Individual at Norwich

Investigation into the circumstances surrounding the
death of a man
at HMP&YOI Norwich in September 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2010
This is the report of an investigation into the circumstances surrounding the
death of a man who died unexpectedly at the age of just 27 years in
HMP&YOI Norwich. He was received at Norwich on the evening of 3
September 2009 and was found dead in bed the next morning.
The investigation was led by one of my colleagues. One of my family liaison
officers contacted the man’s family and offered them an opportunity to ask
questions about his death. In addition to his parents and siblings, he leaves a
partner and children. I offer them, and all those affected by his death, my
sincere condolences.
I am grateful to the Commissioning Manager for Planned Care for NHS Norfolk
for her work in providing a clinical review of the brief time the man spent in
Norwich. I am also grateful to the Safer Custody Manager at Norwich, who
provided a high standard of liaison for both the investigator and clinical
reviewer.
Although my investigator and the clinical reviewer concluded their interviews in
early December 2009, the investigation could not be concluded until the
Coroner received the toxicology report. Unfortunately, it was not received until
18 May 2010. This in turn delayed the clinical review which was received in
my office on 24 June. Although the significant delay in issuing this report was
substantially not of my making, I offer my apologies to the man’s family for any
additional distress which this may have caused.
Following the findings of the toxicology report, the pathologist concluded that
the man died from the combined effects of sedative drugs prescribed for him in
prison and sedative drugs that he brought into prison concealed on his person.
I have found no evidence that he intended to harm himself by ingesting these
drugs.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Jane Webb
Acting Prisons and Probation Ombudsman December 2010
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CONTENTS
Summary
The investigation process
HMP&YOI Norwich
Key events
Issues considered during the investigation
Conclusion
Recommendations
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SUMMARY
In August 2008, the man was sentenced to one year nine months in prison for
grievous bodily harm. He was released on licence from HMP Wayland on 16
January 2009. He was recalled to prison on 3 September after breaching the
terms of his licence. He arrived at HMP Norwich shortly after 3.00pm. He
went through the standard search procedures and first reception health
screen. He was allocated a cell on A1 landing.
The man told the reception nurse that he used zopiclone (used to treat
insomnia), diazepam (used to treat anxiety) and cannabis in the community.
His urine showed that he had taken benzodiazepines (of which diazepam is
one) and cannabis. He was prescribed a reducing dose of diazepam and
painkillers and zopiclone. The diazepam was administered in the presence of
a nurse in his cell. The remaining medication was given to him to hold and
take when required.
He appeared to be in good spirits on the night of 3 September. The night
nurse checked him twice during the night shift and on each occasion he
appeared to be sleeping peacefully in bed.
At about 8.25am, a landing officer opened the man’s cell and asked him if he
wanted to go out for exercise. When he did not respond, the alarm was
raised. Wing staff, health care staff and paramedics attempted to resuscitate
him but he was pronounced dead at 8.55am.
A post mortem examination on 5 September found no apparent cause of
death. Two packages were found in the man’s rectum and four items were
removed from his cell for further examination. Subsequent toxicology reports
showed that the packages removed from his rectum contained buprenorphine,
quetiapine and cannabis and that all these substances were in his system.
Based on these findings the pathologist concluded that he died from the
combined effects of sedative drugs prescribed to him in prison and sedative
drugs that he had brought into prison concealed about his person.
A clinical review of the healthcare received by the man in Norwich concluded
that he received appropriate medical care during his brief time in prison.
I conclude that his death could not reasonably have been foreseen or
prevented by HMP Norwich. He was properly searched when he arrived at
Norwich. His first reception health screen was conducted appropriately and
he was prescribed medication consistent with his presentation and the results
of his urine test.
I make one recommendation about the location of prisoners needing
detoxification and highlight three examples of good practice.
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THE INVESTIGATION PROCESS
1. I was notified of the man’s death in September 2009. The investigation
was allocated to an investigator on 11 September. Notices were issued
to staff and prisoners at Norwich telling them that an investigation would
be taking place, and inviting those who wished to see the investigator to
make themselves known. No one came forward in response. The
investigator wrote to the Coroner and spoke to a Detective Sergeant
from Norfolk CID.
