Individual at Winchester

Investigation into the circumstances surrounding the death of a man at
HMP Winchester on 31 July 2004
Prisons and Probation Ombudsman for England and Wales
June 2005
This is the report of an investigation into the circumstances surrounding the
death of a prisoner who was sentenced to 12 weeks imprisonment on 23 July
2004. He was sent to HMP Winchester and on the morning of 31 July 2004
was found dead in his cell. A Coroner's inquest recorded his death as due to
natural causes.
All deaths of prisoners in custody are investigated, including those from
natural causes. The responsibility for carrying out investigations traditionally
fell to the Prison Service itself but has now been passed to the Prisons and
Probation Ombudsman's Office to bring independence and greater
consistency.
I offer my sincere condolences to the family and friends of the man who died.
I must apologise for the delay in completing this report.
I am grateful to the Governor of HMP Winchester and her staff for their co-
operation with this investigation.
This report makes three recommendations concerning the issuing of
medication and one concerning Winchester's contingency plan for dealing
with deaths of prisoners.
Stephen Shaw CBE June 2005
Prisons and Probation Ombudsman
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CONTENTS
Summary
Investigative process
The deceased
Events leading up to the deceased’s death
Events after the deceased’s death
Post mortem and inquest
Consideration
Conclusion and Recommendations
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Summary
The subject of this report was 56 years old when he died on 31 July 2004 at
HMP Winchester. He had been sentenced to two months and 23 days
imprisonment on 23 July 2004 for threatening behaviour. It was not his first
period of imprisonment at Winchester, having been released from there in
May 2004 after serving another short sentence. Whilst he did not mention any
medical problems on reception, it was noted that he was in poor physical
health. He was prescribed dietary supplements, medication for a chest
infection and inhalers for breathing difficulties.
The man who died had a history of mental illness which was managed
successfully with medication. However, two years before his death, he
stopped taking his medication and this led to the disintegration of his personal
relationships and a decline in his health.
On the evening of 30 July, he complained of being short of breath and was
given two inhalers by an officer. He was found dead in his shared cell the
next morning.
After initially being unable to contact the next-of-kin whom the man had
named on his reception at Winchester, one of his sisters was located. She
has concerns about the way she was informed of her brother's death and the
contact she has had since with Winchester.
A post mortem examination of the man found that he had died due to acute
exacerbation of chronic obstructive pulmonary disease. The Coroner's
inquest into his death took place on 24 November 2004. It found that he had
died of natural causes.
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Investigative process
My practice in cases of apparent deaths from natural causes is to conduct an
initial review to determine the extent of investigation required.
My investigator and a colleague visited HMP Winchester on 4 August 2004
and spoke to staff informally to gather the facts relating to the subject of this
report’s time at Winchester. They were given access to his records, including
his medical records.
The Prison Officers Association and Independent Monitoring Board were
offered the opportunity to meet with the investigators. Neither had any issues
they wished to draw to our attention.
Notices to staff and prisoners were distributed, telling them that an
investigation would be taking place into the prisoner’s death. No responses
were received. His cell mate was released from Winchester shortly after the
death of the man and could not be contacted.
The investigator contacted the man’s sister.. She spoke of her brother's ill-
health, expressed her concern that she had not been told of his death in an
appropriate manner, and felt that she had been treated poorly. These issues
are examined further in my report.
A clinical review of the man’s health care at Winchester was carried out..
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The deceased
He was 56 years old at the time of his death. He was divorced and had one
son. His sister described him as a highly intelligent but complicated person.
He had been a popular and affable man, running his own successful building
company until 2002 when he had encountered personal difficulties and had
been unable to continue. He had suffered from depression and had received
occasional psychiatric treatment over the past 30 years but had been able to
live a relatively stable life provided he took Lithium to control his symptoms.
The man who died stopped taking his medication about two years before his
death and, as a consequence began to suffer from mood swings. He was
unable to continue his work and experienced financial problems. According to
his sister, these might have been resolved but he was unable to tackle them
rationally. In addition, he had received unclear advice about claiming benefits.
Sadly, he began to drink more frequently, and his marriage foundered.
Although his sister had attempted to secure in-patient psychiatric treatment for
him, this was not possible as he was not thought to be in imminent danger to
himself or others. He gradually began to suffer more markedly from poor
health and physical decline. He became verbally abusive and aggressive to
others. This resulted in him being imprisoned at Winchester four times in the
last 18 months of his life for public order offences.
