Individual at Wormwood Scrubs

Investigation into the circumstances surrounding the
death of a man in custody of HMP Wormwood Scrubs, in
September 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2009
This is a report into the death of a man at HMP Wormwood Scrubs in September
2008. The post mortem showed that he died of a heart attack. He had been in
custody on remand for just one month, and it was his first time in prison. .
I offer my sincere condolences to his family for their loss. One of my Family Liaison
Officers, liaised with the man’s parents throughout the investigation process.
The investigation was led by my one of my investigators. I must thank the local
Primary Care Trust for appointing the clinical reviewer. I am also grateful to the
Governor and staff of HMP Wormwood Scrubs, especially the liaison officer, whose
assistance was greatly appreciated by my colleague.
As with all deaths from natural causes, the findings of the clinical review play critical
part in my report. The reviewer, judges that the man should have received greater
care whilst at HMP Wormwood Scrubs. I am particularly concerned about the
emergency procedures.
I make ten recommendations concerning emergency response and first on scene
protocol, chest pain protocol, cardio pulmonary resuscitation (CPR) training, the level
of nursing cover, the standard of record keeping and the protocol following a death in
custody. I am disappointed to have to repeat recommendations about matters upon
which I have previously reported at Wormwood Scrubs
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2009
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CONTENTS
Summary
The Investigation Process
HMP Wormwood Scrubs
Key Findings
Issues
Recommendations
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SUMMARY
At the time of his death in September 2008, the man was on remand and had been
at HMP Wormwood Scrubs since 20 August. He was next due in court in
September.
On arrival at Wormwood Scrubs, the man had an initial first health screen
assessment. It confirmed that he was on prescribed medication for depression and
anxiety: Mirtazapine (an antidepressant) and Quetiapine (an antipsychotic). The
man said that he had seen his doctor recently for a cholesterol count. He also said
he was a smoker but did not use drugs.
The man was seen by the Mental Health Inreach Team in August. He said he was
not anxious and had no thoughts of suicide. In September, he was seen in
Healthcare because he had complained of chest pain but he refused to go to the
local hospital. However, his blood pressure was taken and an electrocardiograph (to
identify abnormal heart rhythms) was undertaken. The results of these tests were
recorded as normal. He was assessed as being fit for light exercise and
employment as a painter.
A week later the man was seen again in Healthcare because he was passing blood
in his stool. A referral was made to the Gastroenterology Department at the local
hospital for further tests. He was seen by the doctor on 11 September because he
felt agitated. As a result his medication was increased just for that day. He spoke to
his parents on the telephone the following day and told them that he had not yet
been for his hospital appointment.
At approximately 8.00pm on Sunday, the man’s cell mate, rang the cell bell as he
had heard him making strange noises. The first officer answered the cell bell and
was told by the cell mate that the man was having problems breathing. The officer
saw the man lying on his bed. The officer went to the office and telephoned the
control room to ask for the assistance of a nurse. The call was not transmitted as an
emergency.
The second nurse found that the man was unconscious and not breathing. The
officer and the nurse, with the assistance of the cell mate, moved him on to the cell
floor. The nurse began cardio pulmonary resuscitation (CPR). Other officers soon
arrived and assisted with CPR.
The call was made for an ambulance with the detail given that there had been a
suicide attempt by hanging. Whilst this information was wholly inaccurate, it was not
critical and did ensure that the 999 call was made.
The first paramedic arrived at Wormwood Scrubs when CPR was being delivered by
prison staff. The paramedic raised concerns over the effectiveness of the airway
management technique being undertaken. The ambulance crew arrived at
Wormwood Scrubs 15 minutes later and assessed that the man had died. He was
pronounced dead by a doctor at 9.08pm. The post mortem shows that the cause of
death was a heart attack.
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There are several key issues arising out of this investigation. According to the
clinical reviewer, the care that the man received was not equivalent to that expected
in the community. Nor were medical records maintained to the required standard.
There is also concern about the emergency response and chest pain protocol.
