Individual at Parc

Investigation into the circumstances surrounding the
death of a man at HMP & YOI Parc
on 31 December 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 & YOI Parc in December 2008. The
post mortem showed that the man died of a heart attack. He had been in custody
since July 2007. The man was 56 years old.
I offer my sincere condolences to the man’s family for their loss. One of my Family
Liaison Officers liaised with the man’s family during the investigation process.
The investigation was led by my one of my investigators. I must thank the
Healthcare Inspectorate Wales for the clinical reviewer. I am also grateful to the
Director and staff of HMP & YOI Parc, especially the liaison officer, whose
assistance was greatly appreciated.
As with all deaths from natural causes, the findings of the clinical review play a
critical part in my report. The reviewer judged that the man received good care
whilst at Parc.
In addition to a recommendation derived from the clinical review, I make two
recommendations concerning the standard of record keeping and the protocol for
prisoners attending court in person rather than by video link. I also recognise the
swift emergency response by uniformed and healthcare staff.
This version of my report, published on the 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 4
The Investigation Process 6
HMP & YOI Parc 7
Key Findings 8
Issues 13
Recommendations 15
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SUMMARY
The man was charged with sex offences and remanded into custody at HMP Cardiff
by the Crown Court in July 2007. He was taking prescribed medication for high
blood pressure, angina, asthma and chronic obstructive pulmonary disease.
Due to the nature of his offences, the man was concerned for his own safety on
arrival at prison and, as a result, he was located in the segregation unit. He
remained in the segregation unit as he was waiting place to become available at
HMP & YOI Parc. After a brief spell in HMP Swansea, the man was transferred to
HMP & YOI Parc in August. He was assessed as unfit for work and gym, and
recommended for a ground floor cell to save him using the stairs.
The prison doctor requested and obtained clinical details from his community doctor
at the doctors Surgery. The records confirmed the man’s medication. They also
provided information that a diagnosis had been made that he had ischaemic heart
disease (reduced blood supply to the heart muscle).
The man had disability assessments reviews conducted by healthcare staff whilst at
Parc. These showed that he was only able to walk short distances and needed to
use a wheelchair for greater distances. He was able to wash and dress on his own
and made use of a shower chair.
Between March 2008 and October 2008, he had 14 separate court appearances.
On each occasion he was assessed as fit to attend. I October, he was sentenced to
16 years in custody.
In December 2008, the cell intercom for cell 12 sounded at 1.04pm. An officer
answered the call and spoke to the cellmate of the man. The cellmate asked for
someone to come as the man was not moving and he thought he was not breathing.
The officer responded straightaway and went into the cell. He found the man lying
on his bed, He was the first officer on the scene. He called to him but did not get a
response. The first officer on the scene made a Code Red call over the radio and an
emergency ambulance was called.
At 1.05pm, two nurses, the first to aid Red Alert, arrived at the cell. They recorded
that the man was mottled in appearance, there was no pulse, he was not breathing
and there was clear signs of cyanosis (bluish coloration of the skin). They
commenced cardiopulmonary resuscitation (CPR) with the aid of an automated
external defibrillator (AED) (a device to diagnose heart rhythm and the application of
electrical therapy allowing the heart to re-establish an effective rhythm.). No output
was identified by the AED so the nurses continued CPR until the paramedics arrived.
The paramedics arrived at 1.15pm and took over CPR. However, their assessment
was that life was extinct and there was no need for him to have continued life
support. The examining doctor attended the prison and pronounced the man dead
at 2.20pm. A hot debrief was held later in the afternoon for staff involved. Support
from the care team was offered.
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The prison’s Family Liaison Officer visited the address of the man’s younger sons in
December 2008 and in January 2009. The man’s eldest children had to be
contacted by the Probation Service, due to the nature of his offences, and they were
given the contact details of the Family Liaison Officer. They have chosen to make
no contact.
There are three issues arising out of this investigation. They concern the routine
review of prescription medicines, the standard of medical record keeping, and the
protocol for sending prisoners with known mobility and health problems to court
appearances. I also recognise the swift response to the emergency incident by both
uniformed and nursing staff.
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THE INVESTIGATION PROCESS
1. My investigator requested all the relevant prison documentation including the
man’s medical and core prison records. My investigator also visited Parc to
interview staff and prisoners who had dealings with the prisoner. My investigator
also saw inside his cell. Notices to staff and prisoners were sent to the prison to
be displayed. These invited anybody with information to talk to my investigator,
but no one came forward as a result.
