Individual at Manchester

Investigation into the circumstances surrounding the
death of a man at HMP Manchester
in July 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2010
This is a report into the circumstances surrounding the death of a man, a prisoner at
HMP Manchester, in July 2009. He was 43 years old. The post mortem determined
that his death had been caused by a cerebral abscess. He had been in custody at
Manchester since January 2005.
I would like to offer my sincere condolences to the man’s partner and family, and to
all those who were touched by his passing.
One of my investigators conducted the investigation on my behalf. In addition, the
local Primary Care Trust (PCT) commissioned a clinical review into the standard of
healthcare the man received in custody. A clinical reviewer led this with the
assistance of a psychiatrist who provided a review of the mental health care. I would
like to thank them both for their assistance with my investigation. I would also like to
thank the Governor of HMP Manchester and his staff for their help.
The man had a long history of complex mental health problems, the most severe of
which was Tourettes Syndrome, an inherited neurological condition. He had also
been diagnosed with Obsessive Compulsive Disorder (OCD). His conditions were
identified as soon as he was first remanded to HMP Manchester. Once sentenced,
he progressed well. With the advice of the man’s partner, staff and other prisoners
learnt to understand how his Tourettes Syndrome could manifest itself, and he
received continued support.
Two days before his death, the man was admitted to the healthcare wing as a result
of staff concerns about his appearance. Tests revealed that he had taken Subutex,
a drug normally used in detoxification from heroin, and he was closely monitored.
However, at 7.10pm, a nurse found him unconscious on his cell floor and efforts by
staff and paramedics to resuscitate him failed.
I commend the prison for the actions taken in ensuring that a complex mental health
problem was dealt with sensitively and that all staff and fellow prisoners were aware
how Mr Hillard’s condition could affect his daily life. I am satisfied that the man’s
care was managed appropriately and make no recommendations as a result of my
investigation.
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 April 2010
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CONTENTS
Summary
The investigation process
HMP Manchester
Key findings
Issues
Good practice
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SUMMARY
On 12 January 2005, the man was remanded into custody at HMP Manchester. He
was 38 years old at that time. He suffered from complex mental health problems,
most significantly Tourettes Syndrome. On reception at Manchester, he disclosed
his mental health problems to medical staff who assessed him. In terms of his
physical health, he was considered fit and well. However, he was given a place in
the healthcare wing so that his mental health needs could be assessed by a doctor.
The man remained in the healthcare wing for the next seven months and had regular
medication reviews. The ‘tics’ which he experienced as a result of his Tourettes
Syndrome would often lead him feeling unable to interact with other prisoners.
However, his general behaviour was considered to be good. During these seven
months, he was also assessed by staff from a Mental Health Hospital with a view to
being admitted for a period of assessment before sentencing, and in August 2005 he
transferred to the hospital under the Mental Health Act. He remained there under
the care of a doctor until May 2006 when he returned to court and was sentenced to
life imprisonment, with a minimum term of one year and 231 days.
The man returned to HMP Manchester and was again located into the healthcare
wing where he remained until June 2007. During this time, medical staff saw him
and reviewed his treatment regularly. They also sought opinions on his care from
staff at the Mental Health Hospital who worked closely with the prison. The man had
prolonged periods where his ‘tics’ were particularly bad and these resulted in him
causing self injury by hitting himself around the head and banging his head against
walls. As a result, he was placed on Assessment, Care in Custody and Teamwork
(ACCT) monitoring on a number of occasions. (ACCT is the Prison Service’s
process to monitor and support prisoners felt at risk of suicide or self-harm. The
prisoner’s movements and interactions with staff and others are closely monitored
and recorded, and a care plan is put in place to reduce the level of distress.)
In June 2007, the man was considered well enough to be moved to a residential
wing. It was considered that his complex mental health problems made him
vulnerable and he was located on a wing for vulnerable prisoners – E wing. Staff
were made fully aware of his problems and how these manifested in his behaviour.
This information was shared with other prisoners on the wing. He appeared to settle
in well and was well liked by both staff and prisoners. However, his time on E wing
was not without problems, and his continued difficulties with his ‘tics’ meant that he
was regularly moved back to healthcare for periods of assessment and to make
changes to his medication.