Wormwood Scrubs has also not followed the protocol outlined in Prison Service
Order 2710, Follow up to deaths in custody, in respect of family liaison and holding a
debrief for staff after a death has occurred.
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THE INVESTIGATION PROCESS
1. One of my investigator, visited Wormwood Scrubs and spoke to staff who knew
the man. My investigator interviewed four members of staff and one prisoner.
Notices were posted to staff and prisoners about the investigation inviting
contributions, but no one came forward as a result. In addition, my investigator
studied all relevant prison records relating to the man. They included his main
prison record, medical records and statements made by staff. My investigator
also saw inside the man’s cell.
2. The local Primary Care Trust carried out a review of the man’s clinical care. I
am grateful to the clinical reviewer for undertaking this review which was
delivered in accordance with my timescales. My investigator discussed aspects
of the man’s treatment with both healthcare staff at Wormwood Scrubs and with
the clinical reviewer.
3. My investigator liaised with London Ambulance Service to obtain information
from their patient record about the CPR techniques being used by staff at
Wormwood Scrubs.
4. As part of the investigation, my investigator attempted to interview the first nurse.
The nurse supplied by Mayday Nursing Healthcare PLC.) Despite several
attempts made through the agency, no contact has been made and no interview
has taken place.
5. My investigator contacted Her Majesty’s Coroner for North London, to inform
them of the nature and scope of my investigation and to request a copy of the
Post Mortem report. Upon completion, my report will be sent to HM Coroner to
assist in her enquiries into the man’s death.
6. One of my family liaison officers, was in contact with the man’s parents
throughout the investigation. His parents raised concerns about the level of
healthcare he received, in particular his treatment for high cholesterol and
changes to his medication for depression. They were concerned about what
caused his high blood pressure and whether the change in his medication was a
contributing factor. They wished to find out why his hospital appointment in
September had been cancelled and the reason given for the delay. His mother
had spoken to him in September. She was concerned as to what treatment he
received as he had told her he was suffering from chest pains. The man’s
parents were deeply concerned and frustrated that there was no point of contact
and no one to speak to at the prison regarding their concerns about their son’s
health.
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HMP WORMWOOD SCRUBS
7. Wormwood Scrubs is a local prison that accepts all suitable male prisoners over
the age of 21 from the courts in its catchment area. The establishment has five
main wings and a number of smaller dedicated units. A and B wings manage
both remand and sentenced prisoners. C wing manages prisoners on the
Intensive Drug Treatment System that offers enhanced support for offenders
with substance misuse problems.
8. Her Majesty’s Chief Inspector of Prisons, conducted a full unannounced
inspection of Wormwood Scrubs between 9 and 13 June 2008. The report of the
inspection includes the following comments:
“Wormwood Scrubs, like many other large local prisons, operated under
considerable pressure. It was taking in around 300 prisoners a week, and
over the previous 12 days had received 240 men new to the prison, often
arriving late. Shortage of staff created further pressure.
“Health services were on special measures as part of a primary care trust
improvement plan. There had been recent investment in the services,
including a major training programme for staff, but no recent health needs
assessment. Clinical governance arrangements were improving, but policies
were not up to date and clinical records were poorly stored.
“One in five hospital appointments had been cancelled in the previous two
months because of lack of staff escorts; this included some cancelled at least
twice. We were not confident that prisoners’ clinical needs were considered
when appointments were cancelled.
“Clinical records were stored on unsuitable filing racks. Although there was a
tracer system, we failed to locate several sets of notes. This appeared to
contradict the NHS Code of Practice for records management.
“The wing treatment rooms were staffed throughout the core day and
evening. Staff operated an open door policy, and we observed some good
interactions between health professionals and prisoners. There were no
policies to ensure the efficient sharing of relevant health and social care
information.”
9. There are three nurses on duty during the night. One nurse is dedicated to the
healthcare unit, another is dedicated to the substance misuse unit, and the final
nurse provides cover for the remainder of the prison population.
