Individual at Leeds

Investigation into the circumstances surrounding the
death of a man
at HMP Leeds in May 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2008
This is the report of an investigation into the circumstances surrounding the death of
a man who was a prisoner at HMP Leeds. The man died in May 2007 in Leeds
General Infirmary after an emergency admission to the hospital for bleeding gastric
ulcers. The post mortem report indicates that he died from a massive
gastrointestinal tract haemorrhage due to a benign gastric ulcer with cirrhosis of the
liver. He was 34 years of age when he died.
I would like to extend my personal condolences to the man’s family and friends for
their loss. The loss of a loved one at any time is difficult, but especially so when they
are relatively young, die suddenly and are in custody.
This investigation was carried out by a colleague of mine. A clinical review (for
which I am most grateful) was undertaken by a doctor on behalf of Leeds Primary
Care Trust (PCT). The Trust’s Clinical Director reviewed the report and interviewed
prison doctors and researched the conditions that led to the man’s death, to help
give greater clarity to my report. I would also like to thank the Governor of HMP
Leeds, and his staff for their help and co-operation during this investigation.
This report has taken a long time to complete, for which I apologise. There are four
recommendations made within this report.
Jane Webb
Deputy Prisons and Probation Ombudsman December 2008
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CONTENTS
Summary
The Investigation Process
HMP Leeds
Key Findings
Issues
Recommendations
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SUMMARY
The man was first remanded in custody on 31 July 2006. He was sentenced to life
imprisonment on 13 December 2006, and died five months later in the early hours of
3 May 2007.
The man arrived in prison with a known medical history of Hepatitis C and alcohol
problems. He received treatment for his alcohol withdrawal and his previous
medication was continued except for a drug called Propranolol. Propranolol is
sometimes used as a preventative measure against varices as it lowers the blood
pressure. (Varices is a condition of enlarged veins that can rupture under certain
circumstances, particularly in people with chronic liver problems such as long-term
alcoholics or Hepatitis sufferers.)
On 21 April 2007, the man was admitted to Leeds General Infirmary as an
emergency as he was suffering from gastric varices. He was treated with a series of
injections to the site of the bleeding and discharged back to prison on 26 April with a
prescription for Propranolol.
On 2 May, at approximately 11.45pm nursing staff were called to see the man who
was complaining of coughing up blood. The nurse recorded his blood pressure and
pulse and these gave her no cause for concern. On examination, the nurse decided
that because she saw no evidence that he had coughed up blood and his cellmate
seemed more distressed than the man was, the man would be alright until the
morning.
At approximately 2.10am on 3 May 2007, the man suffered a serious haemorrhage
from his gastric ulcers. Despite the best efforts of paramedic staff who arrived on the
scene within seven minutes, he died in hospital at 3.31am.
The clinical review does not seek to blame any individual, but points out that
complex medical conditions such as the man’s should be the subject of
comprehensive care plans that enable staff taking responsibility for patients to have
the best possible information and guidance.
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THE INVESTIGATION PROCESS
1. My colleague visited HMP Leeds on 17 May 2007 to review and collect
papers from the prison. Whilst there he ensured that Notices to Prisoners and
Staff were prominently displayed. These notices invited people to contact him
if they wanted to bring any matters to his attention.
2. My colleague also met with members of the Independent Monitoring Board
and the Prison Officers’ Association. He was shown around the prison and
saw the unit where the man was located at the time of his death. My
colleague met several members of the prison staff, including nursing staff.
3. One of our Family Liaison Officers (FLO), made contact with the man’s
mother on 30 May to explain the purpose of the investigation and invite the
family to raise any concerns they wished to be considered and addressed as
part of the investigation. The family will receive a copy of this report. The
mother asked our FLO about her son’s medication. She wanted to know why
he had not received the correct medication for the nine months prior to his
death; a matter I deal with in this report. I hope it helps the family better
understand what happened to the man in the time leading up to his death.
4. The man’s cell mate had been discharged before my colleague could
interview him but his police interview statement taken on the night the man
died was available. My colleague has also been in regular contact with the
West Yorkshire Police over their continued investigation into matters relating
to his death. As with all deaths in custodial settings, the police undertake their
own investigation into matters relating to that death. In respect of the man’s
death, these investigations were protracted which has resulted in a delay to
this report being issued.
5. Leeds Primary Care Trust was asked to undertake a clinical review of the care
the man received while he was in custody. A doctor undertook this review
and this was supplemented by a further report from another doctor, who is
Clinical Director for Leeds Primary Care Trust at the prison.
