Individual at Littlehey

Investigation into the death of a man whilst in the custody
of HMP Littlehey in August 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
This is the report of an investigation into the circumstances surrounding the death of
the man, a prisoner at HMP Littlehey. The man died in August 2009. He was 53
years old. A post mortem showed that the cause of his death was acute pancreatitis
and chollithiasis.
I offer my sincere sympathy and condolences to his family, as I do to all of his friends
and acquaintances who are touched by his passing.
The investigation was carried out on behalf of the Ombudsman by my investigator.
Both he and I would like to thank the Governor of HMP Littlehey and all the staff for
their full and ready co-operation during the course of our enquiries. I also thank the
clinical reviewer for the clinical review he led on behalf of Cambridgeshire Primary
Care Trust (PCT).
This report recognises that the clinical care and consideration given to the man and
his family by the staff, in particular to the prison liaison officer. I make one
recommendation regarding the payment of funeral expenses and recognise four
areas of good practice.
The version of my report, published on my website, has been amended to remove
the names of the woman/man who died and those of staff and prisoners involved in
my investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman January 2010
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CONTENTS
Summary
The investigation process
HMP Littlehey
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was convicted and remanded to custody on 12 May 2005. He was
subsequently sentenced to seven years imprisonment on 21 June 2005, with a non
parole release date of 10 January 2010. He had a history of anxiety, eczema, and
was a smoker.
When he arrived at HMP Bullingdon, the man had a First Reception Health Screen
conducted by a nurse. He told the nurse that he had seen his doctor prior to
entering prison and was taking medication. On 14 July the doctor who saw him and
recorded that he suffered from insomnia, depression and anxiety. The doctor
increased in his antidepressant medication.
Between 13 October 2006 and 21 May 2007, the man was seen by another prison
doctor on 14 separate occasions for anxiety and eczema. By 11 October, the doctor
also diagnosed that he had asthma.
The man transferred to HMP Littlehey on 19 December 2008. At the reception
screening the reception screening nurse recorded that the man was taking
medication for depression, was asthmatic and used inhalers, and suffered from
eczema.
The man saw the prison doctor on 29 January 2009, who recorded that he was
breathless on moderate exertion and questioned whether he suffered from chronic
obstructive pulmonary disease (COPD). The same doctor saw him two weeks later
and confirmed the diagnosis of COPD for which he prescribed an inhaler.
On 26 July, following concerns from staff on the man’s houseblock, and following an
assessment by a nurse, he was taken to Hinchinbrooke Hospital for treatment. The
next day the Deputy Governor, after obtaining medical opinion, authorised the man’s
release on temporary licence to the hospital.
Healthcare staff from Littlehey maintained daily contact with the hospital to obtain
updates on the man’s condition but his prognosis was very poor. The prison family
liaison officer contacted members of the man’s family and made arrangements for
them to visit the hospital.
In August at 00.45am, the man died with family members at his bed side. The prison
family liaison officer went to the hospital and remained with them until 3.00am. Later
that day, the prison contacted the man’s other relatives to inform them of his death.
The prison also offered financial assistance towards the cost of the funeral.
The clinical reviewer highlights that the care the man received at Littlehey was
equivalent with what he would have expected in the community. I make one
recommendation and recognise areas of good practice in maintaining medical
records, the use of restraints, the release on temporary licence and family liaison.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 7 August 2009 when my investigator issued
notices to staff and prisoners. The notices included an invitation to those who
wished to submit information relating to the man’s death to make themselves
known. No one came forward as a result.
2. My investigator visited HMP Littlehey on 13 August. During his visit he was
given copies of all the documentation relating to the man. They included his
main prison record and medical records. He also visited the houseblock to see
the man’s cell.
3. A clinical reviewer was appointed by Cambridgeshire Primary Care Trust to
carry out a review of the man’s clinical care. My investigator and the clinical
reviewer discussed aspects of the man’s treatment and care whilst he was at
Littlehey. I am grateful to the clinical reviewer for providing such a considered
review.
