Individual at Leeds

Investigation into the circumstances surrounding the
death of a man at HMP Leeds in July 2006
Report by the Prisons and Probation Ombudsman for England and Wales
April 2007
This is the report of an investigation into the death of a man on 4 July 2006 whilst he
was a prisoner at HMP Leeds. The man was on a methadone maintenance
programme at the prison when he died. The man had been returned to custody
following a short, unsuccessful period on licence. He was 26. Although the cause of
death is as yet undetermined, it is likely to have involved an adverse reaction to the
methadone occasioned by interaction with mirtazapine.
I wish to offer my sincere condolences to the man’s family for their loss.
Toxicological examination has also shown that he had taken mirtazapine that he had
not been prescribed.
The investigation was conducted on my behalf by one of my investigators. I would
like to extend my thanks to the Governor and his staff at Leeds for their help and co-
operation.
In addition to my investigation, a clinical review was undertaken by the Leeds
Primary Care Trust into the medical care that the man received at HMP Leeds. I am
grateful to the clinical reviewer for conducting that review.
I make one recommendation at the conclusion of this report, echoing that made by
the clinical review.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2007
CONTENTS
Summary 1
The Investigation Process 2
HMP Leeds 4
Key Findings 5
Issues 8
Recommendations 9
SUMMARY
On 20 May 2006, the man arrived at HMP Leeds as the result of his licence being
revoked. The man told the reception nurse that he used heroin, benzodiazepines
and crack cocaine daily, although the urine dip test was not positive for crack.
The man was put onto a 14 day methadone detoxification regime.
On 27 June 2006, the man was seen by a doctor. He was showing some signs
of withdrawal and admitted to using subutex and diazepam he had obtained on
the prison wing. He was put onto a 40ml a day methadone maintenance
programme.
The man was seen in the substance misuse clinic on 3 July. He described
himself as ‘fine’ on the maintenance programme.
About 4.00 am on 4 July 2006, the man’s cell mate was heard banging on the cell
door and shouting. He also pressed the cell bell. A senior officer heard the
banging as she walked onto the wing and went to investigate. She looked into
the cell and the man’s cell mate said, ‘Miss, miss I can’t move him.’
The senior officer looked further into the cell and saw the man kneeling over the
toilet. She called for assistance and other staff arrived. They entered the cell
and saw that there was vomit around the toilet area. The man was found to be
stiff and cold and, although medical assistance in the form of a nurse and
paramedics arrived, there was nothing that could be done for him.
The man was later discovered to have methadone and mirtazapine in his blood.
There is evidence that he had taken the mirtazapine from his cell mate who had
obtained it illegally from another unidentified prisoner. The exact cause of the
man’s death has not yet been determined, although it is believed he had an
adverse reaction to the methadone probably brought about by its interaction with
mirtazapine.
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THE INVESTIGATION PROCESS
1. The investigation was opened at HMP Leeds on 5 July 2006. The Governor
and his staff produced the man’s medical record and a number of other
documents for examination. Notices were distributed around the
establishment notifying staff and prisoners of the investigation, and a number
of staff were formally interviewed.
2. My investigator liaised with the officer conducting the police investigation into
the man’s death on behalf of Her Majesty’s Coroner.
3. Her Majesty’s Coroner was contacted 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 with his enquiries
into the man’s death.
4. One of my Family Liaison Officers contacted the man’s family to inform them
of my investigation. At the time of contact and of writing this report, the man’s
family were unsure if they wanted active involvement with my office.
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HMP LEEDS
5. HMP Leeds is predominantly a Victorian prison. The four original wings (A, B,
C and D) were built in 1847. Two more wings (E and F) were opened in 1994,
together with new kitchens, gymnasium and healthcare centre. Leeds is a
category B local prison for adult male prisoners from West Yorkshire.
6. A Wing consists of four landings, the top three entirely populated by
vulnerable prisoners (those who must be protected from others). The bottom
landing, A1, contains the segregation unit which is known as S1. Other wings
hold convicted and unconvicted prisoners, and D wing is the induction wing.
7. There have been 18 deaths at Leeds since I was given responsibility for
investigating all prison deaths in April 2004. Although not all the inquests
have been held, my analysis shows that six of those deaths were apparently
from natural causes, two murders, eight self-inflicted and two, including the
man’s, were apparently drug related.
8. Although not all the investigations are yet complete, I am aware that the
abuse of prescribed medicines has featured in other recent deaths at Leeds,
and that the Governor and the PCT are investigating further measures to
reduce such abuse.
