Individual at Wakefield

Investigation into the circumstances surrounding the
death of a man
at HMP Wakefield in 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2010
This is the report of the investigation of the death into the circumstances surrounding
the death of the man who died at HMP Wakefield in November 2009. The man had
been in custody since 1984 and was serving a life sentence. He had a history of
mental and physical health problems, including asthma, bowel problems, acid reflux,
cardio vascular and limited mobility. In November at 5.37am, a nurse was called to
the man’s cell and found him in bed not breathing, with no pulse or any signs of life.
An emergency ambulance was called and the paramedic confirmed his death. The
man was 63 years old.
The investigation was undertaken by one of my investigators. Her Majesty’s Coroner
for the County of Yorkshire held a post mortem into the man’s death. It was noted
that his death was of natural causes due to a gastro-intestinal haemorrhage and a
bleeding lower oesophageal ulcer. I extend my sincere condolences to his sister,
family and friends.
A review of his medical care was commissioned with Wakefield District Primary Care
Trust (PCT). I am grateful to the clinical reviewer for her clinical review. I would like
to thank the Governor of Wakefield and her staff for their assistance with this
investigation. I am especially grateful to the prison liaison officer.
I make four recommendations for the attention of the Head of Healthcare. They
include the presentation of medical notes and the documentation of allergies.
Furthermore, I recommend a review of nursing staff skills and a multi disciplinary
approach to long serving prisoners with complex medical problems. I note the good
practice of healthcare and prison staff in managing the man’s medical conditions.
In this final report, the prison service had accepted the four recommendations and
their actions have been added to the recommendations. The man’s family have
seen the draft report and do not have any comments to add.
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 July 2010
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CONTENTS
Summary
The investigation process
HMP Wakefield
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
From an early age the man was educated at a school for children with special needs.
After leaving school he spent most of his adult life in prison for serious offences.
Following his last conviction in 1984, he served his sentence in high security prisons
and Rampton Secure Hospital where he was diagnosed with a psychopathic
disorder. It was noted in his previous medical records that he had been diagnosed
with chronic reflux oesophagitis linked to Barrett’s Syndrome. (This condition is an
abnormal change in the cells of the lower end of the oesophagus [throat] thought to
be caused by damage from chronic acid exposure.)
In October 2007, the man transferred to HMP Wakefield from HMP Frankland. He
was seen by a reception nurse who noted his previous medical history that included
bowel problems, asthma, cardio vascular and obesity. (Throughout his time in
Wakefield he was seen regularly by healthcare staff.) It was recorded by a doctor
that the man had recently under gone full medical investigations for his bowel
problems and no abnormalities were identified.
The man was escorted to hospital on three occasions between February 2008 and
February 2009. The first time was to check his high blood pressure and raised body
temperature. On the last two occasions, he had self harmed by cutting his arm and
leg. Following each act of self harm an Assessment, Care in Custody and
Teamwork (ACCT) plan was opened and he was admitted to the healthcare unit for
observation. (An ACCT plan documents interventions, care and observations of
prisoners at risk of suicide or self harm.) A psychiatrist examined the man on 31
March 2009 and prescribed Largactil, an anti-psychotic medication.
The man was seen in his cell on 26 November by a nurse after wing staff had
reported that he was unwell. His observations (blood pressure and pulse rate) were
in the normal range so he was advised to rest and take some fluids. Two days later
a nurse examined him and again his observations were within the normal range.
The nurse advised him to tell wing staff if his symptoms persisted and to rest.
At about 5.18am on 30 November, a wing officer was carrying out a routine check of
prisoners and looked through the observation panel in the man’s cell door. The
officer saw blood on the man’s’ face, could not get a response from him and
therefore radioed for urgent assistance.
A nurse and three officers responded to the emergency and found the man in bed
with dried blood on his face and no signs of life. An emergency ambulance was
requested and the nurse started cardio pulmonary resuscitation (CPR). Paramedics
arrived at 5.57am and confirmed that the man had died at 6.02am.
The clinical reviewer has made recommendations in her clinical review. I endorse
four of those recommendations and note one other. Furthermore, I endorse the
good practice by healthcare and prison staff in managing the man’s medical
conditions.
