Individual at Liverpool

Investigation into the circumstances surrounding the
death of a man
at HMP Liverpool in July 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2011
This is a report into the death of a man at HMP Liverpool on 16 July 2010. He was
39 years old when he died. The post mortem showed that he died from a heart
attack.
I offer my sincere condolences to the man’s family and friends for their loss. One of
my Family Liaison Team contacted the man’s family to inform them about the
investigation and offer them the opportunity to raise any issues about the care he
received in custody.
The investigation was carried out on my behalf by my colleague. Both he and I
would like to thank the Governor and his staff for their co-operation during the course
of our enquiries.
I also thank the local Primary Care Trust for appointing a clinical reviewer to review
the man’s clinical care. As he died from natural causes, the findings of the clinical
review play an essential part in my report. The reviewer judges that the standard of
care he received was not equitable to that which he could have expected to receive
in the community. I make three recommendations regarding the follow up of hospital
appointments, continuity of care and appropriate level and grade of nursing cover.
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 May 2011
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CONTENTS
Summary
The investigation process
HMP Liverpool
HMP Ranby
HMP Featherstone
HMP Birmingham
Key events
Issues
Conclusion
Recommendations
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SUMMARY
1. The man was born in September 1970, and lived in the Birmingham area. He
was single and had a close relationship with his family. He had a history of
mental illness for which he was prescribed medication, and he had also used
illicit drugs.
2. The man was remanded into custody at HMP Hewell for drug offences on 20
September 2008, and was given a four year sentence on 30 January 2009.
He was transferred to four different prisons between 10 February 2009 and 18
May 2010. They were HMP Birmingham, HMP Featherstone, HMP Dovegate
and HMP Ranby. During this period he continued to take his medication,
which was regularly reviewed by prison doctors. He was also admitted to
hospital in August 2009 and April 2010 and treated on each occasion for
pancreatitis.
3. On 24 May 2010, he transferred to HMP Liverpool. He continued to take his
prescribed medication, however on two separate occasions he refused to
attend an appointment arranged with the prison doctor.
4. At 7.00am on 16 July, the man was found not breathing in his cell. Staff
started cardio pulmonary resuscitation (CPR) and an emergency ambulance
was called. The paramedics arrived and took over CPR but he was
pronounced dead at 7.41am. The post mortem showed that he died of a heart
attack.
5. The prison records showed that his next of kin lived in Birmingham. Due to the
distance and time of day, the decision was taken by Liverpool to ask HMP
Birmingham to notify the family of his death. His family were duly notified later
that day by Birmingham staff. The prison family liaison officer from Liverpool
also spoke to the family in the days that followed and offered support and
financial assistance towards the funeral costs.
6. There are several issues arising out of this investigation. The clinical reviewer
judges that the care the man received was not equitable with what he could
have expected in the community. There are several shortcomings which
should be addressed. Specifically the Primary Care Trust should review the
level and expertise of the night time staffing levels at HMP Liverpool. I am
also very concerned that HMP Featherstone did not follow up his hospital
appointment after he was discharged from hospital.
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THE INVESTIGATION PROCESS
7. The investigation was opened on 19 July 2010 when I appointed my colleague
to investigate the man’s death. Notices were issued announcing the
investigation to staff and prisoners. No one came forward as a result.
8. The investigator visited HMP Liverpool on 22 July. During his visit he was also
given copies of all documentation relating to the man. My investigator
returned on 10 and 11 August and interviewed six members of staff and one
prisoner.
9. The local Primary Care Trust asked a clinical reviewer to review the man’s
clinical care. The investigator and the clinical reviewer discussed aspects of
treatment during his time in custody and jointly conducted interviews at
Liverpool. I am grateful to the clinical reviewer for her involvement in this
investigation and her timely report which is annexed to my report.
10. As part of the investigation the investigator also interviewed two staff at HMP
Birmingham on 12 August, two staff at HMP Featherstone on 26 August and
two staff at HMP Ranby on 9 September. The investigator contacted HMP
Dovegate to obtain the relevant information and documentation and no
interviews were conducted.
11. The investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of the investigation and request a copy of the post mortem report,
which was eventually received on 9 February 2011. Upon completion, the
investigation report will be sent to the Coroner to assist his enquiries into the
man’s death.
12. A member of my Family Liaison Team contacted the man’s family to inform
them about the investigation and invite them to ask any questions or raise any
concerns about the care he received in prison. The family liaison officer and
investigator visited the family on 6 August and they raised the following
concerns:
(cid:127) Was he alone at the time of his death?
