Individual at Lindholme

Investigation into the circumstances surrounding the death
of a man at HMP Lindholme in April 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This is the report of an investigation into the circumstances of the unexpected death
of a man on 29 April 2007, whilst serving a sentence at HMP Lindholme. A post
mortem found that the cause of his death was heart disease. The man was 38 years
old. My colleagues and I would like to extend our condolences to the man’s family
and all those touched by his death.
The investigation was led by one of my investigators. I would like to thank the
management and staff at HMP Lindholme for their assistance and co-operation
during the course of the investigation. An independent review of the man’s medical
care in prison was commissioned from Doncaster Primary Care Trust. The report,
which was received in February 2008, was subject to a further, comprehensive
review by the Assistant Director of Clinical Effectiveness. I am grateful for their
assistance.
On reception to prison in April 2006, the man appeared to be in good health. As his
sentence progressed, he had thoughts of self-harm (and was subject to monitoring
procedures), but there is no evidence that this contributed to his death. Two days
before his death, the man reported sick. He was treated for a minor ailment but later
complained of a pain in his left shoulder and pins and needles in his arm. Early on
the morning of his death he again mentioned the pain and was offered the
opportunity to go to the prison healthcare unit immediately. The man elected to wait
until later. Unfortunately, before he was able to do so, he was found collapsed in his
cell by staff who, with the help of other prisoners, made prolonged and strenuous but
ultimately unsuccessful, attempts to resuscitate him.
I am satisfied that the man’s death could not have been foreseen. I make three
recommendations, two concerning recordkeeping and one about the availability of
radios to staff working in accommodation wings. I apologise for the delay in
publishing this report which was, in part, due to the delay in receiving the clinical
review.
Jane Webb
Deputy Prisons and Probation Ombudsman January 2009
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Contents
Summary 4
The investigation process 6
HMP Lindholme 8
Key events 9
Issues considered during the investigation 22
Recommendations 27
Evidence considered 28
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SUMMARY
The man died on the morning of 29 April 2007, in his cell at HMP Lindholme. He had
been serving a sentence of two and a half years and had transferred to Lindholme in
February 2007, having spent time in other prisons. The man died from a blockage in a
coronary artery. He was 38 years old.
The man was a smoker who had used both drugs and alcohol. His health assessment, on
first entering prison, indicated that he had no mental health or heart problems. However,
in prison he was emotional and said that he felt like self-harming. The man also felt under
threat from other prisoners, having cooperated with police after witnessing a murder in
Jamaica some years before. Between 1 June 2006 and 10 January 2007, the man was
subject to periods of monitoring under the Assessment, Care in Custody and Teamwork
(ACCT) procedures. This process identifies and cares for prisoners at risk of self-harm.
He also had consultations with the psychiatrist and was prescribed medication for anxiety
and mental health problems.
During the morning of Friday 27 April, the man reported sick and was treated for a mouth
ulcer. Later that evening, he told one of his friends, a fellow prisoner, that he had a pain in
his left shoulder and pins and needles in his arm. The man said that he had reported sick.
He had been told that it was muscle strain, given paracetamol and advised to stay in his
cell. The following morning, he mentioned to the same prisoner and an officer that he still
had the pain in his shoulder. The officer offered the opportunity to go to the healthcare
unit (HCU) immediately, but the man elected to wait until the sick parade at around
10.30am.
At around10.20am, an officer went to the man’s cell to tell him that the sick parade had
been called and saw him laying across the bed facing the door. He realised that
something was wrong and tried to find a pulse. Having failed to do so, the officer started
cardio pulmonary resuscitation (CPR) chest compressions, with the assistance of a
prisoner, and called for urgent medical assistance. In spite of considerable attempts at
resuscitation by discipline and nursing staff, as well as paramedics, the man was
pronounced dead at 11.09am.
The Head of Residence and Healthcare implemented the Lindholme death in custody
contingency plan. The police were informed and initially treated the man’s death as
suspicious. Because of their suspicions, the police wanted to break the news to the family,
but they were not able to make contact until the next morning. Support was provided for
prisoners and staff and all open ACCT documents were reviewed. A hot debrief for the
staff involved was conducted. The acting deputy governor wrote a letter of condolence to
the man’s partner in which assistance was offered for travel expenses, but no offer of
assistance with funeral expenses was made. The Coroner raised the issue of funeral
expenses which was passed on to the Governor. A memorial service for the man was
held at Lindholme later the same day which was well attended by staff and prisoners.
I have made three recommendations two relating to recordkeeping and the third relating to
the adequate provision of radios. I am pleased to record that the recommendations
relating to record keeping have been accepted and an action plan put into place. The third
recommendation which was included in response to representations made by solicitors
acting for the man’s partner was added after the original draft was issued and the Prison
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Service has yet to respond.
5
INVESTIGATION PROCESS
1. My investigator visited HMP Lindholme on 14 May 2007. He met the nominated
liaison governor who gave him a full briefing about the circumstances surrounding the
man’s death. The Governor was subsequently briefed by my investigator on later
visits. Offers to meet representatives of the Prison Officers’ Association and the
Independent Monitoring Board were accepted.
2. Notices to staff and prisoners were published inviting anyone who might have
information relating to the man to make themselves known to the investigator. Three
prisoners spoke to the investigator. The investigator met with relevant prison staff,
including members of the chaplaincy and medical departments. Initially, the police
treated this death as one that was suspicious and were investigating it as such. They
re-assessed the evidence following a post mortem examination later on the day of the
man’s death and decided that it was no longer considered suspicious.
3. Copies of the man’s prison and medical records were provided. The Head of
Commissioning, at the Doncaster Primary Care Trust commissioned a clinical review
which was carried out by the Assistant Director of Strategic Support, and the Head of
Clinical Governance. This was subject to a further review by the Assistant Director of
Clinical Effectiveness, which was received on 22 February 2008.
4. One of my family liaison officers offered to visit the man’s partner and mother. The
family chose not have a home visit.
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HMP LINDHOLME
5. HMP Lindholme is a purpose built prison outside Doncaster, South Yorkshire,
which was opened in 1985. It is a split site, part category C Training Prison
and part Immigration Removal Centre. The category C site holds convicted
adult male prisoners. Category C prisons are for those who cannot be trusted
in open conditions but who would not have the ability or resources to make a
determined escape. Lindholme has an operational capacity of 839.