10. As part of the Local Suicide Prevention Strategy, Wormwood Scrubs has a Safer
Custody Hotline. This is a dedicated telephone line for prisoners’ family and
friends to share any concerns they may have about an individual’s wellbeing
whilst in custody. Family and friends may also write to the prison. This service
is publicised in the Visitors Centre, Visits Hall, and in other areas of the
establishment.
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11. All contacts to the Safer Custody Hotline by telephone, or more generally to the
prison by mail, are recorded in the contacts diary. It details the name and
number of the prisoner, the date and time the contact was received, and the
reason for the contact. The record shows what action was taken immediately,
what referrals, if any, were made, and what follow up action was taken.
12. The prison’s Independent Monitoring Board (IMB) published its most recent
report in August 2008. The report raises the following issues that are relevant to
this investigation:
“The Board has seen positive signs of improvement in the services provided
to prisoners, although these have come at a cost to present services.
“The Board welcomes the renovation of medical suites in the Healthcare
Centre while regretting that the cancellation of clinics has led to longer
waiting-lists.
“The Board is concerned that at times because of staff sickness, leave and
suspension, the prison has been staffed at a very basic level with the knock
on effects on association, visits to the library, attendance of outpatient
hospital appointments and other aspects of the regime.”
13. Since January 2006 I have presided over 11 other investigations of deaths at
Wormwood Scrubs, four of which were from apparently natural causes. In
previous investigation reports, I have made recommendations concerning
emergency response, CPR training, record keeping, staffing levels and family
liaison.
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KEY FINDINGS
14. The man was the father of three children, but was separated from his partner.
He used his parents’ address for contact purposes but was known to live at other
addresses. Prior to entering custody he had been working
15. The man appeared in court in August 2008. He was remanded in custody and
was due to attend court for sentencing. He arrived at Wormwood Scrubs
16. On arrival at Wormwood Scrubs, the man had a First Health Screen
Assessment. At this assessment he told the staff that he had been on
prescribed medication for depression and anxiety. His medication was
Mirtazapine (an antidepressant) and Quetiapine (an antipsychotic). He said that
he was a smoker but did not use drugs. He said that he had recently seen his
doctor for a cholesterol count.
17. The next day the man had a General Health Assessment. His weight and blood
pressure were taken and both were recorded as normal. He was asked if there
was any history of illness in the family and he replied that there was not. He was
asked if he wished to give up smoking and he said no. He told the member of
staff that, prior to coming into prison, he had been homeless.
18. In August, the man was interviewed by a member of the Mental Health In-reach
Team. During the assessment he said that he was worried and anxious, and
was missing his children. He also said that he had no intention of hurting himself
or others.
19. Five days later, the man was seen by healthcare staff as he said he had
experienced pains in his chest. He was advised that he needed to go to the
local hospital but he refused to go. His blood pressure was taken, together with
an electrocardiograph (ECG) which records heart rhythms. The results of the
tests were recorded as normal. His blood pressure was taken again some ten
minutes later; it was also within the normal range. He was assessed as fit for
light exercise and work as a painter. He was prescribed aspirin and Gaviscon
(non-prescription antacid medication for heartburn).
20. The man saw a doctor a week later, as he was passing blood in his stool. A
referral was made to the Gastroenterology Department at the local hospital for
tests to be undertaken. Samples were also sent for analysis in advance of the
outpatient appointment.
21. Three days later the man was seen by the prison doctor. He said that he felt
agitated. The doctor increased his prescription for Quetiapine to 50mg just for
that day. On assessment the following day, his medication was returned to his
normal prescribed level.
22. The test results for blood in the man’s stool were returned, and they confirmed
the presence of blood. The Gastroenterology appointment had not yet been
arranged.
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Sunday 21 September
23. The man’s cell mate, told my investigator that he and the man had been on
morning and afternoon exercise together. By this time the man had been in
prison for a month. They were both in their cell, watching television. At
approximately 4.45pm, the man told the cell mate that his chest felt tight. The
man said that he thought it was heartburn. A short while later the man said that
he was getting a pain down his left arm. The cell mate said he would call the
nurse but the man did not want him to.