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THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened on 12 January 2010 when
my investigator visited Wakefield. She was met by the prison family liaison
officer and an officer and reviewed documents from the man’s prison file and
medical records. My investigator asked that copies from those documents be
sent to her.
2. Notice of the Ombudsman’s terms of reference and notices of investigation
had been sent in advance of my investigator’s visit. No members of the
Independent Monitoring Board (IMB) or Prison Officer’s Association asked to
see my colleague. (The IMB are volunteers who monitor the day to day
routines of the prison.)
3. My investigator visited B wing where the man lived and spoke informally to
two prisoners on the wing. Later, my investigator interviewed an officer, who
knew the man well and had been one of his personal officers.
4. A letter from a friend of the man was received by my investigator and my
investigator considered the contents of this letter. No other responses have
been received.
5. A review of the man’s healthcare was commissioned by Wakefield District
PCT. The clinical reviewer carried out that review on behalf of the PCT.
6. One of my family liaison officers wrote to the man’s sister explaining the
investigation and asking whether she had any issues she would like to be
explored. At the time of writing this report his sister has not raised any points
for consideration. I hope the findings of the report help her to understand the
events leading to her brother’s death.
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HMP WAKEFIELD
7. HMP Wakefield is one of eight high-security prisons within the prison estate.
Wakefield was originally built as a house of correction in 1594. It is now a
main lifer centre. The average number of prisoners is approximately 700,
including 100 category A and 10 high risk category A prisoners.
8. Wakefield has a separate healthcare block. There is an out-patient section
and an in-patient facility with capacity for 21 patients. Nursing care is
available for 24 hours, seven days per week. A doctor is in the prison on
Monday to Friday from 9.00am to 5.00pm. Outside these hours, care is
provided via Local Care Direct (the local provider of out-of-hours primary
health care). The in-patient facility contains a palliative care suite which
allows staff to care for patients in advanced stages of serious illness.
9. Her Majesty’s Chief Inspector of Prisons inspected Wakefield in 2008. An
extract from report published in 2009 said:
“Wakefield has improved considerably over the last five years and it is
pleasing that in general the improvement has been sustained. There is still
work to be done on aspects of safety, staff prisoner relationships and
activities, but the principal issue to be tackled is how to motivate and
engage serious sexual offenders, so that their risk is reduced and they can
progress through the prison system.”
10. The IMB published their Annual Report in 2009, an extract from the summary
of that report said:
“We again acknowledge that many improvements have taken place in the
healthcare centre. We feel that treatment clinics that are now provided by
appointment do seem to have improved the service provided. Our
observations around the healthcare unit are positive and patients appear
to be well cared for.”
11. There have been 14 deaths due to natural causes at Wakefield since the
Ombudsman’s office took responsibility for investigating deaths in custody in
2004. Many of those deaths were from terminal or cardiac illnesses.
Previous recommendations for the healthcare services have included the care
of those prisoners with chronic illnesses. The Prison Service has accepted
the recommendations and action plans have been formulated to address
issues on care plans and special clinics.
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KEY FINDINGS
12. The man was remanded into prison in 1983. He was sentenced to life
imprisonment on 16 February 1984 and spent time in the high security
prisons; Full Sutton, Durham, Whitemoor and Frankland. During his period in
Whitemoor, he stayed in the Dangerous Severe Personality Disorder Unit. It
was further recorded that the man spent sometime in Rampton Secure
Hospital. Also, during this time, he received medical care for many illnesses
including bowel, cardio vascular and chronic reflux oesophagitis linked to
Barrett’s Syndrome. (This condition is an abnormal change in the cells of the
lower end of the esophagus [throat] thought to be caused by damage from
chronic acid exposure). He also harmed himself on numerous occasions.
October 2007- January 2008
13. The man was transferred from Frankland to Wakefield on 25 October 2007.
On his reception into Wakefield he was seen by a nurse who wrote in his
medical notes that he had a history of various health problems including
bowel, heart, asthma, eyesight, obesity and was a smoker. (A first reception
health document was not contained in his medical notes.)