2. A clinical review of the man’s medical care was commissioned from
NHS Norfolk. The Commissioning Manager for Planned Care
undertook the review. Her report appears as an annex to this report.
3. The investigator visited Norwich on 17 September and the clinical
reviewer accompanied her. Together they met with the Safer Custody
Manager. The investigator and clinical reviewer read the man’s prison
record and took copies of relevant documents. They visited A wing and
spoke informally to some of the staff. The investigator spoke to the
then Governor on 22 September.
4. The investigator returned to Norwich on 1 December and interviewed
four members of staff. She visited the prison’s reception area to
familiarise herself with the way in which new prisoners are searched for
contraband. She spoke at length to the Head of Security about search
procedures and the use of drug detection dogs.
5. One of my family liaison officers spoke to the man’s mother on the
telephone. She explained the nature and purpose of this investigation
and offered the family the opportunity to share any concerns they had
about his death and raise any questions about his treatment in prison.
The man’s mother said she wanted to know as much as possible about
her son’s brief time in prison. She said that the then Governor and the
prison chaplain broke the news of her son’s death to her in person at
home. She said that she and her son’s partner subsequently visited the
prison and were very well treated. The prison offered to contribute to
funeral costs and staff attended the service.
6. A post mortem examination took place on 5 September at hospital. No
evidence was found of natural disease that caused or contributed to his
death. Blood, urine and tissue samples were sent for examination by a
toxicologist. Two packages found in the man’s rectum and four other
items from his cell were also sent for forensic analysis. The results of
these tests were passed to the investigator and the clinical reviewer on
18 May 2010.
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HMP&YOI NORWICH
7. Norwich is a local prison serving the courts of East Anglia. It holds
remand and sentenced adult men and young offenders. The buildings
are a mixture of Victorian, twentieth and twenty first century builds on
different sites. The adult men and young offenders were integrated in
2009 and the young offender institution was converted into a
resettlement unit for low risk category C prisoners. There is also a
separate category D (open) prison.
8. A Wing is a newly built wing that opened in late August 2009. The new
A wing and activities block consists of the first night centre, induction
unit and integrated drug treatment system (IDTS) stabilisation and
maintenance landings. A2 landing is designed for prisoners requiring
detoxification. Accordingly the cells have large hatches in the doors
allowing nurses to observe the prisoners more clearly and to pass them
medication and drinks during the period when they are undergoing
withdrawal. A wing has cells for 180 prisoners but since opening 30
cells have been doubled and it now accommodates 210 prisoners.
9. The Norwich Independent Monitoring Board (the IMB comprises
independent volunteers who monitor day-to-day life in prisons) report
2009/10 commented that A wing was opened on schedule, the building
was pleasantly light and airy and the transfer of prisoners into it was
well planned and effected efficiently. A number of teething problems
became apparent when the wing was first occupied – the radio signal
was poor or non-existent and the protective glass in the wing offices
meant it was impossible for staff inside them to communicate orally
with staff outside them (when my investigator visited A wing in
September 2009 staff were banging on the windows or gesticulating to
attract the attention of colleagues). These problems have since been
rectified.
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KEY EVENTS
10. In August 2008, the man was sentenced to one year and nine months
imprisonment for grievous bodily harm. He served his sentence at
HMP Wayland and was released on licence on 16 January 2009.
11. On 3 September, he was arrested by police and charged with
possession of a category B drug (cannabis), possession of a category
C drug (Subutex), using threatening words or behaviour, resisting
arrest and obstructing a police officer. His family told my family liaison
officer that he went willingly with the police when arrested.
12. His probation officer notified the public protection casework section at
the National Offender Management Service the same day that the man
had breached the terms of his licence. He appeared before
magistrates and was remanded to custody pending a hearing on 15
September. He was taken to HMP&YOI Norwich, arriving in reception
there at 3.09pm.
