Individual at Risley

Investigation into the circumstances surrounding the
death of a man,
whilst in the custody of HMP Risley,
in October 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2010
This is a report into the death of a man at HMP Risley in October 2009. The
man was 39 years old and died from natural causes. A 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 at the start of the
investigation.
The investigation was carried out by my colleague. Both he and I would like
to thank the Governor and staff at HMP Risley, HMP Manchester, and HMP
Forest Bank. In particular, I would like to thank one of the governors at HMP
Risley and a senior officer for their full and ready co-operation during the
course of our enquiries. I also thank Warrington Primary Care Trust for the
appointment of a clinical reviewer.
I apologise for the delay in publishing this report, and any additional distress it
may have caused. It is important, however, to include the clinical review of
the man’s medical treatment whilst in custody and this was not received by
this office until July 2010. I am, however, grateful to the clinical reviewer who
conducted the clinical assessment of the care received by the man.
The man died from natural causes, and the findings of the clinical review play
an essential part in my report. As the man died within 24 hours of transferring
from Manchester, the clinical reviewer was asked to consider the care that the
man received at Manchester, Forest Bank and Risley. The review judges that
the man should have received greater care whilst at HMP Forest Bank. Also,
I am particularly concerned about the effectiveness of the emergency
response in the early morning at HMP Risley, following the delay the man
experienced in being seen by the doctor.
I make four recommendations concerning emergency response, chest pain
protocol, and assessment of medical records on the transfer of prisoners.
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.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman
November 2010
CONTENTS
Summary
The investigation process
HMP Risley
HMP Manchester
HMP Forest Bank
Key events
Issues
Conclusion
Recommendations
SUMMARY
On 18 February 2009, the man was remanded into custody at HMP
Manchester. On arrival he had an initial healthscreen assessment which
recorded that he smoked, had used cocaine in the last month, had an
operation on his right femur in 1988 and suffered nerve and tendon damage in
his right hand in 2002 for which he was prescribed strong pain relief.
The next day the prison detoxification team doctor (treats individuals with drug
and alcohol withdrawal problems) saw the man and recorded that there was a
family history of cardiovascular disease and diabetes and put a detoxification
plan in place. In the weeks that followed the man saw healthcare staff on a
regular basis due to the pain he experienced in his right hand. On each
occasion he was prescribed appropriate medication.
On 11 August, the man appeared at Crown Court, was further remanded into
custody, and sent to HMP Forest Bank. In the four weeks that he was at
Forest Bank he complained of chest pains on three separate occasions. On
each occasion he was seen by a prison doctor and on the third occasion the
doctor requested an electrocardiograph (ECG) to be undertaken. By the time
he moved from Forest Bank no ECG had been conducted.
The man appeared in Crown Court, from Forest Bank, on 18 September, and
was sentenced to four and a half years in custody and sent to Manchester.
On arrival at the prison he was seen by a nurse who recorded that all his
details were still held and that there had been no change since his last time at
Manchester four weeks previously and did not say that he recently had chest
pain.
On 22 October the man transferred to HMP Risley and it was recorded that no
immediate action was required. The next day, at approximately 6.10am, the
man called for assistance by pressing his cell bell. A nurse arrived at the
man’s cell, accompanied by two officers at approximately 6.27am. He told the
nurse that he had pain across his upper chest, he said he had experienced
the same symptoms in a previous prison, and that he had been waiting to
have an ECG. The nurse prescribed general pain relief, and advised the man
to attend healthcare later that morning for an ECG, but to ring his cell bell if
the pain relief did not reduce his symptoms.
The man reported to healthcare at 9.01am to have the ECG; however the
ECG was not conducted until 10.25am. In light of the ECG results the prison
doctor immediately called for an emergency ambulance. Whilst waiting for the
arrival of the ambulance the man went into cardiac arrest. The doctor, with
the assistance of healthcare staff, commenced cardiopulmonary resuscitation
(CPR) until the paramedics arrived. After a period of emergency treatment
the paramedics took the decision to transfer the man to hospital. After arrival
at the hospital and further emergency treatment, the hospital doctor
pronounced the man had died at 11.40am.
The prison family liaison officer and prison chaplain left Risley within an hour
to attempt to tell the man’s family of his death. In the days that followed, the
prison chaplaincy maintained contact with the man’s family by phone and
personal visit to offer support as well as assisting with the funeral
arrangements. The prison offered financial support towards the cost of
funeral expenses.
