Individual at Manchester

Investigation into the death a man
whilst in the custody of HMP Manchester in April 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2011
This is a report into the death of the man who died at North Manchester General
Hospital, whilst in the custody of HMP Manchester. The man was 68 years old when
he died of natural causes. A post mortem concluded that he had died of
bronchopneumonia and heart failure.
I offer my sincere condolences to his family and friends for their loss. One of my
family liaison officers contacted the man’s family to inform them about the
investigation and to provide them with an opportunity to raise any issues about the
care the man received in custody. I hope that my report addresses their concerns
and gives them a greater understanding of the events leading to his death. I am
sorry that it has been delayed and regret any additional distress this may have
caused.
The investigation was carried out on my behalf by my colleague. Both she and I
would like to thank the Governor of Manchester and his staff, for their co-operation
during the course of our enquiries. In particular, I would like to thank the liaison
officer. Manchester Primary Care Trust were commissioned to provide a clinical
review into the care provided for the man, and I would like to thank the clinical
reviewer for conducting the review.
As the man died from natural causes, the findings in the clinical review play an
essential part in my report. The review shows that the standard of care the man
received was equitable to that which he could have expected in the community and
the clinical reviewer makes no criticism of the man’s clinical care whilst at HMP
Manchester. I do not make any recommendations as a result of this investigation.
The 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.
Jane Webb
Acting Prisons and Probation Ombudsman February 2011
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CONTENTS
Summary
The investigation process
HMP Manchester
Key events
Issues
Conclusion
Recommendations
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SUMMARY
The man was born in July 1941 and lived in Manchester prior to his conviction for
sexual offences in 2006. He was sentenced to an Indeterminate Public Protection
sentence (IPP) with a minimum tariff of 669 days at Manchester Crown Court on 31
July 2007.
On reception into prison, he was taking a number of medications for a heart
condition, angina, high blood pressure, heart disease, high cholesterol, asthma,
chronic obstructive pulmonary disease and skin complaints.
From the time he entered custody until his death, he had regular access to prison
doctors and healthcare staff and also attended outside hospital for his heart
condition to be monitored. His health and medication were reviewed regularly.
However, there were many occasions when he did not go to medical appointments
and refused to comply with the medication prescribed for him (or appeared to have
over-used the medication).
His health progressively worsened and, at the beginning of 2010, he had occasional
difficulty breathing, and his legs appeared swollen. He was seen by the prison
doctor and agreed to start taking medication again to alleviate these symptoms.
Shortly afterwards, the man was admitted into the in-patient healthcare unit at the
prison to enable him to be more closely assessed. The swelling in his legs was
increasing and noted as ‘significant’. Staff assisted him with personal hygiene and
his legs were regularly cleaned and dressed. A review by a doctor on 31 March
found that the man’s heart was not beating effectively and so his medication was
increased to control his heart rate.
Despite daily medical care, the man’s health further deteriorated. On 3 April, he was
admitted to North Manchester General Hospital. As a result of his worsening health,
the security restraints were removed and his family were permitted to visit without
prior arrangement with the prison.
On 12 April, the man’s condition grew worse and he refused to eat or drink, so
became dehydrated. The following day he had a parenteral line inserted in an
attempt to provide nutrients. However, his health continued to decline and he died in
the early hours of 15 April.
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THE INVESTIGATION PROCESS
1. Following notification of the man’s death, my colleague was appointed to
conduct the investigation. HMP Manchester provided a copy of his prison
records, including his medical records. Notices were issued to prisoners and
staff inviting anyone who had information regarding his death to make
themselves known to the investigator. No other witnesses came forward.
2. My colleague visited Manchester prison on 8 June. She met senior managers
there, and conducted recorded interviews with four staff.
3. Manchester Primary Care Trust (PCT) was commissioned to provide a clinical
review into the care provided for the man. A clinical reviewer was appointed to
conduct the review.
4. My colleague contacted Her Majesty’s Coroner to inform him of the nature and
scope of the investigation and request a copy of the post mortem report. Upon
completion, the investigation report will be sent to the Coroner to assist his
enquiries into the man’s death.
5. A member of the family liaison team contacted the man’s daughter on 21 May,
to inform her about the investigation and invite her to ask any questions or raise
any concerns about the care her father received in prison. The man’s daughter
said that she was aware he wrote to healthcare at the prison saying that he did
not always receive his medication for his heart condition in time, which was a
cause of concern. As she asked, I have considered this issue in my report.