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Events leading up to the deceased’s death
The man who died had a short history of offending, but in 2004 he came to the
police's attention several times. On 2 April 2004, he was verbally aggressive
to staff in a travel agency, left the shop and returned shortly afterwards with a
scaffolding pole which he used to smash the entrance door window. He was
then abusive to the police officers who arrived to arrest him. On 27 May, he
was sentenced to three months in custody for criminal damage.
He was sentenced to two months and 23 days imprisonment on 23 July for
threatening behaviour and sent to HMP Winchester. His automatic release
date would have been 2 September 2004.
On reception at Winchester, the man was seen by a Health Care Officer and
asked a series of standard questions about his health. He said that he had
seen his General Practitioner (GP) recently for a general examination, but that
he was not receiving any form of treatment, had not had any operations and
had no worries about his general health. He gave the name and address of
his GP. He said he was a moderate drinker and smoked 20 cigarettes a day.
He was asked specifically about his mental health and answered that he had
not suffered from any psychiatric illness in the past and had not been
prescribed any medication for his "nerves". He added that he had expected to
be sent to prison, no one knew he was there and he was not expecting any
contact with family or friends whilst he was in Winchester. He said that he
was not allergic to anything. However, his medical record has "allergic to
penicillin" across the front.
On 24 July, the man saw a doctor for a medical examination, which is normal
practice for newly-received prisoners. The man told the doctor that he did not
have a previous medical history but had had an operation for a gastric ulcer
without his consent. The doctor noted that he had a post operative scar below
his navel. He described the man as unwell, and noted bilateral crepitation
(crackling noise) in his lungs and that he was wheezing audibly.
On 28 July at 2am, it was noted in the man’s medical record that he was
banging and kicking his cell door, complaining of shortness of breath. He was
physically examined in his cell by a health care worker, at which time he also
complained of constipation. He said he was coughing up green sputum but
the nurse records that it was white. The man was told that the nurse was
unable to find anything especially wrong and would not give him laxatives as
there was no evidence he had constipation.
A doctor saw the man on 29 July and noted that his breathing was distressed,
that there was bilateral wheezing and his body appeared wasted. He
prescribed antibiotics, inhalers and steroids for asthma, and Fortisip, an
energy drink to build him up. The man collected the antibiotics, steroids and
Fortisip on 29 July.
On 30 July at about 7:30pm, an officer answered the man’s cell bell. He was
sharing the cell with another prisoner.. The man said that he was "wheezy,
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short of breath and asthmatic". He told the officer he was having trouble
breathing and asked him to get an inhaler. The officer spoke to the nurse in
the Treatments Room on C2 landing, who checked the man’s file and asked
whether the man would collect the inhaler. The officer said that as the man
was short of breath, he would take it to him. The man’s cell was three floors
up from the treatment room. The nurse gave the officer two inhalers which
were given to the man. The officer watched him take a dose and then left.
According to the cell mate’s police statement, he and the man were not
particularly close. The night before his death they had argued because the
man had taken half of his breakfast pack (sachets of tea, jam and sugar)
without asking. The cell mate ignored the man after that and they both
watched a film on television which had ended around midnight, although the
man was asleep before the film finished.
In the morning of 31 July, at about 8:30am, an officer placed some milk in the
cell. This woke the cell mate. He got up and made a cup of tea for both
himself and the man, but could not wake him. He noticed that the man’s was
cold and that his skin was mottled. He rang his cell bell and kicked the door.
An officer came to the door quickly and summoned assistance. The cell mate
was taken to another cell and then given the opportunity to speak to a
Listener, a prisoner trained by the Samaritans to offer other prisoners support
in crisis situations.
Healthcare staff arrived at 8:35am, although the Inmate Medical Record is
incorrectly dated as 30 July. Resuscitation was not attempted as rigor mortis
had set in, but a doctor was called. The doctor pronounced the man dead at
9:20am.
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Events after the deceased’s death
The man who is the subject of this report had named his next of kin. A prison
Chaplain attempted to contact the person named, but was not successful.
The police were asked to help but were unable to make progress, so the task
was passed to the Coroner's officer to pursue. The Chaplain subsequently
checked one of the man’s previous prison records and found details his sister.
His sister was told by the Chaplain on 1 August that her brother had died.