24. The first nurse came round with the evening medication just over two hours later
at approximately 7.15pm. In interview for this investigation, the cell mate said
that he heard the man ask the nurse to take his blood pressure as his chest felt
tight and he had pains down his left arm. According to the cell mate, the nurse
told the man that it would be taken in the morning.
25. Both prisoners were lying on their beds when, at around 8.00pm, the cell mate
heard him making strange noises and so pressed the cell bell. The first officer
responded at 8.05pm and looked through the observation hatch of the cell door.
The cell mate told officer that the man was not breathing properly. The officer
told my investigator that he saw the man lying on his bed, and could see his
chest rise and fall. The officer went to call for a nurse by telephone from the
Senior Officer’s office. (The officer is not first aid trained.)
26. During the night when a prison is in patrol state there are rules for unlocking
prisoners. There should always be a minimum number of staff present, and the
cell door should only be opened where there is a threat to life.
27. The second nurse was covering the five main wings. She rang the officer from
Healthcare to establish what the problem was. The officer told her that the man
was having difficulty in breathing. The nurse checked the man’s computer and
paper medical records, including his medication chart, before going to B wing.
She told my investigator at interview that she did this to ascertain the man’s
medical history and medication before she went to his cell. She had not been
told that assistance was required urgently.
28. At approximately 8.15pm the nurse arrived at the man’s cell door. She called to
the man and, when she did not get a response, asked the cell mate to shake
him. The cell mate told her that there was no response and that the man’s arm
was cold. The nurse and the officer then went into the cell. The nurse told my
investigator that he had a faint pulse, but was unconscious and not breathing.
The cell mate assisted the officer and the nurse to lift him to the floor, and the
nurse started CPR.
29. The first officer went on to the landing and shouted to an officer to make a Code
One radio call. The Code One radio call was made at 8.20pm and a second
officer and the SO responded without delay. (At Wormwood Scrubs a Code One
call generally signifies that a prisoner is hanging. However, the code is also
associated with someone with breathing difficulties.)
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30. On arriving at the man’s cell, the second officer and SO took over CPR from the
nurse. The SO had recent first aid training. The cell mate was moved to a
holding cell on B wing. The nurse left the cell to go to the treatment room on B
wing and returned with the emergency bag and defibrillator. She took over the
airway management using the air pump (providing breathing to the patient). No
one used the defibrillator.
31. The emergency 999 call was recorded by London Ambulance Service (LAS) at
8.26pm and a paramedic was despatched without delay. The detail given in the
call by the prison was that it was someone had been found hanging. In addition
to the paramedic, an ambulance crew was sent three minutes later. Whilst en
route to the prison, the paramedic was informed that a doctor had been sent for
at 8.31pm.
32. The paramedic, arrived at Wormwood Scrubs and was at the man’s side a
minute later. She saw the prison staff conducting effective chest compressions.
However, she told my investigator that she thought the nurse was not being
effective with airway management. This was because, in her opinion, the man’s
head was not tilted back correctly and there was not a proper seal around the
nose and mouth. The paramedic was told by prison staff that CPR had
commenced at 8.25pm. She took over the CPR procedure. The paramedic later
recorded the time on the LAS Patient Report Form along with the written
comment, “On arrival patient lying on cell floor, prison staff doing effective
compressions, question effective airway management.”
33. The ambulance crew arrived at the man’s side at 8.45pm. They continued with
CPR but made the assessment that he had already died. The paramedic doctor
arrived at 8.51pm and pronounced the man’s death at 9.08pm.
Events after the man’s death
34. Whist the paramedics were still in the prison they responded to another
emergency call which resulted in the prisoner being taken to hospital. This
reduced the number of night duty officers to two as the others were required for
escort duty.
35. The SO spoke informally with staff to offer support following the man’s death.
The Duty Governor, arrived at the prison and asked the SO if she was alright,
offering her the option of going off duty if she thought it necessary. There was
no formal Hot Debrief conducted by senior management for the staff involved.
There were no written records to document the actions taken by the SO or the
Duty Governor.
36. The SO herself told the inmate that the man had died. She told my investigator
that she kept checking on him throughout the night to ensure that he was alright.