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HMP MANCHESTER
6. HMP Manchester is part of the National Offender Management Service high
security estate. It is a complex prison holding those remanded by the courts
and prisoners convicted of serious offences, including category A prisoners and
those serving a life sentence. The maximum prison capacity is 1269 men.
There are two separate accommodation blocks.
7. There is a separate healthcare centre, incorporating inpatients, day care and
pharmacy facilities. Healthcare at Manchester is provided by Manchester
Primary Care Trust. The inpatient unit provides 24 hour nursing care for up to
20 patients.
Independent Monitoring Board
8. Each prison has its own Independent Monitoring Board (IMB), which is made up
of volunteers from the community. The Board’s role is to ensure that the prison
is properly run and that prisoners are treated fairly. Each Board produces an
annual report for the Secretary of State. The report covering the period of 1
March 2008 to 28 February 2010, is the latest report available. In their report,
the IMB made the following comments:
“Patients requiring specialist health services attend by appointment at one
of the local NHS Hospitals. As attendance at such appointments remains
conditional on the provision of escort officers, this often results in the
cancellation of the appointment for operational reasons.
“A specialist nurse for “older prisoners” has been appointed in the last
year. This is an important development, recognising the particular needs
of prisoners who are aged 55 or over. Patient visiting is conducted within
the prisoner’s own environment on the wings with a case load of
approximately fifty individuals being visited on a monthly basis.”
HM Chief Inspector of Prisons
9. A report covering the period 27 July to 31 July 2009, published by the then
Chief Inspector of Prisons noted that there was evidence of strong support from
the Primary Care Trust. This was reflected by an improvement to services and
greater access to a range of prison and specialist clinics. Pharmacy and dental
services were judged to have improved and there was efficient management of
external appointments to clinical services. Further comments included:
“Health services were commissioned by the Manchester Primary Care
Trust (PCT). The prison was strongly supported by the PCT, and there
were regular forums through which they met. The general manager for
specialist services with responsibility for prison health provided the direct
link with the prison; she had established excellent relationships with prison
staff and provided robust support to the whole team. A comprehensive
health needs analysis had been completed in 2008 and updated in 2009.
The prison director of health was a member of several committees,
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including the Prison Partnership Board and the Integrated Governance
Subgroup. Overall, there was good access to health services, most of
which were comparable to those found in the community. Health services
were delivered from discrete areas in the prison; the main healthcare
department was located adjacent to E wing, with treatment rooms on A, D,
E and I wings. In addition, there was a healthcare room in the reception
area.”
Previous deaths in custody
10. The man’s death was one of 32 to have occurred at Manchester since April
2004 when this office began investigating all deaths in prison custody in
England and Wales. Twelve of the previous deaths were due to natural
causes. There are no similarities between those deaths and that of the man.
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KEY EVENTS
2006-2009
11. The man was born in July 1941 and prior to coming into custody lived in
Manchester. He was convicted of sexual offences and sentenced to an
Indeterminate Public Protection sentence at Manchester Crown Court on 31
July 2007 (IPP - IPP means that offenders can be sentenced to life but must
have a minimum period of imprisonment specified at the time of sentence,
which is known as the tariff. Prisoners can be considered for release once the
tariff period has been served). His minimum tariff was 669 days. The man
spent his entire sentence at HMP Manchester, although between 28 June and
31 July 2007 he was remanded to HMP Preston.
12. Following his arrest, he was medically assessed by Manchester Police as part
of Operation Safeguard. (Operation Safeguard is put into place when there are
very few prison cells, and prisoners are instead held in police cells.) These
documents were available to HMP Manchester on his reception there on 1
December 2006. He said that he had a history of heart problems, angina,
bronchitis, chronic obstructive pulmonary disease (COPD) and was a smoker.
13. On reception, the man’s medical record listed his medication as: clopidogrel
bisalfate (used for heart conditions to stop clotting of the blood), digoxin (for
heart conditions), folic acid (a nutrient), furosemide (a diuretic), glyceryl trinitrate
spray (GTN) (for angina), quinine sulphate (to prevent heart arrthymia), ramipril
(for high blood pressure and heart disease), simvastatin (to address high
cholesterol), salbutamol (for COPD), Quvar (an asthma inhaler), atrovent (for
COPD), Dioralite (a mineral replacement drink) and emulsify ointment (for skin
conditions).