During the weekend of 11 July 2009, staff became concerned that the man’s
appeared to be drowsy and was spending a lot of time in his cell. They contacted
healthcare, and a nurse went to the wing, spoke with him, and arranged for him to be
seen by the doctor. In turn, the doctor arranged for blood samples to be taken and
agreed to review him again in two days.
The following day, the Senior Officer on E wing contacted healthcare again as staff
continued to be concerned about him. After consultation with the doctor, he was
admitted to healthcare for observation. On admission, he was assessed by a locum
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doctor and denied taking any illicit drugs when asked. As his symptoms indicated
that he might have ingested drugs that had not been prescribed, the doctor arranged
for a urine test which subsequently found that he had Subutex in his system.
(Subutex is the trade name of the drug buprenorphine. It is an opioid drug similar to
heroin. It is prescribed to treat those suffering from addiction to opiates such as
heroin.)
Although the man initially denied having taken anything illicit, he eventually admitted
that he had taken Subutex two days earlier but could not be sure how much. As a
precaution, all of his other medication was temporarily suspended. In addition, his
temperature and pulse were checked hourly (the frequency was subsequently
reduced).
At 6.44pm in July 2009, a nurse carried out a routine observation on the man and
recorded that he was verbally unresponsive when prompted by staff. Around 25
minutes later, when she returned to check him again, she saw him lying on the floor.
She immediately called to her colleagues for assistance, went into the cell and
attempted to gain a response from him. No pulse or breathing could be detected
and staff attempted CPR until the arrival of paramedics called by the prison’s control
room. With the assistance of nursing staff, the paramedics continued to attempt to
revive him but, sadly, at 7.45pm they declared him dead.
There were initial concerns that the Subutex in his system had in some way
contributed to his death. However, post mortem results concluded that he died as a
result of a cerebral abscess.
This investigation found that HMP Manchester has procedures in place for the
issuing of controlled medication such as Subutex. However, despite the security
measures, illicit drugs are still finding their way into the prison. The investigation has
also found that both medical and discipline staff acted well in ensuring that the man’s
complex mental health issues were dealt with sensitively.
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THE INVESTIGATION PROCESS
1. HMP Manchester provided the man’s prison and medical records for
examination. Notices were issued to staff and prisoners to advise them of the
investigation process and to give them the opportunity to speak with the
investigator. No responses were received.
2. My investigator visited Manchester on 22 July and met with staff including the
Head of Healthcare. He visited the residential unit where the man had lived
and spoke with staff who had known him. He also visited the healthcare
centre.
3. My investigator wrote to HM Coroner to inform him of the nature and scope of
the investigation and to request a copy of the post mortem and toxicology
reports.
4. A clinical reviewer was appointed by the local PCT to conduct the clinical
review on their behalf. Given the man’s history of mental illness, she sought
the assistance of a psychiatrist who has experience of working with patients in
a prison environment.
5. One of my family liaison officers (FLOs) telephoned the man’s partner on 13
August. They discussed the investigation and her initial concerns. His partner
said that she would welcome the opportunity to meet with the FLO and my
investigator at a later date. In a further conversation on 25 August, they
agreed to meet at her home on 9 September.
6. During the visit the man’s partner talked about his mental health problems and
how he had struggled to obtain the appropriate treatment in the community.
She did not say anything critical about prison staff and recognised that they
had done their best to help him. However, she was critical that there did not
appear to be a psychologist based in the prison. The man had been in
custody since 2005, but was eventually assessed by a psychologist just six
months before he died. His partner asked whether a psychological
assessment could have been made available earlier in his sentence. My
investigator explained that the review of the man’s medical care would look at
the handling of his mental health needs. I hope that the report has helped the
man’s partner to understand better the circumstances of his death and
provides some answers to the questions asked. She received and read the
draft report, however, had not raised any specific comments in relation to the
findings at the time of issuing the final version of my report.
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HMP MANCHESTER
7. HMP Manchester is a local prison which takes people who are remanded into
custody from courts in Greater Manchester. It has been part of the High
Security Estate since 2003. The prison has nine wings with a mix of single
and double cells.