37. The man’s parents live in Kent, so the prison contacted Kent Constabulary at
11.00pm and asked them to break the news of his death. Sergeant later
confirmed that the news was given to the man’s parents. Later that day, the
family liaison officer from Wormwood Scrubs, contacted the man’s parents by
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telephone. He was told that the man’s father had been taken to hospital with
chest pains.
38. The Post Mortem report shows that the cause of death was a heart attack.
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ISSUES
Clinical care
39. The clinical reviewer highlights the following issues about the man’s care:
“Despite his reported statements of good health prior to his remand, the fact
remains that the man was a young man with a moderate to high risk of
developing coronary heart disease. Whilst his mental health needs were
attended to in a timely and appropriate manner, the review panel identified
areas for improvement, specifically surrounding the diagnosis, initial
treatment, ongoing care and review of clients with chest pain; and
communication with the healthcare/ home office teams.
“Although clinicians use their physical assessment skills to identify
deteriorating health and triage patients into the most appropriate care
locations, there is evidence that this did not occur in the man’s care. Although
it is unknown whether the immediate investigation by acute trust specialists
would have made a positive difference to his outcome, the failure to
holistically assess and seek the guidance of specialists or to apply best
practice guidance are serious lapses in care.
“The man was reviewed by locum medical staff once following the first
episode of chest pain, and his notes three times. It appears as if each review
was considered in isolation and that at no time was his cardiac history
revisited.
“The man had a responsibility for his own health and should have
proactively sought medical attention. Although improved communication and
rapport between the patient and the healthcare staff may have aided the early
identification of health concerns and facilitated proactive care planning; it is
recognised that this however is not easily attained.”
I urge the Healthcare Manager to consider the findings contained in the clinical
review.
40. The man continued with the same medication that he was taking before coming
into prison. His blood pressure was taken at regular intervals and was within the
normal range.
41. In September 2008, the man had told Healthcare that he had chest pains.
Despite advice, he refused to go to the local hospital. His blood pressure was
taken, along with an electrocardiograph (ECG to record heart rhythms), and the
results of these tests were recorded as normal.
42. One of the prison doctors, referred the man to the Gastroenterology Department
at the local hospital in September. No appointment had been received by the
time the man had died.
43. The clinical review makes the following recommendations which I endorse:
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An urgent review of the current policies and guidelines for the
quantification and treatment for offenders experiencing angina, chest
pain, and cardiac events. It is recommended that this is implemented as
a matter of urgency. The adoption of assessment proformas and
telemedicine technology may be beneficial.
Following development and implementation, all permanent and locum
healthcare staff must be made aware of the chest pain protocol and
national best practice and incorporate into daily practice.
Record keeping
44. Some of the records do not contain times of actions taken or have illegible
signatures with no printed names. There are specific guidelines for doctors and
nurses to complete medical records. It is essential that all contact is recorded
accurately and chronologically to ensure there is an accurate and continuous
history of a prisoner’s needs and treatments.
I recommend that the Governor and Head of Healthcare ensure that all
healthcare staff are reminded of the requirements for accurate and
contemporaneous record keeping in accordance with the required
standards of the General Medical Council and the Nursing and Midwifery
Council.
Failure to identify potential serious health risk
45. The man’s cell mate, has alleged that the man told the first nurse on the evening
medication round that his chest felt tight and that he was getting pains down his
left arm, and asked if he could have his blood pressure checked. The man was
told that this would be investigated in the morning. My investigator has
established from prison records that the nurse was an agency nurse. The nurse
only worked at Wormwood Scrubs for two days.
46. It would be expected that a health professional would be alert to the risks
presented by the symptoms that the man had described. (They are classic
symptoms of a heart attack.) The first nurse could have responded to the man’s
symptoms herself or alternatively called for urgent assistance. Had the
seriousness of his condition been identified at this point, emergency treatment
could have been given at a much earlier stage. The police have interviewed the
nurse and have provided my investigator with a copy of her statement. In it she
states that she has no recollection of having any conversation with the man.