(cid:127) What time were the paramedics called?
(cid:127) Whether his health and medical needs were met?
(cid:127) Why he transferred between so many different prisons?
(cid:127) Specifically the family wish to know why he was transferred from
Birmingham as they lived locally and could easily visit him.
13. I hope that this report answers the family’s questions and helps them to
understand the treatment which the man received and the events leading to
his death.
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HMP LIVERPOOL
14. Liverpool is one of the country’s largest prisons, with a maximum operational
capacity of 1,439. It serves courts from the Merseyside area, and holds
remanded, unsentenced and convicted adult male prisoners. There are seven
residential wings, including those for drug support, vulnerable prisoners,
detoxification, and resettlement. One of the wings holds people who are
unsentenced or on remand, and it is here that prisoners spend their first night
and complete an induction process to help familiarise them with the prison
regime.
15. Healthcare services at Liverpool are provided by the local Primary Care Trust
(PCT). A purpose-built hospital unit, which opened in 2007, allows healthcare
staff to provide outpatient and inpatient facilities. A doctor is on duty every day
during normal working hours, and nursing staff remain on duty throughout the
night. The night nursing cover consists of two Band 5 Nurses and one
healthcare assistant.
16. HM Chief Inspector of Prisons carried out an inspection of Liverpool in
September 2009. The Chief Inspector found that the support for people at risk
of suicide or self-harm was variable. The quality of education and employment
was good, though access to these activities was a problem for some prisoners.
Relationships between prisoners and staff however, were generally good.
17. The inspection report said of healthcare:
“The prison had good relationships with the primary care trust (PCT), with
the governor and head of healthcare as members of the partnership
board. The head of healthcare was a member of the prison senior
management team, which provided support for the development of
healthcare provision.
There was a comprehensive range of primary care services equivalent to
that provided in the community. Prisoners received care in good conditions
that maintained their privacy and dignity. They were escorted to their
healthcare appointments by discipline staff, who continued to supervise
those in the holding rooms. The environment was clean, with measures to
manage the control of infection. The head of healthcare managed a large
team of nursing and support staff in addition to three full-time GPs.”
18. Each prison has its own Independent Monitoring Board (IMB) made up of
volunteers from the community. The Board’s role is to ensure that the prison
is properly run and that prisoners are treated fairly. Each Board produces an
annual report for the Secretary of State. The most recent report from the
Liverpool IMB was produced 2009.
19. In their report the IMB specifically commented on the healthcare unit as
follows:
“The opening of the purpose built facility in 2007 has proved to be a
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considerable asset to HMP Liverpool. The Board considers the general
care to be a high standard in excellent facilities.”
20. The man’s death is one of 24 to occur at Liverpool since April 2004, when my
office began investigating all deaths in prison custody in England and Wales.
Seven of the previous deaths were due to natural causes. There are no
similarities between those and the death of the man.
HMP RANBY
21. HMP Ranby is an adult male training prison located on the outskirts of Ranby,
Nottinghamshire. Holding sentenced category C prisoners, it is a large site,
incorporating both new and old accommodation as well as workshops. On
arrival into prison, prisoners are risk assessed and given a category based on
their offence and the risk that they pose to the public should they escape. The
prison also has a large plastics factory where prisoners are able to work
various shifts making a variety of plastic items that are used across the wider
prison estate.
22. Her Majesty’s Chief Inspector of Prisons undertook an announced inspection
of Ranby from 12 – 16 March 2007. The report said the following regarding
healthcare services:
“Healthcare provision at Ranby had developed well, and prisoners had
good access to a wide range of clinical services. Highly qualified staff
delivered a good standard of care and were committed to progressing the
service, but many felt frustrated at the lack of support at a strategic level
for health services. The department was extremely busy and nurses were
employed on non-clinical duties. Wing-based treatments were in place,
but the volume of prisoners who attended treatment rooms was, in some
areas, overwhelming and prisoners were very demanding. The local
Primary Care Trust directly commissioned GP and mental health services,
and the prison had an overarching clinical governance framework with
relevant policies. There was good access to GP clinics. The mental
health service was slowly developing, although there was a lack of
structured primary mental health systems and staff could only deliver
primary mental health care when other pressures permitted. Pharmacy
provision had improved since our last inspection, and there were excellent
dental services, despite major faults in equipment.”
23. The most recent report from the Ranby IMB covers the period from 1 April
2008 – 31 March 2009. The Board commented positively on the progress in
the education and skills facilities at the prison, and noted how many prisoners
are able to gain qualifications to help their prospects once released. The
Board also expressed concerns about the lack of 24-hour healthcare services
at the prison and felt that this was unacceptable in a prison the size of Ranby,
which is one of the largest Category C prisons in the country.
