Individual at Dovegate

Investigation into the circumstances surrounding the
death of a man at HMP Dovegate,
in October 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2010
This is a report into the death of a man at HMP Dovegate in October 2009. The man
was 68 years old. A post mortem showed that he died from ischaemic heart
disease. I offer my sincere condolences to the man’s family and friends for their
loss.
The investigation was carried out on my behalf by my colleague who is one of the
investigators. We would like to thank the Director of HMP Dovegate and his staff, in
particular Head of Operations for their co-operation during the course of our
enquiries. I also thank South Staffordshire PCT for the appointment of the clinical
reviewer.
As the man died from natural causes, the findings of the clinical review play a critical
part in my report. The review shows that the man had a reasonable standard of care
whilst he was in custody, although there were some shortcomings that should be
addressed.
I endorse the recommendation made in the clinical review concerning cancellation of
hospital appointments. The man missed 14 appointments, the majority cancelled by
Queens Hospital. I am disappointed to repeat this recommendation and ask the
Director, Head of Healthcare and PCT to urgently address this matter. I endorse the
recommendations made concerning medical record keeping and the need to follow
clinical instructions to undertake blood pressure checks. I draw the attention of the
Director and Healthcare Manager to the other recommendations in the clinical
review. I also make one recommendation concerning breaking the news of a death
to the bereaved family.
Jane Webb
Acting Prisons and Probation Ombudsman June 2010
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CONTENTS
Summary
The Investigation Process
HMP Dovgate
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was born in October 1941, and lived in the London area prior to his
conviction on 15 June 2005 when he was remanded into custody at HMP Liverpool.
On arrival it was recorded that he had experienced three heart attacks in the past
and was taking medication for angina, high blood pressure and cholesterol.
The man was sentenced to 22 years in custody on 30 October 2006, and remained
at Liverpool until he was transferred to HMP Dovegate on 19 March 2007. He
continued to take his medication, which was regularly reviewed by one of the prison
doctors.
The doctor referred the man to a consultant cardiologist on 4 April 2007. There were
14 cancelled or rescheduled appointments before he saw the consultant cardiologist
on 27 February 2009, who recommended that he had an exercise tolerance test and
echocardiogram to fully assess his heart condition. An appointment was arranged
for 11 May but. on the day he refused to attend.
The man was admitted to healthcare by a prison doctor on 1 October, so that he
could be closely monitored. Five days later on 6 October, at 5.30pm he was found
not breathing in his cell. Staff started cardio pulmonary resuscitation (CPR) and an
emergency ambulance was called. The paramedics arrived and took over CPR but
assessed that the man had died. He was pronounced dead at 5.55pm. The post
mortem showed that he died of ischaemic heart disease.
The prison records showed that the man’s next of kin lived in Kent. Due to the
distance and time of day, the decision was taken by Dovegate to approach Kent
Constabulary to notify them of his death. The family were notified later that night by
the police.
The prison family liaison officer spoke to the family the following morning and offered
support and financial assistance towards the funeral costs. Dovegate abided by the
family’s wishes that there should not be any prison representation at the funeral.
The family liaison officer did take the man’s money and belongings to his daughter in
person.
There are several issues arising out of this investigation. I do not consider that the
care the man received was equitable with what he could have expected in the
community. The clinical review highlights shortcomings that should be addressed.
Specifically the medical records were not maintained to the required standard,
clinical requests for blood pressure checks were not followed, and I am very
concerned about the number of cancelled or rescheduled hospital appointments.
I also make a recommendation regarding breaking the news to a bereaved family.
The police should only be used as a last resort.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 7 October 2009 when the investigator
issued notices announcing the investigation to staff and prisoners. The
notices included an invitation to those who wished to discuss information
relating to the man’s death to make themselves known to the investigator. No
prisoners came forward as a result.
2. The investigator visited HMP Dovegate on 16 October. During his visit he
was also given copies of all the documentation relating to the man. The
investigator returned on 19 November, 21 December and 6 January 2010 to
interview eight members of staff.
3. South Staffordshire Primary Care Trust asked the clinical reviewer to review
the man’s clinical care. The investigator and the clinical reviewer discussed
aspects of the man’s treatment and jointly interviewed staff at HMP Dovegate.