I recommend that the Primary Care Trust draw my report to the attention of
the Nursing and Midwifery Council who should satisfy themselves that the
first nurse is competent to practise.
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Emergency response
47. The usual number of nursing staff on night duty at Wormwood Scrubs is three.
The second nurse was the sole nurse on duty providing healthcare and
emergency response to the five wings of the prison. The two other nurses each
had a dedicated role in the hospital wing and substance misuse unit. However,
on the evening there was no nurse on the hospital wing and, as a result, the
nurse was expected to provide cover for that area of the prison as well. The
nurse is also an agency nurse.
48. I understand why prisons, particularly in London, are reliant upon agency nurses.
However, the use of agency nurses does hinder effective healthcare cover.
There is a necessary lack of continuity, along with problems relating to
unfamiliarity with the prison layout and its procedures. At interview, the second
nurse told my investigator that most nights the healthcare cover is staffed by
agency nurses.
I recommend that the Governor and Head of Healthcare review the level of
nursing staff, including the cover for the main prison population during the
night duty period.
49. The initial call for assistance made by the first officer provided the nurse on duty
with minimal information. The officer had not received first aid or CPR training.
The second nurse checked the man’s medical records and medication prior to
going to his cell on B wing. This was appropriate action given the information
provided by the first officer. The nurse arrived at the cell door some ten minutes
after the initial call for assistance was made. The nurse only entered into the cell
after she received no response when calling to the man, and after asking his cell
mate to rouse him. The nurse did not have the emergency bag or defibrillator
with her as she had not been told that the situation was an emergency.
50. On entering the cell the second nurse found the man unconscious and not
breathing. She said at interview that she felt a faint pulse. The man was moved
to the cell floor and the nurse commenced resuscitation. The first officer then
asked for the Code One radio call to be made. This was some 15 minutes after
the initial request for nurse assistance.
51. The Code One radio call was made over the radio at 8.20pm. The SO and the
second officer responded immediately. They took over CPR while the second
nurse collected the emergency bag from the treatment room located on B wing.
52. An ambulance was called at 8.26pm, some six minutes after the Code One radio
call had been made. Based on the Code One radio call, London Ambulance
Service was told that it was an attempted suicide by hanging. Whilst the report
was plainly inaccurate, it nevertheless ensured that the prison made an
immediate emergency call.
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53. On arrival at the cell, the first paramedic who witnessed CPR being conducted
was not confident that the airway management technique being used by the
nurse was effective. However, the chest compressions performed by the prison
staff were being made correctly.
54. The clinical review also draws attention to the chest pain protocol and
comments:
“In the community setting patients with chest pain can access their local
emergency department and receive treatment. This standard of care must be
made available to those within the prison setting. As a matter of urgency, all
offenders who complain of chest pain must be initially assessed and treated
by a GP followed by appropriate and timely referral to an acute trust
specialist. As a matter of priority, a chest pain protocol must be implemented
to ensure that all clinical staff are aware of the treatment options and need for
prompt appropriate action.”
I recommend that the Governor should review the emergency response
with specific attention to clarity of response codes, first on scene protocol
and urgent requests for an ambulance.
I recommend that the Governor and Head of Healthcare ensure that all
relevant staff have received updated CPR training
Family liaison
55. Prison Service Order 2710, Follow up to deaths in custody, requires that next of
kin should normally be contacted face to face as soon as possible after a death
has occurred. If the family live too far from the prison, best practice is to ask a
dedicated family liaison officer from a prison closer to the family home to break
the news. Police should only be asked to break the news if there is a safety risk
to staff going to the family home, or for some other pressing reason.
56. In the man’s case, Wormwood Scrubs asked Kent Constabulary to break the
news to his parents. This was done in the early hours of the morning. Whilst I
appreciate the demands on prison staffing during the night, using the police in
this circumstance is at odds with the spirit of PSO 2710 and does not, in my
view, demonstrate the highest level of care and consideration. Subsequent
contact by the prison’s family liaison officer has only been via the telephone.