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HMP FEATHERSTONE
24. HMP Featherstone is a category C closed training prison for adult men
situated about six miles north of Wolverhampton. It holds a maximum of 679
prisoners. The prison was built in 1976 and adjoins HMP Brinsford Young
Offenders Institution.
25. The local Primary Care Trust commissions the health services for prisoners at
Featherstone. The healthcare department offers a wide range of primary care
services, including health promotion and the management and treatment of
long term and acute medical conditions. Featherstone has no inpatient facility
and the health services are not available 24 hours. Badger Harmoni (an
independent provider of primary care services) provides out-of-hours services
on behalf of the NHS.
26. The NHS Trust provides specialist mental health care to the prison. The
Mental Health In-Reach Team comprises community psychiatric nurses
(CPNs) and a consultant psychiatrist. The CPNs work closely with the primary
care nurses and doctors to assess prisoners with potential mental health
problems.
27. Her Majesty’s Chief Inspector of Prisons undertook an announced inspection
of Featherstone from 20 – 24 October 2008. The report made the following
comments:
“There was a GP surgery every morning and the GP was on call until
6.30pm. Out-of-hours medical cover was provided under contract by the
local out-of-hours service, and included coming to the prison rather than
just telephone advice.
“Prisoners were referred to mental health services from a variety of
sources, including self-referral. After they were assessed by one of the
two primary care RMNs [Registered Mental Nurse], a weekly meeting
between the primary care and secondary care team decided the best
course of action for them. This included referral to the chaplaincy, GP,
primary care RMN support or mental health in-reach team.”
28. The most recent report from the Featherstone IMB covers the period from 1
November 2008 – 31 October 2009. The report makes the following
comments:
“The healthcare department provides daytime cover although no in patient
facilities are available. Prisoners who are ill are either transferred to
prisons where in patient facilities are available, or to hospital, as
appropriate.
“Two new prisoner Health Trainers now work in the department, providing
advice about diet, smoking cessation, and health promotion. There are
now medication rooms on the wings, and in-cell medication continues to
be allowed where possible.
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HMP BIRMINGHAM
29. HMP Birmingham is a large local prison serving the courts of Birmingham and
much of the West Midlands. It holds up to 1,450 adult male prisoners, both on
remand and sentenced. The prison has undergone significant improvement
over the last few years, including the building of a new healthcare centre.
30. HM Chief Inspector of Prisons last conducted a full follow up unannounced
inspection of the prison in December 2009. The Chief Inspector noted that,
since the last full inspection in February 2007, “while some progress had been
made, there was still a considerable amount to do to ensure a safe, decent
and effective prison”. Relationships between staff and prisoners were found to
be “a considerable weakness”.
31. Healthcare provision at the prison was found to be “mostly satisfactory”. It was
largely delivered from a “modern, purpose-built unit” by three distinct groups of
staff working in primary care, in-patient care and visiting specialists.
Relationships between healthcare staff and prisoners were identified as good,
particularly on the in-patient wards. All in-patients had a care plan and a
named nurse and officer.
32. The last annual report by the Birmingham IMB covers the period July 2007 to
June 2008. The Board noted that overcrowding within the entire prison
system, and at Birmingham specifically, remained a concern. Healthcare
provision was recognised as having gone through significant changes over the
year. The Board highlighted that healthcare facilities at Birmingham were
viewed as both a local and national resource and that, as a result, “more
robust partnerships” were necessary. Overall, however, the Board was
“impressed with the dedication and professionalism of the staff”.
9
KEY EVENTS
33. The man was born in September 1970 and lived in the Birmingham area. He
was single and had a close relationship with his family. He had a history of
mental illness and had also used illicit drugs. He received treatment from his
community general practitioner. He had a history of previous convictions
relating to drug and theft offences.
34. The man was remanded into custody at HMP Hewell for drug offences on 20
September 2008, and was given a four year sentence on 30 January 2009.
He was then transferred to HMP Ranby on 10 February. (His medical records
for the period he was at Hewell were not included in the documentation given
to the investigator.)
35. On arrival at Ranby, the man saw Nurse A who carried out a routine initial
healthscreen (a health assessment for all new arrivals into a prison). He told
the nurse about his history of mental illness and that he had been prescribed:
(cid:127) olanzapine (treatment of schizophrenia and acute mixed or manic
episodes associated with bipolar disorder)
(cid:127) quetiapine (used alone or in combination with other drugs to treat
schizophrenia and bipolar disorder)
(cid:127) venlafaxine (anti-depressant).