6. My colleague contacted Her Majesty’s Coroner to inform him of the nature
and scope of our investigation and to request a copy of the Post Mortem
report. Upon completion, a copy of this report will be sent to the Coroner to
assist him in his enquiries into the man’s death.
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HMP LEEDS
7. Leeds is a category B local prison that generally accepts adult male prisoners
from West Yorkshire. It was built in 1847, but has had additional wings added
in 1994 and a new gate lodge complex built in 2002. It can accommodate
1,254 prisoners in 680 cells, which means that most prisoners share a cell
with at least one other person.
8. Her Majesty’s Chief Inspector of Prisons, Ms Anne Owers, undertook an
unannounced inspection of Leeds between 22 and 26 August 2005. The
report commented that Leeds presented as a typically overcrowded and
pressurised local prison ‘It exhibits, in acute form, some of the problems
associated with our overcrowded prisons’. There were no observations or
recommendations of particular relevance to the man’s death in that inspection
report.
9. The Independent Monitoring Board’s (IMB) latest annual report says that
‘HMP Leeds is a rapidly improving establishment with a committed and
competent management and staff’. The report points out that 2007 – 2008
saw a reduction in the numbers of deaths occurring within the prison (down
from 11 the previous year to just four in this reporting period).
10. However, this is still one of 29 deaths the Ombudsman’s office has
investigated at Leeds since April 2004. Several of those investigations are
ongoing and a number of reports have yet to be published. However, the
issue of care plans and record keeping is a factor in at least one other
investigation already completed, and features in recommendations here and
another report yet to be published.
11. The move to wing based nursing should, when coupled with the
recommendations in this report for comprehensive care plans, ensure that
higher standards of care are delivered to prisoners who are patients at Leeds.
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KEY FINDINGS
12. On his initial reception into HMP Leeds on 31 July 2006, a first reception
health screen was undertaken on the man. This revealed that he was a
heavy drinker and so he was referred to the doctor for further investigations.
When he was seen later that evening for his secondary health screening he
told the nurse that he had Hepatitis C which is a viral infection that leads to
chronic liver disease.
13. The man then saw a doctor and told him that he had been prescribed
medication in the community. He said that he took Thiamine, Vitamin B
Compound, Spironalactone, Ciproflaxacin, Propanolol and Dihydracodiene.
He also told the doctor that he suffered from depression and paranoia. The
man was started on an alcohol detoxification programme on the evening of 31
July with a reducing dose of Chlordiazepoxide. This is a standard
detoxification regime used in prisons for alcohol withdrawal.
14. The prison contacted the man’s doctor by fax the following day to ascertain
information about his medical history. The GP responded the same day
confirming all of the medication, except the Propanolol. The GP also told the
prison that the man had been assessed by a professor at St James’ Hospital,
Leeds Liver Unit, and diagnosed with alcoholism and Hepatitis C. The man
had undergone a period of residential alcohol detoxification at St Anne’s clinic
(part of the community services in Leeds) in early March 2006. The GP made
the point that the man was a newly registered patient and he therefore did not
know if he was prescribed any other medication.
15. On 16 August, the man was seen by a prison doctor and prescribed all the
medication listed by the GP. This did not include any Propanolol as it was not
listed as being prescribed by the GP. The delay in the man receiving his
medication is reported to be because the doctors did not know the fax from
his GP had arrived with confirmation of the man’s medication. The man was
also given an appointment to attend a clinic for blood tests to be done the
following day. He failed to keep this appointment.
16. The man was treated for a dental abscess on 10 October and referred to the
visiting dentist. It had been noted on his reception health screening that he
had had surgery to his jaw, and it was thought that the infection might be
related to that.
17. The man was seen by a counsellor on 30 October because of the stress and
anxiety generated by his impending trial. The counsellor saw the man on a
number of occasions throughout the following months, until 6 February 2007.
18. The man was convicted of murder on 11 December. He was seen that day in
reception by the nurse who assessed him as being depressed and in a state
of shock following his return from court. The nurse referred the man to the
doctor for some sleeping tablets and opened an Assessment, Care in Custody
and Teamwork document (ACCT). (ACCT is a flexible, prisoner-centred
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assessment and care planning system, which aims to identify individual needs
and offer personalised care and support before, during and after crisis, in a
safe and caring environment.) The ACCT was closed on 19 December.
19. Although the visiting doctor did not see the man on 11 December, he did
prescribe sleeping tablets for the next five nights (10 milligrams Nitrazepam).