14. Between October 2007 and January 2008 the man was seen by healthcare
staff on 14 occasions. During this time his blood pressure was noted to be
variable and his bowel complaints were recorded as having been fully
investigated when he was at Frankland. His medication was regularly
reviewed and tests were carried out following a suspicion of a deep vein
thrombosis (DVT), which proved to be unfounded. During this time, in
consultations, he told healthcare staff that he was allergic to paracetamol and
penicillin however, this had not been noted when he first arrived at Wakefield
15. After an episode of chest pain in November, the man had an
electrocardiogram (ECG) to measure his heart rate, which was noted to be in
normal range. Following an emergency visit to hospital, he was diagnosed
with a chest infection, which was treated with antibiotics. It was recorded
throughout his medical notes that he was not an easy prisoner to deal with.
He was aggressive towards healthcare staff and demanding of their time,
which included refusing treatments and medication, which he often return to
healthcare staff.
January 2008 – January 2009
16. The man’s negative behaviour continued throughout 2008 and he made
frequent visits to healthcare. He was seen on many occasions by the doctors
and his medication was reviewed regularly with the inclusion of appropriate
medication for his ongoing health issues.
17. In February, he was taken to hospital with high blood pressure, a raised body
temperature and a swollen leg. However, following some treatment in the
accident and emergency department, he returned to Wakefield after becoming
violent at the hospital.
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18. On 17 July, following poor behaviour on the wing which resulted in the man
being downgraded to the basic regime (basic regime is the lowest level of
rewards for prisoners), he self harmed by cutting his right arm. He refused
any support or treatment and became aggressive and swore at staff. An
Assessment, Care in Custody and Teamwork (ACCT) was opened. He was
admitted to the healthcare unit for observation. Full case reviews took place
and the ACCT was closed in August when he returned to the wing.
Healthcare staff, with the support of wing staff, continued to monitor his
mental health through regular visits and assessments.
January 2009 – October 2009
19. The man harmed himself again on 6 February by cutting his leg. Following a
visit to Pinderfields Hospital he retuned to Wakefield, was admitted to the
healthcare unit and another ACCT was opened. Following a review of the
ACCT document, the healthcare manager wrote that the man would be
observed in the healthcare unit for a few days. Two days later, the Healthcare
Officer (HCO) noted that the man had been talking of further self harm with
intent to kill himself. The ACCT was revised to increase observations at
irregular intervals.
20. After an appointment with a prison doctor, the man was moved to C wing a
week later and the ACCT was closed. On 31 March, a psychiatrist, examined
the man and prescribed Largactil, an anti psychotic medication.
21. Following another cut to his leg on 16 June, the was seen by healthcare staff.
He did not express any further thoughts of self harm. However, wing staff
prudently opened another ACCT document. During the initial ACCT review
the man told the panel that his medication was not working and he wanted to
see the psychiatrist. He further demanded his television set be returned and
made threats to self harm if his requests were not met. (The man had been
placed on basic regime for poor behaviour and the removal of his television
set was part of that process.) It was noted that he was hostile and
uncooperative throughout the ACCT review process.
22. Later, Registered Mental Nurse (RMN) discussed the man’s behaviour and
mental health with a second doctor. Both health professionals agreed that the
man’s attitude was personality driven as opposed to a mental health
diagnosis. On 21 July, the psychiatrist saw the man for a psychiatric
consultation.
23. Two days later, the man declined an out patient appointment at Pinderfields
Hospital for a computerised tomography (CT) scan of his liver. (A CT scan is
a procedure that takes internal images of the body.) This procedure had been
requested by the doctor at Wakefield in response to the man’s complaints of
pain in his back.
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August 2009 – November 2009
24. On 3 August, a second RMN saw the man who was feeling breathless and
thought he was experiencing an asthma attack. The nurse noted that the cell
was smoky and he told her he had just had a cigarette. He refused to take a
peak flow test, to test his breathing. The nurse advised him about smoking
and the effect it would have on his asthma.
25. On 25 August, a third prison doctor reviewed the man’s medication and
adjusted his prescription. A nurse prescribed pain relief of Tramadol on 20
October, after he complained of continuing back pain.