13. The man went through each stage of the standard search procedure in
order to identify whether he was carrying any contraband such as
drugs or mobile telephones. He was strip searched, which meant that
his clothes were removed in turn to preserve his dignity. He was also
checked with a hand held metal detector and then walked through the
x-ray portal. As a known drug user, he was also searched using a drug
detection dog. The dog gave a positive indication that the man had
come into contact with drugs recently. (A positive indication from a drug
detection dog can mean that the person has drugs on their person or
that they have used them or otherwise come into contact with them
recently.) He told reception staff that he had, “had a spliff recently”.
He then sat on the BOSS chair (body orifice security scanner – a
device for searching for metal objects concealed internally). This did
not indicate that he was concealing any metal object.
14. Following the search procedure, Nurse A completed the man’s first
reception health screen. It included testing his urine and the results
showed positive for cannabinoids and benzodiazepines (a group of
psychoactive sedative drugs used to treat insomnia, muscle spasms
and anxiety). He told the nurse that he had recently been involved in a
car accident and was taking painkillers for whiplash and zopiclone
(usually prescribed for insomnia). He also told her that he was taking
unprescribed diazepam (a benzodiazepine used to treat anxiety) daily
and used cannabis regularly. At interview the nurse told the clinical
reviewer that he appeared “fidgety” consistent with someone
withdrawing from benzodiazepines.
15. Nurse A concluded that the man needed diazepam detoxification. She
prescribed diazepam (in a reducing dose consistent with
detoxification), paracetamol, ibuprofen and zopiclone (a single tablet).
The first dose of detoxification medication is usually given in reception.
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She did not have the required medication at that time so she
telephoned A wing and asked Nurse B to make sure the man received
it on the wing. He was taken to cell A1-24 on A wing. As a prisoner
detoxifying from illicit drugs, he should have been located on A2
landing but appears to have been placed on A1 either in error or
because A2 was full.
16. Nurse B told the clinical reviewer at interview that A wing had only
recently opened when the man arrived at Norwich. She said there was
a lot of confusion in the early days that led to prisoners on
detoxification sometimes being incorrectly located on other landings.
This made it harder for staff to make sure they were receiving
appropriate care. She said that she found out where he was located
and went to his cell. She said he appeared to be settling in well and
was in good spirits. He was playing his music loudly and she asked
him to turn it down. She spoke to him at some length about what
medication he was allowed. She watched him take his dose of
diazepam and gave him his doses of paracetamol, ibuprofen and
zopiclone for that night in possession so that he could take them if and
when he needed to.
17. Nurse C was the substance misuse nurse on duty on A wing during the
night of 3/4 September. Her role is to look after the prisoners who are
detoxifying on A2 landing. She was told at handover that the man had
been put on A1 landing in error. She said at interview that she
remembered speaking to him when she came on duty that night. It
was her practice to introduce herself to all new prisoners undergoing
detoxification. She said he was pleasant and appreciative of her visit.
She remembered that his music was on very loud and an officer told
him to turn it down.
18. Nurse C said that she is not required to check prisoners who are
detoxifying, unless they are very unwell. However, it is her practice to
check them for her own peace of mind. She decided to check the man
partly because he was located on a different landing. As mentioned
previously all the cells on A2 have large observation hatches in the
door allowing the nurses a good view of the prisoner and enable them
to pass medication or drinks at night. Because he was located on A1,
his cell door had a standard observation flap, making it more difficult to
observe him. She remembered checking on him twice during the night
and said he looked to be asleep in bed on both occasions. She last
looked at him before going off duty at about 7.45am. She said she did
not notice anything untoward about his appearance.