4. The investigator contacted Her Majesty’s Coroner for South Staffordshire to
inform him of the nature and scope of the investigation and request a copy of
the post mortem report. Upon completion, my report will be sent to the
Coroner to assist his enquiries into Mr Johnson’s death
5. One of the family liaison team contacted the man’s family about the
investigation. The family had no issues or concerns that they wished the
investigator to explore at that time.
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HMP DOVEGATE
6. Opened in 2001, Dovegate is a category B prison for adult male prisoners
sentenced to over four years and local remand prisoners. It is managed by
Serco under contract to the National Offender Management Service (NOMS).
It currently holds up to 1,146 prisoners. There are 946 in the main prison and
200 in the therapeutic community (TC). Healthcare services in Dovegate are
provided by Serco Health.
7. Her Majesty’s Chief Inspector of Prisons last reported on Dovegate following
an announced inspection in October 2008. The Chief Inspector said that:
“On our last two visits to the main prison, we noted serious weaknesses
in safety and control and a lack of progress between inspections. To the
credit of the Director and his staff, this full announced inspection found a
safer and more controlled prison with reasonable purposeful activity,
although resettlement remained weak.
“The establishment was now much better ordered and considerable
efforts had been made to tackle bullying. A strong emphasis had been
placed on security, and this was not disproportionately affecting the
regime for prisoners. Staff appeared more confident and there had
been a substantial reduction in the use of force.”
8. Regarding the healthcare services at Dovegate, the Chief Inspector made the
following comment::
“Primary health services were reasonable, but were compromised by
shortages of staff and accommodation, which needed a substantial
increase in funding for healthcare to move forward. Chronic disease
management was maintained despite staff shortages, but staff needed
more time to give a quality service to prisoners. Many NHS
appointments were cancelled or rearranged, and pharmacy services
needed further development. Nursing staff administered medications on
their own, which was unsafe. Mental health services were good and
developing, and prisoners were well supported by the primary and
secondary services.”
9. The Independent Monitoring Board (IMB) comprises lay people from the
community who monitor the day-to-day life in their local prison and ensure
that proper standards of care and decency are maintained. The IMB Annual
Report, for the period 2007-08, made the following comments regarding
healthcare services:
“Serco Healthcare has a contract to provide healthcare at HMP
Dovegate. Unlike Home Office prisons the local Primary Care Trust is
not responsible for delivering healthcare at HMP Dovegate, but does
provide support for clinical guidance.
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“Any prisoners requiring more specialist treatment, or emergency
treatment, are transferred to the local District Hospital. This can be
costly, requiring transport, escorts and sometimes bed watches. In the
future it is hoped to provide minor surgery and more specialist clinics in
situ.
“There has always been a high turnover of staff in healthcare, nurses and
GPs, as well as managers. This unit needs some stability particularly at
this time. As part of the ongoing extensions to HMP Dovegate the
healthcare unit is to be increased in size, extra facilities and more single
rooms are to be provided.”
10. This is the 11th death to have occurred at Dovegate since April 2004 when the
Ombudsman began investigating deaths in custody in England and Wales. Of
the ten previous cases, five were due to natural causes. In three of the
previous investigations the Ombudsman recommended that the Director and
Healthcare Manager ensure that medical records are to the standard required
by the General Medical Council and Nursing and Midwifery Council. I have
also had cause to repeat a recommendation regarding cancelled hospital
appointments.
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KEY FINDINGS
11. The man was born in October 1941, and lived in the London area prior to his
conviction. On 15 June 2005 he appeared at Tower Bridge Magistrates Court
and was remanded into custody, initially to HMP Emley, and then to HMP
Liverpool on 27 September.
12. On arrival at Liverpool the man underwent a reception health screen with a
nurse. It was recorded that he had suffered a total of three heart attacks, one
in 1987, 1992 and 1999 and continued to suffer from angina. He was
prescribed the following medication: Atorvastatin (for treatment of cholesterol),
Furosemide (for the treatment of congestive heart failure), Amiodarone (for
the treatment of an irregular heart beat), Losartan (for the treatment of high
blood pressure), Diltiazem (for the treatment of high blood pressure and
angina), Glyceryl Trinitrate spray (for the treatment of angina), and aspirin.