2. A clinical review into his clinical care in prison was commissioned and carried
out for the Healthcare Inspectorate Not for the first time, I am most grateful to
the clinical reviewer for undertaking this review. My investigator discussed
aspects of the man’s treatment with both healthcare staff at Parc and with the
clinical reviewer.
3. My investigator contacted HM Coroner for Glamorgan Valleys, to inform him 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 his enquiries into the man’s death.
4. One of my Family Liaison Officers, has been in contact with the mans family to
offer them the opportunity to be involved in this investigation and to raise any
concerns if necessary. the man’s family has not raised any specific queries for
my investigation.
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HMP & YOI PARC
5. Parc opened in 1997 and is a category B male prison, situated in Bridgend, and
managed by Group 4 Securicor (G4S). It is a modern building built to an
American design. Parc holds up to 1,126 remand and convicted juveniles and
young offenders and sentenced adult males. It includes a unit for vulnerable
adult prisoners.
6. Healthcare services in Parc are provided under contract by Primecare Forensic
Medical Services (Primecare). There is 24 hour primary care and an in-patient
facility with 24 spaces. The clinical care is provided by doctors, registered
general nurses and registered mental health nurses employed by Primecare.
Additionally, there are links with the local NHS Trust and other medical staff visit
the prison to provide services (for example, a psychiatrist, dentist and optician).
There is also a mental health in-reach team.
7. The last full inspection by HM Chief Inspector of Prisons was in January 2006.
Although the Chief Inspector found it to be a disappointing inspection in many
respects, she noted that the prison was moving forward under a new Director
and a clear management strategy.
8. Since my office took over responsibility for investigating all deaths in prison
custody in April 2004, there have been 13 deaths at Parc. There were nine
deaths due to natural causes and two apparently self-inflicted prior to the man’s
death, and there has been one apparent natural cause death since.
9. The prison’s Independent Monitoring Board in its annual report, published in
August 2008, made the following comments:
“During the current reporting period, HMP & YOI Parc again made
conspicuous ongoing efforts to ensure that all prisoners felt safe and were
treated humanely and with dignity and fairness by all those charged with their
care.”
“The Healthcare Unit offers outpatient clinics over a wide range of need such
as Asthma, Detox, Hepatitis, heart disease and Genitourinary triage, as well as
chronic diseases such as diabetes and epilepsy. One of the strengths of the
Healthcare Unit at HMP &YOI Parc is its ability to carry out minor operations
and suturing, reducing the need for prisoners to be sent to local hospitals.”
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KEY FINDINGS
10. The man was born in South Wales in 1952. He had a daughter and son from his
first marriage, and two sons from a second relationship.
11. The man was charged with sex offences and remanded into custody at HMP
Cardiff by Newport Crown Court in 2007. On arrival at the prison a First Health
Screen assessment was conducted. This confirmed that he had received recent
treatment from his own doctor.
12. He said that he had prescribed medication of Furosemide (used to treat
congestive heart failure and accumulation of fluid under the skin), Lisinopril
(used to treat high blood pressure and angina), Beclometasone aerosol (used to
treat asthma and sinusitis), Omeprazole (used in treatment of digestion
difficulties), Salbutamol inhaler (used to provide relief of asthma and chronic
obstructive pulmonary disease), co-codamol (combined medication of codeine
and paracetamol) and aspirin.
13. It was recorded that his blood pressure was 140/85 and pulse 80, and his weight
was 89kg. (The normal range for blood pressure is 100/70 to 140/90, varying
through the day depending on the individual’s activities. A blood pressure
reading of greater than 140/90 is classed as high and a reading of 90/60 or
below is classed as low.) The man confirmed that he had been a smoker for
some 40 years and was an ex-miner. He told the nurse that he had problems
with asthma, angina, peripheral vascular disease (obstruction of the large
arteries in the legs and arms), bowel problems, breathing difficulties and had
suffered minor cerebrovascular accidents (commonly known as strokes) in the
past. He said that he had been in prison before some ten years previously. Due
to the nature of his offences he was concerned for his own safety on arrival in
prison, and as a result he was located in the segregation unit.