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KEY FINDINGS
9. The man was sentenced to two years imprisonment for an offence of burglary
by Leeds Crown Court on 3 January 2006. He was released on licence from
HMP Lindholme on 16 May. The licence was revoked on 18 May after the
man failed to comply with the imposed curfew conditions.
10. The man arrived at HMP Leeds on 20 May 2006, and was seen in the
reception area by a healthcare nurse. He said he drank five pints of beer
daily and used £30 each of heroin and crack a day, as well as £10 worth of
benzodiazepines. He told the nurse that he had last used the drugs on 18
May. As part of the health screening process, the nurse asked the man if he
had any thoughts of self harm. He said that he did not, but said that he
wanted help in relation to his alcohol and drug use. At the end of the
screening process, the nurse decided that the man was fit for normal location
and work within the prison. She referred him to the medical officer for
detoxification assessment.
11. The man saw the medical officer the same day and was put onto a 12 day
alcohol detoxification programme and a 14 day opiate detoxification
programme. The latter was a reducing methadone regime, beginning with
20ml on the first night.
12. The man was seen by one of the prison’s CARAT workers (Counselling
Assessment Referral Advice and Throughcare) on 22 May. He said that he
was feeling vulnerable in custody and was referred to the safer custody detox
programme and the Bradford Drugs Intervention Programme. The man’s
CARAT worker said during interview that when she saw him he was anxious,
and that in his case feeling vulnerable meant feeling shaky and a ‘bit down’.
The CARAT worker was clear that the man did not voice or exhibit any signs
of being vulnerable to self-harm.
13. On 24 May, the man put in an application to go onto the drug maintenance
programme. He was put onto the triage list. Eligibility for the programme
depends in part on how long the person would remain in custody, but at that
time the man’s Earliest Date of Release (EDR) had not been calculated.
14. On 3 June, the man refused to take his 2 mls of methadone on the last day of
his detox. It is not known why.
15. The man saw a doctor on 5 June and asked for methadone maintenance. As
he was still on the detox regime, the doctor decided to continue with
symptomatic relief. The following day, the man was placed on the waiting list
for the substance misuse triage clinic. He was also referred to the registered
mental health clinic for assessment regarding possible dependence
syndrome.
16. On 7 June, The man was seen in the substance misuse clinic by a nurse.
She tested his urine and it was positive for opiates and benzodiazepines. He
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was placed on the waiting list to see one of the doctors about being put onto a
maintenance programme.
17. On 13 June, The man was seen by one of the healthcare nurses. He said
that since finishing his detox he had become increasingly paranoid, anxious
and depressed, although he again denied any thoughts of actually harming
himself. The man was allowed to rest in his cell for the remainder of the day
and to miss education classes.
18. The man failed to attend education during the morning on 15 June and for the
whole day on 20 June. On the first occasion he was given an official warning
but on the second no action was taken as the man said that he had been
feeling unwell.
19. The man was seen again by a healthcare nurse on 22 June. She noted that
he was still feeling anxious and felt that he was not coping with his education
classes. Another day’s rest in his cell was given, and it was noted that he had
still not been seen at the mental health clinic.
20. The next day, the man was seen by a nurse at the mental health clinic. She
noted that, in her view, all of his problems revolved around his drug use, and
that his anxiousness was all part of coming off drugs. She detected no
evidence of mental illness. The man was told to see the duty doctor if he felt
he needed medication. It was clear from my investigator’s interview with the
mental health nurse that she had been aware of the man for some time before
she saw him. She said that other nurses had quite a few issues with him
regarding his drug needs. She said that the man had wanted more drugs,
either subutex or methadone and diazepam in particular. In her professional
opinion, the mental health nurse said that the man wanted the diazepam for
detox reasons rather than any mental health issues.
21. On 27 June, the man was seen by a doctor in healthcare. The man again
requested methadone maintenance. He admitted to the doctor that he had
been using illicit subutex on the wing and occasionally had also taken
diazepam. He claimed to have last used illicit drugs two days previously. The
doctor agreed that the man should go onto a maintenance programme,
starting with 30ml of methadone that day and then a maintenance dose of 40
ml thereafter.
22. The man attended the substance misuse clinic on 3 July, although the staff
were not sure why. The man said that he was doing fine on the maintenance
programme and that he might want a reducing dose in the future. He also
asked to be put onto subutex before his release and was advised to put in an
application closer to the time.