14. From 1 December 2006 to January 2010, the man had regular access to prison
doctors and healthcare staff and also went to hospital when his heart condition
was monitored. On 4 April 2007, however, while at court, he was suspected of
having a heart attack and was taken to Rochdale Infirmary. He discharged
himself the next day, and was taken to HMP Preston, where he remained for
the rest of his trial.
15. After being sentenced, he returned to Manchester. In reception, he was seen
by the first prison doctor, who did not assess him fully as there was no transfer
information. The first prison doctor arranged for some blood tests to be done,
and the man was seen the next day by a second prison doctor. The second
prison doctor undertook further observations and arranged for medication to be
prescribed.
16. The man’s medication was reviewed at appropriate intervals and he also had
blood tests taken, during which he was compliant with the treatment. There
were many instances when the man refused to take his medication, accept
treatment or attend healthcare and hospital appointments despite proactive
encouragement from healthcare staff. On each occasion that the man refused
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treatment, he signed a disclaimer stating that his refusal was against the advice
of the healthcare staff.
17. On one occasion, on 14 August 2009, the man requested a new supply of
furosemide a week before his previous supply should have run out.
(Furosemide is a diuretic which is often used to treat the symptoms of heart
failure by preventing water retention.) The pharmacy raised this issue with a
doctor, who decided that the man should no longer have this medication in
possession. (In possession medication is held by the prisoner; otherwise, each
dosage is dispensed by healthcare staff when required and is taken in front of
the member of staff.)
2010
18. On 22 January 2010, the first nurse who saw the man recorded that he refused
to collect his simvastatin medication, as he wanted to take it later in the
evening. He declined the opportunity to discuss this with a doctor. The man
raised this concern again with a third prison doctor on 9 February, when it was
agreed he could have the medication dispensed daily, to enable him to take it
later in the evening.
19. The first nurse recorded that, on the following two days, the man still refused to
collect his medication. The third prison doctor offered another appointment to
discuss the reasons. On 17 February, a second nurse recorded that the man
again refused to collect his medication. The clinical reviewer reports that,
because the man refused to attend medical appointments or collect his
medication, his prescription was stopped.
20. On 3 March, the first nurse recorded that the man’s blood pressure was 123/88
(The normal range for blood pressure is 100/70 to 140/90, although the
pressure varies throughout 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.) He was seen on the wing by healthcare
staff at the request of wing staff, as he had said he was unable to go to the
segregation unit due to being ‘constipated but having diarrhoea’. He was
observed by the first nurse to be breathing heavily and having trouble speaking,
although he was able to walk without assistance. His breathing became easier
and he was shown breathing exercises to calm himself. He was subsequently
able to walk to his cell.
21. The healthcare centre received another request from discipline staff at 6.45am
on 15 March. They were asked to assess the man, whose legs were swollen,
and a third nurse attended. She noted that the man was sitting in his chair
smoking, had swelling to both feet and legs and recorded his blood pressure as
129/81. The man confirmed that he had not been taking his medication, having
said that he was unable to access the treatment room on the 1’s landing (this is
the ground floor) as he was located on the 2’s (the first floor). He told the third
nurse that he did not believe his legs were any worse than they had been. It
was agreed that he should be moved to the ground floor to encourage him to
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collect his medication. An appointment was made for the man to be assessed
by the doctor later the same morning.
22. The man refused to attend this appointment. A further appointment was made
for the afternoon and the third prison doctor recorded that the man also refused
to attend this assessment. Instead, the doctor went to assess the man in his
cell, recording that he had occasional shortness of breath and swollen ankles
since stopping his medication. He sometimes slept propped up to help his
breathing. The man agreed to start taking his digoxin, ramipril, clopidogrel,
furosemide and simvastatin.
23. On 18 March, The second nurse recorded an improvement in the man’s
appearance and that he was walking better. Four days later, a telephone call
from discipline staff was received by healthcare, advising that the man was
having difficulty walking and his legs were swollen. He was unable to access
the showers, which are on the first floor, and he wanted to be admitted to
healthcare as an in-patient. A fourth nurse recorded that, following consultation
with the second prison doctor the man would not be admitted as an in-patient.