14. The man remained in the segregation unit as he was waiting a place to become
available at Parc. Whilst in the segregation unit, daily reviews were completed
to check on his health and well being. He was seen by the prison doctor in 2007
who confirmed that he was taking the correct medication.
15. In July, he was transferred to HMP Swansea. On arrival an initial health
assessment was completed. It confirmed the details of his medication and
medical history. The man was again concerned for his own safety and was
therefore located in the segregation unit. Seven days later, he was seen by the
prison doctor who repeated his medication.
16. The man was transferred to HMP & YOI Parc in August. A Reception Health
Screen assessment was completed by a Nurse. The man's medical problems
and medication were fully discussed and recorded. He told the nurse that he
had no mental health problems and no thoughts of self harm. The reception
health screen assessment nurse assessed the man as unfit for work and gym,
and recommended that he be allocated a ground floor cell. The nurse arranged
for the man to spend his first night in the healthcare centre.
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17. The following day, he was seen by the prison doctor and had a full review of his
medication. The doctor wanted the man to remain in healthcare for a period of
observation, but he refused. The doctor therefore requested that the man be
located on normal location but in a ground floor cell. The doctor also sought
clinical details from the man's community doctor. The details were faxed to the
prison later that afternoon. They confirmed the man's medication. In addition,
the notes contained information that a diagnosis had been made that he had
ischaemic heart disease (reduced blood supply to the heart muscle).
18. Three days later, he had a disability assessment. It showed that he was only
able to walk a short way and needed to use a wheelchair for greater distances.
He was able to wash and dress on his own and made use of a shower chair. It
was recorded that he had problems with his short term memory.
19. In August, the man appeared at the Crown Court. He was assessed as fit to
attend by a nurse. The Crown Court further remanded him into custody and he
returned to prison.
20. A nurse conducted a second disability assessment in September. The nurse
recorded that the man still could not walk far and needed to use a wheelchair for
longer distances. However, he was able to deal with his personal hygiene
without assistance.
21. In October, the man saw a nurse in healthcare as he was experiencing back
pain. The nurse referred him for a doctor’s appointment. He was seen by the
prison doctor the following day and was prescribed Diclofenac (a non-steroidal
anti-inflammatory drug used to reduce acute pain and inflammation).
22. The man next saw a nurse in healthcare in November, as he was experiencing a
tingling sensation in his hands and feet. The nurse referred him for a doctor’s
appointment. He was seen by a doctor the following day. He told the doctor that
he had recently had nose bleeds. The doctor recorded his blood pressure as
140/100, with a pulse of 80. The doctor asked for blood tests to be completed
and intended to review the man when the results were received.
23. Three days later, the man was required to attend court. He was assessed fit to
attend, and healthcare gave him a letter to give the court saying he suffered from
asthma and angina. Following the court hearing, the man remained on remand
and was taken back to Parc. Four days later, the nurse that took the disability
assessment took blood samples from the man in accordance with the doctors’
request. The results of the blood tests were received by the prison in November
and reviewed by the doctor.
24. The man next appeared in the Crown Court in December. He was assessed as
fit to attend, and again healthcare gave him a letter for the court regarding his
health conditions. Following the court hearing, he was again remanded into
custody and returned to prison.
25. In January 2008, one of the nurses that were the first to the Red Alert saw the
man in his cell as he was concerned he was having a stroke. The nurse did not
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think he was experiencing a stroke. He had full normal range of movement to
both arms but was anxious about the heaviness of his left arm. The nurse
recorded his blood pressure as 140/90 and his pulse as 110. The man told the
nurse that he was anxious about his solicitor visiting the next day. The nurse
stayed and talked to the man for some time before taking his blood pressure
again (it was recorded as 120/90, with a pulse of 86). The nurse requested that
the man be reviewed later that day.
26. At 4.30pm, the nurse that took the disability assessment went to the man. He
said that his arms felt the same as when he had had a mini stroke some years
ago. The nurse conducted a strength test in his arms which showed there was
no difference. The nurse reviewed the man again at 6.00pm. His blood
pressure was recorded as 140/95, with a pulse of 98. An electrocardiogram
(ECG) (to measure and diagnose abnormal rhythms of the heart) was also
completed. In light of the results of the ECG, the nurse spoke to the doctor on
the telephone at 6.20pm and faxed the ECG results to him.