4. My investigator contacted HM Coroner to inform him of the nature and scope of
my investigation and to request a copy of the post mortem report. Upon
completion, this report will be sent to the Coroner to assist in his enquiries into
the man’s death.
5. One of my family liaison officers contacted the man’s family to inform them of
the investigation. The man’s mother and brother said that they did not have
any concerns. They stated that they were grateful to the staff at Littlehey for
their sympathetic and professional manner.
6. My family liaison officer and my investigator later met part of the man’s
extended family, who raised the following concerns:
(cid:127) They had not been informed that he had been admitted to hospital.
(cid:127) They were not informed that he had died.
(cid:127) There were difficulties meeting the costs of the funeral expenses.
(cid:127) They had not received his belongings.
(cid:127) They had not received equal treatment from the staff at Littlehey
7. I have attempted to address the issues raised within the report and I hope that it
provides a better understanding of the treatment he was given and the events
following his death.
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HMP LITTLEHEY
8. HMP Littlehey is a category C prison. It can hold 726 male offenders. It first
opened in 1988 and has eight residential wings. Three additional units have
been added since the prison was originally built, and all the rooms on these
units have privacy locks and en suite showers.
9. Approximately ten per cent of the prisoners are serving life sentences. A small
proportion of the prisoners are category D which enables them to work outside
the prison. The prison offers sex offender treatment programmes, as well as
extensive industrial work and education opportunities.
10. The prison was most recently inspected by HM Chief Inspector of Prisons
during an announced inspection between 2 and 6 July 2007. In her subsequent
report, the Chief Inspector commented:
“This full announced inspection confirmed that Littlehey remained an
impressively safe prison, with mutually respectful staff-prisoner relationships,
a reasonable amount of purposeful activity and an appropriate focus on
resettlement. Health services were adequate, although some waiting lists
were long. Mental health in-reach services were particularly well integrated
into the work of the establishment. Littlehey remains an impressive and
improving prison, able to work effectively with some very high risk prisoners.
It provides a fundamentally safe and respectful environment, in which
prisoners are generally occupied purposefully. Some impressive
interventions are available for sex offenders. Inevitably, there is scope for
improvement but, overall, staff and managers are to be commended on what
they have achieved so far.”
11. The latest Independent Monitoring Board annual report was for the period
ending January 2009 and the report contained following comments:
“The Board considers that overall Littlehey continues to be a well-run
establishment where prisoners live in a safe and respectful environment.”
“Healthcare continues to operate well, despite an increase in the prison
population during the period of review, and received a positive report
following an audit conducted by the area team.”
“The core team, which is NHS run, is supported by other skilled technicians
on a county wide basis to meet the needs of the prisoners, including the
provision of Psychotherapy and Psychology.”
“The Healthcare centre runs a number of pro-active initiatives including a 10
week smoking cessation course which currently has a long waiting list. Other
clinics include those for diabetics, asthmatics and prisoners with heart or
lung disorders.”
12. Provision of healthcare is the responsibility of Cambridgeshire Primary Care
Trust with the general practitioner service being provided by a local GP
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practice, and therefore does not provide 24 hour cover. Medication is
administered every week or month to those prisoners who have been risk
assessed as suitable for holding it in their own possession. It is administered
on a daily basis to other prisoners, when either they are judged to be at risk or
the medication is considered unsuitable to be held in their possession.
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KEY FINDINGS
13. The man was born in November 1955. He was divorced and had two sons and
a daughter. He was convicted and remanded to custody on 12 May 2005, and
subsequently sentenced to seven years imprisonment on 21 June 2005, with a
non parole release date of 10 January 2010. The man had a history of anxiety,
eczema, and was a smoker.
14. When the man was remanded in custody, he was sent to HMP Bullingdon. On
arrival there he had a First Reception Health Screen conducted by a nurse.
(The health screens are conducted to obtain a brief confidential medical and
psychiatric history from the prisoner to ensure that he receives the appropriate
medical treatment and medication as required.) The man told the nurse that he
had seen his doctor before coming into prison and was taking medication of
Propranolol (used to treat anxiety) and Diprobase (used to treat eczema).
