Individual at Dovegate

Investigation into the circumstances surrounding
the death of a man at HMP Dovegate
on 25 February 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2010
The man was a prisoner at HMP Dovegate when he died of a heart attack on 25
February.
I would like to extend my condolences to the man’s family and friends and all those
affected by his death. From his prison records, it is clear that the man was popular
with both staff and fellow prisoners.
One of the Ombudsman’s investigators, was appointed to investigate the
circumstances of the man’s death. I would like to apologise for the delay in issuing
this report, which was due to work pressures within this office. A clinical review was
commissioned from South Staffordshire PCT, who appointed the Clinical Reviewer to
lead the review panel. I am grateful for their contribution to this investigation.
I am also grateful to the assistance provided to the investigator by the Director of
Dovegate and his staff. In particular, I would like to thank the prison’s Liaison
Officer, for his help.
The man had little contact with healthcare during his time in prison. On 25 February,
he attended the gym as usual but told a PE instructor that he had a pain in his back.
He was taken to healthcare and seen by a nurse, who referred him to a doctor.
When the doctor saw him, he asked him to take his top off. As he did so, the man
collapsed. Although staff attempted to resuscitate him, sadly they were
unsuccessful. The man was pronounced dead shortly after arriving at Queen’s
Hospital, Burton on Trent.
The clinical review panel makes one recommendation, which I endorse, and it
concerns responsibility for calling an ambulance in an emergency.
Jane Webb
Acting Prisons and Probation Ombudsman February 2010
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CONTENTS
Summary 4
The investigation process 6
HMP Dovegate 7
Key Findings 9
Issues 15
Conclusion 17
Recommendation 18
3
SUMMARY
In September 2007, the man was remanded in custody at HMP Birmingham charged
with offences relating to the illegal importation of controlled substances. He was
sentenced in November at a local Crown Court to 12 years imprisonment.
The man transferred to HMP Dovegate on 17 December, so that he could attend
various courses to address his offending behaviour. He attended the gym for the
first time on 19 December, where he undertook an induction and completed a health
questionnaire. He reported no health problems, signed a disclaimer to that effect,
and became a regular attendee.
The man attended healthcare on a number of occasions for various ailments. He
had dry skin, eczema, a pain in his neck and a pulled muscle in his back when he
briefly returned to Birmingham in September 2008.
When the man returned to Dovegate on 29 October he was seen by healthcare in
reception. Again he reported no health problems.
Over the next few months the man was described as a “model prisoner”. He worked
on the wing servery and appeared to have good relationships with staff and
prisoners.
On 25 February, the man attended the gym at approximately 1.35pm. He trained by
himself that afternoon, which was unusual, however, he talked and engaged with
other prisoners.
At the end of the session at approximately 2.40pm, the man mentioned to a Physical
Education Instructor (PEI) that he had a pain in his back. The PEI thought he might
have trapped a nerve. Once back on the wing, he spoke to the PEI again and asked
to be taken to healthcare as his back was hurting badly and he had pins and needles
in his hands. Another PEI escorted him to healthcare and recalled that he told her
he thought he had trapped a nerve.
At 3.30pm the man was seen by a nurse. He told her that whilst in the gym he had
felt some chest pain, but this had gone away. However, he now had pain radiating
to his hands. The nurse took his pulse, blood pressure and blood oxygen saturation
level and decided he should see a doctor. When the doctor received the nursing
report, he thought it sounded like a sprain, although he was concerned about the
radiation of the pain. Although the observations taken by the nurse did not indicate
immediate danger, the doctor asked to see him immediately.
The man saw the doctor at 3.50pm. The doctor took a history of what had happened
and still believed that the pain was a spinal pain induced by weightlifting. As the
doctor commenced his examination, he fell to the ground. He lost consciousness
and had a seizure which lasted about three minutes. Although still breathing, the
doctor noticed the man appeared cyanosed. Less than a minute later the man
stopped breathing. The doctor and a nurse began cardio-pulmonary resuscitation
(CPR), including use of a defibrillator. An ambulance was called and paramedics
arrived at the prison at 4.37pm. They took over CPR and at 5.00pm, a femoral pulse
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was established in the man’s groin. The paramedics then transferred him to
hospital. CPR continued at the hospital, but no pulse or signs of breathing could be
found. The man was pronounced dead at 5.50pm.