27. The doctor rang back ten minutes later and advised that the man was to be sent
to the emergency department at the Princess of Wales Hospital, Bridgend. An
ambulance was called straightaway, and a letter of referral, with a copy of the
ECG, was sent with the escorting officers. At 9.15pm, the man returned to
prison from hospital and was seen by a second disability assessment nurse.
The hospital had made the diagnosis that the man had a chest infection and had
been given advice to stop smoking. The nurse referred the man to see the
prison doctor the next day.
28. The following day, the man did not attend the doctor’s appointment, nor did he
attend the asthma clinic appointment the next day (15 January). There are no
records of these two appointments being followed up. The man was assessed
as fit to attend court on 16 January, and again he was remanded in custody and
returned to prison.
29. The second disability assessment nurse conducted a further disability
assessment on 5 February. The nurse recorded that the man could still only
walk short distances unaided and needed the use of a wheelchair. He remained
able to deal with his personal hygiene without assistance.
30. In February 2008, the man had an appointment with a Consultant Urologist
(specialist in urinary tract, kidneys and bladder). The man told the Consultant
Urologist that he refused to accept any proposed treatment. (There are no
copies of any referral letter or formal response from the Consultant Urologist,
just a handwritten note by a member of healthcare administration team.)
31. From the beginning of March to the end of May, the man had five separate court
appearances. On each occasion, he was assessed as fit to attend and the court
remanded him into custody and he was returned to prison.
32. The man had an asthma clinic assessment in July. As noted earlier, the man
was a former miner and had been diagnosed as having pneumoconiosis
(occupational disease caused by inhaling dust). He told asthma clinic
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assessment nurse that he had been a smoker for 40 years and had no intention
of giving up. The nurse recorded that he was not using his inhalers as
prescribed and advised him to do so.
33. Between September and October, the man had a further nine appearances in
court. On each occasion he was assessed as being fit to attend. In October
2008, he was sentenced to 16 years in custody. On arrival back at prison, he
was located in healthcare for observation due to the potential stress he might
have been feeling at the length of his sentence. The following day, he was seen
by a review nurse. The nurse recorded that the man was in a good mood and
appeared to accept his sentence. He said that he had already been in prison
over a year whilst on remand. The man said that he wished to go back to D
block to get support from his peers. He was moved to D block later the same
afternoon.
34. The man saw the prison doctor as he had a cough and pain in his legs on 11
November. The doctor recorded that he had a cough that produced yellow
phlegm and he was in pain in both his back and legs. The doctor prescribed
Amoxicillin (antibiotic) and ibuprofen (pain relief).
35. In December 2008, the first officer on the scene was in the wing office when the
cell intercom for cell 12 sounded at 1.04pm. The officer answered the call and
spoke to his cellmate who asked for someone to come as the man was not
moving. The cellmate also thought that the man was not breathing. (I
understand it was normal for the man and the cellmate to remain in their beds
until lunch time.)
36. The first officer on the scene went into the cell and found the man lying on his
bed. The officer called to the man but, not obtaining a response, made a Code
Red call (call for emergency assistance, person not breathing) over the radio.
An emergency ambulance was called.
37. At 1.05pm, two nurses, the first to aid the Red Alert, arrived at the cell. They
noted that the man was lying on his left side. It was recorded that he was
mottled in appearance, there was no pulse, he was not breathing and there was
clear signs of cyanosis (a blue colour to the skin caused by insufficient oxygen in
the blood). The two nurses started cardiopulmonary resuscitation (CPR) with
the aid of an automated external defibrillator (AED) (a device to diagnose heart
rhythm and the application of electrical therapy allowing the heart to re-establish
an effective rhythm.). No output was identified by the AED so CPR continued.
Two further nurses arrived at the cell and took over CPR. Again no output was
identified by the AED and CPR continued, whilst the staff waited for the
paramedics.
38. The paramedics arrived at 1.15pm and took over CPR. However, once they
judged that the man had died they stopped their efforts. The examining doctor
attended the prison and pronounced the man dead at 2.20pm.
39. A hot debrief was held later in the afternoon for staff involved in finding and
attempting to save the man. Care team support was offered and made available.
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40. The prison’s Family Liaison Officer visited the address of the man’s two younger
sons on 31 December 2008 and 1 January 2009. The prison offered financial
assistance towards the cost of the man’s funeral.