13. From 30 September 2005 to 30 October 2006 the man appeared at Liverpool
Crown Court on 39 occasions. On his last appearance, on 30 October, he
was sentenced to 22 years in custody and remained at Liverpool
14. The man transferred to HMP Dovegate on 19 March 2007. A reception health
screen was conducted by a nurse who noted both his past medical history
and current medication. The nurse noted that he had no mental health issues
and had no thoughts of harming himself. His blood pressure was recorded as
150/70. (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.). His weight was 145kg.
The man told the nurse that he experienced breathing problems when he
exerted himself. The nurse made an appointment for him to see the doctor on
26 March.
15. The man did not attend the doctor’s appointment on 26 March. There is no
evidence in the medical records to say why this was or what follow up action
was taken, if any.
16. On 4 April a prison doctor, sent a referral letter to the cardiologist at Queen’s
Hospital, Burton on Trent. The doctor wrote that the man was obese, had
experienced three heart attacks in the past and had problems walking and
breathing. The doctor added that he had fluid on both his lungs and legs.
There is no entry in the medical record to show whether the doctor actually
saw the man before making the referral.
17. Queen’s Hospital replied by letter 24 April, received by Dovegate on 30 April,
giving an appointment for the man to see a doctor on 16 May. The letter said
that this was the first available appointment “within the clinical priority of the
consultant”. On examination of the medical records, the investigator saw
there was a handwritten note on the letter with the words “fully booked -
reschedule”. When interviewed the Healthcare Manager, explained that the
system at Dovegate allowed four prisoners each day to go out for hospital
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appointments. This is because uniformed staff were needed to escort the
prisoners. If there were more appointments than places on any given day,
priority was based on clinical need. Healthcare would contact the hospital to
re-arrange the necessary appointments. Any emergency admissions to
hospital were in addition to the four planned appointment visits. The
Healthcare Manger went on to say that, as in the community, the hospital also
cancelled and/or rescheduled appointments.
18. The table below shows the sequence of appointments made for the man
between April 2007 and April 2008, at the Queens Hospital, detailing the
instigator of the cancellation or rearrangement.
Date Appointment Reason
24/07/07 Appointment arranged for 16 May Cancelled by Dovegate
03/05/07 Appointment changed to 27 June Changed by hospital
13/06/07 Appointment for 27 June changed to Changed by hospital
25 July
24/07/07 Appointment for 25 July changed to 1 Changed by hospital
August
25/07/07 Appointment for 1 August changed to 2 Changed by hospital
August
05/09/07 Appointment for 24 September Cancelled by Dovegate
06/09/07 Appointment for 24 September Changed by hospital
changed to 21 November
20/11/07 Appointment for 21 November Changed by hospital
changed to 27 February 2008
18/01/08 Appointment for 27 February time Changed by hospital
changed from 9.30am to 2.00pm
21/01/08 Appointment for 27 February changed Cancelled by Dovegate
to 23 April
24/01/08 Appointment for 23 April changed to 28 Changed by hospital
May
11/02/08 Appointment for 28 May changed to 27 Changed by hospital
May
22/04/08 Appointment for 27 May changed to 18 Changed by hospital
July
19. Between 24 July 2007 and 22 April 2008 the man had his medication
reviewed by the prison doctor on 12 separate occasions. Each review was
recorded in the medical records, however it was not possible to identify which
doctor made the entry, and some of the notes were illegible. The notes do not
make it clear whether he was actually seen by the doctor or the review was
undertaken in his absence. There were no changes to his medication during
this period.
20. On 27 May the man’s medication was reviewed again by an unidentified
prison doctor. The doctor recorded a request for the man’s blood sample and
pressure to be taken. This was carried out by an unidentified nurse on 10
June, but the entry in the notes only stated that a blood sample was taken.
There is no entry concerning his blood pressure.
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21. The next letter from the Queen’s Hospital was received at Dovegate on 12
June. It gave details of an appointment for the man on 18 July. A handwritten
note on this letter stated that his appointment was to be moved to
accommodate the needs of another prisoner, and a further letter was then
received changing the appointment to 26 September.
22. Between 20 June and 14 August, there were three further reviews of the
man’s medication. Again, on each occasion, the doctor could not be identified
from the entry made and there were no changes to the prescription.
23. The Queen’s Hospital next sent a letter on 29 August to Dovegate to cancel
his appointment for the 26 September, and reschedule it for 28 November.
Two weeks later there was another medication review conducted, by an
unidentified doctor, and no changes were made to the man’s medication.