20. On 13 December, at Leeds Crown Court, the man was sentenced to life
imprisonment with a tariff of 18 years imprisonment. The same day that he
was sentenced, the visiting doctor changed the Nitrazepam prescription for
one of 7.5 milligrams of Zopiclone for five nights.
21. The man was seen again by the counsellor on 19 December and was
described as still in a state of shock with symptoms akin to that of Post
Traumatic Stress Disorder (PTSD). The counsellor went on to say that the
man gave an essentially honest account of himself, was direct and was not
someone who was trying to get more medication, the inference being he
genuinely needed help. The counsellor made the point that the man was,
nevertheless, showing positive signs in that he was making plans for the
future. The man thought he might like to become a Listener if he were to be
accepted for the training, and also to undertake some sort of self development
course. (Listeners are trained by Samaritans to provide confidential emotional
support to fellow prisoners in distress.)
22. The man was seen by the Lifer Management unit at Leeds on 22 December
and a plan for his immediate custodial needs was drawn up. This included
ongoing support from the counsellor to help him come to terms with his long
sentence. Although he was expecting a life sentence if he was found guilty, it
had still come as a shock to him when that happened. The man was also
allocated, as a first stage lifer prisoner, to HMP Wakefield or HMP Gartree.
23. On 3 January 2007, another visiting doctor, saw the man in his morning
surgery at the prison. He found that the man was suffering from depression
and prescribed Mirtazepine (an anti-depressant) for a month, to be reviewed
on 3 February. The visiting doctor did not think that the man was suicidal,
although he did say that he was not sleeping properly and did not have any
interest in things generally.
24. When the visiting doctor saw the man two days later, he was sleeping better
thanks to the Mirtazepine, but had feelings of anxiety. The man requested a
prescription for Diazepam, but the visiting doctor was not in favour and
instead prescribed a low dose of Haloperidol for his anxiety.
25. The prison doctor saw the man on 18 January and stopped the Haloperidol
because the man said it was not having any effect. He prescribed a short
course of Zopiclone again.
26. On 25 January, the prison doctor changed the Zopiclone for Nitrazepam to
help the man with his insomnia. The prison doctor saw the man the following
day, when he complained of a pain in his right thumb which had lasted for two
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or three weeks. The prison doctor diagnosed De Quervain’s disease and
prescribed a cream to be rubbed in to the affected area.
27. The man went to see the prison doctor on 29 January complaining of a rash
on his body. It was thought he had scabies, and he was given some cream to
treat this. He was seen again on 15 February with the same problem and re-
treated.
28. The counsellor recorded in the medical notes on 6 February that he had seen
the man in passing on the wing. The man asked to be taken off the list for
counselling which the counsellor agreed.
29. A Month later on 5 March, the man was seen by the prison doctor because he
was depressed. The prison doctor recognised that the man had been on
Mirtazepine for two months, and that this was not working. He therefore
changed the prescription of Mirtazepine to one of Trazodone 100mgs, to be
reviewed after one month.
30. A doctor saw the man on 2 April and recorded in the clinical notes that the
man was still not sleeping well. He was feeling angry all the time and getting
into fights. The man told the doctor that he was getting no benefit from the
Trazodone. The doctor stopped the medication and asked that the man be
reviewed in one week’s time. The man did not visit a doctor because of
depression again.
31. A nurse saw the man on 21 April because he was not feeling well. He told the
nurse that he had abdominal pain, had been vomiting since the previous day
and had dark coloured stools for two days. Whilst she was assessing him, he
vomited dark coloured blood. An ambulance was called and the man was
admitted to Leeds General Infirmary.
32. The man was at Leeds General Infirmary for five days until 26 April
undergoing treatment for gastric and oesophageal varices (in this instance the
enlarged veins were within the oesophageal wall or the lining of the stomach).
The man was prescribed Propranolol by the hospital doctors when he was
discharged from the infirmary.
33. When the man returned to the prison on 26 April, he was seen by another
doctor who recorded in the clinical notes that the man stated he had
repeatedly requested his Propranolol. The man said that it had not been
prescribed at his initial reception because he had not been able to cite the
dose. The doctor also reviewed the notes and was unable to find any
reference to the man previously having any signs of oesophageal varices.
