officer for
the day. Prior to working at Manchester prison, this officer had worked for
GSL, which is the company that provides security for the courts. The officer
said that he had met the man previously when he worked at court, and he
recognised him when escorting him to the wing. He said that the man walked
with the other prisoners up the slope from reception to the wing, and they all
went first to G wing to leave some prisoners there. They then went to I wing
and the officer said that the man went straight upstairs. He noticed that lots of
prisoners crowded round him and that the man was talking to them. The
officer said that he told the man to follow him, and the man said that he was
“just getting my breath”. The officer thought that the man delayed following
him so that he could continue to chat to the other prisoners, and did not see
him struggle or appear unwell. He said that throughout the walk to the wing
the man was quiet and polite.
33 The Movements Officer’s opinion of the man’s wellbeing differs from that of a
prisoner on I wing who talked to one of my investigators. This prisoner said
that he had known the man for about 20 years, and had met him inside and
outside prison. He said that on 4 November he was standing on the 4s
landing of I wing when he saw the man come to the gate, and that he saw
immediately that he did not look his usual self. The prisoner described the
man as holding his stomach, being crunched forward and with glazed eyes.
34 The man arrived on the wing between 7:00 and 8:00pm and a further officer
first saw him talking to other prisoners. He was responsible for allocating cells
to new prisoners and for completing the Cell Sharing Risk Assessment. The
form assessed the man as low risk to himself and others, and suitable for a
10
shared cell. The man asked the further officer where he would be located,
and asked “to go low”, meaning to a cell on one of the lower landings. This is
not an unusual request as food and treatments take place on the lower
landings. The officer told him that there was no room on the first landing, but
there was on the third. The man then went up to the third landing, despite not
having been allocated a cell, and was told to come back down to wait for his
interview. He told the further officer that he did not feel well and was told he
could sit down on the landing to wait for the induction interview. When
interviewed for this investigation, the officer described this man as looking as
though he was withdrawing from drugs, and said that his appearance was not
unusual.
35 The man was then interviewed by a second officer who completed the First
Night Induction interview between 7:00 and 8:00pm. This officer is an
experienced officer who applied to work on I wing when it opened, and was
given a short induction to the specialist work of the wing. He said that the
wing had better staffing levels than most, as the prisoners need more care
and attention, many coming straight from the street and having little family or
community support.
36 The interview provides information about the wing routine, and asks prisoners
what their needs are. It lasted for about ten minutes and took place in the
wing office with the door shut, so that it was confidential. Prisoners are told
that there will be a full interview the next day. The second officer ended the
interview record by noting that the man “looks ill from the effects of drugs” and
that he “states he is ill but will be okay”. The second officer knew the man
when he had been in prison previously. He described him as a pleasant
individual, who did not come across as a drug user, and he was surprised to
see him on I wing. On this occasion, the second officer said that the man told
him he was not well, and felt “rough on the drugs”. He asked if he had seen a
doctor on reception and did not refer him again as, in his opinion, his drug
withdrawal symptoms were average for newly received prisoners. He knew
that the man would receive the Secondary Reception Healthscreen the
following morning.
37 The prisoner on I wing told my investigator that he helped the man to carry his
bedding to cell I.4.7, which is on the top landing of the wing. It is a double cell
and the man shared it with another prisoner. The prisoner on I wing said that
the man went to his cell and lay down. The prisoner on I wing said that some
prisoners told staff then that the man was ill and not fit to be on the wing. He
also said that the man vomited during the evening.
38 The second officer conducted the evening roll check, when all prisoners are
locked in their cells for the night and are accounted for. It took place at
approximately 8:45pm and the second officer said that he had no recollection
of which landing he checked or of anything untoward from the man’s cell.
39 Generally I wing has its own member of staff on duty overnight. On 4
November a regular I wing officer was detailed to work on the wing for the
night. No information about the man was passed from the evening staff to the
11
night staff. Soon after the shift began, the regular I wing officer said he was
told that the healthcare centre was short staffed and so he and the H wing
officer would have to cover both H and I wings whilst the other went to
healthcare. The regular I wing officer staffed the wings first and arranged with
the H wing officer that they would swap over at about 1:30am.