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ISSUES
Prescription medicines
41. The clinical review highlights the following issue regarding prescription
medicines:
“… blood was taken on the 20th November and the results were reviewed on the
23rd, which showed slightly raised cholesterol at 3.19mmol/L [normal is less than
3]. When the man entered prison life, he was taking Simvastatin to reduce his
cholesterol, but this reviewer could not find any reference to this in the
prescriptions he was given at HMP Parc, although it is mentioned in the Transfer
in Check List. Simvastatin is recommended to be given to prevent cardiovascular
events in patients with atherosclerotic cardiovascular disease (from which the
man suffered). Additionally, the man was taking aspirin to prevent another stroke
and ibuprofen occasionally, but these drugs should be given under caution to
people with asthma, as they could initiate an asthma attack (from which the man
also suffered).”
42. I therefore endorse the recommendation made in the clinical review:
Head of Healthcare should ensure medical staff routinely review the
medications of prisoners on poly-pharmacy for interactions, contra-
indications and omissions.
Record keeping
43. The findings of the clinical review are that the standard of healthcare given to the
man by staff was good. However, although the medical records were in order,
some of the entries were illegible (including the signatures). There are specific
guidelines for doctors and nurses on the completion of medical records. It is
essential that all contact is recorded accurately and chronologically to ensure
there is a continuous history of a patient’s needs and treatments.
The Head of Healthcare should ensure all healthcare staff are trained and
kept updated in the requirements of accurate and contemporaneous record
keeping in accordance with the required standards of the General Medical
Council and the Nursing and Midwifery Council.
Use of court video link
44. Whilst at Parc, the man had numerous court appearances at Newport Crown
Court. On each occasion he had been deemed fit to attend.
45. Given that the disability assessments that had been undertaken for the man
confirmed he had limited mobility, as well as suffering from COPD, it seems
reasonable that consideration should have been given to using the video link as
this was available for all South Wales courts. I do of course appreciate that
several factors may determine whether prisoners attend court in person, even
though a video link is available. Indeed, this can be driven by the defending
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solicitor or the prisoner himself. Nevertheless, I think the following
recommendation may be helpful:
The Director should review the process for utilising the court video link to
ensure its appropriate use for those prisoners with specific health and
disability needs.
Emergency response.
46. The staff who responded to the man’s need for emergency assistance on 31
December 2008 acted with great speed and professionalism. The clinical
reviewer highlights how swiftly and correctly the staff responded in the attempt to
resuscitate the man. This was very good practice.
The Director should recognise the professionalism displayed by the staff
who were directly involved in the swift emergency assistance provided to
the man.
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RECOMMENDATIONS
1. Head of Healthcare should ensure medical staff routinely review the medications
of prisoners on poly-pharmacy for interactions, contra-indications and omissions.
Accepted. Current processes ensure that medical staff/pharmacist routinely
reviews the medications: The pharmacist routinely reviews medication charts for
interactions, contra-indications and omissions. For patients requiring I.P.
medications, the patient is risk assessed pre-dispensing and then risk assessed
every 6 months with a medication review. All medication is prescribed for a
defined period of time, (maximum 28 days); therefore ensuring that medication is
regularly reviewed. Regular medication review clinics occur. This has been
actioned
2. The Head of Healthcare should ensure all healthcare staff are trained and kept
updated in the requirements of accurate and contemporaneous record keeping
in accordance with the required standards of the General Medical Council and
the Nursing and Midwifery Council.
Accepted. There are currently some processes in place to ensure that clinicians
are kept updated in the requirements of accurate record keeping; however, the
regular monitoring of record keeping performance is necessary to ensure
adherence to GMC/NMC standards. Regular weekly staff meetings are held to
highlight and discuss issues around clinical practice including any
documentation issues. To be completed by 30 June 2009.
3. The Director should review the process for utilising the court video link to ensure
its appropriate use for those prisoners with specific health and disability needs.
Accepted. Deputy Director and Healthcare Manager to review protocol for
ensuring court video links are used where appropriate for prisoners with specific
health and disability needs. To be completed by 31 July 2009.
4. The Director should recognise the professionalism displayed by the staff who
were directly involved in the swift emergency assistance provided to the man.
Accepted. All staff have been commended by the Director for their actions.
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