26. The third prison doctor examined fully the man on 4 November and took
extensive medical history from him. The man told the doctor that he had a
cough for nine days. The doctor noted that the man had high sugar levels
from a blood test in August and was overweight. The doctor advised him to
cut down his sugar intake. The man’s observations were recorded as blood
pressure 148/93, normal range is 130/80 and a pulse rate of 80 beats per
minute (bpm), normal range is between 60-100 bpm.
27. Two weeks later, the third prison doctor saw the man in the healthcare unit
and a diagnosis of cellulitis, an infection, was noted on his left leg. An
antibiotic was prescribed and again, the man was advised to lower his sugar
intake.
28. A second nurse was asked by wing staff to see the man in his cell on 26
November. He was complaining of feeling unwell and passing blood in his
urine. His blood pressure reading was 144/77, with a pulse rate of 85bpm
and temperature of 37 degrees. He further told the nurse he had diarrhoea
and pain in his groin. A sample of urine was tested and no abnormalities
were detected. The nurse spoke to the third prison doctor about the man’s
symptoms and the doctor said there was no need for antibiotics but he would
see him if he got any worse. The nurse advised the man to rest and take
plenty of fluids. She returned to see him later that evening and his
temperature was normal at 36.5 degrees. The nurse again advised the man
to take plenty of fluid.
29. Two days later, a third RMN saw the man at the request of wing staff. Staff
told the nurse he had been shaking and did not feel well. The RMN took a
blood pressure reading of 140/70 and a pulse rate of 62bpm. The man
complained of pain in his left arm but not in his chest. The nurse told him to
tell wing staff if his symptoms persisted and notified healthcare staff on night
duty of the man’s present ill health.
30. At 11.02pm, a fourth RMN was contacted by wing staff. The man wanted the
nurse to be aware of his symptoms and that he felt unwell. The nurse wrote
in his medical notes that she had been fully briefed, and if he felt very unwell,
she would visit him during the night. The following day on 29 November at
2.05pm, the third RMN wrote that the man had been seen that morning in his
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cell. He said he felt better and had been chatting and smoking with his
friends, although he still had loose stools.
31. About 5.18am on 30 November, the first officer on the scene was carrying out
a routine check of prisoners. The officer looked through the observation panel
of the man’s cell door, saw blood on his face and could not get a response
from him. The officer radioed for urgent assistance and for a member of the
healthcare staff to go to the man’s cell. Three officers immediately went to the
cell and opened the door. The officers could not find a pulse and they thought
that the man appeared to be dead.
32. The first nurse on the scene arrived at the cell at 5.38am and saw him lying in
bed with dark dried blood around his mouth, on his sheets and pillow. There
was no pulse or signs of breathing and he was cold to the touch. Despite the
signs that the man had died, the nurse commenced cardio pulmonary
resuscitation (CPR) and asked for an emergency ambulance to be called. At
5.57am a paramedic arrived at the man’s cell and, after an examination,
confirmed death at 6.02am.
33. Following the man’s death, a prison family liaison officer, and a member of the
chaplaincy team visited the man’s sister to inform her of her brother’s death.
The family liaison officer continued to support the man’s sister in the days
following his death. A memorial service was held in Wakefield’s chapel which
was attended by the man’s family. The prison offered funeral expenses to his
family.
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ISSUES
Clinical care
34. A review of the man’s medical care was commissioned with Wakefield PCT.
The clinical reviewer appraised the man’s medical notes and met my
investigator to determine the extent of her report. They agreed to concentrate
the review on the man’s most recent time in custody.
35. The clinical reviewer reviewed the man’s medical notes and recorded that it
was poorly presented, confusing and incomplete. This significantly impacted
on the time taken to undertake the chronology for her report. My investigator
supported her findings and was unable, as a non clinician, to fully examine the
notes and get a clear timeline of the man’s medical history and interventions
throughout his sentence.
36. Whilst it is difficult to keep medical notes in a semblance of order, particularly
for the case of long serving prisoners, they should be time ordered so they
can be comprehensively read. I agree with the clinical reviewer’s
recommendation about the maintenance of medical records.
The Head of Healthcare should review the methods available to produce
printed information from System 1 so that an accurate account of
healthcare can be provided. Systems should be put in place for
maintaining individual medical records in a structured way.
37. I also note that the further advises that a yearly healthcare summary of
prisoners remaining in custody for over five years.