8. Healthcare at the prison is commissioned by the local Primary Care Trust.
The healthcare centre provides 24 hour nursing care and medical cover, and
has beds for up to 20 patients.
9. Every prison in England and Wales has an Independent Monitoring Board
(IMB). The members are volunteers who monitor the day-to-day life in their
prison and ensure that proper standards of care and decency are maintained.
The Manchester Independent Monitoring Board report for 2007-08 noted that
a number of the beds in the healthcare centre were used for non-clinical use
due to prison overcrowding. They also reported that at least half of the
prisoners being monitored under the Assessment, Care in Custody and
Teamwork procedure were located in healthcare.
10. Following the issue of the draft report, Manchester emphasised that since the
publication of the IMB report, the number of beds on the healthcare has been
reduced from 38 to 20 and patients are now admitted to the healthcare mainly
on clinical need only.
11. HM Chief Inspector of Prisons published a report on Manchester in 2007.
There has been a more recent inspection by her, the findings of which were
published in December 2009. However, this report comments on the last
report prior to the man’s death. The inspection in 2007 found that a number of
prisoners were inappropriately admitted to the healthcare centre, mirroring the
concerns raised by the IMB. The Chief Inspector recommended that
admission to the healthcare centre should be on the basis of clinical needs
alone.
12. The man’s death was one of 29 to have occurred at Manchester since April
2004 when I began investigating all deaths in prison custody in England and
Wales. Ten of the previous 28 deaths were due to natural causes.
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KEY FINDINGS
The man’s reception at HMP Manchester
13. The man had spent several periods as an inpatient on psychiatric units since
being diagnosed with Tourettes Syndrome and Obsessive Compulsive
Disorder (OCD) as a teenager. While in the community, he struggled at times
to take the medication prescribed to keep his condition under control. This
often led to him committing offences that both his partner and his probation
officer described as a “cry for help”. The man’s partner feels that he did not
receive the appropriate care that he required while in the community.
14. In January 2005, he committed arson while he was again having trouble with
his medication and was subsequently remanded into custody on the grounds
of public safety. He arrived at HMP Manchester on 12 January. He was 38
years old at that time.
15. On his reception at Manchester, a health screen was completed. During the
screen, the man said that he had previously been in custody and had been
homeless in the last year. He said that he had not seen a doctor in the last
few months but listed the medication that he was currently receiving. In
addition to his mental health problems, he is recorded as saying that he
suffered from asthma but had no concerns about his physical health. Other
than his prescribed medication, he said that he did not use drugs and did not
drink alcohol. The man’s partner told my investigator and FLO that he would
not drink alcohol as it reacted badly with his medication, and that he had never
taken drugs other than those prescribed. He also told the nurse conducting
the screen that he had been diagnosed as having Tourette’s Syndrome and
Obsessive Compulsive Disorder which had led to him spending time in
psychiatric hospitals as well as receiving care in the community.
16. The nurse asked the man whether he had any history of self-harm and he
replied that he had taken an overdose in 2002. However, he said that he did
not have any current thoughts of self-harm or suicide. As a result of the
information he gave and his previous history, the nurse referred him to the
doctor and the mental health team, and he was admitted to the healthcare
centre.
17. The following day, a doctor carried out a psychiatric assessment of the man.
The doctor recorded that he was rational and coherent during the assessment
and that he provided a very good insight into his previous mental health
problems. The man told the doctor that he had been in prison in 2001/2002,
and after this had spent time in a hostel, but he had not been employed. The
doctor recorded that the man should continue with his current treatment and
his community psychiatric nurse (CPN) in Blackpool should be contacted for
further information.
18. During January, the man’s CPN visited him in prison. The prison healthcare
team also continued to try and obtain his previous psychiatric reports. As well
as liaising with the CPN, the doctor contacted another doctor who had treated
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him at a psychiatric hospital, to try to get him referred. In mid February, the
second doctor’s secretary advised the first doctor that the man would be
considered for a bed placement once they received a referral.