15. He also told the nurse that he smoked twenty cigarettes daily and had no
intention of attemping to give up. He said that he had never used illicit drugs in
the past. His blood presssure was taken and recorded as 130/78. (The normal
range for blood pressure is 100/70 to 140/90, although the pressure does vary
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 gave the details for his next of kin, as his father
who lived in Cheshire.
16. On 21 June, the man saw the nurse in reception following his court appearance
and recorded that he said that he felt well at that time as he had been expecting
a longer sentence than seven years. The nurse advised him to contact
healthcare straight away if he felt he was unable to cope.
17. One week later he saw a nurse in healthcare and said that he was not sleeping
and experienced both tremor and panic attacks. The nurse referred him to see
the prison doctor. The first prison doctor, saw him on 14 July and recorded that
he suffered from insomnia, depression and anxiety. His blood pressure was
recorded as 120/80. The doctor prescribed an increase in Propranolol from
40mg to 80mg and Mirtazapine 30mg (an antidepressant).
18. The prison doctor reviewed him a month later and, because he said he felt
worse, increased the prescription of Mirtazapine to 45mg. A second prison
doctor, saw him on 25 November, and recorded that he felt very well and he
was to continue with the same dose of medication.
19. On 23 February 2006, he again saw the second prison doctor who recorded
that he had experienced side effects from taking his medication and wanted to
reduce the amount of Mirtazapine. The doctor also recorded that his blood
pressure was 180/100. He reduced the dosage of Mirtazapine to 30mg but
maintained the level of Propranolol.
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20. The second prison doctor next saw him on 31 March. He diagnosed that he
had dermatitis, and recorded that his blood pressure was 150/88. The doctor
prescribed Dermovate cream (a corticosteriod cream used to treat skin
disorders).
21. Between 13 October 2006 and 21 May 2007 he saw the second prison doctor
on 14 separate occasions for anxiety and eczema. The doctor continued with
the medication of Propranolol, Mirtazapine and Dermovate cream.
22. On 20 June, he returned his medication of Propranolol and Mirtazapine to
healthcare. The Healthcare Officer (HCO) recorded that the man said that he
did not want to take any more medication.
23. On 29 August, Bullingdon was contacted by the man’s ex-wife, in a letter dated
27 August. She requested the removal of her contact details from all the prison
records and asked that all contact with her and the children was to cease. The
prison replied by letter the same day informing her that her telephone number
had been blocked, all mail would be blocked and the children’s names were
removed from the authorised visitors list. The man was informed, by interview,
that all contact with his ex-wife and children was to cease
24. By 11 October, the man was experiencing both depression and anxiety, as well
as eczema. He saw the second prison doctor who prescribed the previous
level of Mirtazapine and Betnovate cream (used to treat eczema). The doctor
also diagnosed that he had asthma and prescribed a Salbutamol inhaler (used
to treat asthma).
25. Two weeks later the man saw a third prison doctor, who reviewed the treatment
given for asthma. The doctor recorded that the Salbutamol had made some
improvement to the man’s breathing, but he still experienced shortness of
breath. The doctor prescribed a Beclometasone inhaler (used to treat asthma)
in addition to the Salbutamol.
26. The third prison doctor next saw the man on 7 February 2008. The doctor
reviewed the medication for eczema and recorded that he had an eczema rash
on his face and prescribed hydrocortisone cream (used to treat skin disorders)
and a continuation of the same dose of Mirtazapine. The same doctor saw the
man four weeks later and noted that he had dry skin with several eczema
patches on his arms, upper legs and back. The doctor prescribed Clobetasol
Propionate ointment (used to treat skin disorders), Dermol shower emollient (a
dermalogical neutral shower gel) and E45 cream.
27. The man saw a fourth prison doctor, on 4 September, who reviewed his
asthma. The doctor recorded that the man said he had stopped smoking five
months ago, he was not coughing but still got breathless on going up stairs.
The doctor continued with the Salbutamol and Beclometasone.