23. At about 8.00 pm that evening, a prison officer opened the flap to the man’s
cell while doing the final count on the wing. The man went up to the flap and
asked the officer if he could have a shower. The officer explained that it was
too late for such requests, which the man seemed to accept. The officer
thought it was a strange request as prisoners should know not to ask for
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things like that at that time of night. The prison officer had not seen the man
previously but did not think that the way he presented was any cause for
concern.
24. At about 4.00 am on 4 July, the senior officer was conducting a routine visit to
the wings. As she walked onto B wing, she heard someone banging on a cell
door. She looked along the landing and saw a cell bell light go on outside cell
B2-36. She went straight to the cell and looked through the small observation
window, switching the cell bell off and turning on the cell light at the same
time. The man’s cell mate was looking back at her, obviously distressed. He
said, ‘Miss, miss, I can’t move him.’ The senior officer asked him to put on the
main cell light, which he did. She was then able to see more of the cell, and
could see the man kneeling over the toilet as if being ill. She asked the cell
mate if the man was being sick and if he was breathing. At the same time she
saw a second officer walking along the landing towards her. The senior
officer asked him to radio for assistance, anticipating the need to enter the
cell. The cell mate said, ‘No, it’s not right. He’s not breathing. I can’t touch
him.’
25. The senior officer took out her keys, told the cell mate to sit on his bed, and
started to open the cell door as she saw two officers and a second nurse
coming towards her. She entered the cell and could tell that something was
wrong. The man felt very cold and the senior officer could not feel a pulse.
There was vomit in and around the toilet area. The second nurse entered the
cell and it was obvious to her immediately that the man was dead. The man’s
cell mate was taken out of the cell, his clothing bagged and he was relocated
onto C wing. He was put into a cell with two Listeners (prisoners who
volunteer to be trained by the Samaritans and then provide a similar service).
26. The paramedics had been called by the control room and they arrived at 4.26
am. After carrying out their checks they pronounced the man dead. The staff
involved took part in a hot debrief later that morning before going off duty. It
gave the staff the opportunity to talk through the events and their involvement.
Just before 10.00 am, a governor and a doctor from the prison visited the
man’s parents to break the sad news of his death.
27. When the man’s cell was searched, an empty tablet bottle belonging to a
prisoner on C wing was found. When the police questioned the man’s cell
mate he said that he had taken the empty bottle from his previous cell mate
before being located with the man. He said that he had kept some
mirtazapine tablets in the bottle. He added that he had purchased the tablets
from another prisoner whom he refused to name.
28. When the man’s blood was analysed, it was found to contain methadone and
mirtazapine, both in non-lethal quantities. At the time of writing this report, the
exact cause of the man’s death has not been determined. In the clinical
review into the man’s medical care, it states that mirtazapine is an anti-
depressant which adds to the sedating effects of opiates (including
methadone). The clinical reviewer believes the interaction of the two drugs
was a key factor in the man’s death.
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ISSUES
29. On 27 June, the man told one of the doctors that he had been using illicit
subutex and diazepam that he had obtained within the prison. The man’s
death would appear to be a tragic accident, probably caused by an interaction
between his prescribed medication and drugs prescribed to other prisoners.
30. Like every other prison, Leeds has protocols and procedures in place to try
and limit the availability of both illegal and prescribed drugs. However, as
noted in paragraph 12 above, there have been a number of recent deaths at
the establishment where the availability of drugs within the prison has been an
issue.
31. In her follow-up unannounced inspection report of August 2005, the Chief
Inspector of Prisons wrote about the availability of illicit drugs. “Detoxification
regimes had improved considerably and maintenance programmes were
offered. However, there was some evidence that subutex was used as
currency within the prison and that was reflected in mandatory drug testing
figures. Routine testing on the voluntary testing units did not cover subutex.
It was, therefore, possible that the use of subutex in the prison was more
widespread than was recorded. In our survey, 43% of respondents said it
was easy to get illegal drugs, compared to the 32% benchmark.”
32. I am aware that the prison, in conjunction with the local police, has been
looking at further measures to prevent illicit trafficking and drug use. I echo
the recommendation that the clinical review makes:
The Governor and Leeds PCT should consider if there are any further
steps that can be taken to reduce the illicit use of medication
prescribed within the prison.
33. My investigator found that staff reacted promptly and professionally when
alerted to the situation in the man’s cell. Unfortunately, it was evident to both
the security staff and the nurse who entered the cell that the man was already
dead.
34. No evidence was found to indicate that the man had any thoughts of harming
himself, or that he intended his drug taking that night or early morning to end
his life.
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RECOMMENDATION
The Governor and Leeds PCT should consider if there are any further steps
that can be taken to reduce the illicit use of medication prescribed within the
prison.
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