19. The man’s medical record indicates that his medication was kept under
regular review and he was very aware of the medication that he felt worked for
him and that which did not. A letter was sent to a third doctor at another
psychiatric hospital to arrange for him to assess the man with a view to
admitting him to the hospital. The prison continued to pursue this, and in May
2005 a nurse spoke to the man as there appeared to be some confusion
whether he had been seen by the third doctor. After speaking with the man,
the nurse recorded that two CPNs from the third doctor’s clinic had seen him.
20. The man’s ‘tics’ caused by his Tourettes Syndrome continued to be monitored.
These were more severe at times and he would become very agitated and
injure himself. When he was received into custody he had told nursing staff
that he was HIV positive, but blood tests carried out in May indicated that this
was not the case. On the healthcare unit he would attend education and
associated with other patients, but at times when his ‘tics’ became difficult for
him to control he would refuse to attend education or take part in the regime.
Despite this, he was recorded as always remaining compliant and polite
towards staff.
21. When he was feeling well, the man’s reluctance to comply with his medication
regime continued. Nursing staff spoke with him and explained the importance
of adhering to the regime to maintain his mental well-being. As previously
mentioned, he was very aware of the medication that he was prescribed and
was vocal in telling the doctors what he felt worked for him and what did not.
Throughout his time in custody, his medication was kept under regular review.
22. The third doctor reviewed the man on 27 June 2005 to provide an assessment
report to the court on whether a hospital order could be made under the
Mental Health Act. At his subsequent court hearing on 22 July, he was
convicted of arson and an order was made under section 38 of the Mental
Health Act for him to be admitted to a psychiatric hospital for a period of
assessment prior to sentencing. Immediately after the court hearing, he
returned to Manchester’s healthcare wing until a bed became available at the
hospital.
23. The man transferred to the psychiatric hospital on 16 August 2005.and
remained there until 24 May 2006 when he returned to court for sentencing.
He was sentenced to life imprisonment with a minimum term of one year and
231 days. The third doctor, who had been treating him at the hospital,
provided a final report to the court. He indicated that the man’s psychological
needs were complex and unlikely to be met in the healthcare unit of a local
prison. He added that, if the man transferred to a prison for those serving
longer sentences, he might have the opportunity of engaging in a more
constructive and stable therapeutic relationship with psychological services.
The doctor confirmed to the court that arrangements had been made to
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coordinate care planning initiatives with the Mental Health In Reach Team
(MHIRT) at Manchester.
24. The team leader who had looked after the man at the psychiatric hospital also
wrote a report for Manchester. She highlighted areas that the prison would
need to be aware of in relation to how his ‘tics’ might affect his behaviour. She
also mentioned issues that he had with taking his medication. She said that,
on occasion, he would get ideas into his head that he wanted to change his
medication. At these times, he had been known to hide his medicines. It is
clear from her report that the man’s partner had been involved in his care
planning while he had been at the hospital.
The man’s return to HMP Manchester, May 2006
25. Following his court appearance, the man returned to HMP Manchester. On
arrival, a nurse assessed him and completed a health screen. The nurse
again recorded all his previous medical history and noted that he appeared
calm during the interview. Following the reception process and the health
screening, he was again placed in the healthcare unit.
26. The day after he arrived back into custody, he was recorded as being up and
down in mood and given reassurance by nursing staff. He was assessed later
that day by a doctor who recorded that he had accepted his life sentence and
there were no signs of him being at risk of self-harm.
27. During a review on 8 June, a doctor and the man discussed the possibility of
him moving to a residential wing. He told the doctor that he would benefit from
a change to a different medication, but the doctor advised to continue with his
current regime. Following this consultation, a registered mental health nurse
(RMN), who had known him for some time, arranged a meeting with the lifer
officer to discuss how he could be best placed in the prison to meet the
necessary targets in his sentence plan. (A lifer officer is an officer trained to
deal with the specific needs of a life-sentenced prisoner. As part of their role,
they speak with newly-sentenced prisoners, explain the life sentence process,
and ensure that they are allocated to an appropriate prison to meet the
requirements of their sentence plan.)