6. Since April 2004, healthcare at Lindholme has been provided by the
Doncaster Primary Care Trust. There are no inpatient beds and medical
services are provided by a doctor from a local practice who visits daily and
sees prisoners who have applied for an appointment. The clinical staff provide
a day time service, and are all appropriately qualified. Sickness and
treatments are managed by nursing staff.
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KEY EVENTS
7. The man was first received into prison at HMP Pentonville on 27 April 2006
when he was remanded into custody by Newham Magistrates’ Court. On 18
July, he was convicted at Snaresbrook Crown Court. He was subsequently
sentenced on 15 August 2006 to a total of two years and six months’
imprisonment and recommended for deportation at the end of his sentence.
8. At his initial reception interview in Pentonville, the man named his partner as
his next of kin. He said they lived together with their small children in London.
9. The man’s First Reception Health Screen document indicates that he had
asthma but was taking no medication. It also shows that he used both heroin
and crack cocaine and was an occasional user of alcohol. He said that he had
no suicidal thoughts or intent. The man was prescribed no medication but was
referred to a doctor for detoxification. The clinical record shows that on the
following day, 28 April, the man refused to see the doctor and that he
appeared well, stating that he had no withdrawal symptoms.
10. After a conversation on 1 June between the man and a staff member during
which he said that he felt like self-harming, an Assessment, Care in Custody
and Teamwork (ACCT) document was opened, it remained open until 5.25pm
on16 June. (The ACCT process is used to provide additional support and
monitoring for prisoners at risk of self-harm.) On 10 June, during his
Secondary Health Assessment, it was recorded that the man had chronic back
pains and that he was “depressed, tearful and at times feels suicidal”. An
additional note indicated, “Patient very low in mood”, however, this
assessment of the man’s mood was not reflected in the ACCT ongoing record.
He was referred to a mental health doctor. The ACCT document shows that
the man progressively improved during the period that this additional support
was provided. It was noted on 16 June that he had no further thoughts of self-
harm due to improved contact with his family. A post closure interview was
planned for 26 June, but there is no evidence that this took place.
11. The man’s clinical record notes that on 26 June he complained of pain in his
left shoulder and that on examination there was a “full range of movement of
left shoulder. Old injury at left acromial clavicular joint. Well healed.”
Transfer to HMP Belmarsh
12. On 15 August, the man was sentenced and sent to Belmarsh, where he told
staff that he used both drugs and alcohol. The Cell Sharing Risk Assessment
indicates that, from documents available, staff thought the man had not
previously been subject to self-harm monitoring procedures. He said he did
not feel suicidal and was assessed as a low risk. Staff deemed him suitable to
share a cell.
13. An undated and unsigned Secondary Healthcare Assessment was completed
in which the man was recorded as having “osteoporosis bad back shoulder”.
He also said he was depressed. During the assessment, it was also noted
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that he had asthma but was not using a pump and that he did not have
diabetes, heart disease, cerebrovascular accident (CVA), high blood pressure
or epilepsy and accordingly was not referred for assessment in any of these
areas.
14. During his induction interview on 16 August, the man was noted as being
tearful. As a result, he spoke to a chaplain and a Listener (a prisoner trained
by the Samaritans to provide confidential emotional support to other prisoners
in distress). Afterwards, he said he felt better and was no longer feeling
suicidal or at risk of self-harm. Once the induction interview was concluded,
an ACCT document was opened as a precaution. During the ACCT
assessment interview the man was again tearful and low in mood. He told the
interviewer that he missed his family but was not suicidal. He also said that he
had previously suffered from depression. A referral was made to the
Community Psychiatric Nurse (CPN) because the man “Has issues in his head
and would like to speak about it.”
15. The following day, it was noted in the man’s ACCT document that he had
been threatened by other unnamed prisoners and that sometimes he heard
voices telling him to kill himself. On 22 August, he saw the Community Mental
Health Team who recorded that he was distressed during the interview. He
denied any previous mental health problems but refused to grant consent to
contact his doctor. In the note of the meeting, it is recorded that the man had
been suffering from flashbacks, having witnessed a murder in Jamaica and as
he had co-operated with police, he feared reprisals from those who had
carried out the murder. The outcome of the meeting was that he should
remain subject to the ACCT procedure, receive further exploration of his
mental health status and attend the CASS Unit (occupational health) to help
relieve his anxiety and provide support. A note made on 23 August in his
record of events similarly records that he was experiencing flashbacks as a
result of the murder and the perceived risk of reprisals.
16. During an ACCT review on 25 August, the man repeated what he had
previously said about the murder and said he had come to the UK because
the people involved were out to get him. He was able to name the people only
by their street names. The man’s third ACCT case review took place on 29
August, when he was reported to be very tearful and focussing on suicide. His
level of risk was identified as raised.
17. During the morning of 1 September, the man was seen by an occupational
therapist in the CASS Unit who felt that he required further assessment by a
psychiatrist. The psychiatrist interviewed him that day and concluded that he
should be admitted to the healthcare centre for assessment. He was admitted
immediately to Ward 1 and was described as anxious and agitated. A care
plan was formulated with the aims of minimising the risk of self-harm,
elevation of his mood and to reduce his agitation and anxiety. The care plan
shows that nursing reviews took place on 8 and 15 September.
18. The fear of reprisals from other prisoners figured large in the man’s mind and
on 2 September he told medical staff about the murder and that some of the
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people involved were in Belmarsh. Again, he could only give their aliases. In
spite of this, he settled well and had contact with his family by telephone and
in social visits. An ACCT case review took place on 6 September when he
was reportedly settled in mood but claimed to have occasional thoughts of
self-harm. A note of a further interview with the psychiatrist on 7 September
records that he was to stay in the healthcare centre where his mood was
consistently reported to be good with no indications of intent to self-harm.
During this period he attended the CASS Unit, for art and other sessions, and
the gymnasium where he interacted well with other prisoners.
19. The man’s fourth ACCT case review took place on 12 September when it was
reported that he continued to experience some thoughts of self-harm, but his
risk level was, nevertheless, seen as low. He also said that he wished to
return to Pentonville because it was closer for his family to visit.