40 The cells in I wing all have bells to enable prisoners to summon assistance.
The bells sound throughout the wing and also show up on a board in the wing
office. They are cancelled from outside the cell. I understand that at night
time the bells are audible from all the wings in that part of the prison, and that
officers routinely look across the landing to see which wing it comes from. I
am also told that the direction of the sound of the bells is indistinct and, for
example, one bell ringing on 12 occasions would sound the same as 12 bells
being rung separately. The cell bell system does not provide an electronic
record of bells being rung, and there is no routine for recording them in the
prisoner’s history sheet or the wing observation book, even when it is rung for
exceptional circumstances.
5 November 2005
41 The regular I wing officer said that he spent most of the night in the wing
office, occasionally going to H wing. He worked on the computer, had a drink
and attended to the bells which rang, which he said were prisoners asking for
their night lights to be turned off. At about 1:25am the regular I wing officer
said that the bell for cell I.4.7 rang. He went to the door and opened the
observation flap to see the man’s cellmate in the toilet area and the man
himself on the top bunk. The regular I wing officer said that the man told him
that he had “pains in his guts” and, as he was shortly due to go to healthcare,
he said he would go and report it to healthcare staff. He described the man
as sitting up and holding his stomach. He said that he “was lucid, seemed to
be okay and looked better than a lot of prisoners who were detoxing”. He also
said that there was no sign that the man had vomited. At this point, the
regular I wing officer said that the H wing officer arrived, and so he went to
healthcare and passed the message to a male nurse there. He said that the
H wing officer telephoned healthcare too as the cell bell had been rung again.
42 The prisoner’s cellmate was released before this investigation began and he
has not replied to my investigator’s letter. Before his release, he made an
application to see a probation officer and the application form has been made
available to the investigation team. In it, the cellmate describes the night he
spent in the same cell with this man, referring to the respect which the man
showed him and to his own distress at spending the night with someone who
was in pain and who quickly died.
43 The prisoner on I wing told my investigator that the man’s cell bell rang for
long periods of time throughout the night, that an officer came, and then
medical staff, and it still continued to be rung. Another prisoner also stated
that he heard the bell at 3:00am and an officer said that “nothing could be
done overnight” and was abusive about prisoners ringing their bells.
12
44 The H wing officer told the investigation team that it is not usual for a lot of
bells to be rung, but that it was a busy week and they were being rung non-
stop. He said that he worked the first part of the night in healthcare, and then
went to I and H wing to relieve the regular I wing officer. When he got there
he said that the regular I wing officer heard the bell from I.4.7 and went
upstairs. The H wing officer went to the door and opened the observation
flap. He saw the man standing up and asked if it was a medical emergency.
The man replied that he had pains in his stomach and wanted some
Gaviscon, a medication for indigestion. The H wing officer said that he
shouted to the K and G wing officers to telephone for assistance.
45 As well as the officers on duty on the wings through the night, the prison is
staffed by a principal officer and a senior officer, Oscars 1 and 2 respectively.
On the night of 3 / 4 November, Oscar 1 was based in the bottom part of the
prison. He was assisted by the Oscar 2. The Oscar 2r was interviewed for
this investigation. Shortly before the man’s death she had changed job and
gone to work for the Security Department. Previously she had worked in the
Control Room, and she was familiar with the Oscar 2 night duties. She spent
the night checking that staff were doing what they were supposed to be doing,
making sure that prisoners requiring closer monitoring were being attended to,
and dealing with any eventualities.
46 At about 2:15am, the Oscar 2 said that she was in healthcare when a
telephone call was received concerning the man. The message was that a
prisoner was being sick on I wing and requested the healthcare officer on
duty, Hotel 1, to go and look at him. This request was not recorded in the
Control Room log, the wing observation book or any other prison record. It
was entered in the man’s medical record, but regrettably this was not done
contemporaneously and was only written up the following night after the
man’s death.