He also told the nurse that he smoked cigarettes and had used illicit drugs in
the past.
36. The man was transferred to HMP Featherstone on 8 May and saw Nurse B
who conducted a further initial health screen noting his medication. Prison
Doctor A reviewed his medication four days later but made no changes. The
next contact with healthcare staff was on 31 May when he saw Nurse C as he
complained of toothache and the nurse prescribed ibuprofen (pain relief) for
three days.
37. On the morning of 26 June, the man complained of abdominal pain that had
become worse over the previous two days. His blood pressure was recorded
as 150/90. (The normal range for blood pressure is 100/70 to 140/90,
although the pressure does vary throughout the day depending on the
individual’s activities. A blood pressure reading of greater than 140/90 is
classed as high and a reading of 90/60 or below is classed as low.) Prison
Doctor A assessed that his symptoms indicated the possibility that he was
passing a kidney stone and referred him to the emergency department at
hospital for further tests.
38. A risk assessment was completed that authorised a two officer escort and the
use of an escort chain which was authorised to be removed for treatment
purposes only. (On each occasion when a prisoner is escorted outside of the
prison to hospital a risk assessment is completed which considers the risk to
the public, potential for escape and likelihood of outside assistance. The
assessment informs the decision about the number of escorting officers and
10
the type of restraint to be used, that is single cuffs or a two metre long escort
chain with cuff at either end. It also determines the circumstances and the
authority required for the restraints to be removed. The risk assessment is
reviewed by a prison manager each day that the prisoner is in hospital and
amended where necessary.)
39. The hospital made the diagnosis that he suffered from colic (intermittent
abdominal pain) and he returned to the prison the same day. Three days later
Prison Doctor B saw him and prescribed a seven day course of Buscopan
(treatment of intestinal spasms). After a further ten days, he saw Nurse B as
he complained of having diarrhoea. The nurse gave him advice on his diet
and advised him to rest in his cell for three days.
40. Healthcare staff were called to see the man on 16 August by prison officers as
he had collapsed. Nurse D noted that he had been found on the floor, lying on
his side apparently unconscious however he was able to get up and sit in the
chair in the cell. He told the nurse that he had pain in his stomach. The nurse
recorded his blood pressure as 104/68 with a pulse of 98, gave him
paracetamol and made an appointment for him to see the doctor the following
morning.
41. The next morning Prison Doctor B saw the man who said that the pain in his
stomach had become worse overnight. The doctor referred him to the
emergency department at the hospital for further tests. A new risk assessment
was completed that authorised a two officer escort and the use of escort chain
authorised to be removed for treatment purposes only.
42. Following an assessment by hospital staff, he was admitted to hospital for
treatment. Whilst he was in hospital, healthcare staff from Featherstone
liaised with the hospital staff to check on his progress. Nurse E, from
Featherstone, also visited him in hospital on two separate occasions. A
hospital nurse told the nurse that the diagnosis was that the man had
pancreatitis (infection of the pancreas) and pneumonia (inflammatory condition
of the lung).
43. Prison records show that, whilst he was in hospital, the man attempted to
obtain drugs and get them into the prison with the intent to supply them to
other prisoners. For this matter he was charged by the police to appear at
Magistrates Court at a later date.
44. The man was discharged from hospital back to prison on 30 August. There is
no discharge letter found in his medical records from the hospital. The
Healthcare Manager said at interview that discharge letters were received and
scanned into the electronic medical record and did not know why there was no
discharge letter for his period in hospital. The investigator has subsequently
obtained a copy of the discharge letter from the hospital.
45. Prison Doctor B saw him two days later and recorded that he had been
prescribed tramadol (for moderate to severe pain) on discharge from hospital
with the diagnosis of acute pancreatitis. The doctor changed the prescription
11
of tramadol to tradorec (for moderate to severe pain) for a period of seven
days.
46. A week later the doctor saw him again who said that he still experienced
abdominal pain. The doctor prescribed a reduced dose of tradorec from
200mg to 100mg for a further seven days.
47. Between 17 September and 24 February 2010, the man saw the mental health
team on seven occasions of which two appointments were with a consultant
forensic psychiatrist. Changes were made to the levels of his existing
medication with the addition of mirtazapine (anti-depressant). During the
same period prison doctors reviewed his prescribed medication on four
separate occasions.