At the consultation stage of the report the Prison Service said that the
establishment maintain that there was a need to balance the need to deliver the
news personally to the man’s family with the need for timeliness. Due to the time
of night and the distance in which next of kin live from the establishment the latter
seemed to be important. However, in contacting another prison in the vicinity of
the family home would still provide the opportunity for a Prison Service official to
break the news in accordance with Prison Service policy. Indeed, this has been
my experience elsewhere in the Prison Service.
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57. The man’s parents have told my investigator that they tried to contact the prison
to speak to someone about their concerns for their son’s health. They said there
was no point of contact and that there was no one they could talk to. As I have
noted earlier, there is in fact a dedicated telephone line for a prisoner’s family and
friends to share any concerns they may have about their wellbeing whilst in
custody. This is publicised in the Visitors Centre and Visits Hall, amongst other
places. The general prison switchboard should advise and refer relevant callers
to the dedicated number.
At the consultation stage of the report the Prison Service made the commented
that the Hotline is for families to voice any concerns about violence, bullying or
self harm issues and is not appropriately managed or resourced for this
additional function. Whilst I recognise the Prison Service comment I still
maintain that there needs to be a way for families to report genuine concerns
about health and well being of prisoners and this, in my view, is appropriate to
the safer custody function.
The Governor should ensure that staff deployed as family liaison officers
adhere to the guidance provided by PSO 2710 when liaising with bereaved
families following a death in custody.
The Governor should satisfy himself that staff operating the general prison
switchboard are alerting callers to the existence of the dedicated Safer
Custody Hotline. He should also review the publicity material relating to
the Hotline to ensure that it is well situated and makes clear that the
Hotline can be used by families concerned about general health matters.
Hot debrief
58. There was no formal hot debrief conducted for all the staff involved in
responding to the man’s death. The SO provided informal support to the staff on
duty at the time. Duty Governor provided informal support to the SO. There is
no written record of the support given to staff.
59. Senior management did not hold a formal hot debrief with all the staff involved in
the events surrounding the man’s death. PSO 2710 clearly states:
“There must always be a hot debrief immediately after the incident and
provision for this should be made in local contingency plans. A senior
member of staff must act as debriefer and a duty care team member must
also attend.”
I recommend that the Governor ensures that formal hot debriefs take place
in accordance with PSO 2710 and are documented.
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RECOMMENDATIONS
For Head of Healthcare
1. An urgent review of the current policies and guidelines for the
quantification and treatment for offenders experiencing angina, chest
pain, and cardiac events. It is recommended that this is implemented as
a matter of urgency. The adoption of assessment proformas and
telemedicine technology may be beneficial.
2. Following development and implementation, all permanent and locum
healthcare staff must be made aware of the chest pain protocol and
national best practice and incorporate into daily practice.
3. I recommend that the Head of Healthcare ensure that all healthcare staff are
reminded of the requirements for accurate and contemporaneous record keeping
in accordance with the required standards of the General Medical Council and the
Nursing and Midwifery Council.
4. I recommend that the Primary Care Trust draw my report to the attention of the
Nursing and Midwifery Council who should satisfy themselves that the first nurse
is competent to practise.
5. I recommend that the Head of Healthcare review the level of nursing, including
the cover for the main prison population during the night duty period.
For the Governor
6. I recommend that the Governor should review the emergency response with
specific attention to clarity of response codes, first on scene protocol and urgent
requests for an ambulance.
7. I recommend that the Governor and Head of Healthcare ensure that all relevant
staff has received updated CPR training.
8. The Governor should ensure that staff deployed as family liaison officers adhere
to the guidance provided by PSO 2710 when liaising with bereaved families
following a death in custody.
9. The Governor should satisfy himself that staff operating the general prison
switchboard are alerting callers to the existence of the dedicated Safer Custody
Hotline. He should also review the publicity material relating to the Hotline to
ensure that it is well situated and makes clear that the Hotline can be used by
families concerned about general health matters.
10. I recommend that the Governor ensures that formal hot debriefs take place in
accordance with PSO 2710 and are documented.
At the time of issuing the final report the Prison Service had not provided any
responses to the recommendations.
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