19. At about 8.25am on 4 September, Officer A began unlocking the cells
on A2 landing. He opened the man’s door and asked him if he wanted
to go out for exercise. He got no response and, on looking more
closely, saw that he was blue in colour. He called to Officer B for
assistance. Officer B said she went into the cell with Officer A and they
tried to wake him by calling his name and touching him. She said he
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looked to be asleep under his blankets. The bedding had not been
disturbed. He did not respond so Officer B used her radio to call a
code blue emergency (signifying that a prisoner is unconscious or
having breathing problems). Because of difficulties with the radio
signal on the wing she also ran to the wing office and banged on the
glass to attract the attention of other staff.
20. Officer C was also on duty on A wing. He heard Officer A say to a
prisoner, “exercise fella” and then call to Officer B for assistance. He
realised that something was wrong and went to the man’s cell. He saw
both officers trying to wake him. Officer B left the cell and Officer C
said he and Officer A turned the man over on the bed. As they did so
they heard a gurgling sound and took this as an indication that he was
still breathing. They moved him on to the floor and placed him in the
recovery position. At this point Officer D and a Principal Officer (PO)
entered the cell.
21. Officer D checked the man for signs of life but could find none. The
officers placed him on his back and Officers D and A began cardio
pulmonary resuscitation. The PO asked a Senior Officer (SO) to call
for an ambulance and to get emergency response nursing staff.
However, the emergency response nursing staff arrived shortly
afterwards because they had received the radio message from Officer
B.
22. Two nurses and a Healthcare Assistant (HCA) heard the emergency
code blue on the radio and immediately made their way to A wing. Due
to poor radio reception they thought that the emergency was on A4
landing but when they got to A wing they were told the emergency was
in cell A1-24. The HCA was asked to collect the emergency bag
containing a defibrillator from A5 landing.
23. The HCA said he attached the defibrillator to the man and no shock
was advised. (If there is no electrical activity in the heart the defibrillator
will advise not to shock but to continue CPR.) He continued CPR and
the nurses set up a bag and mask to give him oxygen. After one cycle
of CPR the defibrillator analysed him and again advised no shock. The
healthcare staff continued CPR until the paramedics arrived at about
8.40am. The paramedics continued CPR. They also attached a 12
lead electro cardiogram (ECG) machine to him and it showed a flat line
(indicating that there was no electrical activity in his heart). At 8.55am
the paramedics pronounced that he had died.
24. The prison’s death in custody contingency plan was followed. Four
items were removed from the man’s cell by the police and given to the
Coroner’s pathologist. They were a paper cup containing tablets, a
torn Somerfield bag and two plastic wrappings. All the prisoners who
were subject to monitoring under the Assessment, Care in Custody and
Teamwork procedures (ACCT - the National Offender Management
Service’s process for monitoring prisoners thought to be at risk of
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harming themselves) were reviewed. An officer in Safer Custody
visited a friend of the man who was subject to ACCT. The then
Governor and the chaplain visited his parents to break the news of their
son’s death.
25. A post mortem (PM) examination was completed at hospital on 5
September. The pathologist found no evidence of natural disease that
caused or contributed to the man’s death. Neither did he find any
injuries or evidence of assault or restraint. Two packages were found
in his rectum and sent for forensic analysis along with the four items
removed from his cell with samples of his blood, urine and other
tissues.
26. The first of the packages discovered in the man’s rectum was found to
contain one whole, one half and one fragment of 8mg buprenorphine
(Subutex – an opioid used to treat opioid addiction) tablets and small
amounts of cannabis in three different forms. The package was dry
and therefore the examining chemist concluded that it was unlikely that
any of the contents had leaked into his body. The second package
was found to contain 12 buprenorphine tablets, 8.95g of cannabis in
flowering form and 6.4g of cannabis in resin form. Although this
package was damp, the chemist concluded that the contents had not
leaked out into his body.
27. The paper cup removed from the man’s cell contained the paracetamol
and ibuprofen given to him at the prison as part of his detoxification
regime. The cup also contained part of a blister pack containing two
Seroquel tablets. (Seroquel is the brand name of a preparation
containing quetiapine. It is used to treat schizophrenia, bipolar disorder
and anxiety disorders and was not prescribed to him.) The examining
chemist concluded that the Somerfield bag and the two wrappings
removed from the cell had at one point been part of the packages
found in his rectum.