47 A male nurse was Hotel 1 that night. Oscar 2 said that the male nurse got the
medical record and was aware that he had a positive drug test. Oscar 2 used
her radio to inform the Control Room that they were moving through the
prison and, together with the male nurse and the dog handlers, they went to
cell I.4.7.
48 Oscar 2 said that she looked through the observation flap and saw the man
sitting on the top bunk with his legs swung over the side. She said that he
was very polite and apologetic, and she told him not to worry. The cell was
unlocked and the male nurse went in whilst she remained at the door, in sight
and earshot of the conversation. She heard the man tell this nurse that he
had pains in his stomach and had not eaten since Wednesday. He was told
that the pains were due to withdrawal from drugs and would be worsened
because he had not eaten. Oscar 2 said that the male nurse gave the man
some medication and his cell mate got him some water. She thought that the
exchange took about five minutes, at the end of which she said that the man
was told to ring the bell again if there were any more problems. She said that,
in her non medical opinion, the treatment given to the man was appropriate.
Had she been concerned otherwise, she would have ensured that further
13
steps were taken. It was Oscar 2’s opinion that the man would not have been
so polite and amenable if he had been ringing the cell bell before.
49 The male nurse has worked at Manchester prison for over a year, initially as
an agency nurse and then for the Prison Service. He regularly works nights,
dealing with emergencies and preparing paperwork for the following day, and
also regularly works as Hotel 1. The shift begins at 7:45pm and ends at
6:45am. The nurse also described the night of 4/5 November as extremely
busy, particularly because no staff had been provided to monitor the gated
cell in the healthcare centre. He said that the shift began badly because the
computer system had failed and so he was initially unable to prepare the
records for the following day, a task which he said usually took three to four
hours.
50 At about 2:30am the male nurse said that he was called to I wing, because
the regular I wing officer said a prisoner was complaining of stomach pain.
He went to the wing and, when he got to the cell, the man was sitting on the
top bunk with his legs dangling over the side. He said that the man was
conversational and there were no visible signs or symptoms. He had a good
colour, there was no evidence of pain and he was not sweating. The man told
him that he had stomach cramps and had not eaten for two days. The male
nurse had been told that the man had vomited, and asked him about it. The
man told him that he had not been sick. The male nurse gave his patient
Gaviscon tablets, saw him take them with water and told him to ring the bell if
he had any more pain and to go to Treatments in the morning.
51 The male nurse did not examine the man or take any general observations of
his pulse, blood pressure, temperature or breathing as he did not think that his
condition warranted them. He said that he thought there were two possible
explanations for the pain: either that the man was withdrawing from drugs or
he had excess stomach acid. Had he thought that there were other
explanations, he said that he would either have carried out more observations
or arranged for the man to be admitted to hospital. He did not ask, and the
man did not disclose, whether swallowing drugs could be an explanation for
his symptoms.
52 The male nurse said that the man’s cellmate was present throughout the time
that he spent in the cell, and that he did not say anything about the man or his
condition.
53 After assessing the man, the male nurse said that he returned to the
healthcare centre where he completed the work on the computer and went off
duty without hearing any more about him. The nurse said that he realised he
had omitted to record his assessment when he returned to duty that evening
and heard of the man’s death. He said that he advised his manager of his
error and then completed the entry in the medical record.
54 The H wing officer was present whilst the man’s cell was opened and
remained on H and I wing for the rest of the night. He carried out the morning
roll check between 5:15 and 5:30am when he saw the man on the mattress
14
on the floor. The H wing officer said that he spoke to the man to ask how he
was, and the man sat up and said that the indigestion was alright. He did not
ring his bell again during the night and the H wing officer went off duty
between 6:45 and 7:00am.