20. The man saw the psychiatrist again on 14 September, who recorded that he
was settled in healthcare and was not low in mood. The psychiatrist also
noted that he was considering discharging him from Healthcare to facilitate a
transfer to another prison. The man’s clinical record shows that he wanted to
return to Pentonville to be near his family but was still concerned about his
personal safety if he transferred back to the accommodation blocks at
Belmarsh. On 19 September, he was transferred to Houseblock 1. His review
prior to discharge concluded that he remained settled and had no existing
thoughts of self-harm. He appeared to settle well on the Houseblock but again
expressed a wish for a transfer to Pentonville.
21. The man attended an ACCT case review meeting on 21 September. During
the meeting, he became upset and said that he was suicidal. He was,
nevertheless, recorded as at low risk of self-harm.
22. On 24 September, the man’s personal officer introduced himself and briefly
discussed his depression. Just after midday, the man reported that he was
feeling depressed and at 7.40pm he asked to speak to a Listener. He had a
psychiatrist’s appointment scheduled for 25 September but did not attend and
was offered another appointment on 16 October. He was reported to be low in
mood on 27 September. His sixth ACCT case review took place on the
following day when he said that little had changed and he was reported to be
uncommunicative. His risk level was again recorded as low.
23. The man was reported to be in a low mood on both 30 September and 1
October. On 4 October, he requested and used the dedicated Samaritans
telephone (a phone with a direct line to the Samaritans which can be used by
prisoners in distress). The following morning, in response to a question from a
staff member, he said that he was “good and had no thoughts of self-harm”.
He asked the same staff member later that day about a transfer out of
Belmarsh and was reportedly in good spirits. However, by early evening, staff
again reported that his mood had declined. He was said to be in better spirits
on the morning of 6 October. However, by 2.00pm during an ACCT case
review, he had become emotional because he was missing his family and
wanted to return to Pentonville. He also said he had been threatened by other
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prisoners on Houseblock 2. His recorded self-harm risk level remained low.
On 7 October, his personal officer reported that he was much more cheerful
than he had been in the previous few weeks and that he had suggested to him
on several occasions that he should see the doctor if his depression
continued. He agreed to this.
24. On the morning of 10 October, a member of the education staff submitted a
security information report regarding the man’s depression and possible
bullying. The report said he had been very depressed and crying. Also, that
he was concerned about being in a cell with two other prisoners. He had said,
“It can be dangerous for three in a cell – two can turn on one”. During the
afternoon, a further security information report was submitted from the CASS
Unit. The man had reported that he had been threatened by another prisoner
in a corridor on the way back from a social visit the previous day and that it
was related to the murder he had witnessed many years before. Records
show that he spoke to two members of staff, an hour apart, during evening
association, telling them that other prisoners in Belmarsh were trying to kill
him.
25. On the morning of 13 October, members of the security staff discussed with
the man how he felt about being under threat. They recorded that the man
was happy, his situation was improving and he wanted to remain where he
was. He agreed that if the situation altered he would speak to staff
immediately and signed the entry. Immediately after this meeting, his eighth
ACCT case review was conducted. It was recorded that the man was feeling
depressed and not sleeping well. He remained at low risk of self-harm.
26. The man had an assessment with the psychiatrist on 16 October. He said that
he was finding it a little difficult on Houseblock 1 and that some bullying had
taken place that he had discussed with staff. The psychiatrist observed that
he was dishevelled and showed other signs of self neglect. He requested
sleeping tablets and the psychiatrist noted that antidepressant drugs might be
appropriate depending on the man’s clinical presentation. On 17 October, a
Mental Health Team referrals meeting advised that he should continue with
Occupational Therapy and attend the CASS Unit. The following day, the man
transferred to Houseblock 2. During the evening, he asked to see a Listener
on the following day and said that he would be alright for that night. At
lunchtime on 19 October, he complained to wing staff that he was no longer
feeling alright because he had not spoken to his children for a long time and
would like to make a telephone call to them. The man’s ninth ACCT case
review on 20 October confirmed that his self-harm risk level remained low.
27. The man’s tenth ACCT case review took place on 27 October. He said that he
did not feel too bad because he had spoken to his partner but had not seen
his children because it was too far for them to travel and this upset him. He
said at the review that he had heard voices telling him to kill himself or his
cellmates. His risk of self-harm was recorded as raised. On 3 and 14
November, The man’s ACCT case reviews confirmed that his self-harm risk
level had returned to low, although he was still emotional about his lack of
contact with his family. Staff put in place procedures to ensure that he was
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able to telephone his family outside of normal wing regime times. His ACCT
case review on 20 November records that he was much more stable,
communicative and confident. His risk level remained low.
28. On the same day, the man saw the psychiatrist who noted that he was feeling
better as he had received a letter accepting him for transfer to HMP
Coldingley. He also noted that the man had been tearful and said that he had
been threatened again by other prisoners. His fourteenth ACCT case review
on 24 November records that he had been seen by the psychiatrist and had
been placed on antidepressant drugs. He had said that he did not feel too bad
but wanted more contact with his family, if possible via the telephone. His risk
level remained low.
29. On 29 November, a post traumatic stress (PTS) counsellor noted in the man’s
clinical record that he had been very distressed about events in his life and
arrangements had been made for him to have six weekly counselling
sessions, after which a review of his needs would be made. The same day,
the duty senior officer (SO) noted that the man had misled him regarding
recent contact with his family and that communication played a large part in
the man’s ACCT care map. The duty senior officer also suggested that a log
be kept of the man’s family contacts to ensure that he did not manipulate staff.
Later in the evening, an officer noted that the man had expressed a desire to
come off the ACCT process.
30. An entry in the ACCT case review the next day, records that the man was still
a low risk. It was noted that he was still taking medication, occasionally had
concerns about self-harm and had spoken about wanting a transfer. The man
saw the PTS counsellor on 6 and 7 December. He was recorded as being
much more positive and expected to transfer shortly to Coldingley shortly,
having been allocated a place. He was looking forward to attending several
courses, including an industrial cleaning course. His main problem was noted
as the difficulty in accessing a telephone to speak to his family as he never
managed to get to the front of the queue during the association periods.
Access to a telephone call was given to him after the review.