48. He was transferred to HMP Dovegate on 24 February, as a short term
measure, due to security concerns regarding his attempts to get illicit drugs
into Featherstone and supply them to other prisoners. (His medical records for
the period he was at Dovegate were not included in the documentation given
to the investigator.)
49. The man was transferred to Ranby on 11 March, and a further healthscreen
assessment was conducted by Nurse F. The nurse confirmed his current
medication and referred him to the Mental Health Team.
50. Two weeks later he saw Nurse G as he complained of back pain. He
described to the nurse that the pain radiated from the bottom of his back down
to his toes on his right leg. The nurse advised him to keep moving his back
and prescribed diclofenac (anti-inflammatory).
51. On 21 April, at approximately 1.45pm, officers found the man collapsed on the
floor of his cell and immediately requested urgent medical assistance. Two
nurses arrived at the cell within a minute and found him on the floor. He told
the nurses that he had been on the toilet, felt in pain, become dizzy and
passed out. He told the nurses that he had felt like this before he was
admitted to hospital in August the previous year.
52. The nurses asked for an emergency ambulance to be called. His blood
pressure was recorded as 95/62, which increased to 110/72 after a couple of
minutes. Paramedics arrived and assessed that he needed to be admitted to
hospital for further treatment and so he was taken to hospital. A risk
assessment was completed that authorised a two officer escort and the use of
escort chain which was only to be removed for treatment purposes.
53. The man was discharged from hospital back to Ranby on 28 April. There is no
evidence in the medical records that healthcare staff from Ranby maintained
contact with staff at the hospital to check on his progress. Prison Doctor C
saw him, who said that the hospital wanted to operate on him but he refused.
The doctor recorded that the discharge summary from the hospital confirmed
the diagnosis of pancreatitis and that no pain relief had been prescribed. He
12
prescribed paracetamol and requested that blood tests were to be done the
following week.
54. The medical records show that the man did not attend appointments arranged
with a nurse for the blood samples to be taken on 4, 6 and 10 May. However
he did see Prison Doctor D on 14 May who recorded that he still experienced
pain in his abdomen but it was not significant. The doctor recorded blood
pressure as 110/80, took the blood samples, prescribed further paracetamol,
advised that he rested in his cell for two weeks and wished to review him the
following week.
55. On 18 May, the man had a court appearance and was taken to the Magistrates
Court. At interview a governor said that when a prisoner from Ranby has to
attend court it is usual that they return to the same prison. He went on to
explain that, if there was a distance involved, then the prisoner might be sent
to a prison close to the court to stay and then return to Ranby as soon as
practicable. He also said that it was healthcare’s responsibility to notify any
medical issues that would affect a prisoner’s court appearance or transfer.
The Healthcare Manager at Ranby said at interview that when a prisoner
leaves the establishment for a court appearance a printout of their medical
records and a seven day supply of any medication for the prisoner is sent with
the security staff in case the prisoner does not return immediately to Ranby.
56. The man was given a three month custodial sentence that was to be
concurrent with his existing sentence. Following his court appearance, he was
taken to HMP Birmingham. On arrival he saw Nurse H at 7.36pm who
conducted a healthscreen check. The nurse recorded that the man had
prescribed medication and confirmed the details of his medical history from his
medical records. The same evening Prison Doctor E confirmed his medication
was to continue.
57. The following day Nurse I conducted a second healthscreen with the man.
The nurse recorded that his blood pressure was 110/72, that he smoked 30
cigarettes a day, had been in hospital previously with pancreatic problems and
was taking medication for mental health problems. The nurse assessed that
he was fit to attend the gym and gave health education advice.
58. On 20 May, healthcare at Ranby received a letter from a consultant surgeon at
the hospital, which was dated 12 May and had been dictated on 7 May. The
letter said:
“The man was admitted recently with clinical features suggestive of
pancreatitis. He responded to conservative management. The ultrasound
scan during this admission did not show any gallstones.
“I am arranging for him to see me in my clinic in a few months time to
assess his progress.”
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This letter was scanned into the electronic medical records system by
healthcare administration. There is no evidence to show that this letter had
been seen by any medical professional at Ranby.
59. Four days later, the man was transferred from Birmingham to HMP Liverpool
as the result of an overcrowding draft. At interview Senior Officer (SO) A
explained that overcrowding drafts are controlled at a national level within the
National Offender Management Service to minimise overcrowding in prisons
by moving prisoners around the prison estate. The SO said that on the day
when the man was transferred, Birmingham had been instructed to send ten
prisoners to HMP Liverpool. He told the investigator that the criteria for
prisoners to be put on the overcrowding draft would be those with short
sentences and no outstanding medical appointments. He said that healthcare
staff would advise her if a prisoner could not be transferred on medical
grounds.