Overview of the man’s medical history
38. The man’s medical notes indicated that he had experienced various health
problems throughout his time in custody. Entries in those notes showed that
medical investigations had been carried out at varying intervals with a
negative result, except for Barrett’s Syndrome.
39. He was treated for chronic reflux oesophagitis, (when stomach acid flows
back into the throat area), a condition associated to Barrett’s Syndrome. The
man underwent medical investigations including bowel procedures and
biopsies in 2002, which were found to be normal. He was prescribed
medication with a holistic term of Proton Pump Inhibitors (PPIs). (This group
of drugs work on the cells that line the stomach, reducing the production of
acid.)
40. The most significant medical investigations took place in the hospital in 2007.
The man had cardiac, bowel and further biopsy procedures but nothing
untoward was noted.
41. Most notable were the number of occasions that he refused healthcare
treatment and his periods of self harm. He would not take advice from
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hospital staff and would discharge himself from their care or stop investigative
procedures. However, he often later had second thoughts, apologised and
asked for help on several occasions.
42. The man was seen by a psychiatrist and diagnosed with an untreatable
psychopathic disorder. His behaviour was unpredictable, and at times
aggressive and abusive. The last set of notes are illegible from the
psychiatrist, due to poor electronic copying, however an assessment at
Rampton Secure Hospital in 1999, recorded that no further psychiatric
hospital treatment would be of benefit to him.
43. The clinical reviewer noted that the man’s pattern of self harm remained the
same during his period in Wakefield. On the occasions he self harmed, an
ACCT document was opened and he was monitored in the healthcare unit,
followed by continued care on the wing.
44. Throughout his time in custody, the man consistently complained about
healthcare services. Nevertheless, it was noted by the man that all
complaints had been fully investigated and been unfounded.
First reception health screening document
45. The man had been in several prisons before his transfer to Wakefield
however, on reception a first reception health screening document was not
evident in his medical notes. Whilst a medical history was taken from the man
and well documented on the electronic system, a reception screening should
have been found in his medical record. I am unable to say whether one was
completed or not. I note the clinical reviewer’s recommendation held in the
clinical review referring to first reception health screen documents.
The man’s allergy to some medications
46. It is apparent from previous medical history that the man was allergic to
penicillin which was first documented in 1985, but removed in November
2009. He had been given this medication on three occasions whilst at
Wakefield with no adverse reaction. Likewise, the man had told healthcare
staff that he was allergic to paracetamol but it was prescribed on one
occasion with no reaction. However, he had signed a request for medication
in 2005, saying he was not allergic to paracetamol.
47. These supposed allergies were not noted on his reception into Wakefield but
the man seemingly told healthcare staff during consultations.
48. The clinical reviewer commented:
“There appears to have been a lack of awareness by some nurses
regarding the man’s documented allergy to both paracetamol and
penicillin.”
49. I endorse the following two recommendations.
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The Head of Healthcare should review the systems in place to document
allergies in medical records, on prescriptions charts and pharmacy
records.
An audit of existing skills and competencies within the nursing team
should be carried out in order to identify training needs in relation to
prescribing and administering medication with particular reference to
allergic reactions.
The man’s refusal of medical treatment
50. Investigations were undertaken and the diagnosis of chronic reflux
oesophagitis linked to Barrett’s Syndrome and a hiatus hernia (where the
stomach protrudes into the diaphragm) was noted as a possibility in 1992.
However, the medical investigations in 2007 did not refer to a hiatus hernia,
but did accept a diagnosis of Barrett’s Syndrome.
51. The man was prescribed the appropriate medication for all his conditions, but
frequently returned it to healthcare staff or refused to take it. His non
compliance in taking his medication may well have impacted on his
symptoms. He was referred for an endoscope procedure in 2009, but it is
unclear from the medical notes whether he received this appointment or not.
52. It was noted that the man appeared to have a history of anaemia but no cause
was found for the condition. He was prescribed the appropriate medication
but again repeatedly returned it to healthcare which again may have impacted
on his health. In July 2009, he refused to attend hospital for a scan
appointment on his liver.
53. Lastly, the man was diagnosed with asthma in 2001, and whilst he often
refused to co-operate with its monitoring he was prescribed an inhaler and
seen by healthcare staff when experiencing an asthma attack.