There is one recommendation arising from the clinical review. This concerns the
process to ensure that staff are fully aware of who is responsible for calling an
ambulance in an emergency, and that it is clearly documented on the incident log.
5
THE INVESTIGATION PROCESS
1. An Investigator was appointed to conduct this investigation. She was sent all the
man’s prison records from Dovegate, including his medical records. Notices
were issued to both prisoners and staff inviting anyone who had information
regarding the man’s death to make themselves known to the investigator. Two
prisoners made contact with the Investigator they were spoken to informally and
the evidence of one of the prisoners is used in this report.
2. The Investigator visited Dovegate on 18 and 19 May 2009 to carry out taped
interviews with staff and untaped interviews with two prisoners.
3. One of the Ombudsman’s Family Liaison Officers, contacted the man’s family to
explain the role of the Prisons and Probation Ombudsman and to offer them the
opportunity to participate in the investigation. The man’s family did not want a
visit from the investigator, but did raise a concern that the man’s quick diagnosis
and treatment may have been compromised as he was in prison.
4. South Staffordshire PCT were commissioned to conduct a clinical review and
appointed a Senior Clinical Governance Manager, to conduct the review. The
Director of Dovegate convened a panel involving experts in prison care to
evaluate her findings.
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HMP DOVEGATE
5. HMP Dovegate is a prison near Uttoxeter, Staffordshire. It opened in 2001, and
is operated by Serco, under contract to the National Offender Management
Service. It holds up to 860 male prisoners, usually serving sentences of between
four years and life. Dovegate offers education, work opportunities and courses
to help prisoners deal with their offending behaviour. Healthcare services are
provided by Serco Health.
Her Majesty’s Chief Inspector of Prisons
6. Her Majesty’s Chief Inspector of Prisons last conducted an announced
inspection in 2008. Her report noted that the prison had, since the previous
inspection, become a “safer and more controlled prison with reasonable
purposeful activity”, although resettlement remained weak. Her Majesty’s Chief
Inspector of Prisons also noted that the personal officer scheme was
underdeveloped, but that healthcare staff, though stretched, provided a
satisfactory service.
7. The Personal Officer scheme was described more fully as “generally good and
well managed”. The scheme had been changed in 2008, with officers allocated
to cells rather than prisoners. However, only 48 percent of prisoners understood
the role of the officer, and some staff seemed unclear as well.
8. Her Majesty’s Chief Inspector of Prisons also discussed healthcare
arrangements at the prison. After commenting that there were insufficient staff at
the time of the inspection, Her Majesty’s Chief Inspector of Prisons also
commented that provision of emergency equipment outside of the healthcare unit
was poor. All healthcare staff had undertaken mandatory CPR (cardiopulmonary
resuscitation) training.
Independent Monitoring Board (IMB)
9. Each prison has an IMB, made up from members of the local community who
monitor the prison on a daily basis to ensure prisoners are treated humanely and
are prepared for release. Each IMB produces an annual report for the attention
of the Secretary of State for Justice.
10. The last published report for the Dovegate IMB covers the period from October
2007 to September 2008. Of matters relevant to this investigation, they
commented that healthcare had suffered because of a turnover in management,
and that they were uncertain how effectively the personal officer scheme was
working. Overall, however, the IMB believed that Dovegate had become “calmer
and more orderly”.
Personal officers
11. Each prisoner is allocated a personal officer. They provide the prisoner with a
named point of contact should they have any problems or issues that they wish
to raise.
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Incentives and Earned Privileges Scheme (IEPS)
12. The Incentives and Earned Privileges Scheme (IEPS) has three levels.
Prisoners start on standard level. If privileges are removed, they move to basic
level until their behaviour or conduct improves. Prisoners can also move to
enhanced level, which can lead to a prisoner getting privileges such as more
association time or phone calls.