24. On 13 October prison doctor reviewed the man’s medication and again made
no changes. A week later the lead nurse for the chronic heart disease clinic,
saw the man. The nurse recorded that his blood pressure was 162/89 and
referred him to the doctor. A prison doctor saw the man on 12 November,
and prescribed Simvastatin (for treatment of high cholesterol) in place of
Atorvastatin.
25. Dovegate received a letter from the Queen’s Hospital on 21 November, which
cancelled the man’s appointment on 20 February 2009 and rescheduled for
27 February 2009. (The investigator found no evidence that the man’s
scheduled appointment for 28 November had been cancelled, nor was there
any letter from the Queen’s Hospital found in the documentation that
rescheduled this appointment to 20 February 2009). On the same day the
man had an appointment with the lead nurse for chronic heart disease but
wing staff said that he was not well enough to attend. The nurse re-booked
the appointment for 4 December and advised that the man was to contact
healthcare immediately if he needed any assistance.
26. The man did not attend the appointment arranged on 4 December and there
is no evidence of any follow-up action being taken. Four days later a prison
doctor reviewed the man’s medication and there were no changes made to
the prescription.
27. On 2 January 2009 the man had another appointment with the nurse but
again failed to attend. Five days later the prison doctor repeated the man’s
prescription.
28. The nurse saw the man in the nurse clinic on 26 January. The nurse
recorded his blood pressure as 188/96 and set a review for four weeks time.
The nurse also noted that blood tests were required for both glucose and
cholesterol.
29. The blood samples were taken on 10 February but there is no record of the
results, nor a review by either a nurse or doctor. The following day the prison
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doctor reviewed the man’s prescribed medication and no changes were
made.
30. On 27 February the man saw a doctor at the cardiology department of
Queen’s Hospital. The doctor sent a letter to a prison doctor that outlined the
findings of his assessment. The doctor wrote that the man complained of
exertion angina, which had become worse over the past few months, and he
had an exercise tolerance of about 50 metres. The man’s blood pressure was
recorded as 138/83 with a regular pulse of 82 per minute. In addition his
heart sounds were normal and the results of a chest x-ray were clear. The
hospital doctor recommended that the man had an exercise tolerance test and
echocardiogram (creates two-dimensional pictures of the cardiovascular
system) in order to evaluate his coronary artery disease, and prescribed
Nicorandil (for treatment of angina).
31. The prison doctor reviewed the man’s medication on 10 March and no
changes were made. Two days later Dovegate received two separate letters
from the Queen’s Hospital. The first was for an appointment for an exercise
tolerance test on 6 April. This had a handwritten note on it which stated
“reschedule”. The second was for an appointment for an echocardiogram on
7 April.
32. Queen’s Hospital sent a letter on 17 March with a rearranged appointment for
the exercise tolerance test on 11 May. Six days later he had an appointment
with the lead nurse but he failed to attend. There is no record of any follow up
action taken. The prison doctor next reviewed, and repeated the man’s
prescribed medication on 6 April. The man also failed to attend two further
appointments with the lead nurse on 10 and 22 April, and the prison doctor
conducted a further medication review on 6 May.
33. On 11 May, an unidentified nurse recorded that the man was fit to attend an
outpatient appointment that day. However a Consultant Cardiologist at
Queen’s Hospital, sent a letter to the prison doctor dated 22 May, stating that
the man had refused to attend his appointment for the exercise tolerance test
and echocardiogram. The Consultant Cardiologist suggested that the man
required a coronary angiogram (procedure to access the blood filled
chambers of the heart for both diagnostic and treatment purposes).
34. The Consultant Cardiologist wrote directly to the man at the same time to
explain his recommendation for the angiogram, which would be carried out at
Glenfield Hospital. The Consultant Cardiologist asked the man to provide his
written consent to have the procedure. There is no entry in the medical
record that the reason for the procedure was explained to the man by any
member of the healthcare team, nor that he refused to have it done.
35. There were then four further reviews of his medication on 3 June, 29 June, 27
July and 25 August. The first three were conducted by the prison doctor, the
last by an unidentified doctor. No changes were made at any of the reviews.
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36. On 24 September a nurse responded to a call for medical assistance to attend
to the man. He complained of shortness of breath and said this had
happened several times over the past two weeks, but he had not told anyone.