31. The man attended a third PTS counselling session on 13 December in which
he was reported to be tearful and fearful for his life. His next two ACCT
reviews on 14 and 21 December were at variance with this, indicating that he
had no problems and that his risk of self-harm remained low. On 20
December, the man underwent a psychiatric review which recommended that
he remain in shared accommodation in view of his self-harm risk, that he
should continue with his medication, attend CASS and counselling and that
the transfer to Coldingley be expedited.
32. The man’s ACCT review on 28 December noted that although his risk
remained low he had raised the matter of other prisoners at Belmarsh being
“after him” and that he feared for his safety. He also voiced his concern that
he had not yet moved to Coldingley. At his next review on 4 January 2007,
the risk remained low and the reviewer explained to the man that a move to
Coldingley had been delayed as he remained subject to the ACCT process.
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The reviewer noted that he intended to close the ACCT on 10 January if no
further concerns were raised. It was duly closed on that date and a post
closure interview was scheduled for 12 January. During the post closure
interview, the man was described as being much more settled and relaxed
and he felt confident that he would be alright. On 24 January, the man
attended a fourth PTS counselling session and was recorded in the
continuous clinical record as being more settled but still fearful for his life.
33. On 26 January, the man transferred from Belmarsh to HMP Bedford. On
reception, an anti depressant, mirtazapine, was prescribed 15mg nightly for 14
days and E45 cream for a skin condition. The mirtazapine prescription was
repeated on 8 February, again for 14 days. The man transferred to HMP
Doncaster on 16 February. During his initial health assessment, he reported
that he had tried to self-harm in the past but no details were recorded. He was
recorded as having no current thoughts of self-harm. He also said that he was
on an elevated level (30mg) of mirtazapine to that recorded at Bedford. He
was referred to the doctor for an assessment of his physical health.
HMP Lindholme
34. Just under a month later, on 23 February, the man transferred to HMP
Lindholme. On arrival, medical staff conducted an assessment in which he
asked to see a doctor about his medication and raised an issue about his skin
condition. He also told them that he had been a crack and cocaine user until
six months before and was a smoker who refused help with cessation of
smoking.
35. On 27 February, a note in the clinical record indicates that the man was
prescribed mirtazapine 15mg nightly for 28 days. A further note dated 5
March says “Rx – signed prescription card for Mirtazapine” but the
Prescription and Administration Chart does not support these entries. Neither
entry is endorsed by a clear signature.
36. A Registered Mental Nurse (RMN) saw the man in the healthcare centre on 8
March. The nurse recorded that he was quite emotional and that he missed
his children and family. He also expressed concerns about his personal safety
after his release. The man denied any current thoughts of self-harm but said
that he suffered flashbacks related to witnessing a murder. He requested that
the mirtazapine dosage be doubled to 30mg.
37. On 12 March, an entry in the Prescription and Administration Record Chart
appears to indicate that the man was given 16 paracetamol tablets in
possession for a headache. On 20 March, a note in the medical record
indicates that the doctor had reviewed his medication.
38. A staff nurse noted in the clinical record records that the man failed to attend a
doctor’s clinic on 3 April. Between 4 and 23 April, the mirtazapine 15mg
prescription for depression was repeated for a further 28 days and other
medications were prescribed.
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39. On Friday 27 April, at around 11.30am, the man reported sick. He was seen
by the staff nurse who recorded on the form for prisoners attending healthcare
for sick/treatments that he had administered treatment to the man but not that
he attended as a result of being sick. The Prescription and Administration
Record Chart indicates that the staff nurse gave the man Bonjela for a mouth
ulcer. No other treatment is recorded and the staff nurse does not recall
whether he had discussed any other matter with the man. The second
member of staff, a Registered General Nurse and healthcare officer on duty at
that time, did not see the man at all during that day.
40. A prisoner who was a friend of the man and lived in a neighbouring cell on E
wing said that on the evening of Friday 27 April he had spoken to the man who
had complained of a pain in his left shoulder and pins and needles in his arm.
The prisoner told him to report sick and the man said that he had done so. He
had been given paracetamol and told that it was a muscle strain and to stay in
his cell. The man then shut himself into his cell which the prisoner said was
not out of the ordinary because he was studying for his parenting exam. The
prisoner said he next saw the man briefly in the toilet area of spur 2 on the
evening of Saturday 28 April between 4.30 to 5.00pm and had not seen him
during the course of the day.
41. Another fellow prisoner and friend of the man, was also located in E wing. On
the evening of 28 April, the prisoner helped the man with his parenting
coursework. At interview, he said that he did not remember the man
complaining of any illness or pain and that he last saw him at around 3.00am
on the morning of 29 April when he went to bed.
42. On Sunday mornings at Lindholme prisoners are allowed to lie in. An officer
came on duty at 7.15am on 29 April. He checked the E wing roll as soon as
he arrived and confirmed it was correct at 7.30am. He remembers seeing the
man during the roll check and described him as laying on the bed to the right
of the door with his head to the rear of the cell. He was on his side facing into
the room, asleep.
43. The prisoner who was friends with the man, and who he had previously
complained to, got up at around 8.00am on 29 April and met the man in the
corridor. He was holding his shoulder again and said that it hurt. The prisoner
told the man to tell the duty officers and went to the servery to serve breakfast.
44. At 8.15am, the main shift staff arrived. On Sundays there is one additional
member of staff. A second officer arrived on E wing and the first officer
collected the breakfast meal, returning to the wing ten minutes later. The
spurs were then unlocked for prisoners to collect their breakfast.
45. Another resident of spur 2 was serving breakfast with the second officer on the
morning of 29 April. The man had told him earlier that he had a pain in his
shoulder. He recalled that the second officer had said that it was probably the
way the man had slept and offered to put him on the list for sick if he couldn’t
wait until the sick parade. The man agreed to wait. The resident of spur 2
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and the second officer then went to the food servery. The man did not get up
for breakfast which was served until 8.45am.
46. By 8.50am, the two officers were supervising the running of the wing. At
around 10.20am, a radio message was broadcast ordering gate 22 to be
staffed. This gate is the muster point for prisoners wishing to report sick and
for routine medical treatments.