60. When the man arrived at Liverpool, he saw Nurse J who completed an initial
healthscreen. The nurse recorded that he appeared fit and well, and was
taking medication for mental health illness. He was seen that same afternoon
by Prison Doctor F who authorised that his medication should continue and he
was to be reviewed in two weeks time.
61. On 9 June, the man was due to have the review with a doctor. However
Healthcare Assistant A recorded that he refused to see the doctor as he had to
wait and so he was taken back to the wing. A further appointment for a review
was arranged for 28 June but he did not attend this either. There was no
further healthcare interventions with him until 16 July.
62. The investigator interviewed the man’s cellmate to establish how the man had
been during the day on 15 July. He said that the man was very friendly and
easy to talk to. He said that the man had been in the cell for the previous four
days but he had not told the cellmate that he felt unwell. The cellmate said
that during the evening the man had what he believed were four sleeping
tablets. He took three of the tablets and gave the cellmate the other one.
Events of 16 July
63. In the early hours of the morning the cellmate recalled that the man was
awake and complaining about pain in his chest and arms. He told the
investigator that the man pressed the cell bell and some officers came to see
what the matter was.
64. At approximately 5.00am Officer A responded to the cell bell from the man’s
cell. The officer said at interview that he arrived at the cell door and looked
through the observation flap to see what the problem was. The man asked the
officer to get a doctor or a nurse as he was in pain. The officer recalled that he
indicated that the pain was in his abdomen and chest area. He went to get
medical assistance from the nurse who was on duty and also informed the
officer in charge of the prison, SO B, that medical assistance had been
requested. (Prisons go into patrol state during the night and nursing staff are
14
not permitted to have cell keys. This means that they can only enter a cell
when officers are present.)
65. Within a couple of minutes Nurse K, along with SO B and Officer B, went into
the cell which the man was sharing with his cellmate. The nurse recorded that
he was sitting in his chair and appeared calm. He told the nurse that he had
coughed up blood and he had no feeling in his left arm. He also said that he
had been in hospital with pancreatitis. The nurse recorded his blood pressure
as 128/74. The nurse also checked his pupils which appeared to be dilated
and so he wondered whether he had taken an illicit drug. The nurse reassured
him that that he would come back and review how he was after 30 minutes.
66. The nurse confirmed at interview that there are two nurses on duty during the
night, one based in the healthcare department the other based in the main
prison. During the early hours of 16 July, the nurse said that he was the nurse
on duty to respond to request for medical assistance for the main prison
population. He explained that, after seeing the man, he was called to see
another prisoner elsewhere in the prison.
67. At approximately 5.50am, the nurse went back to check on the man. He saw
him through the observation hatch, sitting reading and smoking a cigarette.
The nurse asked how he was and he said that he had a pain in the side of his
head. The nurse told him that he would check again in 30 minutes. He
returned 30 minutes later and the man said that the pain was bad. The nurse
gave him some paracetamol and advised him to see the doctor later that
morning.
68. He returned to review him at 7.00am before handing over to the day staff. He
was lying on the floor and the nurse called but got no response and then
asked officers to open the cell straight away.
69. On going into the cell, the nurse found that he was not breathing and
immediately called for an emergency ambulance, started cardio pulmonary
resuscitation (CPR) and asked one of the officers to get the emergency bag
with the first aid equipment. The emergency bag was brought into the cell and
the nurse continued CPR and was quickly joined by Nurse L. The automated
external defibrillator. (The defibrillator, or AED, is a portable electronic device
that diagnoses rhythms after cardiac arrest and can deliver defibrillation (an
automated electric shock). The AED was attached to him and it advised not to
deliver any defibrillation. The nurses continued with the CPR as directed by
the AED until the paramedics arrived at approximately 7.25am and took over.
The paramedics continued to attempt to resuscitate him but they confirmed at
7.41am that he had died.
70. Later that morning a debrief was held with staff involved in the incident and
support was made available. Particular consideration was given to the support
and needs of the man’s cellmate and his relocation to another cell.
71. Prison Service Order (PSO) 2710 ‘Follow-up to deaths in custody’
recommends that the next of kin is told in person about a death in custody.
15
Due to the distance between Liverpool and the man’s family’s home, HMP
Birmingham was asked to visit them. A family liaison officer and the Imam
from Birmingham went to their home to break the news of his death. Following
the initial contact made by staff from Birmingham, the prison family liaison
officer from Liverpool maintained contact with the family. Liverpool
appropriately followed the PSO, including offering financial assistance towards
funeral expenses.