55 Two further officers started first on 5 November, and took over from the H
wing officer. Both said that the handover was brief and there was no
information about any prisoners being unlocked during the night, or of any
other concerns. One of the further officers carried out the morning count at
about 6:40am and saw the man lying on the mattress on the floor. He said
that this was not unusual, especially for prisoners who are withdrawing from
drugs, as prisoners seem to find it more comfortable. The other of the two
further officers said that he also checked prisoners, beginning with any new
prisoners and those at risk of harming themselves. The officer who
completed the First Night Induction was also on duty in the morning and said
that, to his knowledge, no information about the man was handed over from
the night staff and he was unaware that he had been attended to by
healthcare staff during the night.
56 The first prisoners to be unlocked in the morning are those who are due to
attend at the treatments room to receive medication. The man’s cellmate was
one of those and cell I.4.7 was unlocked by one of the further officers at about
8:00am. When the cell was unlocked, the cellmate left without saying
anything to the officer, either about himself or the man. The man was lying on
his stomach on his mattress on the floor, and told the officer that he was too ill
to go down for treatments. This officer thought that he looked ill, but when he
checked the treatments list the man’s name was not on it. He called down
over the landing to check and then told the man that he was due to be seen
later in the morning by the doctor. The man said that that was alright. The
officer then continued unlocking the other cells and then remained on the
landing for about ten minutes whilst prisoners returned from treatments. He
said that he was a short distance from the man’s cell and was in earshot
throughout and did not hear anything either from the man or from other
prisoners. He did not consider getting earlier medical attention as he knew
that the doctor would be on the wing within the next hour or so.
57 The above officer returned to the office at about 8:30am to carry on with other
duties, and then went back to the landing to unlock prisoners for association.
He again unlocked cell 1.4.7 and saw the man and his cellmate, who were
unchanged from when he had seen them earlier. He returned to the office
and met a female nurse as she came on duty. The officer said that he told the
female nurse the man was not well and asked her to have a look at him. The
female nurse told him that she would be seeing the man as part of his
induction.
58 The prisoner on I wing told the investigation team that, after the prisoners
were unlocked, the man’s cellmate told him that the man had been ill all night.
The prisoner on I wing went to see him, and he said that the man was lying on
the floor on his mattress and there was vomit on the floor of the cell. The man
got up to go to the toilet, but slumped forward, and the I wing prisoner caught
15
him and put him on to the bed. He started to vomit again, with what the I wing
prisoner described as looking like blood, and so he supported him so that he
would not fall forwards and choke. He remained in this position until other
prisoners alerted staff who came and one of them, the officer responsible for
allocating cells, took his place.
59 One of the two further officers first heard the shouts from prisoners on the
fourth landing at 8:50am, about ten or fifteen minutes after he spoke to the
female nurse. He and the officer responsible for allocating cells ran up to the
cell. He saw that the man was back on the bed, leaning over the floor which
was covered with what he described as a dark brown liquid and first thought
was blood. He immediately shouted down the landing to the female nurse,
and then a second female nurse also arrived and so he left the cell. One of
the two further officers remained in the vicinity in case he could assist, and got
towels to soak up the liquid from the floor and landing.
60 The female nurse had gone to I wing at about 8:00am in order to begin
administering medication and to see the new prisoners for their secondary
healthscreen. She said that she spent about an hour giving treatments and
attending to a specific prisoner, before going to I wing to begin the induction
interviews. As the man was one of the new prisoners, the female nurse had
his medical record with her. It contained the First Reception Healthscreen
completed the previous day. When she arrived on the wing, she said another
prisoner told her that the man was unwell and she replied that she would see
him shortly. At this time, the female nurse was unaware that the man had
been attended to by one of her colleagues during the night. The information
had not been handed over to her and there was no entry in his medical
record.
61 The female nurse went to put her records in the office and heard the shouts
from prisoners on the fourth landing. She saw the officers run upstairs and
thought that she would go to help. She arrived at the cell and saw the vomit
on the floor and that the man was on the bed and vomiting. She realised that
he was unwell and told him that she was going to get some medication to stop
him being sick. She said that he nodded his head in reply.