47. In his initial note of events dated 29 April, the first officer said that he went to
the man’s cell, E202, at 10.18am to tell him that the sick parade had been
called. The officer used his pass key to enter the cell, looking through the
door hatch at the same time. He saw the man lying across the bed on his left
side with his feet touching the floor. His face was looking directly at the door
and his eyes were open. Realising that something was wrong, the officer went
directly to the man and tried to find a pulse in the exposed left side of his neck,
whilst at the same time looking around the cell for a ligature. The man was
warm to the touch but the officer could not find a pulse. The man’s arm was
trapped by the bed and would not come free. After several seconds the officer
moved him onto the bed from the position he had found him in. He laid the
man on his back and his legs remained over the side of the bed. The officer
then started cardio pulmonary resuscitation (CPR) chest compressions and
realised that he needed help to carry on. The officer did not have a radio.
There is only one radio on each wing and it is held in the wing office. He went
out of the cell and shouted to three prisoners to go and tell the second officer
that he needed urgent medical assistance on spur 2. One of the three
prisoners ran to the wing office where he relayed the message to the second
officer.
48. The first officer returned to the cell to continue CPR with the prisoner who was
the man’s friend following closely behind. At interview, the first officer said
that he needed to get the man lying flat on the bed and the prisoner assisted
him to do so. The prisoner noticed the man’s hands were cold but that there
was no stiffness in his body. The first officer said that he had real difficulty
clearing the man’s airway. There was a lot of mucous in his mouth and he
could not move his tongue out of the way. The first officer resumed CPR and
was doing chest compressions to try to get some air into the man’s lungs. The
prisoner realised that the first officer was having difficulty. When the officer
stopped chest compressions to give a breath, the prisoner stepped in and took
over the chest compressions for about five minutes. During this time, the first
officer believed he found a pulse but this subsequently disappeared. They
continued with CPR. Initially the breathing lifted the man’s chest wall but after
a while the airway became blocked again. The first officer cleared the man’s
mouth of mucous again and restarted the breaths.
49. At about 10.30am, as soon as the other resident had told him that medical
help was required, the second officer telephoned the healthcare unit to call for
assistance. He locked the office door and ran to spur 2 where he saw the first
officer and the prisoner performing CPR on the man. He then left the cell and
broadcast a “code blue” radio message to the communications room. (A code
blue is the Lindholme coded message for a patient who is having respiratory
15
problems or has a compromised airway and an emergency response is
required.) Nursing staff at the HCU received the telephone message and at
10.33am had also received the “code blue” radio message. A staff nurse took
the emergency response bag from the healthcare centre. The bag contains
an oxygen cylinder, airway, blood pressure machine, blood monitoring
machine, suction machine and basic medication. Accompanied by a second
staff nurse, she took it down the stairs, out through Gate 22 and towards E
wing.
50. As the two nurses approached A wing they were met by two prisoners. They
were distressed and shouting that “he isn’t breathing” and that “an officer is
working on him”. The first staff nurse then asked one of the prisoners to help
carry the emergency bag. The two prisoners took the bag and the nurses
followed them to E wing. As they crossed the yard, by their account
alternately walking and jogging, some prisoners shouted at them to run faster
which the staff nurse found intimidating. They arrived at E wing at about
10.35am. On arrival, the nurses shouted that the defibrillator, located in the
Care and Separation Unit (CASU), should be brought over and an ambulance
called. The staff nurse said at interview that she believed that there were
three defibrillators at Lindholme, at that time located in CASU, J and K wings.
51. The second officer had returned to the cell where prisoners were beginning to
congregate to watch what was going on. He moved the prisoners away from
the cell to allow the prisoner and the first officer to carry on CPR uninterrupted
and to allow the medical staff to have unimpeded access when they arrived.
52. The two nurses followed the two prisoners to cell E202. When they arrived,
the second staff nurse saw the first officer performing cardio pulmonary
resuscitation (CPR) on a prisoner who was laying on the bed. She said that
the bed was firm and suitable to be used for CPR.
53. The two staff nurses established that the man was not breathing and had no
detectable pulse. The second staff nurse believes that the first staff nurse
said that the man’s airway was compromised and that they needed to get an
airway into his throat. The first staff nurse put an airway into the man’s throat
to establish an open airway and whilst doing so, noticed that his tongue and
lips were slightly swollen and had a bluish tinge to them. She connected the
oxygen to a face mask and put it over the man’s face. She then repositioned
his head backwards to maintain the airway and used both hands to ensure a
good seal around the mask. Whilst the first staff nurse was working at the
man’s head end, the second staff nurse had started chest compressions at a
rate of 30 compressions to two breaths. The first officer continued with this
rhythm.
54. Soon afterwards, the orderly officer arrived at cell E202 bringing with him the
defibrillator from CASU. The three people working on the man had completed
about three cycles of CPR when the defibrillator arrived. The second staff
nurse shaved a small area of the man’s chest to allow the defibrillator pads to
be in secure contact. The first staff nurse stopped compressions for a short
while to allow the attachment of the defibrillator pads and to allow the
16
defibrillator to go through its automated functions. The defibrillator found no
shockable rhythm in the man’s heart and gave instructions to continue CPR.
55. At about 10.40am, having heard the “code blue” radio message, the head of
residence and healthcare, went to E wing. At the same time, he heard an
ambulance arriving at the main gate. The Communication log records that at
10.42am staff were moving prisoners from outside D, E and F wings to allow
ambulance vehicles access to the front of E wing via gates 6, 8 and 24. A
paramedic car arrived at the main gate at 10.43am and, at 10.51am, an
ambulance was en route to E wing.
56. A third staff nurse had now joined the other nurses and the first officer in the
room. She describes the first officer as being at the head of the bed with his
back to the window and looking exhausted. The nursing staff swapped
positions so that the second staff nurse compressed the bag, the third staff
nurse the seal on the man’s face and the first staff nurse the compressions.
The defibrillator went through its routine several times, interspersed by CPR,
until the first response paramedic arrived at about 10.47am.
57. On arrival, the paramedic asked for the man to be moved off the bed and onto
the floor. The prison defibrillator was disconnected and he was placed on the
floor by the first officer and the paramedic. The paramedic then replaced the
prison defibrillator and airway with ambulance service equipment, using a
portable suction device to help him do so. Shortly afterwards, two more
emergency ambulance crew members arrived to assist the first paramedic with
the CPR and administration of intravenous drugs. The prison staff then
handed the resuscitation attempts over to the paramedics and waited outside
the cell.