28. Sentence planning involves interviewing a newly sentenced prisoner and
agreeing a plan which assesses their needs and risks and will assist in
addressing offending behaviour. The sentence plan provides continuity during
the entire sentence and is designed to reduce reoffending on release. The
sentence plan is also used by the Parole Board in their decision making,
providing information on a prisoner’s progress.
29. The man settled in well to the regime on the healthcare unit and was recorded
as being compliant. He also began to attend education. The Tourettes
Society contacted healthcare staff, offered to provide the prison with fact
sheets, and gave them a helpline number in case staff needed advice.
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30. Regular meetings continued to take place to discuss the man’s care, attended
by staff from Guild Lodge to share advice on his treatment. Although he
remained compliant with his medication regime, on a number of occasions he
voiced concern that he felt it needed to be changed. In late July, his ‘tics’
began to get worse and this affected how he interacted with other prisoners.
As a result, he chose to complete his education work in his cell. The
escalation in his ‘tics’ was constantly monitored by both the nursing staff and
MHIRT at Manchester, as well as practioners who visited regularly from the
psychiatric hospital.
31. During 2006, the man was recorded as having injured himself during “bad
episodes” by banging his head on cell walls and punching himself. Because
of this self-injury, he was placed on Assessment, Care in Custody and
Teamwork (ACCT) monitoring in August 2006. Although he said that he was
not suicidal, staff were concerned that his continued self-harm could lead to
permanent injury. It was decided at a case review on 22 October to stop the
monitoring.
32. The man remained in the healthcare centre during the first part of 2007 and
continued to receive regular reviews of his treatment and support from staff.
His medical record shows that during this period he attended education and
the social discussion group held in the healthcare unit. He is said to have
made a substantial contribution to the group in these sessions.
33. Staff tried to find a place in a residential wing for the man and he told them
that he was looking forward to moving to E wing. On 3 May, the RMN
recorded on his medical record that she had spoken with the doctor and the
man was considered fit enough to move out of the healthcare unit. She wrote
that she would need to liaise with the Senior Officer (SO) on E wing to arrange
a place. She also recorded that when he moved to any wing the MHIRT
would follow up to provide support. He remained in the healthcare unit until 8
June when he was moved to K wing, while he awaited a cell on E wing. When
the RMN was told of his move, she emphasised to staff on K wing the
importance of moving him to E wing quickly.
34. The man initially appeared to be settling well onto K wing. He attended
education and mixed with other prisoners. The RMN recorded that she would
contact his probation officer to discuss the next steps to refer him to other
services.
35. On 26 June, the man was placed on ACCT monitoring again after he told staff
that he had tried to hang himself with a pair of jeans. He said that he had not
gone through with it because “it hurt”. When staff asked him why he had
taken this action he told them that he had been sexually assaulted by another
prisoner. Staff asked him whether he wanted the police to investigate but he
declined saying that he just wanted to return to the healthcare wing. Staff
found no evidence to support his claims, no further action was taken, and the
ACCT document was closed following the interview. No further concerns were
raised by him in relation to this.
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36. However, on 11 October the RMN was told by staff on E wing that the man
had “smashed up his cell”. She went across to speak to him and discovered
that he had actually smashed his radio. He told her that his ‘tics’ were
becoming out of control and he was having compulsive thoughts. He said that
he had been in contact with his partner. He denied any eating disorder
problems, which were known to be trigger indicators for him becoming unwell.
He told her that he had been compliant with his medication since arriving on
the wing and that he had not had any altercations with either staff or prisoners.
The RMN recorded that there appeared to have been a gradual deterioration
in his mental state over the previous couple of weeks which had gone
unnoticed. He agreed that he needed to be readmitted to the healthcare unit
so he could be monitored for a short while.
37. Once the man returned to healthcare, his medication was reviewed and this
appeared to reduce the severity of the ‘tics’ that he said had led him to smash
his radio. It was recorded that he settled well and told staff that he was feeling
all right and looking forward to returning to E wing. Towards the end of
October, the RMN contacted his probation officer and staff at the psychiatric
hospital to arrange a meeting to discuss his future care.