62 The female nurse left the officers in the cell with the man and went along the
landing to telephone healthcare. She spoke to a second female nurse and
asked her to bring some Stemetil to the wing. The female nurse returned to
the cell and saw that the man was on the floor, still vomiting, and had
deteriorated in the three minutes that she estimates she was away. She
checked his pulse and breathing, put him in the recovery position and at
8:56am asked for Hotel 1, the nurse on duty, to be called and for an
ambulance. She also asked the officer responsible for allocating cells to
collect the emergency bag which contained oxygen. The request for the
ambulance was made by the other of the two further officers who used his
radio to contact the control room. By this time, 8:56am, other officers were
returning prisoners to their cells and the man’s cellmate was placed with two
other prisoners.
16
63 The radio request for urgent assistance was also responded to by a prison
officer, who was the Oscar 1 in charge of the day to day running of the prison
and reporting to the duty governor. The prison officer was promoted to this
position in March 2005, and had not had any specific training in responding to
deaths in custody although he was familiar with the prison’s plans for dealing
with such events. He was on duty the previous evening and had seen the
man when he was in reception. At the time he had not thought that the man
was ill. He had noticed him talking to staff and thought that he had a friendly
manner. When the prison officer arrived at work in the morning, he did not
receive a handover of overnight events and was unaware that the man had
been seen by healthcare staff, which was not recorded anywhere. The duty
governor confirmed that he too had no information about the man’s condition
or that he had been attended to during the night.
64 The prison officer was in another part of the prison with another officer when
the alarm was raised and they set off towards I wing, meeting the second
female nurse who was also on her way. When the female nurse asked for
medical assistance, Hotel 1 was already occupied with another emergency
and so the second female nurse, realising the demands on her colleague,
attended instead. By the time she arrived at 8:57am, the female nurse had
managed to put an oxygen mask on the man. The two staff attempted to
insert an airway to assist his breathing but found it difficult because he
continued to vomit. By this time they both had soiled clothes, the cell floor
was covered in liquid and the other officer and the officers attempted to soak
up the fluid. They remained at the door in case other assistance was needed.
The prison officer recognised that it was turning into a serious occurrence and
started to log events at 9:12am.
65 The female nurse and the second female nurse continued to attempt to insert
an airway and were successful, and the second female nurse began cardiac
chest compressions at 9:08am. The ambulance arrived at the prison at
9:06am and the paramedics reached the cell at approximately 9:12am, where
they took over the man’s treatment. The duty governor arrived at the cell at
about the same time. The female nurse provided the paramedics with
information from the man’s medical records and they strapped him to a chair
to carry him down off the landing to the waiting ambulance at 9:24am. The
prison officer escorted the ambulance out of the prison which left at 9:35am.
He then returned to the wing to check on staff and prisoners. The female
nurse told the investigation team that she then continued with her regular
duties, and both she and the second nurse wore their soiled clothes until
going off duty at the end of the day.
66 One of the duty chaplains also responded to the radio messages about the
man’s deteriorating condition. He was on G wing at the time interviewing new
prisoners, and made his way to I wing where he found out the man’s name
and that he had said that he was a Muslim. This chaplain contacted the other
duty chaplain, an Imam, to tell him about the man. By the time the Imam
arrived, the man had been taken to hospital and so they did not actually meet.
17
67 The governor, who was in charge of the establishment, was in the control
room and monitored the incident from there. He watched the ambulance
leave the prison at 9.40am, taking the man to hospital. The police were
informed of the possibility of a death in custody. The man’s death was
pronounced at 10:00am and the police were asked to attend the prison, which
they did at 11:15am.
68 The post mortem found that the man died from natural causes: the inhalation
of vomit due to a severe degree of gastritis.
Information for prisoners
69 By the time the man was taken to hospital, other prisoners on the wing had
been returned to their cells and were not having association. Officers who
were interviewed for the investigation said that they were not asked to give
out information about the man’s health and subsequent death, but to respond
to any questions. The officer who completed the First Night Induction said
that he told prisoners later in the day, after the man’s death was confirmed.