16
ISSUES
Clinical care
72. The clinical reviewer is not satisfied that the care the man received was
equitable to that which he could have expected to receive in the community.
The conclusion of the clinical review was that:
“The care received in custody by the man was not equitable with the care
he would have expected to have received within the wider community.”
Communication between HMP Featherstone and NHS hospital
73. There are concerns about the man’s continuity of care and the clinical reviewer
highlights issues following his discharge from hospital, having been treated for
pancreatitis. The reviewer comments:
“The prison clinical records include an entry stating admission date,
discharge date and that follow-up would be in six weeks. However there is
no copy of that discharge letter in the clinical records. This document was
received by the investigating team following a request as part of this
investigation. The information on this letter is conflicting: it initially states
no follow-up will be arranged and then later states that follow-up will be in
six weeks.
“There is no record of a hospital follow-up appointment being arranged or
attended. Following his discharge from hospital the man was seen by
medical or nursing staff on four occasions complaining of abdominal
discomfort or indigestion. There is no record of any hospital follow-up
arrangements being checked.”
74. It is clear from the clinical records that no action was taken by healthcare staff
at Featherstone to follow-up his discharge from hospital. Furthermore he was
seen on four more occasions complaining of abdominal pain but no reference
was made to the previous admission to hospital. He was at Featherstone for
five months after being in hospital and I find it unacceptable that no follow-up
action was taken. I therefore make the following recommendation:
The Head of Healthcare at HMP Featherstone should review the
process for managing discharge of prisoners from hospital back to
prison. This should include engaging with the PCT as
commissioners, to ensure that prisoners with follow up
appointments to see hospital specialists do so in the time that could
reasonably be expected in the community.
Transfer of medical information between prisons
75. Prison Service Order (PSO) 3050, ‘Continuity of healthcare for prisoners’
contains the guidance for the continuity of healthcare received by prisoners,
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which includes guidance on reception, transfer and discharge of prisoners.
This PSO specifically states:
“Transfers between prisons are generally planned. The Health Standards
for Prisoners performance standard states that the following must take
place.
“Current healthcare needs are assessed and continuity of care ensured
when prisoners are transferred between establishments, from
establishments to outside NHS hospitals for inpatient care, or released
into the community.
“Ensuring information on continuing care is conveyed to other
establishments on transfer and to NHS hospitals for outpatient and
in/outpatient appointments.
“Previously prisoners have been passed ‘fit’ for transfer. In future, local
policies should ensure that there are systems in place to ensure
appropriate and continuing care in any transfer or release.
“Ensuring continuity of care and effective communication with colleagues
that this implies is essential to patient care and thus central to good
practice.”
76. Prior to his court appearance on 18 May 2010, the man had been admitted to
hospital with a second episode of pancreatitis. He was discharged back to
HMP Ranby and a discharge letter stated that he was to have a follow-up
appointment in a few months time.
77. After the court appearance, which was held in Walsall, he did not return as
expected to Ranby. Instead he was taken to HMP Birmingham but he only
stayed there for five days before being transferred to HMP Liverpool because
of an overcrowding draft. The clinical records show that healthcare staff from
Ranby contacted their colleagues at Liverpool to inform them of his
outstanding mental health issues, but no mention was made of the pancreatitis
episodes nor the proposed follow-up hospital appointment. The clinical
reviewer makes the following comment:
“Follow-up appointments are usually arranged by hospitals after the
patient has been discharged. Therefore the clinic appointment date and
time may be sent to the patients address some weeks after discharge. If
the patient has changed address then this appointment may be missed.”
78. Whilst I accept that prisoners are regularly transferred between prisons for a
variety of reasons, there is an expectation that clinical records are swiftly and
effectively transferred. Healthcare departments should speak to each other to
ensure that there is continuity of care.
The Governor and Head of Healthcare at HMP Featherstone, HMP Ranby
and HMP Birmingham, and the Director and Head of Healthcare at HMP
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Dovegate should adhere to PSO 3050 “Continuity of healthcare for
prisoners” so that prisoner’s clinical records on transfer from other
establishments are fully appraised by healthcare staff for any family
medical history, ongoing treatment or outstanding clinical requests.
Level and grade of nursing cover at HMP Liverpool
79. The clinical reviewer has considered the staffing levels and grade of nurses on
duty at night at Liverpool and makes the following comments:
“At HMP Liverpool the night nursing cover consists of two Band 5 Nurses
and one Health Care Assistant. Nurse K was the Band 5 Nurse on duty in
the main prison. Nurse L was the Band 5 Nurse on duty in the in-patient
wing along with a Health Care Assistant.