28. Forensic analysis of the man’s blood and urine samples showed that
he had consumed buprenorphine, cannabis, paracetamol, ibuprofen,
zopiclone, quetiapine and diazepam. Based on the findings of the
toxicologist, the pathologist concluded that he died as a result of the
combined effects of the sedative drugs found in his system, with
buprenorphine likely to have made a major contribution.
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ISSUES CONSIDERED
Clinical care
29. The clinical review at annex 1 contains a complete account of the
medical treatment received by the man during his brief time in Norwich.
I consider that the reception health screen and first night prescribing for
him were appropriate. There was no evidence to suggest that he had
recently taken any opioid substance (such as buprenorphine) that
would combine fatally with the benzodiazepines in his system and
those prescribed for detoxification. His urine showed positive for the
presence of benzodiazepines and cannabis, which was consistent with
the information about his drug use that he gave to Nurse A.
30. As has been explained previously, A wing was a newly opened wing.
One of its functions is to provide an integrated drug treatment service
(IDTS) for prisoners needing detoxification. The dedicated
detoxification landing is A2. In order to implement an IDTS, a prison
must complete a planning tool kit. One of the three main factors in
respect of safer custody in the planning toolkit for local prisons is that
there must be unrestricted observation through large observation
hatches on cell doors.
31. Because the man incorrectly was given a cell on A1 his door only had a
regulation observation panel. However, the clinical review concludes
that his location away from the detoxification landing, though not ideal,
did not impact negatively on the care he received because nursing staff
made sure it did not. Nurse B made a point of explaining to him that he
was not located where he should have been and advised him to ring
his cell bell if he needed anything during the night. She also introduced
him to Nurse C which was good practice. Nurse C decided to make
regular checks on him even though she was not required to. This is
another example of good practice.
32. At interview with the clinical reviewer, nursing staff expressed
frustration at the number of times that prisoners requiring detoxification
were inappropriately located away from A2. Prisoners are especially
vulnerable in the early stages of detoxification and the ability of staff to
observe them unrestrictedly is crucial. I know that senior managers at
Norwich were aware of this problem at the time and it was regarded as
one of the teething troubles associated with opening a new wing.
However I consider it sensible that checks are made to ensure that the
problem has been resolved.
I recommend that the Governor satisfies himself that prisoners
needing detoxification are now routinely located on A2.
The prison accepted this recommendation at draft report stage and
commented:
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“Prisoners needing detoxification are now routinely located on A2,
however due to increased numbers of prisoners requiring detox this
may not always be possible. When prisoners are located on other
landings within the “A” Wing complex” protocols have been put in place
by healthcare that the prisoners are given the same amount of
care/checks.”
33. As soon as he realised that the man was not responding Officer A tried
to establish if he was still breathing. While turning him over the officer
heard a gurgling sound which he took as evidence that he was
breathing. He and Officer C therefore moved him into the recovery
position on the floor. Officer D then checked for signs of life and when
he could find none, CPR was started. This is the correct procedure to
follow when finding a person unconscious. Ascertaining whether an
unconscious person is breathing is not always straightforward. I am
satisfied that staff reacted appropriately and started CPR as soon as
possible. From the statements made by the staff concerned, it appears
that the man was already dead when he was discovered.
The prison’s response to the man’s death
34. A wing became operational on 31 August 2009. It is a new building
and in the few days between the wing opening and the man’s death a
number of problems became apparent. The radio signal on A wing
was poor and the nature of the glass and design of the wing offices
(known as ‘bubbles’) meant staff inside the offices could not hear what
was going on outside and vice versa. At interview staff said that they
were not all supplied with radios. Radios were allocated according to
role. This meant that theoretically a landing might have no staff
carrying a radio. This, in combination with the fact that the new landing
offices were not equipped with telephones, gave rise to concerns about
safety of staff and prisoners and the ability of staff to respond in an
emergency.