58. The second staff nurse went back to the HCC to collect the man’s medical
record (IMR) to check it for any medical conditions or relevant treatment of
which the paramedics would need to be aware. She noticed that his reception
screening indicated that he had attempted suicide some months before.
When she got back to the cell she told the paramedic about the suicide
attempt and the paramedic asked if anyone had seen a ligature. A small piece
of material from a tee shirt with the hem cut to form an apron shape was
recovered from around the man’s upper left leg. The first officer described the
material as being about six inches square with six inch tapes on either side.
The paramedic removed it and put it to one side on the floor.
59. The first officer remembers one of the paramedics saying that there was blood
in the mucous in the man’s mouth. The third staff nurse noticed that the
paramedic had difficulty inserting the replacement airway into the man’s throat
and that a lot of bloody mucous was being removed by the suction device.
She had also noticed that the man’s tongue was swollen.
60. When the Orderly Officer arrived on E wing, the head of residence and
healthcare briefed him and left him in charge of the wing and prison regime.
The head of residence and healthcare went to open the Command Suite at
around 10.55am. As he did so, the emergency ambulance arrived outside E
17
wing. On opening the Command Suite he took possession of the man’s prison
record.
61. Once it was attached to the man, the paramedics’ defibrillator went through
several automatic cycles but was ultimately unsuccessful. At 11.09am,
paramedics pronounced the man dead and stopped the resuscitation
attempts.
62. At 11.09am, on receipt of a telephone call informing him that the man had
died, the head of residence and healthcare implemented the Lindholme death
in custody contingency plan and noted the action times. He informed the
police at 11.14am and issued an instruction to the orderly officer to relocate all
the other prisoners on E2 spur to other spurs on the wing.
63. Soon after the man died, the orderly officer became aware that a possible
ligature had been found in the cell by staff engaged in trying to resuscitate
him. At about the same time, a police constable arrived at the cell. After
briefing, the police constable went into the cell for a few minutes. He was
unhappy about the scene in the cell and wanted to discuss the matter with his
senior officer, which he did by telephone from the Command Suite.
64. The orderly officer ordered that the spur be cleared of people, the metal grille
door to be chained shut and the solid outer door locked. An officer did so and
remained outside the outer door to ensure that there was no unauthorised
access to the spur.
65. At around 11.30am, the head of residence and healthcare spoke with the Area
Manager to discuss informing the man’s next of kin. He was unable to send
Lindholme staff to break the news because of the distance to his partner’s
home in London. It was initially proposed that staff from a prison local to her
home should undertake the duty, but because of the possible suspicious
nature of the death, police indicated that they wished to break the news. They
attempted to do so that afternoon but there was no one at home. They
eventually contacted her on the morning of 30 April.
66. A Detective Sergeant (DS) arrived at Lindholme at around 11.45am and went
to E202. He then went to the Command Suite and told the head of residence
and healthcare that because there appeared to be blood in the man’s throat
he was treating it as a suspicious death. He also called out his senior officer a
Detective Inspector and Scenes of Crime Officers (SOCO). E2 spur was
sealed.
67. Two members of the Lindholme Independent Monitoring Board (IMB) arrived
at about 12.25pm and went immediately to E wing. On arrival at E wing, they
went upstairs to an office to see the deputy head of offender management.
The deputy head was trying to calm down the prisoner who had helped in the
initial attempt to resuscitate the man.
68. The head of residence and healthcare restricted the prison regime throughout
the afternoon and evening of 29 April. Prisoners on wings G, K and J were all
18
confined to their wings and the exercise yard. Wings A – F were restricted to
their wings and all movement of prisoners on and off E wing was stopped.
69. Five prisoners from E wing had scheduled social visits for that afternoon. The
visits were allowed to go ahead after the prisoners involved had changed their
clothing to preserve any evidence. Because of the disruption to their visits,
the prisoners’ visiting orders were reissued for use on another day.
70. The chapel is in the same compound as E wing and for that reason the normal
Sunday afternoon service was cancelled. Two of the chaplains provided
pastoral care to prisoners especially those on E wing. Support for prisoners
was also provided by the IMB and Listeners. A member of the care team was
released from his duties to provide support for staff for the rest of that day.
71. At around 1.00pm, the head of residence and healthcare asked for a review of
all open Assessment, Care in Custody and Teamwork (ACCT) documents.
However, the Death in Custody Contingency plan checklist indicates that the
orderly officer was supposed to have undertaken this task at 10.55am. At
1.45pm, the detective inspector and the SOCO arrived at E wing and began
their investigation of the scene which they indicated would take up most of the
afternoon.
72. Funeral directors took the man’s body to Sheffield Medico-Legal Centre at
4.30pm for a post mortem examination later in the evening. A hot debrief for
the staff involved was conducted at around 5.45pm.
73. The detective inspector rang the head of residence and healthcare at home at
around midnight to tell him that the police no longer regarded the death as
suspicious. The head of residence and healthcare informed the prison of this
development and instructed that the clothing removed from prisoners should
be returned the next morning.
74. One of the members of the chaplaincy team spoke to the man’s partner on
Monday 30 April when she telephoned. They were in contact on four further
occasions between his death and 10 May. The chaplaincy member said that
she was very emotional during the calls and they spoke about a memorial to
the man which was something she found comfort in. They also spoke about
the possibility of her visiting Lindholme. Initially, she didn’t want to visit but
during a call on 10 May she said that she would wait until the man’s mother
arrived from Jamaica, then she would call again. The acting deputy governor
wrote a letter of condolence to the man’s partner on 30 April in which
assistance was offered for travel expenses, but no offer of assistance with
funeral expenses was made.
75. On Thursday 3 May, a principal officer from Lindholme attended the local
Coroner’s Court where an inquest, attended by the man’s father, was opened
and adjourned. The Coroner raised the issue of funeral expenses and the
matter was referred to the Governor. A memorial service for the man was held
at Lindholme later the same day, which was well attended by staff and
prisoners.
19
Post mortem examination
76. On the instructions of the Coroner, a forensic pathologist carried out a post
mortem examination at Sheffield Medico–Legal Centre between 6.45pm and
8.10pm on 29 April 2007. Samples were taken for further examination.