38. The man returned to E wing on 14 November. An entry in his wing history file
made staff aware that his condition could make him say or do things
involuntarily and that he should be monitored. He began to attend education
again and took an active part. However, his ‘tics’ continued to be erratic and
staff regularly updated healthcare staff on his condition and raised concerns.
39. In February 2008, the man refused the offer of a place at HMP Wymott, a
category C prison. He explained that he would prefer to go to HMP Preston
as he was familiar with it and it would be an easier journey for his partner.
40. The man was reluctant to return to healthcare for respite care. In June 2008,
he told the RMN that he wanted to progress to another establishment where
he would be able to complete courses. He felt that moving to healthcare
would not benefit him in the long term. His ‘tics’ continued to get worse, and
on 27 June staff on E wing asked an officer to speak with him as he was now
having thoughts of hurting others. The officer and a nurse agreed that a
couple of days in healthcare would be beneficial for him and would allow his
medication to be reviewed. Staff on E wing kept his cell open so that he could
be monitored easily while arrangements were made.
41. Later that day, the man was admitted to healthcare where he remained until
21 January 2009. A psychologist conducted a psychological assessment and
in a letter dated 31 July 2008 said that the prison psychology team would be
willing to arrange a further assessment. However, it was considered that this
and other psychological treatment needs, including offence-related work,
would not be effectively met while he remained in healthcare.
42. During his time in healthcare, he continued to struggle with controlling his ‘tics’
and injured himself on a number of occasions by punching himself and
banging his head against walls and the floor of his cell. He became
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particularly anxious in September 2008, and harmed himself when he found
out there were plans to move him back to a residential wing. Staff provided a
protective head guard which he wore at first, but then stopped using it as he
thought it prevented him from feeling “relieved”. He was also placed on ACCT
monitoring and spent time in a “safer cell” so that he could be monitored
easily.
43. In October 2008, following an assessment by a doctor, it was decided that the
man should be referred to the local hospital for a further examination of his
eye that had become swollen as a result of his continued self-harm. However,
he declined to go despite nursing staff advising him of the potential
consequences for his health by not doing so. He signed a disclaimer to
indicate that he had refused treatment.
44. Despite some earlier apprehension when the man returned to E wing in
January 2009, he settled back into the regime quickly and began attending
education on a daily basis where he received favourable reports. Staff and
prisoners were fully aware of his condition and offered him support. He spoke
to staff about how he was feeling, and would discuss with them any thoughts
that he had about hurting himself. No further concerns about his ‘tics’
recorded.
The man’s progress with sentence plan
45. The man’s partner wrote to both the prison and her local Member of
Parliament several times to highlight his condition and to enquire about his
progress. He had been assessed early in his sentence as requiring
psychological treatment to reduce his risk of re-offending. His partner asked
whether he would receive the treatment that would enable him to progress
with his sentence. She had been told by the prison that they did not have a
psychologist.
46. The prison confirmed that the healthcare unit at Manchester does not have a
dedicated psychologist as part of its team, although there are forensic
psychologists who deliver offending behaviour courses in a different
department. It is possible that, because the man’s need was seen as medical,
a delay in a referral to the forensic psychology team occurred.
47. A parole review took place in April 2008 and again indicated that he would
require psychology intervention if his level of risk was to be reduced.
Following this a member of the forensic psychology team at Manchester was
asked to work with the man. He is recorded as engaging well with her and,
apart from a brief spell when he was having difficulties with his ‘tics’, he saw
her regularly to complete one to one work. She completed her one to one
work with him in April 2009 and a report on his progress was in the process of
being written at the time of his death.
48. The man’s partner wrote to the prison asking for him to be moved to open
conditions. The Governor responded and explained that, because he was a
discretionary life sentence prisoner, the prison was unable to reduce his
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security category any lower than C. He added that it would be for the Parole
Board to make such a decision, and the next review was due to take place in
April 2010.
49. The prison also made efforts, in consultation with the psychiatric hospital, to
refer the man to a new Personality Disorder Unit. The Consultant Forensic
Psychiatrist, who assisted the clinical reviewer, has outlined the steps taken.
His report is attached as an annex.