34. At approximately 11.45pm on 2 May, the man saw a nurse in his cell on C4
landing, because he had told the night orderly officer that he was coughing up
blood. When the nurse arrived she took his blood pressure (blood pressure
92/60 which is slightly low, pulse 50 which is quite slow) and pulse. The man
seemed to be alright to the nurse and he did not appear too concerned about
his condition, so she advised that he should see the wing nurse the following
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day if he felt no better. The man told the nurse that he was prescribed
Propranolol (which lowers blood pressure), and she could see no evidence of
his having coughed up any blood. She said in interview that it was the man’s
cell mate, who was most concerned about his condition, not the man himself.
35. At 2.10am on 3 May 2007, the man collapsed in his cell and his cell mate
summoned staff assistance. The nurse was in the vicinity of the prison centre
at the time and joined staff in the emergency call. She discovered the man
lying on the floor with signs that he had vomited a large amount of blood. An
ambulance was called and arrived at 2.17am. Paramedics took the man to
hospital, but despite all their efforts, the man died at 3.31am.
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ISSUES
36. The clinical review says that Propranolol is used in the first place to reduce
the incidence of bleeding from varices, as well as the chance of a re-bleed.
The man was not prescribed Propranolol at his initial reception, neither was
there any follow up of his chronic liver disease. The Clinical Reviewer points
to research that shows that the risk of initial variceal bleeding in some patients
can reduce from 45 per cent to 22 per cent if Propranolol is prescribed. The
Clinical Reviewer therefore concluded that the ‘lack of use of Propranolol may
have contributed to his first GI [gastro intestinal] bleed in prison’.
37. The Clinical Director for Leeds Primary Care Trust at Leeds prison has added
some additional thoughts and comments to the clinical review undertaken by
the Clinical Reviewer. The Clinical Director picked up on the Clinical
Reviewers point that the man had not been prescribed Propranolol at his first
reception. The Clinical Director discussed the matter with a Consultant
Hepatologist at St James’s University Hospital, who also reviewed the man’s
medical notes. The Consultant referred to emerging evidence that prescribing
Propranolol in situations where oesophageal varices might occur is proving
effective. The Clinical Director goes on to say in his report that, in the man’s
case, the omission of Propranolol medication was not a factor as he died as a
result of an acute gastric ulcer bleed. There was no evidence at post mortem
of any oesophageal varices.
38. The Clinical Reviewer did not conclude that the man’s final illness was
attributable to the lack of Propranolol. He confirms that the man died from a
ruptured gastric ulcer. However, the Clinical Reviewer says that there are
case studies to suggest that treating varices with injections carries its own
risks of further bleeding at the site of treatment. He suggests that it is
plausible that all these factors are interlinked, and he says that varices can be
difficult to detect after death.
39. It would therefore seem unfair to conclude that the omission of Propranolol at
the man’s first reception was a specific cause of his death. It would be fair
though to say that emerging good practice for chronic liver disease
management should include consideration of Propranolol.
40. The Clinical Director made some useful observations on the prescribing of
medication for people entering prison for the first time. He observed that the
man gave a good account of medication prescribed by his own doctor. The
Clinical Director noted that reasonable attempts were subsequently made to
verify those prescriptions. The Clinical Reviewer points out that the fax
containing confirmation of the detail of the man’s medication appears to have
taken two weeks to be filed – and that this is unacceptable.
41. The Clinical Director lays out a pragmatic solution to prescribing problems for
new arrivals in prison:
‘Where patients present with boxes or lists of medication with a clearly
defined dose, then this information will be taken at face value and the
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medication prescribed to the patient. Similarly, where the patient does
not have the medication or a list, but is clearly able to report the dose
of the medication, then this information will be taken at face value and
prescribed. The exception to this would be medication that has an
abuse potential, which includes benzodiazepines, opiates (typically
methadone, buprenorphine or dihydrcodeine) or where medication is
toxic in overdose e.g. tricyclics and antidepressants. However, in all
the above cases, confirmation would still be sought from the GP.
Where the patient is unable to recall the dose and there is no
confirmation, then the medication will not be written up, but
confirmation will be sought urgently from the GP.’
The healthcare manager should develop a system to confirm a
prisoner’s medication on reception into the prison.
42. Both the Clinical Reviewer and the Clinical Director also recognised that
Hepatitis C is a major health concern within the prison population. Whilst
most patients who have liver disease who come into prison will not have any
symptoms, they recommend that there should be an improvement in the
uptake of anti-retroviral treatment (treatment that slows the effects of a virus
like Hepatitis).
The healthcare manager should review the needs of patients with
Hepatitis C and liver disease. They should develop a clinical policy for
chronic liver disease to improve the delivery of anti-retroviral treatment,
including staff education and training.