28. Five weeks later, the man was seen by a fifth prison doctor, who recorded that
he had cellulitis (an infection of the skin) on his lower right leg and prescribed
Flucloxacillin (an antibiotic used to treat skin infections). The doctor also
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recorded that the man’s mood was stable and he had no sleeping difficulties,
and therefore continued with the same level of Mirtazapine.
29. The man was transferred to HMP Littlehey on 19 December. At the reception
screening the nurse recorded that the man had been prescribed Mirtazapine for
depression, was asthmatic and used inhalers, had eczema for which he used
E45 cream and took his blood pressure which was 175/92.
30. On 29 January 2009, the man was seen by a sixth prison doctor, who recorded
that he was breathless on moderate exertion. The doctor wondered whether he
suffered from chronic obstructive pulmonary disease (COPD) which is the
narrowing of the airways causing shortness of breath. The doctor also noted
that the man had a few patches of eczema on his legs and abdomen. The
doctor prescribed a Seretide inhaler and a Ventolin inhaler (both used to treat
asthma). He saw the man two weeks later and confirmed the diagnosis of
COPD and prescribed a Tiotropium inhaler (used to treat COPD).
31. The man next saw the sixth prison doctor on 12 March, when the doctor
reviewed the treatment for COPD. The doctor recorded that he was able to
walk up stairs without the need to stop. He decided to continue the same
medication and advised him to exercise.
32. On 25 July at 7.00pm, a member of wing staff went to see the man as he
complained of stomach pain and had been sick. The staff member rang the out
of hours doctor service who recommended that he was sent to the emergency
department at the local hospital. The member of staff gave the doctor’s advice
to the man but he refused to go to hospital.
33. At approximately 8.30am on Sunday 26 July, a nurse responded to a call from
staff on the man’s wing as they were concerned about his medical condition.
The man told the nurse that he had felt pain in his abdomen since 6.00pm the
previous evening and had been vomiting since the early hours of the morning.
The nurse contacted the on-call doctor by telephone and gave the detail of the
man’s symptoms. It was agreed that he was to be transferred to hospital for
assessment and treatment.
34. The man was taken to Hinchinbrooke Hospital by taxi, escorted by two prison
officers. The bedwatch risk assessment was authorised by a Senior Officer
(SO) who stated that single cuffs were to be used. They would be removed
with Duty Governor’s approval to allow medical treatment and, without
approval, for life saving intervention if necessary. By 9.00pm, the man’s
condition had deteriorated significantly. One of the officers on escort contacted
Littlehey and the Deputy Governor gave the authorisation to remove all
restraints.
35. The next day at 12.00pm, the Deputy Governor reviewed the bedwatch risk
assessment and, due to the man’s condition, amended the escort to one officer
with no restraints. Later the same day, after receiving medical advice from the
hospital, the Deputy Governor authorised the man’s release on temporary
licence to Hinchinbrooke Hospital.
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36. The same day the prison family liaison officer contacted the man’s father who
he had named as his next of kin. Regretably when the prison family liaison
officer telephoned, the man’s mother answered and told the prison family
liaison officer that his father had died three months earlier. As the man’s
mother and brother lived in Cheshire, which is a considerable distance from
Littlehey, the prison family liaison officer organised accommodation for them in
a local hotel for the following night.
37. On 28 July, the prison family liaison officer met the man’s mother and brother at
the hotel and accompanied them to the hospital where they had the opportunity
to speak with the doctor. The following day, the prison family liaison officer met
his mother and brother at the hospital who said that they were returning home
that day but planned to return when there was a change in his condition.
38. Healthcare staff maintained daily contact with the hospital to obtain updates on
the man’s condition. The hospital had made the diagnosis of acute pancreatitis
(sudden inflammation of the pancreas which can have severe complications
and high mortality despite treatment). By 29 July the prognosis was judged to
be very poor.
39. On 4 August, the hospital contacted the prison family liaison officer and asked
that the man’s mother and brother be contacted as his condition had further
deteriorated. The prison family liaison officer spoke to the man’s brother who
said that he and his mother would visit the hospital and expected to arrive at
9.00pm that evening.