The prisoner on I wing told the investigator he was told about the man’s death
by another prisoner, who was a wing cleaner, at tea time.
70 Those prisoners considered to be at risk of harming themselves were checked
by staff, and the man’s cellmate was spoken to by an officer and the Imam
who checked on his wellbeing. There were no special arrangements for any
prisoners who were friends with the man, and no checks were made to find
out who they might be.
71 The prison officer said that he and the duty governor discussed whether to put
a notice up to inform prisoners of the man’s death. They decided not to do so
until the notice about the Ombudsman’s investigation was published.
Contact with the man’s next of kin
72 The man had named his partner as his next of kin, and it was she who was
initially told that he had been admitted to hospital. The prison’s plan for
dealing with deaths in custody identifies the police as responsible for
providing the initial information for the next of kin, and they contacted the
man’s partner in person at 10:29am after he had been taken to hospital. The
governor, who was in charge of the establishment, said that the police were
asked to visit as they had local knowledge of the area and could get to the
home more quickly.
73 The man’s partner told his brother and sister what had happened and they all
went to the hospital. The man’s brother telephoned the prison to ask for more
information and was told that, as he had not been named by the man himself,
the information could not be passed on. His brother said that he understood
why this was the case and said that he was spoken to kindly.
74 The first duty chaplain was also involved in liaising with the man’s next of kin.
The man’s partner telephoned the prison to speak to him and he learnt that,
18
although the man had said he was Muslim, he had actually been baptised as
a Roman Catholic fairly recently. Later at about 3:00pm the first duty chaplain
and the governor who was in charge of the establishment visited her at her
home, after she had been to the hospital. She said that the man had had an
upset stomach a few days previously and had had similar symptoms. His
partner provided contact information for the man’s family and said that they
would be arranging the funeral.
75 The man’s partner visited the prison at 4:00pm on 6 November after the cell
had been released by the police and it had been cleaned. She was escorted
by the governor who was in charge of the establishment and they went to the
cell where she laid some flowers and spoke to the man’s cellmate. The man’s
belongings were handed to her as she left the prison. Unfortunately, no-one
from the prison asked her how she would like his clothes to be returned, and
they were washed without her agreement. In future the prison’s Family
Liaison Officer may find it helpful to find out beforehand whether the clothes
should be washed or not.
76 The chaplain subsequently spoke to the man’s brother and sister and met
them later in the week to discuss the funeral arrangements including the
prison’s payment of expenses. The man’s brother and sister hope to come
into the prison to meet the prisoner on I wing, but as yet the visit has not taken
place.
77 Both the man’s partner and his siblings have enquired about the bruise on his
forehead, but I have been unable to ascertain how or when it was caused.
The pathologist has explained that it occurred shortly before the man’s death,
which was when he staggered in the cell, moved position and was caught on
one occasion by the prisoner on I wing.
Support for staff
78 By the time the prison officer returned to I wing, he said that a member of the
staff care team was also there and offering support to staff. A debrief meeting
took place later in the day. It was attended by most of the staff involved, other
than the female nurse and the other of the two further officers, and the
support of the staff care team was offered. The meeting reviewed the actions
by staff once the man’s condition was made known. It did not consider events
of the previous night or the absence of information about his condition during
the night.
79 Because the female nurse was being interviewed by the police when the
debrief meeting took place, and because she states that she is not provided
with regular, individual line management support, the interview for this
investigation was the first time that she had had the opportunity to discuss the
care she gave to the man and any learning from his death.
19
Issues considered during the investigation
Detoxification arrangements during the week and at the weekend
80 The prison has introduced a drug detoxification programme which uses
Subutex. This is a once daily, slow release medication which is prescribed
after checks have been made with a prisoner’s community prescriber. It is
said to be more controlled and prisoners have fewer symptoms. Because the
community prescribers are not available at the weekend, prisoners who arrive
at the weekend or on a Bank Holiday are prescribed DF118 which relieves
their symptoms and makes them drowsy, which is what was arranged for the
man.