77. The pathologist’s conclusion, outlined in his witness statement dated 9 July,
was that the man had evidence of heart disease and died as a result of a
blockage of the left coronary artery. Following further toxicological
examination, no significant drugs were found from the samples taken,
although paracetamol in an amount consistent with therapeutic use was
evident.
ISSUES CONSIDERED DURING THE INVESTIGATION
Medical care
78. A clinical review of the care provided for the man by the prison’s healthcare
team was commissioned from the Head of Commissioning at Doncaster PCT.
20
A further review was conducted by the Assistant Director of Clinical
Effectiveness. I received the comprehensive report on 22 February 2008.
79. The man had no reported history of heart disease. However, the pathologist
mentioned evidence of ischaemic heart disease to which his history of
smoking and drug use would have been contributing factors. He concluded
that the man had died as the result of a fatal thrombotic occlusion of the left
coronary artery following symptoms of left shoulder pain in the preceding few
hours. The pathologist confirmed this was in keeping with referred pain from
myocardial ischaemia. The clinical reviewer judges that the man received
comprehensive care for his mental health problems throughout his time at
various establishments.
Attendance at treatment clinic on 27 April 2007
80. On the morning of Friday 27 April, the man attended a sick/treatment clinic.
One of the two nurses on duty saw the man and recorded that he had
administered treatment. However, he did not record that the man had
attended for sick, as opposed to routine or ongoing treatment. The
Prescription and Administration Record Chart shows in the sick section that
medication was given for a mouth ulcer. No other treatment is recorded and
the nurse said that he did not recall discussing any other matter with the man.
81. A fellow prisoner and friend of the man said that on the evening of 27 April he
had spoken to the man who complained of a pain in his left shoulder and pins
and needles in his arm. He advised the man to report sick and the man said
that he had done so. The man also told him it had been diagnosed as muscle
strain for which he had been given paracetamol and told to stay in his cell.
82. The last recorded issue of paracetamol to the man is outlined in an entry on a
Prescription and Administration Record Chart dated 12 March and relates to a
headache. (The clinical reviewers comment that the entry is unclear.)
However the toxicological results, reported in the post mortem examination
report, indicate that on 29 April concentrations of paracetamol were present in
the man’s body. He considered these were likely to represent therapeutic use
but added that he could not fully exclude the possibility of a previous
overdose.
83. I have found no evidence that the man obtained paracetamol outside of the
legitimate channels. It is not known whether he had saved the drug from the
supply given to him on 12 March and used it just before his death or whether
he took an overdose of the drug. According to the staff nurse who saw him on
27 April, he was not given paracetamol. However, the prisoner who was the
man’s friend reported at interview that the man had told him that he had been
given the drug by healthcare staff. The clinical reviewers note that “From the
statements and evidence available it has not been possible to reach any
conclusion about whether the man did discuss shoulder pain with Healthcare
on 27 April 2007 or exactly when he first developed this symptom.” They also
note that “The medical records are variable and, in some cases, very difficult
to read. The lack of any entry in the IMR to match attendances at sickness
21
clinics at HMP Lindholme has added to uncertainty about events.” The lack of
clarity in the healthcare record keeping leaves doubt surrounding the truth of
this potentially significant event and in common with the clinical reviewers, I
am unable to reach a conclusion on this aspect.
The Governor and PCT should ensure that the standard of record
keeping meets Royal College of Nursing guidelines and is consistent
with all current professional guidance. This should include keeping a
record of all consultations, recording symptoms, investigations,
treatment given or planned and any non attendance for treatment. The
record should also include a chronology of all appointments and sick
arrangements.
Staff training on record keeping should be mandatory. Regular audits of
records should take place, with action plans to address deficiencies.
The audits should be reviewed by the PCT.
Delivery of emergency care on 29 April
84. Between 10.18am and 10.20am on the morning of Sunday 29 April, The first
officer went to the man’s cell (E202) to tell him that the sick parade had been
called. He found the man collapsed and realised that something was seriously
wrong. He therefore went directly to him and tried to find a pulse in the left
side of his neck but was unable to do so. He did note, however, that the man
was warm to the touch. In order to start CPR, he had to move the man from
the position in which he found him. By the first officer’s account, this took
several seconds. He also realised that he needed help so he went out of the
cell, shouted to three prisoners to tell the second officer in the wing office that
he needed urgent medical assistance and then returned to the cell. The
prisoner referred to earlier in the report, assisted the first officer.
85. On receiving the message from another prisoner, the second officer
telephoned the healthcare unit for that assistance and then ran to spur 2
taking the E wing radio with him. On arrival, he saw the first officer and the
prisoner performing CPR. He then left the cell and broadcast a “code blue”
radio message to the communications room.
86. Two staff nurses received the radio message from the communications room
at 10.30am. There is a discrepancy in that the second officer’s recollection is
that he had telephoned HCU with that request. The first record of radio traffic
regarding this incident is noted at 10.33am, a delay of about ten minutes from
the man’s discovery by the officer.
The Governor should consider whether the number of radios issued for
the use of accommodation wing staff is adequate.
87. As the two staff nurses left HCU at 10.33am, they received another radio
message that the incident was now designated a “code blue” emergency. The
first staff nurse carried the emergency response bag from HCU. This
contained an oxygen cylinder, airway, blood pressure machine, blood
22
monitoring machine, suction machine and basic medication. Accompanied by
the second staff nurse, she took it downstairs and out towards E wing. They
estimate that the journey took them about two minutes and this is supported
by the communications room log. Two prisoners from E wing assisted them
with the bag. The communications room log also records that the orderly
officer, was also en route to E wing.
88. At 10.36am, as they entered E wing but before arriving at cell E202, the two
nurses requested that an emergency ambulance be called and the defibrillator
be collected from CASU. On arrival at E202, they took over the attempts to
resuscitate the man. The communications log records that an ambulance had
been called at 10.37am.
89. On his way to E wing, the orderly officer met an officer who gave him a
shoulder bag containing the defibrillator. At around 10.40am, the third staff
nurse received a telephone call requesting her help. She postponed the sick
parade, left the main healthcare building and arrived on E wing some two
minutes later.
90. On arrival at the cell, the orderly officer saw the three nurses and the officer
administering CPR to the man. The defibrillator was then used to assist in the
resuscitation attempts. When the defibrillator was connected there was no
detectable sign of life from the man. CPR was continued manually and six or
seven further defibrillator cycles were attempted.