This would reduce his independence and was not comparable to the care he
would receive in the community (where he would not be treated as an in-
patient). However, consideration would be given to transferring him to a
different establishment with better facilities to meet his needs. In the interim, it
was proposed that the man should be transferred back to the first floor landing
to enable him to access the showers. Healthcare staff would take his
medication to him to further promote his cooperation and ensure that his
condition was regularly reviewed
24. However, following further concerns about the man’s health, it was agreed to
admit him to healthcare for a period of assessment. A fifth nurse recorded the
man’s blood pressure as 80/40. The swelling to his legs was recorded as
significant, but he was not suffering from shortness of breath and was lucid. He
was closely monitored throughout the day and provided with information to help
reduce the swelling and stiffness in his feet and knees. He was encouraged to
stay as mobile as possible as fluid was oozing from his feet and legs. The
man’s diuretics (which helps ease fluid retention) were increased and, later the
same evening, his blood pressure was recorded as 85/50.
25. The next morning, a sixth nurse recorded that the man had an unsettled night
as his legs continued to ooze fluid and remained swollen. His blood pressure
was recorded by the nurse as 100/60. The man was assisted to bathe, and his
legs were dressed as they were still oozing fluid. The man continued to eat and
drink independently, was able to move around his cell and made no complaint
of pain or discomfort.
26. On 26 March, The fifth nurse recorded that his blood pressure was 90/55. The
care plan was reviewed and was consistent with his medical needs. His lower
legs and feet remained swollen and oozing fluid, but the man was able to wash
independently and move around his cell. Later the same day, the second
prison doctor recorded that the man had lost two kilograms in weight in the
three days since he was admitted to in-patients. His legs remained swollen and
10
while the man said that he experienced no shortness of breath, the prison
doctor recorded that there were reduced breath sounds and crackles in his
chest.
27. Over the following four days, healthcare staff recorded that the man was
assisted with his personal hygiene, his legs were regularly dressed and he was
encouraged to raise his legs when sitting. On 31 March, a fourth prison doctor
reviewed the man. The doctor recorded that his heart was not beating
effectively and increased the digoxin medication to control the heart rate. The
fourth prison doctor consulted the medical registrar at North Manchester
General Hospital, to discuss changes in his medication as blood tests had
shown that the man had reduced sodium levels, which could result in an
admission to hospital. The Care Plan was reviewed and remained relevant.
The man remained in the healthcare centre overnight.
28. The man’s blood pressure was recorded as 92/67 on 1 April. He reported that
he slept intermittently and was again encouraged to elevate his legs. The
second prison doctor assessed the man and recorded that he felt weak. The
doctor noted that the increased digoxin had improved his heart rate but there
remained concerns regarding the diuretics affecting sodium levels. An
electrocardiogram (ECG, a test to measure the electrical output of the heart)
was requested and blood tests were taken and sent for urgent review. The fifth
nurse recorded that, when she contacted the Oldham biochemistry laboratory,
they reported not receiving the blood sample. A second medical registrar at
North Manchester General Hospital, was consulted and advised that a further
blood sample should be taken the following morning.
29. On 2 April, the man’s blood pressure was recorded as 83/60. He was moved to
a different cell that provided more space. He was also given a hospital bed,
where he was able to elevate his legs, which were redressed. The second
prison doctor reviewed the ECG results from the previous day and was not
unduly concerned. He noted that the man’s breathing had improved as had the
swelling to his legs. Later the same day, the blood test results revealed that the
man’s sodium level had dropped slightly. Following consultation with a third
medical registrar at North Manchester General Hospital, the second prison
doctor agreed to stop the furosemide and increase the ramipril.
30. The next day, the man reported that he slept well during the night and was
sitting up in bed watching the television. Later the same morning, his blood
pressure was recorded by a seventh nurse as 74/59. An hour later it was
recorded as 81/51 and further blood tests were taken. The man’s condition
deteriorated, he became very drowsy and less responsive and he was admitted
to North Manchester General Hospital.