35. In this case the emergency response healthcare staff did hear the
emergency call on the radio. Although they understood the emergency
was on A4 landing they were pointed to the correct location as soon as
they got to the wing.
36. My investigator spoke to the then Governor about these issues in
September 2009. He said that a new aerial was due to be put up
nearer the wing which would improve the radio signal. He also said
that more staff radios were on order. My investigator confirmed that a
new aerial went up in February 2010 and that the issues with the signal
and radios have since been resolved. I have therefore decided not to
make a recommendation about the radio system.
37. I am pleased that the then Governor and the prison chaplain went in
person to break the news of the man’s death to his parents. It is
properly the responsibility of the prison to break the news of a death in
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their custody. His mother said the family were treated well and
sensitively by the prison. All the staff interviewed reported that they too
had felt well supported.
38. In the hours immediately following the man’s death, staff raised
concerns about a prisoner on A wing who was on an open ACCT
document and who had been friends with him. The prisoner was
visited by a member of the Safer Custody Team and arrangements
were made for him to see a nurse and have an ACCT review. This is
another example of good practice.
Searching and drug detection
39. Prison staff do not have the power to conduct intimate searches of
prisoners. During the mandatory strip search if staff have a strong
suspicion that a prisoner has concealed an item on their person, they
are only allowed to ask the prisoner to squat or bend over.
40. The Head of Security explained to my investigator that prisoners are
not routinely searched using drug detection dogs but they are used in
reception when possible. The dog handler will usually be able to tell
whether the dog is certain that drugs are concealed on the prisoner or
whether it is more hesitant. A hesitant indication might indicate that a
person has come into contact with or taken drugs relatively recently. If
a dog gives a positive indication then security staff ‘flag’ the prisoner for
a later cell search. The ability of a drug detection dog to detect
whether a prisoner has drugs concealed on his person depends on
how carefully the drugs have been handled.
41. The problem of drugs and other contraband being brought into prison is
unfortunately common. Prisoners, like the man, who are recalled from
licence may know in advance that they are likely to return to prison and
they have the opportunity to ‘prepare’ by concealing drugs before they
appear at court. I am pleased to see that staff in Reception at Norwich
recognised him as someone who was known to use drugs and
searched him additionally using a drug detection dog. Had he lived
beyond his first night in custody, I would have expected the positive
indication given by the drug detection dog to have resulted in a search
of his cell and a mandatory drug test during his first days in custody. In
the circumstances of this case I do not consider that staff could
reasonably have been expected to do more at the time of his reception,
to find out whether he had brought drugs in with him.
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CONCLUSION
42. This is a sad story. The man was a young man with a young family. I
do not know whether he was expecting to return to prison on 3
September 2009. The contents and nature of the packages concealed
about his person suggests that he was. He appears to have made a
determined attempt to bring contraband into Norwich and to conceal
those drugs in a way that made it unlikely staff would find them during
the reception process.
43. I have found no evidence that he was aware of the risk in combining
the drugs prescribed for him and those he brought into the prison.
There is no evidence that he intended to harm himself and no evidence
of third party involvement in his death. I do not believe that his death
could have been reasonably foreseen or prevented by staff at Norwich.
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RECOMMENDATIONS
1. I recommend that the Governor satisfies himself that prisoners needing
detoxification are now routinely located on A2.
The prison accepted this recommendation at draft report stage and
commented:
“Prisoners needing detoxification are now routinely located on A2,
however due to increased numbers of prisoners requiring detox this
may not always be possible. When prisoners are located on other
landings within the “A” Wing complex” protocols have been put in place
by healthcare that the prisoners are given the same amount of
care/checks.”
Good practice
1. When Nurse B realised the man had not been given a cell on the
detoxification landing, she made a point of explaining to him that he
was not where he should be and advised him to ring his cell bell if he
needed anything during the night. She also introduced him to Nurse C.
This is good practice.
2. The decision by Nurse C to make regular checks on him because he
was not located on the detoxification landing was good practice.
3. The visit by the Safer Custody Officer to the man’s friend was good
practice.
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