Admission to healthcare in July 2009
50. Over the weekend of 11 July 2009, staff on E wing became concerned about
the man as he appeared to be sleeping a lot during the day and had no
energy. They reported this to healthcare staff and the doctor assessed him in
his clinic on 13 July. He recorded that the man said he felt well mentally but
was sleeping a lot. As he appeared drowsy and over-sedated, the doctor
decreased his medication. He also asked for urgent blood samples to be
taken and wrote that he would review him again in two days. The man’s
partner told the investigator that she had spoken to him on the telephone that
weekend and was concerned that his speech appeared slurred.
51. A Senior Officer (SO) told the RMN on 14 July that staff were concerned about
the man. She reassured the SO that the man was due to be seen again the
following day by the doctor. She then relayed the staff concerns to the doctor
and the decision was made for him to be admitted to the healthcare unit.
52. A locum general practitioner assessed the man and observed that he was
tired, lethargic and not himself, but did not complain of any pain or breathing
problems. He recorded the possibility that the man had either taken a drug on
the wing or had been spiked with a drug, and asked for a urine test to be
carried out.
53. The results of the urine test showed a positive reading for Subutex. (Subutex
is the trade name of the drug buprenorphine. It is an opioid drug, prescribed
to treat opiate addiction. At Manchester, all those prescribed Subutex are
required to take their dose in sight of a nurse to prevent it being stored and
used inappropriately.) When the results of the man’s test came back, a nurse
recorded that he was to have hourly observations, including blood pressure
and temperature. If these remained within the normal range for four hours,
they could be reduced to two-hourly. The nurse also noted that, if he
remained physically well, the observations should be continued throughout the
night at four-hourly intervals. Staff monitored him over the next couple of
days. In view of the Subutex in his system, a decision was taken to
temporarily withdraw his other medication, and he indicated that he
understood this.
54. A doctor spoke to the man on the morning of 16 July. He initially denied
taking Subutex but then admitted that he had taken some two days earlier but
could not say how much. The doctor recorded that he appeared alert with a
normal respiratory rate, and he was due to restart his normal medication the
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following day. He also asked for observations on the man to be continued
every two hours during the afternoon. Following an observation later that
afternoon, his blood pressure was noted to be high but not excessively so.
55. A nurse recorded that, while carrying out the man’s observations at 6.44pm,
she asked him to respond to her verbally and he just smiled and nodded his
head. She added that he continued to appear verbally unresponsive when
prompted by staff. At 7.10pm, she went to check on him again and saw him
lying on the floor of his cell. She immediately alerted an officer and a second
nurse who were also on the healthcare landing. Together, they entered the
cell.
56. The first nurse attempted to gain a verbal response from the man, before
checking his pulse and breathing without success. She then ran to collect the
emergency response bag from the treatment room. A call had also been
made via the radio for further medical assistance and a third nurse went to the
cell. The first nurse began cardio pulmonary resuscitation (CPR) while the
third nurse assessed the man’s airway. They attached a defibrillator to his
chest. (A defibrillator is a machine that can restart the heart in some cases of
cardiac arrest by giving an electric shock.) Staff continued to perform CPR
rotating with one another to ensure that efforts were maintained. The
defibrillator remained attached to the man and advised that no shockable
rhythm had been detected. Paramedics arrived at 7.23pm and continued to
work with nursing staff in the resuscitation attempts. Unfortunately, he
remained unresponsive and at approximately 7.45pm paramedic staff
pronounced him dead.
Actions following the man’s death
57. HMP Manchester arranged for the man’s partner to be notified of his death.
The staff at the prison knew his partner, and that she had health concerns of
her own, and were concerned that if the news was received late at night she
might not have anyone to support her. As a result, the decision was taken to
visit her the following morning. The RMN, who had been involved in the man’s
care and had known both him and his partner for some time, was asked to
attend when the news was broken so that she could offer support to the
partner.
58. At the prison, staff involved in attempting to resuscitate the man had a debrief
and a record made to identify any immediate concerns with procedures.
Prisoners on E wing were saddened by his death and they organised a
collection. The monies raised were passed to the man’s partner. She was
very moved by the gesture and told my FLO that she intended to use the
money to have a bench in memory of him placed in her local park.