43. When the nurse took the man’s pulse and blood pressure on 2 May, they
showed that he had a pulse of 50 with a blood pressure of 92/60. The blood
pressure readings are described by the Clinical Director as ‘borderline low’
and both the Clinical Reviewer and Clinical Director are of the opinion that this
should have prompted further observations with a view to calling the
emergency doctor. The Clinical Reviewer remarked in his clinical review that
when the nurse did access the man’s medical notes no comparative blood
pressure readings were available as his blood pressure had not been
recorded since his arrival at the prison.
44. In interview the Nurse was uncertain how she became aware that the man
was prescribed Propranolol. Initially she thought she had consulted the man’s
medical notes to gain this information before she made her first visit to him at
11.45pm. Subsequently she is unsure whether she saw it on his medical
record after she saw him, or whether he told her he received Propranolol.
This is significant because low blood pressure readings with fast pulse
readings are an indication of internal bleeding. The man’s low blood pressure
reading was not accompanied by a fast pulse, and it was actually quite slow,
which is at variance with internal bleeding.
45. The Clinical Reviewer says that Propranolol could slow the heart rate and
consequently mask a rapid heart rate that would be an indicator of further
bleeding. The Clinical Director considers that the nurse should have
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recognised the risk of further bleeding, given that she was presented with a
patient with low blood pressure who had disclosed he was coughing up blood
and who had recently been in hospital with oesophageal varices.
46. Rather than singling out an individual, the Clinical Reviewer is inclined to look
at ways of changing the system under which nurses are expected to work
when they are making autonomous decisions. He makes the point in his
clinical review that there is no care plan system for complex clinical problems,
and that one should be developed. There was no system for handing over
care for patients who had these complex clinical needs between shifts or
within various locations within the prison.
The healthcare manager should develop a system of care plans for
complex medical cases, including a handover between clinical teams.
47. One area where the Clinical Reviewer was critical of the nurse was in her
initial handling of the man’s acute emergency at 2.10am on 3 May. Although
the initial response was swift, and the ambulance arrived just seven minutes
after the alarm was raised, the nurse apparently made no attempt to record
any vital signs.
48. In her interview with the investigator on 12 September 2007, the nurse said
she was accompanied by her nursing colleague, at the medical emergency
timed at 2.10am. The nurse believes they tried to obtain vital signs from the
man, but they were unable to get any due to his weakness. In any event, no
record of this attempt was made.
49. In the investigators interview with the nurse of 22 January 2008, the nurse
gave a description of the typical workload expected of a nurse working nights.
It is clear from this description that nursing staff do not have access to clinical
systems at the time of consultation, nor is it always easy to make written
records of their interactions with patients soon afterwards. This is not
acceptable. Managers should remind staff of the importance of making notes
at the same time as patient consultations, and provide the necessary
resources to enable this to happen.
The healthcare manager should develop a means of recording patient
consultations in the clinical record in a timely manner.
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RECOMMENDATIONS
1. The healthcare manager should develop a system to confirm a prisoner’s
medication on reception into the prison.
The Prison Service accepted this recommendation in full and said:
Clinical Director and Senior Medical Officer will devise a protocol of conditions
that need next day reception telephone confirmation. A procedure will be
piloted for non-clinicians (admin staff) to contact practices about clinical
information. The pilot will be monitored, staff trained as required and pathway
rolled out in April 2009.
2. The healthcare manager should review the needs of patients with Hepatitis C
and liver disease. They should develop a clinical policy for chronic liver
disease to improve the delivery of anti-retroviral treatment, including staff
education and training.
The Prison Service accepted this recommendation in full and said:
HMP Leeds has been offering in-house Consultant-led Hepatitis C clinics and
treatments since February 2008. HMP Leeds is involved in regional planning
of services and are involved in the development of a national training package
with the Royal College of General Practitioners (RCGP).
3. The healthcare manager should develop a system of care plans for complex
medical cases, including a handover between clinical teams.
The Prison Service accepted this recommendation in full and said:
Everyone returning from a bedwatch with a chronic disease to have a care
plan upon reception back into prison that is reviewed regularly with ongoing
handover between nursing staff at the end of shifts. This is to be implemented
by January 2009.
4. The healthcare manager should develop a means of recording patient
consultations in the clinical record in a timely manner.
The Prison Service accepted this recommendation in full and said:
System One medical records system due to be implemented November 2008.
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