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KEY FINDINGS
13. In September 2007, the man appeared with two others at a local Magistrates’
Court charged with offences relating to the illegal importation of controlled
substances. He was remanded in custody to HMP Birmingham to await trial at a
local Crown Court.
14. The man’s medical record from his time at Birmingham is incomplete. However,
between May and June 2007, he was prescribed Ibuprofen (an anti inflammatory
or pain killer), peptac liquid (usually prescribed for indigestion) and Permethrin
dermal cream.
15. On 16 October, the man pleaded guilty to the charges against him. One month
later, on 20 November, he attended healthcare and saw a Nurse. He said he
was suffering from neck pain, and had done so for some time. He had
previously taken Ibuprofen for the pain, but had not on this occasion. Before
coming to prison, he had sought treatment from a physiotherapist. He was given
Ibuprofen and a leaflet containing exercises for his neck. He also told the Nurse
that he was suffering from heartburn and dry skin. He was prescribed a further
course of peptac liquid and aqueous cream to help his skin condition.
16. The man was sentenced on 27 November at a local Crown Court to 2 years
imprisonment. He was seen on his return to Birmingham by reception staff and
did not report having any problems.
17. As part of his sentence plan, the man moved to HMP Dovegate on 17 December
so that he could attend various courses to address his offending behaviour. He
told officers that he would appeal against the length of his sentence but did not
have any other problems. He was assessed as being of low risk in terms of
sharing a cell. He also saw a healthcare worker, who noted that he had
medication in possession (Ibuprofen, aqueous cream and peptic liquid). It was
also noted that he was a smoker and not used drugs in the past two years. The
man confirmed that he had no health concerns and that there was no history of
health problems in his family. A series of physical observations were taken,
which the clinical reviewer has described as being “within normal range”.
18. The man attended the gym on 19 December, and was given an induction by a
PE instructor (PEI). The PEI completed a questionnaire with the man, in which
he confirmed that he had no health problems. One of the questions specifically
asked was whether he had suffered from chest pain, and he replied that he had
not. He was then allowed to use the gym facilities.
19. On 24 December, the man went to healthcare. He was prescribed further
aqueous cream for his dry skin and Gaviscon (a treatment for indigestion). A
week later, on 30 December his first personal officer, made an entry in the man’s
wing file saying he had settled well on the wing.
20. The man moved wing on 11 January 2008. His new personal officer (second
personal officer) recorded that he did not have any problems. A week later, he
went to healthcare as he had a dull pain in his neck. He was referred to a
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physiotherapist, but declined to attend the appointment on 28 February. In the
meantime, he moved cell (which meant he changed personal officer again) and
started work in the kitchen servery.
21. Over the next two months, the man continued to work in the servery, earning
several positive comments in his wing file for his work and attitude. On 14
March, he attended a sentence planning board, which agreed short term goals of
attending courses, continuing with his Open University course and maintaining
his current standards.
22. On 20 May, he saw a doctor in healthcare as he had mild eczema on his hands.
He was prescribed cream. The doctor also requested a fasting blood test,
although it is not clear whether this was conducted. On the same day, he was
allocated his third personal officer, after a change in allocations at Dovegate.
The third personal officer had known the man for several months, having
previously been his support personal officer (who acts as personal officer should
the main officer be unavailable) and commented that “his compliance is good
and his work on the wing servery is good … he is polite to both staff and
prisoners”.
23. The man returned to see the doctor on 20 June, once again concerned about the
eczema on his hands. The doctor again prescribed cream, but also advised the
man to wear non-latex gloves while working in the servery. The man was also
advised that day that he had successfully completed a course on victim
awareness.
24. In an entry on the man’s wing file made by third personal officer on 22 June, he
noted that the man regularly attended the gym and had regular visits from his
family. The next day, the man was advised that he did not need to take an
enhanced thinking skills course as he was deemed to be a low risk of reoffending
in the future.
25. Over the next few months, the man received several further positive comments
in his personal file. However, on 7 July, he tested negative during a mandatory
drugs test. In September, he changed jobs and began work in the wing laundry,
and had funding agreed for a further Open University course in business
management.