15
ISSUES
Awareness of the man’s condition
59. The prison consulted the Tourette’s Society to gain more information on the
condition and its symptoms. They were also open to advice offered by the
man’s partner and ensured that this was shared with staff on the residential
wing. The information provided was laminated and displayed on the wing so
that both staff and prisoners would know what to be aware of.
I commend the prison for its actions in ensuring that a complex mental
health problem was dealt with sensitively, and that all staff and prisoners
were made aware of how the man’s condition could affect his daily life.
Use of Subutex
60. The man’s partner told the investigator that he had always been adamant that
he would not take any illicit or non-prescribed medication, as he felt that it
would react badly with his prescribed medicine. For the same reasons, he did
not drink alcohol when he lived in the community. The results of his routine
drug tests in prison had all been negative. It is difficult therefore to understand
why he would suddenly choose to take Subutex.
61. My investigator was told that Manchester issues Subutex under strict
guidelines and prisoners are required to take it in sight of nursing staff. This
process reduces the risk of Subutex being traded and taken illicitly. However,
the prison acknowledged that some prisoners would still attempt to obtain
Subutex and, although systems are in place to prevent this and other drugs
entering the prison, inevitably some will get through.
62. The man clearly knew what he was taking as he later admitted to healthcare
staff, but how he came by the Subutex and why he took it remains unknown.
It is possible that he thought the Subutex would relieve his symptoms. There
is no evidence to suggest that he took Subutex after having developed a drug
habit.
Admission to healthcare in July 2009
63. When wing staff noticed changes in him, they quickly drew their concerns to
the attention of healthcare staff who, in turn, followed them up. He was
monitored closely by both wing and nursing staff and, following assessment by
a doctor, was admitted to healthcare. A locum doctor who later examined him
suspected he had used or been given illicit drugs, and tests taken after his
admission subsequently revealed him to have taken Subutex.
64. The post mortem gives the cause of the man’s death as a cerebral abscess.
The symptoms for such a condition include those that he displayed: lethargy
and speech difficulties. The doctors and healthcare staff would have had no
reason to suspect this to have been the case and I judge that the course of
action they followed was appropriate. A number of things can cause a
16
cerebral abscess. One cause is infection following head trauma, and this is
significant in his case given that he would often hit his head on walls when
experiencing a bad ‘tic’.
Clinical reviewer’s findings
65. The psychiatrist assisting the clinical reviewer concludes that the treatment the
man received in relation to his mental health was appropriate to meet his
needs. Equally, the clinical reviewer indicates that the medical care he
received in custody, particularly following his admission to healthcare in July,
was appropriate and delivered to a good standard.
66. The psychiatrist makes two recommendations in his report relating to the
psychiatric hospital. The first relates to the referral criteria for patients and the
second to the timescales for referrals and decisions to be made. These
matters are outside my remit, but I support them and commend them to the
local mental health trust.
Conclusion
67. The man had clearly struggled for many years with very complex mental
health problems, and he was said to have committed offences as a way of
highlighting his need for help and support. He had a supportive relationship
and, at the time of his most recent offence, appeared to have found some
stability in his life.
68. It was apparent to my investigator that he was well known and well liked those
who had contact with him at Manchester, and that his death had touched
many people. Although his mental health problems are well documented, his
physical health was not considered poor. Although the cause of death has
been given as a cerebral abscess, there is no indication as to how this might
have occurred. However, trauma to the head, such as that which he would
inflict on himself, can reportedly be a contributing factor.
69. The investigation has found that the level of medical care the man received in
terms of both his mental and physical needs was appropriate. In addition, the
way in which staff and prisoners dealt with his condition with understanding
and sensitivity should be commended.
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GOOD PRACTICE
I commend the prison for its actions in ensuring that a complex mental health
problem was dealt with sensitively, and that all staff and prisoners were made
aware of how the man’s condition could affect his daily life.
After receiving the draft report Manchester responded by saying the Governor would
publish notices to staff and prisoners formally acknowledging the efforts made in
ensuring that the man’s mental health problems were dealt with sensitively.
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