40. The prison family liaison officer contacted the hospital the following day and
was informed that the man’s mother and brother had been at the hospital all
night. The prison family liaison officer went to the hospital in the afternoon to
meet them and remained at the hospital until 7.00pm.
41. At 00.50am on 6 August, the hospital contacted the prison family liaison officer
to say that the man had died at 00.45am. The immediately went to the hospital
to be with the man’s mother and brother and stayed with them until 3.00am.
42. Later that day Deputy Governor and the prison family liaison officer met the
man’s mother and brother at their hotel to offer condolences and further
support. Deputy Governor was made aware of the man’s extended family and
contacted his ex-wife so that his children could be informed of his death.
43. In the days that followed the prison family liaison officer maintained contact with
the various members of the man’s family and arranged for them to visit
Littlehey. The family were in disagreement over the funeral arrangements, and
eventually the man’s ex-wife took over the arrangements. The prison offered
financial assistance towards the cost of the funeral. The man’s ex-wife
informed the prison that she was applying for financial assistance towards the
cost of the funeral, which she expected to be in the region of £800. She
discussed with the Deputy Governor the amount of money in the man’s prison
account and whether it could be used in lieu of financial assistance.
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44. When the man’s ex-wife visited Littlehey on 8 August, she gave the Deputy
Governor a letter authorising the use of money from his prison account. The
prison used this money for the funeral and offered to pay the balance. The
Deputy Governor assured her that the prison would ensure that at no point
would she be placed in financial difficulty.
45. Due to the disagreements between the man’s family the Deputy Governor
sought advice from the National Offender Management Service (NOMS) about
the dispersal of the man’s money and personal effects. The written advice was
received on 11 August, which stated:
“None of the prisoner’s money or personal effects should be released to any
one member of the family without the prison receiving a ‘Grant of letters of
administration’. The family, or their solicitor, will have to apply to the
Probate Registry and the person(s) who are in receipt of the Grant will then
become the ‘administrator’ of the deceased’s estate. This should be
explained to the prisoner’s relatives when necessary.”
46. The Deputy Governor told the man’s ex-wife of the requirement to obtain the
letters of administration on 26 August. Following the funeral the funeral
directors sent their invoice directly to the prison, who paid them direct. Since
the funeral the prison has not received any contact from any of the man’s family
regarding his estate.
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ISSUES
Clinical care
47. The clinical reviewer considered the care that the man received whilst in
custody and concluded that it was equitable to that which he could have
expected in the wider community. The review also stated that all NHS policies
and procedures were followed.
48. The review did consider whether the man’s death could have been avoided. In
the review the clinical reviewer stated:
“Acute pancreatitis is a sudden inflamation of the pancreas. Depending on
its severity, it can have severe complications and high mortality despite
treatment.”
49. The review highlighted good practice in record keeping, and specifically stated:
“Record keeping at both HMP Bullingdon and HMP Littlehey was of a high
standard with clear, consecutive entries which were easy to follow and the
person responsible for entering the clinical record was clearly stated. The
high standard was maintained throughout the notes.”
Use of restraints and release on temporary licence
50. Unfortunately there have been too many reports in which the Ombudsman has
been critical of the use of restraints when prisoners are escorted at outside
hospital. As soon as the man’s condition deteriorated, the Deputy Governor
gave the order to remove all restraints. It is pleasing therefore to recognise the
good practice adopted by Littlehey.
51. I also recognise the good practice adopted by Littlehey in taking appropriate
action after medical advice was received by releasing the man on temporary
licence. This ensured that he was treated with dignity and respect during his
final days in hospital.
Family Liaison
Liaison with the nominated next of kin
52. PSO [Prison Service Order] 0500 (Reception) makes it clear that “Staff must
ask prisoners for the name, address and telephone number of their next of kin
and accurately record the information.” PSO 2710 (Follow-up to deaths in
custody) instructs prisons to “Arrange notification to the next of kin and any
other person reasonably nominated by the prisoner.” The prison will therefore
only contact the nominated next of kin, and will often not have details or
knowledge of anyone else.