26. On 30 September, he had a blood pressure check (the reason is not recorded),
which was within normal limits at 147/81.
27. The man returned to court in October after a confiscation order was made under
the Proceeds of Crime Act. (The man was ordered to pay £5247.12 within six
months or face a further period of custody.) During the hearings, he moved to
HMP Birmingham. When he arrived there on 20 October, he was seen by
healthcare. He said he had pulled a muscle in his back. He was referred to a
Prison Doctor and prescribed pain relief.
28. Returning to Dovegate on 29 October, the man was seen by healthcare staff in
reception. He reported no problems. Three days later, he applied for his
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security categorisation to be reviewed, and expressed a preference for a transfer
to a prison near to his family. While this was being considered, he applied for
permission to have an electric guitar sent into Dovegate as he was a guitar tutor.
He was told that this would be unlikely, as he already had one in his possession.
29. The man was notified on 1 January 2009 that his application for recategorisation
had been successful. Recommended prisons included HMP Wymott, Buckley
Hall and HMP Risley. On 4 January, he made a further application to bring in a
guitar, this time provided by a charity. The application was not authorised by
reception.
30. Over the next two months, the man continued to work and attract positive
comments from staff. On 22 January, his third personal officer noted that he was
“a model prisoner”. The man agreed on 14 February to help in the servery when
it was short staffed, but also recommended another prisoner who wanted the
next available job.
Events of 25 February
31. On the afternoon of 25 February, at approximately 1.35pm, the man attended the
gym. The investigator spoke to a PE instructor at Dovegate, who knew the man
and who said that he used the gym regularly. He explained that all prisoners are
given an induction to the gym, and sign a health disclaimer before they are
allowed to attend.
32. The PE instructor recalled that the man had trained by himself that afternoon.
He explained that this was unusual, as he normally trained with others. The PE
instructor said, however, that the man was talking to other prisoners during the
training session, and, being only ten feet from him, he could see that he was fine.
33. At the end of the session, at 2.40pm, the prisoners were searched as normal
before being escorted back to the wings. Before they left the gym, the man saw
the PE instructor and mentioned that he had a pain in his back. The PE
instructor recalled that the man was shrugging his shoulders and thought he
might have trapped a nerve in his back. They then walked back to the main
prison together.
34. After the PE instructor finished putting prisoners back on the wing, the man
approached him again and asked if he could be taken to healthcare. He said
that his back was now hurting badly and he had pins and needles in his hand.
The PE instructor agreed, and took him to healthcare. As the next gym session
included prisoners from healthcare, the PE instructor met his colleague, and
fellow PEI, at the healthcare gate and asked her to take the man to see a doctor.
35. The fellow PEI escorted the man into healthcare and recalled that he said he
thought he had trapped a nerve. She asked him to take a seat and went to the
nurses’ station to speak to a healthcare assistant. The assistant told her that she
would ask a Nurse to see the man.
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36. Another prisoner was also waiting in healthcare. He told the investigator that he
thought the man waited for some time before being seen, and that he could not
sit down because of the pain in his back.
37. At 3.30pm, a Nurse on Duty saw the man. He mentioned that he had felt some
chest pain while in the gym, but this had gone away and he now had back pain
radiating to his hands. The Nurse took his pulse, blood pressure and blood
oxygen saturation level, and decided that he should be referred to the doctor.
38. The Doctor who was running an afternoon clinic when he received a nursing
report about the man. He believed that the pain described sounded like a
possible sprain, although he was concerned about the radiation of the pain.
Although the observation measurements did not indicate immediate danger, he
asked that the man be brought to see him immediately.
39. The man was seen by the Doctor who ran the afternoon clinic as soon as he had
finished with his previous patient, which was at 3.50pm. The doctor took a
history of what had happened, and still believed that the pain was in keeping with
a spinal sprain caused by weightlifting. The man was breathing normally. The
Doctor asked the man to remove his upper body clothing so he could examine
him. As he stood up, the man fell to the ground, hitting his head on a wall as he
fell (the Doctor described the examination room as small). The Doctor went
straight to him and noticed that he had lost consciousness and had started to
have a seizure. The doctor called out for help, and a Prison Custody Officer
(PCO) went into the room to see what was needed. The Doctor asked him to get
a nurse, and the PCO asked the Nurse who had previously assessed the man to
assist. The seizure lasted for three minutes. The Doctor noticed that, although
the man was still breathing at this point, he had become cyanosed (cyanosis
occurs when there is a lack of oxygen in the blood, and can be seen when parts
of the body, for example the lips, appear blue).