81 There is no suggestion that the different arrangements for the week days and
weekends had a bearing on the man’s death, but nevertheless I suggest that
all avenues are explored to ensure that the most appropriate treatment is
available, regardless of the day that a prisoner arrives. The use of DF118 for
heroin detoxification is no longer in line with practice in most prisons and is
not favoured by my office. DF118 is not licensed for detoxification but may be
used for symptomatic relief.
Information for staff and prisoners about swallowing illegal substances
82 Although the post mortem states that the man died due to natural causes,
there was an early suspicion at the prison that his death might have been
attributed to swallowing illegal substances prior to coming into custody, and
so I consider the matter here. The prison has provided information that, in the
previous 12 months, there were no such incidents.
83 Staff interviewed confirm that there is no standard routine for making such
enquiries and no information or publicity available for prisoners. The incidents
which have become known have only come to the attention of staff when a
prisoner has disclosed, and then urgent hospital attention has been arranged.
It would seem sensible for information to be available to all prisoners about
the risks from swallowing such substances and the steps they should take if
they are concerned.
Recording of healthcare interventions
84 There were two events which were not recorded accurately by healthcare
staff. First the man’s medical record states that his urine was tested on 5
November. It was actually tested the previous day on his arrival at the prison
but was not recorded until the next morning. Whilst not significant to this
investigation, it is confusing. Secondly, and more importantly, there was no
contemporaneous record of the nursing interventions provided during the
early hours of 5 November and the record was made after the man’s death.
This is particularly concerning as standards for professional practice require
patient records to be written as soon as possible after an event, providing
current information on the care and condition to be recorded.
20
Records of bells
85 The cell bell system at Manchester prison does not provide an electronic
record of bells being rung and no manual record is made either. I have made
recommendations about the bells in previous reports.
86 It would not be practical or proportionate to suggest that a record be kept
each time a bell is rung. Information from officers interviewed for this
investigation is that during the week of the man’s death the bells were rung
frequently. This was described as unusual, and the investigators were told
that generally prisoners only made appropriate use of their bells. Those who
used them inappropriately would be warned about their conduct, others would
ring them to have the night light turned off or for a medical emergency.
87 With this in mind, I am surprised and concerned that a record was not made in
the wing observation book that the man had rung his bell, especially as in the
event he had required the cell to be opened and nursing intervention. I
recommend that the Governor consider when the use of a cell bell should be
recorded, and advise that this should certainly happen if it leads to a prisoner
being unlocked during the night.
Record of prisoners who are unlocked during the night
88 As well as my concern about the delay in completing the medical record
during the night of 5 November, I am also concerned that neither Control staff,
nor Oscar 1 nor 2, nor the dog handlers nor wing staff recorded that the man’s
cell was unlocked whilst the prison was in a patrol state. Indeed, the only
record of the unlock was the belated entry in the medical record. This is
contrary to good practice and to prison policy and the Governor should remind
all staff of the importance of timely and accurate recording.
89 Not only does this mean that the record is inaccurate, but it reduces the
possibility of proper handovers of information. In this man’s case none of the
staff on duty in the morning, from the duty governor down, were aware that he
was treated during the night. I recommend that the Governor remind staff of
the importance of full handovers of information between day and night staff.
Quality of healthcare provided for the man during the night of 5 November
90 The clinical reviewer states that the nursing interventions during the night
were appropriate given the information available from the man’s records and
the lack of extreme symptoms. The treatment offered was on the prison’s list
of discretionary medicines and was known to the man himself. However the
clinical reviewer recommends that basic observations of pulse, respiration,
blood pressure and pulse are made whenever a prisoner is assessed by a
nurse during the night. Furthermore, I believe that a physical examination of
the man would have enabled a diagnosis of an acute abdomen to be
confirmed or excluded.