She was surprised that the Chaplain had telephoned her and had expected
that the Governor would contact her also. She telephoned the prison and
spoke to the Duty Governor. She says the governor said he had not said
anything to her because he "had nothing to say." This remark had annoyed
her deeply as she did not regard her brother's death as "nothing" and
considered that Winchester did not appreciate the hurt they had caused her.
A governor, telephoned her later to say that it was normal for the Chaplain to
break the news of a family member's death and that he was sorry for her
brother's death. She felt angry that it had taken conversations with three
people before a senior manager expressed their sympathy to her.
My investigators discussed the breaking of news of a bereavement with the
governing Governor. She said she had understood that the person named as
the next of kin was unhappy that the Chaplain had contacted her as opposed
to someone more senior. As far as she was concerned, the Chaplain's role
was appropriate as the person named as the next of kin (whom she
understood, wrongly, at that time was the man’s ex wife) was not strictly next
of kin in legal terms.
Winchester's Contigency Orders for a death of a prisoner state:
"If next of kin are within reasonable travelling distance, arrange a
meeting between them and a nominated Governor and appropriate
Chaplain. Another Governor and Chaplain to be named as stand-in
and a record kept."
Prison Service Order 2710: Follow up to Deaths In Custody, chapter 6
paragraph 4 states:
"A senior member of staff must be appointed as the named point of
contact for the family and a second person named as available in the
first person's absence … Continuity in dealing with the family will
enable the establishment to meet its primary task, i.e to establish
rapport and trust with the family in helping them to come [to] terms with
what has happened …"
The man’s sister lives over 100 miles away from Winchester. The
contingency plans do not specify how families should be contacted and by
whom, if they live outside a "reasonable travelling distance" from the
establishment.
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Post mortem and inquest
A post mortem examination took place on 2 August 2004. The pathologist
concluded:
"There is sufficient natural disease present to explain the death, in the
form of longstanding chronic obstructive pulmonary disease
(emphysema and chronic bronchitis) and patchy infection (an acute
change). Chest infection is a common complication of chronic
obstructive pulmonary disease of this severity. There are no significant
older injuries to the chest, including no old and healing rib fractures,
which may have precipitated the development of such an infection.
There are no fresh injuries to the body and no findings to suggest
restraint."
The Coroner's inquest into the man’s death was held and the jury returned a
finding of death by natural causes.
Clinical review
The clinical review concludes that Winchester provided the man with
appropriate care and management for his presenting symptoms. It notes that
the man did not provide Winchester with all the relevant information about his
health during the initial health screen. The review makes two
recommendations about the fact that inhalers were not issued to the man
directly by healthcare staff, and that they were issued without an assessment
of the man’s current medical problems.
Conclusion
I take the view that, during the time he was in Winchester, the prison provided
reasonable care to the man who died. I have, however, three concerns about
the way Winchester dealt with the man’s health care.
First, although the man did not tell the prison of any health problems when he
arrived, the doctor who saw him on 24 July noted that he was unwell. The
prison ought, therefore, to have obtained the man’s consent for his GP to be
contacted to obtain his full medical history. There is no evidence that this was
done.
Second, health care staff should not have issued prescription medication to
the man on 30 July without first checking his clinical condition. I appreciate
that the medication had been prescribed the previous day, but on 30 July the
man who died was complaining of serious symptoms and a further medical
assessment would have been prudent.
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Third, the medication should have been issued to the man by health care
staff, and not by a prison officer, to make sure that the medication reached
him and that he knew how to use it.
Although I think it is best practice for a Governor grade to contact the family in
the event of a death in custody, I understand why this role is often fulfilled by
the Chaplain. Their training and experience of means that they will frequently
have come into contact with, and have experience of, dealing with families at
crisis points. Nevertheless, it would have been good practice for a governor if
not the Governor, to have contacted the man’s sister shortly afterwards to
reflect the view that the death of the man was taken seriously. Once the
man’s sister felt she had to telephone the prison to find out why no Senior
Manager had contacted her, the chances of establishing effective rapport
between herself and Winchester had diminished.
Recommendations
I recommend that the Governor works with the prison’s health care service to
ensure that:
Where prisoners are observed or noted to have health problems, consent is
sought to contact their GP to obtain their medical records;
Heath care staff do not issue prescription medication to patients without
having assessed their clinical condition;
Health care staff issue medication direct to patients, and do not use third
parties to deliver medication.
I recommend that the Governor of Winchester amends the establishment's
death in custody contingency plans to specify that a Senior Manager should
contact the bereaved family once the Chaplain has made the initial contact.
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