54. It is noted that he often refused to attend medical appointments and did not
always comply with his medication. The doctors and healthcare staff were
aware and recorded this in his medical notes.
Conclusion of the clinical review
55. The clinical reviewer noted that the man had been known to healthcare staff
at all the prisons he had been in during the last 25 years. Whilst his
behaviour had been challenging, she judges that his healthcare was managed
appropriately. Medical investigations took place for his physical health
problems despite the man’s view and lack of belief in the results. The man
seldom complained of dyspepsia (indigestion) or any related symptoms.
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56. The clinical reviewer noted:
“There is nothing to suggest that in the days prior to his death that any
signs or symptoms relating to his oesophagitis were ignored.”
57. Nevertheless, the clinical reviewer has noted that whilst the man had complex
health problems, a multi disciplinary approach to its management and care
was not apparent. No management plans were evident for his ongoing health
problems and no member of the healthcare staff was identified to oversee and
co-ordinate his care.
58. I endorse the following recommendation made by the clinical reviewer.
The Head of Healthcare should review the clinical leadership within the
primary healthcare setting, and audit roles, responsibilities and working
practices to develop a structured case management approach to
prisoners with complex long term conditions.
59. The clinical reviewer concluded her review by reiterating that the poor
presentation of the man’s medical records made the compilation of the clinical
review extremely difficult and time consuming.
Good Practice
60. The clinical reviewer noted that it was evident from the documentation that
there were times when the man was exceptionally difficult, and was
inconsistent when describing his health problems. Nevertheless, healthcare
staff treated him in a professional manner. He refused some medical
procedures, medication and treatments but was offered the opportunity to
change his mind and take advice and care from staff.
61. It was also evident from the man’s personal officer that wing staff cared well
for the man despite occasional abuse and disruptive behaviour. The man
was diagnosed with a mental health illness and this was monitored by all staff
at Wakefield.
62. I note the following comment by clinical reviewer and recorded it as good
practice:
“The healthcare professionals and officers involved in managing the man’s
healthcare should be commended.”
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CONCLUSION
63. The man underwent numerous medical investigations which included a
diagnosis of chronic reflux oesophagitis linked to Barrett’s Syndrome. Whilst
being treated for this health problem it is known that he often refused
medication and medical interventions. His attempts to self harm were
managed appropriately through ACCT documents and he was seen by a
psychiatrist in March 2009.
64. The clinical reviewer makes several recommendations around managing long
serving prisoners with complex medical conditions, the presentation of
medical records, documentation of medical allergies and the auditing of
nursing staff skills.
65. I judge that the man received appropriate care from both healthcare and
prison staff taking into consideration his mental health problems which may
have impacted on his challenging and inappropriate behaviour.
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RECOMMENDATIONS
For the Head of Healthcare
1. The Head of Healthcare should review the methods available to produce
printed information from System 1 so that an accurate account of healthcare
can be provided. Systems should be put in place for maintaining individual
medical records in a structured way.
Accepted - “Monthly meetings with Systm One facilitator for additional staff
training. Electronically produced prescriptions are in the process of being
implemented to maintain accurate records.”
2. The Head of Healthcare should review the systems in place to document
allergies in medical records, on prescriptions charts and pharmacy records.
Accepted – “Medication audit completed March 2010 and report due during
Summer.”
3. An audit of existing skills and competencies within the nursing team should be
carried out in order to identify training needs in relation to prescribing and
administering medication with particular reference to allergic reactions.
Accepted – “Practice Development Facilitator is monitoring training & has
developed a spreadsheet for mandatory & personal development training.“
4. The Head of Healthcare should review the clinical leadership within the
primary healthcare setting, and audit roles, responsibilities and working
practices to develop a structured case management approach to prisoners
with complex long term conditions.
Accepted – “Matron and Practice Development Facilitator in place with effect
from October 09. Audit delayed due to suspension of several members of
staff. Structured case management process is being developed during
April/May 2010. Group clinical supervision is scheduled fortnightly &
individual clinical supervision has now been commenced.”
Good Practice
1. I note the professionalism of both healthcare and prison staff in managing the
man’s medical conditions.
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