40. Less than a minute later, the man stopped breathing independently. The Doctor
who ran the afternoon clinic had prepared a mask and oxygen, and started using
an ambu-bag (a mechanical device to aid breathing) to ventilate him. The Doctor
then could not find a pulse and commenced cardio-pulmonary resuscitation
(CPR) with the Nurse that first assessed him when he came into Healthcare that
day. At the same time, he also requested that an ambulance be called (he
estimated that he asked for the ambulance at around 4.00pm).
41. Several nurses and other staff arrived after a medical emergency was called
over the radio system, and they helped the doctor and nurse to administer CPR.
A defibrillator was brought to the room, and gave the man two controlled shocks
(the defibrillator was attached by the Doctor but delivered the shocks
automatically).
42. An incident log was opened in the control room, and was maintained by a PCO.
He noted that, at 4.00pm, the control room was informed by the Head of
Operations at Dovegate, that an ambulance had been called (she had been
relayed this information by staff at the scene). Another Nurse, who had
12
responded to the emergency call, also asked whether an ambulance had been
called and was assured that it had been.
43. The PCO that maintained the incident log then recorded, at 4.15pm, that the
control room contacted the Ambulance Service to request assistance.
Ambulance Service records show that the call was received by them at 4.21pm
and an ambulance was despatched at 4.23pm.
44. Meanwhile, the Head of Operations had arrived following the emergency call.
She ensured that a log of events was kept in healthcare, and also arranged for a
member of the care team to speak to the PCO that was first to respond to the
call, who had been shaken by events. All other prisoners in healthcare were
removed back to their normal location
45. Paramedics arrived at Dovegate at approximately 4.37pm. They were escorted
to the healthcare centre and took over CPR. The paramedics also gave the man
adrenaline, atropine (used for the treatment of an extremely low heart rate) and
amnioderone (used for the treatment of an irregular heart beat). At 5.00pm, an
independent femoral pulse was established (the femoral pulse is found in the
groin). The paramedics then transferred the man to Queen’s Hospital, Burton on
Trent. The ambulance left Dovegate at 5.25pm and arrived at 5.42pm. Two
PCO’s accompanied the man to hospital. He was not handcuffed.
46. The man was met by a full cardiac arrest team on his arrival at Queen’s Hospital.
Another two rounds of CPR were administered, and he was given more
adrenaline. No pulse or signs of breathing could be found however, and the man
was certified as dead at 5.50pm by the Emergency Department consultant.
47. One of the PCO’s that accompanied the man to hospital telephoned Dovegate
and informed them of the man’s death. After the ambulance left for the hospital,
the Director, held a hot de-brief (a meeting with all staff who had been involved
with the emergency to discuss what had happened) with staff involved to ensure
that all immediate issues had been addressed. The Director issued a notice to
staff and prisoners informing them of the man’s death, and the Head of
Operations went to the house block where the man had lived and informed the
prisoners in person. She also went to each block and informed prisoner
representatives and peer support workers (often known as Listeners, that is
prisoners who are trained by the Samaritans to offer support to other prisoners).
48. The man’s family were informed by the prison’s Anglican chaplain. A couple of
days later, the prison's Family Liaison Officer, accompanied the Chaplain to visit
the family. Both attended the man’s funeral, and the Chaplain led a memorial
service at the prison, which was attended by both prisoners and members of the
man’s family.
49. On 2 March a pathologist carried out the post mortem examination. He found
that the man had died from a myocardial infarction (a heart attack), due to a left
descending coronary thrombosis.
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50. HM Coroner for the Staffordshire (South) Coroner’s District, held an inquest into
the man’s death on 27 April. The jury concluded that the man’s death was due
to natural causes.