91. The communications log records that at 10.43am a first response paramedic
arrived by car. On arrival at the cell, the paramedic instructed that the man
was to be moved from the bed to the floor. The paramedic then removed the
airway that was in place, used a suction machine to remove any obstruction
from the man’s airway and inserted an ambulance service airway. The first
staff nurse continued with the chest compressions.
92. At 10.51am, an emergency ambulance arrived with two crew members. The
first response paramedic maintained the man’s airway while the second
paramedic began administering drugs intravenously through the man’s right
arm. The third paramedic took over the chest compressions. At 11.09am, the
lead paramedic declared that the man had died.
93. It is apparent to me that every effort was made by prisoners, prison officers
and prison medical staff in the attempt to sustain the man’s life until the
paramedics arrived. They, in turn, made every effort to resuscitate him but
ultimately the attempts to do so were unsuccessful. I believe that the prison
officers involved that morning acted in a timely manner in recognising the
seriousness of the situation, summoning appropriate help and rendering what
assistance they could personally.
94. However, there was a perception by prisoners that nursing staff had not
attended E wing quickly enough, which led to some unfortunate exchanges
between staff and prisoners. The issue was addressed with prisoner
representatives later in the week by the chaplaincy and the IMB Chairman.
23
95. Nursing staff who responded initially attended the incident, several hundreds
of yards away from the HCU, and within two minutes of receiving messages
from the wing staff and communications room. It was fortunate that two
prisoners met them to carry the heavy emergency bag for most of the
distance. Had they not done so, the nursing staff would have taken longer to
arrive. They might also have suffered from the effects of carrying the bag and
their effectiveness in trying to resuscitate the man might well have been
impaired.
96. As a consequence, there are plans for some of the heavier items, principally
the oxygen bottle, to be located strategically throughout the prison. This will
obviate the need for staff to carry heavy equipment for long distances.
97. Special mention should be made of the prisoner who was the man’s friend’s
involvement. It was especially traumatic for him as it occurred on the first
anniversary of his father’s death in similar circumstances and, sadly, with the
same outcome. His actions were commendable.
98. The first officer made strenuous attempts to resuscitate the man for an
extended period until he was relieved by the nurses and paramedics. He
should also be commended for his actions. I concur with the clinical
reviewers’ recommendation that everyone involved in the attempt to
resuscitate the man should be commended.
Provision of defibrillators
99. Following a previous death in custody at Lindholme, an action plan dated
December 2006 identified the need for extra defibrillators and oxygen bottles
and by the end of January 2007 they had been provided. The healthcare
manager, who took up post in January 2006, said that her department had
difficulty sourcing suitable cabinets to be installed on the wings. By 29 March
2007, the cabinets had been delivered along with appropriate oxygen signage.
The Works Department were contacted at the beginning of April 2007 to
arrange installation of the cabinets, but for various reasons they were not
installed until after my investigator visited Lindholme on 14 May. Following the
man’s death, the healthcare manager indicated that three further defibrillators
were required for installation on B and E wings and in the Industrial complex.
These were delivered on 15 June and cabinets were ordered.
100. On the day of the man’s death, the single operational defibrillator in the main
prison was located quickly, collected and brought into use within a very few
minutes of the first calls regarding the emergency. The defibrillator found no
shockable rhythm in his heart so CPR was advised and continued manually by
the staff present. Further attempts to use the Prison Service and Ambulance
Service defibrillators had the same outcome. The provision and use of
defibrillators was therefore not a factor in the man’s death.
24
101. It is unfortunate that following a previous fatal incident at Lindholme, the
resultant recommendation and action plan to provide more defibrillators was
delayed. It was evident to my investigator that managers and other staff were
unaware that the defibrillators were not in place. The situation was addressed
soon after the investigator visited and to Lindholme’s credit, further steps have
been taken since the man’s death to provide more defibrillators and
emergency equipment at strategic points in the prison.
Self-harm and personal safety
102. Following his reception into prison, the man sometimes felt as if he might harm
himself. He missed his family greatly. He also had flashbacks relating to a
murder he had witnessed in Jamaica some years previously and had
expressed fears that his life was in danger because of the assistance he had
given to the police. Those fears continued during his time in prison as he was
apparently threatened by Jamaican gang members at HMP Belmarsh.
Appropriate actions were taken by all of the prisons within which he was
located to prevent reprisals. He had also spent extended periods subject to
ACCT monitoring because of the risk of self-harm. The man was seen
frequently by a psychiatrist in the early part of his sentence and was
comprehensively supported by staff.
103. The man’s fears and worries were, for the most part, resolved by the time he
arrived at Lindholme although he still missed his family. There was no
suggestion that self-harm played any part in his death and, what appeared to
be a ligature was later found to be a piece of cloth used as a bandana.
Although his death was initially considered by the police to be suspicious, their
investigation revealed no evidence of any criminal act.
25
RECOMMENDATIONS
I make three recommendations:
1. The Governor and PCT should ensure that the standard of record keeping meets
Royal College of Nursing guidelines and is consistent with all current professional
guidance. This should include keeping a record of all consultations, recording
symptoms, investigations, treatment given or planned and any non attendance for
treatment. The record should also include a chronology of all appointments and
sick arrangements.
The Prison Service accepted this recommendation and in an action plan received
from them on 31 July 2008 responded that:
“All staff conform to the current guidelines on record/ record keeping and records are
maintained when patients attend for any appointment treatment or for special sick
.We also record when patients fail to attend.
Royal College of Nursing guidelines will be given to all staff and a record of this will
be maintained as evidence.”
This action was completed in September 2008
2. Staff training on record keeping should be mandatory. Regular audits of records
should take place, with action plans to address deficiencies. The audits should
be reviewed by the PCT.
The Prison Service accepted this recommendation and in an action plan received
from them on 31 July 2008 responded that:
“Royal College of Nursing guidelines will be given to all staff and a record of this will
be maintained as evidence
Medical records are currently audited by our GP provider. An Audit tool for record
keeping is in place and is monitored on a monthly basis.”
This action was completed in September 2008.
3. The Governor should consider whether the number of radios issued for the use of
accommodation wing staff is adequate.
The Prison Service has yet to respond to this recommendation.
26