He told the nurse that he had experienced three heart attacks in the past and
had refused to attend recent reviews with the nurse. The nurse made an
emergency appointment with the doctor for the next morning. The man told
the nurse that he would attend.
37. The nurse further recorded that the emergency bag did not contain an oxygen
saturation testing (SATs) machine or a stethoscope and so no details could
be recorded. The Healthcare Manager said, at interview, that there are five
emergency bags each containing a list of the equipment and consumables in
the bag, including a SATs machine and stethoscope. There was no
explanation as to why these items were missing. She said that it was the
nurse’s responsibility to ensure that anything used from the emergency bag
was replaced.
38. There is no record whether the man was seen by a doctor the following day
as requested by the nurse. Five days later an unidentified nurse responded to
a request from wing staff to see him as he was complaining of
breathlessness. The nurse recorded that he refused to be examined.
39. The prison doctor saw the man on 1 October and recorded that he was
grossly obese, was short of breath on undressing and his ankles were
swollen. The doctor increased the prescription of Simvastatin to 40mg and
Furosemide to 40mg. Later that afternoon, after reviewing the case the prison
doctor took the decision to admit him as an in-patient in healthcare for close
monitoring, although the man wanted to remain on his wing.
40. On admission to healthcare, a care plan was produced by the Deputy
Healthcare Manager. This detailed the care interventions required for the
man. They included monitoring his blood pressure daily, monitoring and
recording the episodes of shortness of breath and identifying any aids or
assistance to reduce his breathlessness. The Healthcare Assistant (HCA)
checked the man at 4.10pm, 6.05pm, 6.50pm and 7.45pm. On each occasion
it was recorded that there were no concerns and he said that he was
breathing more easily.
41. The next day the man was seen by the HCA at 8.00am, 11.40am, 5.10pm and
5.35pm. It was recorded that he had lunch but refused his tea, however there
were no other concerns. During the day the prison doctor saw the man noting
that there had been an excellent response and that he had a good nights
sleep for the first time in days. The prison doctor recommended that the man
should remain in healthcare, continue with the same medication and have
blood tests. There is no record in either the clinical record or care plan that
the man’s blood pressure was taken as detailed in the care plan, or that blood
samples were taken as requested by the prison doctor.
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42. The following day a HCA saw the man at 8.30am, 12.00pm, 3.30pm, 4.00pm
and 5.55pm. It was recorded that he had lunch and again refused tea and
there were no other concerns.
43. The HCA saw him the next day at 8.00am, 2.00pm, 4.30pm and 5.00pm.
Again the man had lunch but refused tea, and spent most of the day in his cell
asleep. No other concerns were recorded.
44. The following day the man was seen by two HCA at 9.15am and 1.45pm. He
told of them that he wanted to go back to his own houseblock and asked to
see the doctor. The prison doctor saw him at 4.00pm and recorded that his
ankles were less swollen, he still felt tired and his pulse was 100 after a short
walk. The doctor increased the level of Furosemide to 80mg. In the time he
was in the healthcare centre, there is no record in either the clinical record or
care plan that the man’s blood pressure was taken.
Events of 6 October
45. At 7.40am a HCA checked on the man who was asleep. No problems
overnight were recorded. Later at 9.40am a HCA saw him and again no
problems were noted.
46. The prison doctor saw the man at 2.00pm. The man said that he felt much
better; and in fact he said that he felt “great”. The doctor recorded that had a
good normal colour, his chest was clear and requested that blood samples
were to be taken that day.
47. In accordance with the regime at Dovegate all prisoners are locked in their
cells at 4.30pm for the evening roll count (a security check to ensure all
prisoners are accounted for). The man was seen at 5.00pm, sitting on his bed
watching the television.
48. At 5.30pm prisoners are unlocked to collect their evening meal. Prison
Custody Officer (PCO) unlocked the man’s cell and called to him that it was
meal time. The man was lying on his bed and did not respond. The PCO
went into the cell to see if he was alright. On approaching him, PCO Edwards
could see that his face was discoloured. He immediately called for urgent
medical assistance and started cardio pulmonary resuscitation (CPR). A HCA
ran into the cell and assisted with CPR and the 999 emergency call was
made.