21
91 The clinical reviewer has confirmed that staff were working under pressure in
healthcare that night, and this was aggravated by the absence of the officer to
watch the prisoner in the gated cell. The reviewer makes recommendations
about the administrative duties required of nursing staff, which I endorse.
Protective clothing or spare uniforms
91 By all accounts there was a lot of vomit on the man’s clothes, those of the
staff who attended to him and within the cell and landing area. This meant
that the nursing staff had to work for the rest of the day in soiled clothing. The
matter was raised at the staff de-brief and has been raised in similar situations
previously. I recommend that the Governor ensures that staff are provided
with fresh clothing after dealing with any such incident.
Information for prisoners
92 The prisoner on I wing was not alone amongst the prisoners who were spoken
to in saying that he would have appreciated some information about the man’s
health and subsequent death. He had known the man for two decades, had
supported him at the beginning of the emergency and had witnessed a
distressing scene. It is essential that prisoners are given appropriate
information in a timely and appropriate manner, to stop potential
misinformation being passed to families or the media and speculation
amongst prisoners which can lead to mistrust and prisoners feeling
unsupported. I recommend that the Governor agrees and publishes guidance
for managers on informing prisoners about the death of one of their peers in a
timely manner.
Support for staff
93 The majority of staff were positive about the support they received, with the
exception of the female nurse. She did not attend the debrief meeting as she
was being interviewed by the police, and has not had the opportunity of
individual supervision to enable her to evaluate the events of 5 November.
22
Conclusion
94 The man was experiencing what appeared to be detoxification symptoms
when he was first arrested and then when he arrived at Manchester prison.
The induction procedures confirmed his drug use and he was prescribed the
usual medication provided at the weekend. He was located in a specialist
drug and alcohol detoxification wing where officers and healthcare staff work
closely together and I have been impressed with the co-ordination and
respect between them.
95 He complained during his first night of stomach pains and was treated by a
healthcare nurse for indigestion. The next morning the man’s condition
deteriorated and, despite prompt attention from wing staff, healthcare and the
paramedics, sadly he was pronounced dead at 10.00 am.
96 The man’s death is now known to be due to natural causes. In the course of
my investigation I have identified a number of matters which the Governor and
Primary Care Trust should address. These concern the detoxification
prescribing at the weekend, information about swallowing illegal substances
and the records of the night time interventions provided for the man. I also
identify issues regarding the records of night time cell bell use, spare uniforms
for staff, information for prisoners and support for staff following the death of a
prisoner. The clinical reviewer makes additional recommendations regarding
the doctor’s omissions on the First Reception Healthscreen, and the
administrative tasks required of nurses working at night, which I endorse.
23
Recommendations
Prison
1 The Governor and Primary Care Trust should together provide information
for all prisoners about the risk of swallowing illegal substances and the
action to be taken if they are concerned.
2 The Governor and Primary Care Trust should remind all staff who
attended the man during the early hours of 5 November of their
responsibility to record their actions in accordance with the requirements
of the professional bodies.
3 The Governor should consider how the use of cell bells at night time
should be recorded, and implement whatever system he decides is
suitable.
4 The Governor should arrange for replacement clothing to be provided for
staff whose uniforms become contaminated in the course of their work.
5 The Governor agrees and publishes guidance for managers on informing
prisoners about the death of one of their peers in a timely manner.
6 The Governor and Primary Care Trust should ensure that support is
provided for all staff, including those who are unable to attend the debrief.
Primary Care Trust
7 The Primary Care Trust should ensure that the quality of detoxification
arrangements is the same regardless of whether prisoners arrive during
the week day or weekend.
8 Doctors should ensure that they complete all relevant sections of the First
Reception Healthscreen.
9 The date of urine tests should be recorded accurately.
10 Nurses attending to prisoners at night time should routinely include the
recording of temperature, pulse, respiration and blood pressure in their
observations.
11 All nursing and support staff should be aware of the symptoms likely to be
experienced by prisoners who use drugs.
12 The head of healthcare should review the administrative tasks required of
nurses on night duty, and explore alternative arrangements.
24