THE INVESTIGATION PROCESS
1. My investigator studied all relevant prison records relating to the man.
They included his main prison record, medical records and statements
made by staff. Notices were also posted to staff and prisoners in Risley
about the investigation and three prisoners came forward. My
investigator visited Risley on 8, 13 January and 2 February 2010 and
interviewed a total of seven members of staff and the three prisoners.
2. My investigator visited HMP Manchester on 19 January and 9 February,
and interviewed six members of staff.
3. My investigator visited HMP Forest Bank on 15 and 26 January, and
interviewed three members of staff.
4. My investigator also interviewed two members of staff from G4S
(transport of prisoners to courts and transfers between prisons) on 29
January.
5. Warrington Primary Care Trust identified a medical practitioner to carry
out a review of the man’s clinical care. I thank the clinical reviewer for
undertaking this review. My investigator discussed aspects of the
man’s treatment with healthcare staff at Risley, Manchester and Forest
Bank and with the clinical reviewer. I requested the review within ten
weeks of the man’s death and received it on 28 July 2010. The delay
receiving the review has significantly affected the timeliness of my own
report. However, I thank the clinical reviewer for his comprehensive
report.
6. My investigator wrote to Her Majesty’s Coroner to inform him of the
nature and scope of the investigation. A copy of the Post Mortem report
was made available. The investigator maintained contact with the
Coroner to update him on the progress of the investigation. Upon
completion, a copy of the investigation report will be sent to the Coroner
to assist in his enquiries into the man’s death.
7. One of my Family Liaison team contacted the man’s family at the
beginning of the investigation and offered them the opportunity to raise
questions and concerns for us to consider. The man’s family raised the
following concerns:
(cid:127) They believe the man had been complaining of chest pain for
three or four weeks before his death and question whether he
would have survived if he had been diagnosed and treated as
soon as he started to complain of chest pains.
(cid:127) They wish to establish if there is any evidence that staff at HMP
Manchester had labelled the man as “a complainer” and were,
therefore, slow to respond to his health needs.
(cid:127) They want to understand the reasoning and rationale about the
timing and reasons for the man’s transfer to HMP Risley.
(cid:127) They would have appreciated an acknowledgement of his death
from HMP Manchester, and the absence of any condolences
contrasts unfavourably with the very sensitive letter they had
received from the Governor at HMP Risley.
8. I have attempted to address the issues raised by the man’s family within
this report and I hope that it provides a better understanding of the
treatment he received and the events leading up to his death.
After having the opportunity to see the draft report, the man’s family
were angry and upset to read what a fellow prisoner said during his
recorded interview. They wished the final report to reflect the fact that
that they did not know this man nor had they received a call from him on
the day of their relative’s death as he stated in the interview transcript.
HMP RISLEY
9. HMP Risley is a modern, purpose built prison that opened in 1964. It is
a category C training prison. Since the opening of a new wing in 2003,
it has a capacity of 1,085, making it the largest category C prison in the
country.
10. Healthcare staff are available in Risley 24 hours a day. By day, there is
a doctor in the prison; at night, cover is provided by nursing staff.
Prisoners who require in-patient treatment are referred to other prisons
or to outside hospital.
11. The prison was most recently inspected by HM Chief Inspector of
Prisons during an unannounced inspection between 14 and 18 July
2008. In her subsequent report, the Chief Inspector made the following
comments:
“Aspects of reception, first night and induction remained poor and,
while violence reduction arrangements had been strengthened,
staff struggled to cope with the pervasive influence of readily
available drugs and gang activity.
“Few prisoners had long journeys to Risley, but some were told of
their transfer only on the same morning. Most arrived in good time,
but some said they had been kept waiting outside reception in vans
over lunch breaks. Relationships with escort contractors appeared
satisfactory. Most transfers in were planned and wasteful moves
kept to a minimum.”
12. Regarding healthcare services at Risley, the Chief Inspector stated in
her report:
“New arrivals were given a written information sheet on healthcare
services, but this was poorly presented and available only in
English. All were seen by a member of healthcare staff in
reception. Their immediate health needs were assessed and they
were offered an appointment with a GP the following day.