49. Duty Manager and a HCA arrived at the cell and continued with CPR until the
paramedics arrived at 5.50pm. The paramedics took over CPR but assessed
that the man had died. He was pronounced dead at 5.55pm.
50. The prison records showed that the man’s next of kin lived in Kent. Due to
the distance and time of day, the decision was taken by Dovegate to
approach Kent Constabulary to notify them of his death. They were notified
later that night by the police.
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51. The prison family liaison officer and a Governor spoke to the family the
following morning and made the offer of support and financial assistance
towards funeral costs. Dovegate abided by the family’s wishes that there
should be no prison representation at the funeral, but the Governor took the
man’s money and belongings to his daughter in person.
52. A hot debrief for all staff involved in the emergency response was held and full
care and support was offered to staff affected. The post mortem showed that
he died of ischaemic heart disease.
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ISSUES
Clinical care
Cancelled appointments
53. The clinical review into the care that the man received made the following
comments:
“The care that the man received at Dovegate was not fully up to the
standard that he could have expected in the community. On arrival his
medical history and medication were correctly assessed and recorded.
However during the period 24 April 2007 and 27 February 2009 there
was a total of 14 cancelled or rescheduled hospital appointments at
Queen's Hospital, four of which were instigated by Dovegate, before the
man saw the consultant cardiologist on 27 February 2009.”
54. This is not the first occasion that an investigation of a death in custody at
Dovegate has highlighted the issue of cancelled or rearranged hospital
appointments at the Queen’s Hospital. It should be noted that cancellation of
appointments made by the hospital impacts on Dovegate’s ability to effectively
manage clinical need and patient care. I endorse the following
recommendation:
The Director and Healthcare Manager should review the process for
managing outside hospital appointments, by engaging with the PCT as
commissioners, to ensure that the waiting time for prisoners to see
hospital specialists meets the time that could be expected in the
community. Consideration has to be given to the “choose and book”
approach and fixed timeframes for access to services for all prisoners
to be equitable as those of people in the community.
55. A copy of this report will be sent to the Chief Executive of the PCT and I draw
their attention to this recommendation.
Monitoring blood pressure
56. There were several occasions in the man medical records where clinical
requests had been made for blood pressure checks to be undertaken but no
recorded action was taken. In addition, when he was admitted into healthcare
on 1 October, the care plan included daily blood pressure monitoring. The
clinical reviewer commented:
“Both the prison doctor and the Deputy Healthcare Manager had
requested the man’s blood pressure to be regularly monitored due to his
medical condition in his stay in healthcare. However no record could be
found, in either his main clinical record or the care plan drawn up on 1
October, of regular blood pressure checks.”
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57. I endorse the following recommendation:
The Healthcare Manager should review the process for taking blood
pressure levels and to ensure that all healthcare staff follow appropriate
clinical requests and documented treatment plans. All results must be
promptly acted upon and documented, so that prison doctors can make
timely documented clinical decisions.
Medical record keeping and missed appointments
58. There were a number of illegible entries made in the man’s medical records
made by unidentified staff. There were also no entries made to explain why
he failed to attend various appointments in healthcare, whether any follow up
action was taken and no evidence of when test results were received and
action taken. It is unclear therefore what action healthcare staff did or did not
take.
59. The clinical review makes the following comment regarding clinical records at
Dovegate:
“Clinical record keeping is below the standards expected of the Nursing &
Midwifery Council (NMC) and the General Medical Council (GMC). There
are specific guidelines from the GMC and NMC for doctors and nurses to
complete medical records in a contemporaneous way. It is essential that
facts are recorded accurately and chronologically to ensure there is
record and continuous history of a prisoner's needs and treatments.”
60. I endorse the following recommendation:
The Director and Healthcare Manager should ensure that all healthcare
staff comply fully with the requirements for accurate and
contemporaneous record keeping in accordance with the required
standards of the General Medical Council and the Nursing and Midwifery
Council.
61. The clinical review concludes that:
“The death of the man was a shock to many of the healthcare and prison
staff at Dovegate. The man had a history of obesity and poor lifestyle
that will have contributed to his subsequent death. He suffered with heart
problems and breathing difficulties before he was admitted to the prison
system and continued to suffer while carrying out his custodial sentence.
There may have been other medical interventions that may have
prolonged his life but it is impossible to say for how long it may have
done so, nor is it possible to say if the man would have consented and
complied with them. Ultimately he was an independent adult able to deal
with his health and personal needs.