“Band 5 Nurses without clinical examination skills training are not qualified
to perform clinical examinations and therefore may be unable to make
appropriate clinical decisions
“Outside of the custodial system the man would reasonably have expected
to have been fully assessed and examined by a clinician qualified in
clinical examination skills.
“Arrangements should have been made for him to be assessed by a more
senior clinician. This may have necessitated attendance at a hospital.”
80. Had his symptoms been appropriately assessed in the early morning of 16
July, it may have resulted in him being admitted to hospital and earlier
intervention could have taken place. Whilst accepting that we cannot know
whether an admission to hospital would have affected the outcome, I support
the clinical reviewer’s findings and make the following recommendation:
The Primary Care Trust and Head of Healthcare at HMP Liverpool should
urgently review the level and grade of nursing staff available on duty
throughout the night, to ensure appropriate clinical assessment of
symptoms is possible at all times.
Emergency response
81. I judge that the staff who responded to the man’s need for emergency
assistance acted with great speed and professionalism. The clinical reviewer
makes the following comment:
“When he was discovered collapsed and unresponsive, there was an
immediate and appropriate response by Nurse K and Prison officers.
Emergency equipment was immediately made available and
cardiopulmonary resuscitation was commenced. Paramedics attending
gained swift access to the prison and cell.”
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82. I agree with the comments made by the clinical reviewer and recognise the
actions taken by the staff at Liverpool in responding to the emergency
situation.
Family liaison
83. I am pleased to note that Liverpool contacted HMP Birmingham to ask their
family liaison officer to contact the man’s next of kin. As Birmingham was
closer to the family home, it meant that the news of his death was given face
to face in a timely manner, by an appropriately trained member of Prison
Service staff, accompanied by an appropriate faith representative. Liverpool
followed the guidance set out in PSO 2710 ‘Follow up to deaths in custody’,
and I am pleased that Birmingham readily agreed.
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CONCLUSION
84. I recognise the issues highlighted in the clinical review and accept the
reviewer’s judgement that the standard of care that the man received whilst he
was in custody was not fully equitable to what he could have expected to
receive in the community.
85. In particular, I am concerned that there was no follow up of a hospital
appointment whilst he was at HMP Featherstone. Continuity of care suffered
as information was not properly assessed at each of his subsequent transfers
to other establishments. I appreciate that he was being treated for
pancreatitis, which was not the cause of his death, but nevertheless I am
concerned that his condition was not investigated properly.
86. More importantly, the clinical reviewer judges that the absence of appropriately
trained nurses at night at HMP Liverpool meant that his symptoms could not
be appropriately assessed, meaning that a chance of earlier intervention was
missed. There is no way that I can know whether this would have saved his
life, but nevertheless it is a serious concern that should be addressed.
87. Following his death Liverpool appropriately followed the guidance given in
PSO 2710, “Follow up to death in custody”. I am pleased that HMP
Birmingham readily assisted to ensure that his family were properly informed
and supported.
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RECOMMENDATIONS
1. The Head of Healthcare at HMP Featherstone should review the process for
managing discharge of prisoners from hospital back to prison. This should
include engaging with the PCT as commissioners, to ensure that prisoners
with follow up appointments to see hospital specialists do so in the time that
could be reasonably expected in the community.
Accepted
2. I recommend that the Governor and Head of Healthcare at both HMP
Featherstone, HMP Ranby and HMP Birmingham, and the Director and Head
of Healthcare at HMP Dovegate should adhere to PSO 3050 “Continuity of
healthcare for prisoners” so that prisoner’s medical records on transfer from
other establishments are fully appraised by healthcare staff for any family
medical history, ongoing treatment or outstanding clinical requests.
Accepted,- However In response HMP Ranby said that they:
“meet this recommendation through existing practice. The entries on system
1 show that on 20/5/10 the administrator at Ranby scanned a letter received
from the clinic that the man attended before leaving the establishment.
Although no telephone call is recorded it is normal practice for the
administrator to contact the prison holding the prisoner to follow this up. The
evidence of an appointment letter being generated by HMP Birmingham
demonstrates that they were aware of this matter.”
3. The Head of Healthcare at HMP Liverpool should urgently review the level
and grade of nursing staff available on duty throughout the night to ensure
that appropriate clinical assessment of symptoms is available at all times.
Accepted - A full review of night staff has been undertaken by the Head of
healthcare.
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