31. A risk assessment must be completed when prisoners go to hospital
appointments. This determines the level of escort and the restraints
(handcuffs) required for the safe custody of the prisoner. Restraints are applied
if the risk assessment states they are necessary, and prison staff are allocated
to escort for the prisoner. When a prisoner is admitted to hospital, prison staff
carry out a bed watch duty and complete a log of activities. A regular
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management check of the bed watch is carried out by a duty governor. Visits
from the family may be allowed but they are closely monitored to ensure that
they do not impinge on the security of the bed watch.
32. The risk assessment will consider the following:
(cid:127) The prisoner’s medical condition. When there is doubt, the prison’s
medical officer will be asked to advise on any medical objections to the
use of restraints.
(cid:127) The prisoner’s behaviour in prison.
(cid:127) Home circumstances.
(cid:127) The nature of the offence (criminal history), the risk to the public and
hospital staff, including the risk of hostage taking.
(cid:127) The prisoner’s motivation to escape, likelihood of outside assistance
and their conduct whilst in custody.
(cid:127) The physical security of the hospital.
(cid:127) There will also be an assessment of visits restrictions.
33. According to the policy for performing hospital bed watches in force when the
man was in hospital, the following options were available to the Governor:
(cid:127) Escort and bed watch with two officers or more, with restraints.
(cid:127) Escort and bed watch with two officers or more, without restraints.
(cid:127) Escort and bed watch with one officer, without restraints.
34. Following this risk assessment, the Duty Governor authorised that the man
would be escorted by two prison officers and an escort chain used. (The escort
chain allows one of the escorting officers to be handcuffed by wrist to the
prisoner’s wrist via a chain and allows greater access of treatment and
comfort.)
35. Over the next few days, the man‘s ramipril was discontinued in order to try to
regulate his blood pressure. He also received intravenous anti-biotics for
cellulitis (skin infection) in his legs. Healthcare staff reported that he did not
cooperate with taking oxygen and also refused to eat. On 9 April, the third
nurse from HMP Manchester healthcare centre visited North Manchester
General Hospital and was advised that the man was very unwell. A consultant
advised the nurse that they had requested an urgent
oesophagogastroduodenoscopy (OGD, a procedure in which a camera is
inserted into the oesophagus) and that the man had refused to be fed via a
tube.
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36. The man was visited by the third nurse again at 10.45am, who obtained his
authority to retain a copy of his medical record. The chaplaincy department
were alerted to the man’s condition and contacted his next of kin. The man was
encouraged to have a feeding tube, but despite several attempts to get him to
agree, he declined and was placed on an intravenous drip. At 1.50pm, the man
was visited by the Operations Governor. Permission was given for all restraints
to be removed due to his deteriorating medical condition. Visits from the man’s
family would be allowed, although they had to be arranged with the prison. The
man’s daughter visited later that day, and stayed for approximately 90 minutes.
She was given permission for the man’s son to visit from Cyprus.
37. Over the next few days, the man continued to receive medical care and
encouragement to eat. He also received further visits from his family. On 12
April, the man’s condition continued to deteriorate and he refused to eat and
drink and became dehydrated. An eighth nurse recorded that the hospital were
considering returning the man to the prison for nursing care. There was no
significant improvement or decline in the man’s condition the following day. He
was taken to theatre where a parenteral line (which provides nutrition though a
vein) was inserted. .
38. On 14 April at 8.55am, the man’s daughter was contacted and advised to visit
because of her father’s continuing decline. The officer who was performing
bedwatch duties, contacted Senior Officer (SO) at the prison who confirmed
that visits were unrestricted and did not need to be booked through the prison.
The man received a visit from his daughter and son at 11.55am. They were
advised of his condition and life expectancy and stayed for much of the day. At
2.55pm, the Security Governor visited.
39. Following a continuing decline, at 2.29am the next morning, the man was
pronounced dead. An officer rang the prison control room to inform them of the
man’s death. A second prison governor, was contacted at home and told that
the man had died. He attended the prison as possible, to ensure that the
prison’s contingency plans for a death in custody were adhered to correctly and
support staff present when the man had died.
40. A prison chaplain who had spoken to the man’s family in the preceding few
days was also contacted at home and told that he had died. The chaplain
contacted the ward sister at the hospital who confirmed that she had already
contacted the man’s family.
41. The second prison governor carried out a de-brief with the staff who had been
with the man when he died and ensured that they were aware of on-going
support available to them.
42. The prison contributed towards the funeral costs and staff from the prison
attended.