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53. When the man was admitted to hospital, Littlehey correctly contacted his father,
the nominated next of kin. On making contact with the nominated address, the
prison were informed by the man’s mother that his father had sadly died.
Nevertheless she was told about the seriousness of the man’s illness.
54. The man’s mother and brother told my family liaison officer that they were very
impressed with the care service offered by the prison and I recognise the good
practice followed by the prison family liaison officer.
Liaison with the extended family
55. The extended family only became known to the prison after his death. On
being made aware of them, the prison contacted them by telephone. The
man’s ex-wife has asked why she and the children had not been told that he
was in hospital.
56. Bullingdon had received a letter from the man’s ex-wife, dated 27 August 2007,
requesting that all communication with him was to cease. The prison provided
written confirmation, dated 29 August 2007, stating that all forms of
communication with her ex-husband, and between him and his children, would
cease. Littlehey, therefore, correctly followed the instructions in PSO 2710 by
only using the next of kin details given by the man.
Payment of funeral expenses
57. The family were in disagreement over the funeral arrangements, which placed
Littlehey in the position of needing to maintain contact with the various family
members. The man’s ex-wife took over responsibility for the funeral
arrangements and she informed Deputy Governor that she was applying for
financial assistance towards the cost of the funeral expenses. She said that
she expected to receive £800, and the prison offered to pay the balance of the
funeral costs.
58. However the man’s ex-wife could not afford to pay out any monies without
receiving financial assistance. The Deputy Governor assured her that the
prison would ensure that she would not be placed in financial difficulty. The
amount of money in the man’s prison account was discussed and his ex-wife
provided the prison with a letter of authority on 8 August for the transfer of
money out of this account as part payment towards the funeral costs.
59. On 11 August Littlehey received the advice from NOMS headquarters regarding
the man’s estate. This advice meant that no monies should have been taken
from the man’s account, and indeed as they were divorced, his ex-wife had no
authority over his account.
60. When my colleagues visited the man’s ex-wife, she said that she was not
entitled to claim any financial help because she was divorced. She said that
she had told the Deputy Governor this, although the prison has no record or
recollection of this being said.
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61. PSO 2710 states that prisons should offer to pay a reasonable contribution
towards funeral expenses. The figure quoted in this PSO is £3,000. It also
specifically states “This offer should be made irrespective of whether the family
is entitled to claim a grant from the Social Fund.” Therefore Littlehey should not
have taken into account any potential claim for other financial assistance, or
used money from the man’s personal account.
62. Littlehey correctly paid the funeral directors direct. On consideration of the
facts presented, I expect the man’s personal account to be reimbursed, from
prison funds, for the amount taken towards meeting the cost of the funeral
expenses.
I recommend that the Governor ensures the prison adheres to the
instructions contained within PSO 2710 in regard to the offers to pay
funeral expenses.
63. I fully appreciate the difficult time experienced by all family members on the loss
of someone close. I am satisfied, however, that overall Littlehey dealt with the
difficult circumstances following the man’s death in a sensitive and
compassionate manner.
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CONCLUSION
64. I am satisfied that the man received a standard of care in prison that was
equitable to that which he could have expected in the community. The clinical
review confirms that the cause of his death could not have been predicted or
prevented.
65. My report recognises the good practice adopted by Littlehey regarding the use
of restraints and the release on temporary licence. I also recognise the good
practice adopted by the prison family liaison officer, in the sensitive and
professional manner in dealing with the man’s mother and brother in the period
following his admission to hospital.
66. Following the man’s death, Littlehey were faced with the difficulty of dealing
with the various members of his extended family who were in disagreement
about the funeral arrangements. I am satisfied that overall Littlehey managed
this difficult situation in the most compassionate way possible. However I do
make a recommendation regarding the offer of payment of funeral expenses as
I find the use of money from a prisoner’s personal account inappropriate.
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RECOMMENDATIONS
1. I recommend that the Governor ensures that the prison adheres to the
instructions contained within PSO 2710 in regard to the offers to pay funeral
expenses.
Accepted. The prison service has accepted this recommendation, and has
reimbursed £800 back into the man’s personal prison account.
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