“I could find nothing to suggest that the healthcare staff or department
intentionally or accidentally failed in their duty of care to the man,
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however I do feel that there can be improvements made at all levels with
appropriate processes established and monitored, to minimise the
inequity between prison healthcare services and those available within
the community setting.”
Family liaison
62. Prison Service Order 2710, Follow up to deaths in custody, requires that the
next of kin should normally be contacted face to face as soon as possible
after a death occurs. If the family live too far from the prison, best practice is
to ask a prison closer to the family home to break the news. The police
should only be asked to break the news if there is a safety risk to staff going
to the family home, or for some other pressing reason.
63. In the man’s case, Dovegate asked Kent Constabulary to break the news to
his family. This was carried out later in the same evening that he died. Whilst
I appreciate the demands on prison staffing during the night, using the police
in this circumstance is at odds with the spirit of PSO 2710 and does not, in my
view, demonstrate the highest level of care and consideration. Subsequent
contact by the prison’s family liaison officer was by telephone and a visit to
return his money and belongings.
64. Dovegate may have considered there was a need to balance the need to
deliver the news personally to his family with the need for timeliness. Due to
the time and the distance in which his next of kin lived from the establishment
the latter seemed to be important. However, in contacting another prison in
the vicinity of the family home would still have provided the opportunity for a
Prison Service official to break the news in accordance with Prison Service
policy. Indeed, this has been my experience elsewhere in the Prison Service.
The Director should ensure that the family liaison officer from Dovegate,
or another prison, is used to inform the family of a death in custody.
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CONCLUSION
65. I recognise the issues highlighted in the clinical review and judge that the
standard of care that the man received whilst at Dovegate was not fully
equitable to what he could receive in the community. The standard of record
keeping was below what is expected and there was no follow up of clinical
requests. There were a considerable number of cancelled or amended
hospital appointments, many outside the control of Dovegate, which the
prison and PCT need to address. However, I also recognise that ultimately he
was an independent adult able to deal with his health and personal needs.
66. Prison Service Order 2710, Follow up to deaths in custody, requires that next
of kin should normally be contacted face to face as soon as possible after a
death has occurred. Whilst I appreciate that his family lived a considerable
distance from the prison, all possible attempts should have been made to
deliver the news to the family face to face by the Prison Service rather than by
the police.
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RECOMMENDATIONS
1. The Director and Healthcare Manager should review the process for
managing outside hospital appointments, by engaging with the PCT as
commissioners, to ensure that the waiting time for prisoners to see hospital
specialists meets the time that could be expected in the community.
Consideration has to be given to the “choose and book” approach and fixed
timeframes for access to services for all prisoners to be equitable as those of
people in the community.
Partially Accepted - The HCC will be conducting a full review of the referrals
to hospital. All referrals to hospital are seen within 18 weeks, which is the
same as that of the NHS. Choose and Book can not be considered as
individual patient passwords/ and electronic referrals could lead to a security
breach.
2. The Healthcare Manager should review the process for taking blood pressure
levels and to ensure that all healthcare staff follow appropriate clinical
requests and documented treatment plans. All results must be promptly acted
upon and documented, so that prison doctors can make timely documented
clinical decisions.
Accepted - The HCC has gone through a major change in the last two
months. New staff, policies and procedures are now in place to stop this
happening. Nurse Team Leaders and management checks are being
implemented to audit and confirm adherence to policies. Detailed training
plans in place to support the recording of clinical information. IMRs recorded
for and monitored daily. Completed June 2010 and on going processes.
3. The Director and Healthcare Manager should ensure that all healthcare staff
comply fully with the requirements for accurate and contemporaneous record
keeping in accordance with the required standards of the General Medical
Council and the Nursing and Midwifery Council.
Accepted - New staff now recruited; as part of the recruitment and induction
process all new clinical staff have received policies on clinical recording of
data. This is an on going issue, and as the staff develops, we should see a
vast improvement in data quality. Team Leaders and the Deputy health care
manager are now tasked to do random checks. Recruitment of a new full
time GP has assisted in record keeping. Completed June 2010 and on going
processes.
4. The Director should ensure that the family liaison officer from Dovegate, or
another prison is used to inform the family of a death in custody.
Accepted - Contingency Plans revised to reflect this.
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