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ISSUES
First reception health screening
43. The man was transferred to Manchester from Preston in July 2007. He did not
undergo an initial assessment at Manchester, as he was transferred there from
another prison, and had been at Manchester only a few months previously.
(The man had been moved to Preston after being taken to hospital after
suffering a suspected heart attack at court.) However, he did see a doctor the
day after he arrived and had his medication reviewed at that stage.
44. Current guidance on the reception of prisoners is contained in Prison Service
Instruction (PSI) 52/2010, “Early Days in Custody”. This replaced the previous
Prison Service Order 0500, which dealt with reception. PSI52/2010 states, at
paragraph 2.36, that:
“Prisoners spending their first night in the current prison following transfer
from another establishment may undergo the detailed medical assessment
on the following day, (or if this is not possible, no later than one week after
arrival) unless there are urgent health issues that must be addressed on
the day of arrival. “ (The italics in the quote mean that this section is
mandatory.)
It is clear that, given the current instruction, it was appropriate for the man not
to see medical staff when he returned to Manchester, assuming that he had no
immediate medical needs. At the time, it was not local practice to re-screen
when a prisoner was transferred from another prison. Although he had only
gone to Preston after being taken to hospital with a suspected heart attack, he
had discharged himself the next day. In the circumstances, I believe that he
was treated appropriately when he returned to Manchester.
The man’s non compliance with treatment
45. Throughout his time in custody, the man often did not take his medication or
chose not to attend appointments with healthcare staff. Despite advice to the
contrary, the man remained a heavy smoker. Overall, from the medical record,
it seems that the man was offered advice on many occasions, but he often
declined to accept it. I believe that healthcare staffed acted appropriately when
trying to encourage the man to comply with his medical regime, but that he
chose not to do so.
Whether the man was refused appropriate medication
46. The man’s daughter told my investigator that she had seen a copy of a letter he
wrote to healthcare saying that he did not always receive medication for his
heart condition in time. There does appear to have been one occasion, in
August 2009, when the man requested furosemide but was refused as he had
already received it. As a result, he was no longer allowed to hold his
medication in his own possession.
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47. In 2010, the man continued to refuse to take his medication. As a result, his
prescription was stopped in February, after he refused to attend several
appointments with medical staff. The medication was prescribed again on 16
March, after the second prison doctor went to see the man (the man had, again,
refused to attend an appointment).
48. I believe that these might be the occasions that the man’s daughter is referring
to. While these events have been noted by the clinical reviewer in her clinical
review, she has not made any recommendations or made any adverse
comment on this issue. I accept that staff at Manchester acted appropriately in
their dealings with the man and his medication.
Overall assessment of the care provided to the man
49. The clinical reviewer has found that, despite continual attempts, healthcare staff
found it difficult to engage the man and help him maintain a routine. She
judged that he was treated appropriately when he was an in-patient. The
clinical reviewer has not made any recommendations as a result of her review.
The man’s time in hospital
50. When a prisoner is escorted to hospital, a risk assessment is made as to the
level of restraint and escort that is used. I am pleased to note that the
assessment was reviewed regularly, and that restraints were removed at an
appropriate time.
51. I am also pleased to note that contact was established with the man’s family,
through the chaplaincy department, soon after he was taken to hospital. Again,
I believe there was a good reassessment of his condition, leading to the
decision to allow unrestricted visits that did not have to be booked through the
prison.
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CONCLUSION
52. The comprehensive clinical review found that while the man was in prison he
chose to take responsibility for managing his medical condition. However, his
compliance with medical advice and taking medication was inconsistent.
53. The man had a progressive chronic condition which was managed by
healthcare staff within the constraints of his compliance. He failed to attend
many doctor’s and hospital appointments. Of course, as in the community, the
man had the right to choose to do so. He was made aware by staff of the
consequences of not accepting treatment.
54. I believe the man received a great deal of medical input during the final weeks
of his life. Prison healthcare remained in contact with the hospital, and were
therefore able to provide him with up to date and appropriate care for the
management of congestive cardiac failure. When eventually he was admitted
to hospital, the risk assessment was revised and, as he deteriorated, the
restraints were completely removed. I am sure that seeing her father without
restraints and being allowed open visits made the circumstances easier for the
man’s daughter.
55. The Prison Service received the draft report. They commented that they had
identified no issues or inaccuracies in the report.
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