14
ISSUES
Clinical care
51. The Senior Clinical Governance Manager, was appointed by South Staffs PCT to
lead a clinical review into the care the man was given. She convened a review
panel which included experts in prison healthcare and accident and emergency
procedures. The review panel also consulted the West Midlands Ambulance
Service.
52. As can be seen from this report, the man had very few dealings with healthcare
during his time in prison. He had reported heartburn and acid reflux, and was
prescribed medication for this. He was also prescribed aqueous cream for dry
and itchy skin. Finally, he twice mentioned that he had back problems. On the
second occasion, he said that the pain was a result of pulling a muscle while in
the gym.
53. The man first complained of a pain in his back to the PEI at approximately
2.40pm. He told the PEI that he thought he may have a trapped nerve as he had
done this in the past. It is hard to be sure of the timescale, but it was not until the
man arrived back on C wing that he asked to see a nurse. PEI Deverall said he
would take him straight to healthcare. According to the Doctor that was in
charge of the afternoon clinic that day notes, he saw the man at 3.50pm. I
cannot say whether there was a delay in the man seeing the doctor, as it is
unclear what time he left the wing. However, a fellow prisoner told the
investigator that the man was in the waiting room in healthcare for at least an
hour and ten minutes. This does not seen to tally with the timescale as it would
suggest that the man went to healthcare immediately from the gym.
54. The panel found no fault with the treatment given to the man on the day of his
death. However, they were concerned that there appeared to be confusion over
the calling of an ambulance. Although the Doctor that was in charge of the
afternoon clinic asked for an ambulance to be called at 4.00pm, and other staff
including the Nurse that responded to the emergency call asked whether an
ambulance had been called, the Ambulance Service recorded that the first
contact they received was at 4.21pm. The panel found that “no single person
took responsibility for calling the ambulance” and made the following
recommendation, which I endorse. I cannot say whether these delays impacted
on the man’s death, however, he received immediate treatment from the doctor
and healthcare staff and this continued until the paramedics arrived.
The Director should ensure that clear processes are introduced to ensure
that all staff are fully aware of who is responsible for calling the ambulance
and this is clearly documented on the incident log.
Personal officers
55. During this investigation, I have looked through the man’s prison record. I am
pleased to note that there were frequent entries made by his personal officers
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(especially his third personal officer) in his record, and that these showed that
the officers knew the man well. This is good practice.
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CONCLUSION
56. The man reported to PE staff on 25 February 2009 that he had pain in his back
following a gym session. He was taken to healthcare and, after being seen by a
nurse, was referred to a doctor. When the doctor saw him, he was asked to
undress, as he did so, he collapsed. The doctor began to administer CPR and
called for help. Other staff responded and eventually an ambulance crew
arrived. The man was taken to Queen’s Hospital, Burton on Trent, but was
pronounced dead at the hospital.
57. The clinical review panel found that there was confusion over when an
ambulance was called. While the man received continuous care from trained
staff, the delay in calling an ambulance was unfortunate, and a recommendation
has been made to address this.
58. The man’s family were concerned that being in prison may have adversely
affected the man’s diagnosis and treatment. During his time in prison he came
to the attention of healthcare staff for dry skin, eczema, indigestion, a pain in his
neck (he was given an appointment to see a physiotherapist, but declined to
attend) and a pulled muscle in his back. He visited the gym regularly and at the
gym induction completed a questionnaire to say that he had no health problems
and specifically that he had not suffered from chest pains. When he returned to
Dovegate on 29 October he was seen by healthcare staff in reception and
reported no health problems. With this in mind, and given that the man was
seemingly a fit and active young man, it is hard to see how such a tragic event
could have been foreseen whether he had been in prison or not. Also, the man
was being examined by a doctor at the time he collapsed and so received
immediate treatment, something which may have been less likely outside prison.
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RECOMMENDATIONS
1. The Director should ensure that clear processes are introduced to ensure that
all staff are fully aware of who is responsible for calling the ambulance and
this is clearly documented on the incident log.
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