Prisoners with identified specific health needs were offered an
appointment with the GP or other health professional as appropriate
and given their appointment slip to take away with them.
“Prisoners attending the healthcare centre at treatment times were
assessed by a nurse and could if necessary be offered a same day
appointment on weekdays. At weekends, the local out-of-hours
provider was used or an appointment made for the following
Monday.
“Out-of-hours medical cover was provided by a local service and
the three senior nurses on the healthcare team were also on call on
a rota basis to support healthcare staff. Emergency clinical
equipment was located in the healthcare centre. Staff said this was
regularly checked, but there was no written record.
“A number of policies and procedures were available in the
department, but these were either not signed or out of date.”
13. Each prison in England and Wales has an Independent Monitoring
Board (IMB) formed of volunteers from the local community. The IMB is
responsible for monitoring day-to-day life in the prison and to ensure
that proper standards of care and decency are maintained. The most
recent annual report published by the IMB for the period 1 April 2008 to
31 March 2009 does not contain any issues that impact on this
investigation.
14. Prior to the death of this man, there have been six previous deaths at
Risley since the Ombudsman began investigating all deaths in prisons
in 2004. There are no similarities between the previous deaths and that
of this man’s.
HMP MANCHESTER
15. HMP Manchester is a Victorian local prison which accommodates
people who are remanded into custody from courts in Greater
Manchester. It has been part of the High Security Estate since 2003.
The prison consists of two blocks containing a total of nine wings with a
mix of single and double cells.
16. Healthcare at Manchester is commissioned by the Manchester Primary
Care Trust. The healthcare centre provides 24 hour nursing care and
medical cover, and has beds for up to 20 patients, who are admitted on
clinical need only.
17. Manchester was last inspected by Her Majesty’s Chief Inspector of
Prisons in July 2009. In her report the Chief Inspector summarised
Manchester as follows:
“Manchester is a complex and large prison, which needs to manage
a varied population, including those involved in gang activity. It is
commendable that it has managed to retain its local prison focus,
and to provide purposeful activity for a large number of prisoners,
while holding securely its category A prisoners. The focus and
direction of its resettlement work needs attention: in particular, the
services for drug and alcohol users. More fundamentally managers
need to explore and remedy the lack of trust between some staff
and prisoners, building on the strong relationships in some parts of
the prison to ensure that interactions are both appropriate and
positive.”
18. Specifically with regard to transfers, in the report the Chief Inspector
said:
“The escort contractor was Global Solutions Limited (GSL) and
relationships between reception staff and GSL were good. There
were approximately 80 receptions each week and around 150
discharges each month. Reception staff said that they were not
always told what time escort staff would arrive to collect prisoners
who were being transferred.”
“The cellular vehicles we looked at were clean and held
refreshments. In our survey, prisoners responded significantly more
positively than at comparator establishments about their safety
during transit, the attention paid to their health needs during the
journey, their comfort and the frequency of toilet breaks. Prisoners
were not handcuffed in the vehicles or when moved into the
reception area, except for those who had been identified as
presenting an escape risk. Prisoner escort records were fully
completed and paperwork was checked thoroughly by reception
and escort staff before prisoners were accepted.”
19. The Chief Inspector looked at the complaints procedure, and made the
following comment:
“The most common areas of complaint were accessing property,
visits, healthcare and matters relating to telephones. The quality of
responses was variable. Although some provided a satisfactory
response, others were poor and merely repeated the
establishment’s rules and routines, rather than answering the
prisoner’s specific issues. Performance reports indicated that no
complaints had been substantiated between April and July 2009.
Quality checks were carried out by the audit team.”
20. On reviewing the healthcare services, the Chief Inspector’s findings
were:
“There was evidence of strong support from the primary care trust.
Primary care services had improved and there was access to a
range of in-house and visiting specialist clinics. The introduction of
telemedicine had significantly reduced the number of prisoners
going out of the prison for NHS assessment. The healthcare
application system was not sufficiently robust, and the absence of
prisoner focus groups meant that prisoners were unaware of
significant changes in healthcare delivery. The management of
external NHS appointments was efficient, and inpatient health
provision satisfactory. Overall, there was good access to health
services, most of which were comparable to those found in the
community.”
21. The latest IMB report for Manchester was produced in 2008 in which
they made the following comments:
“The problem of prison overcrowding has a very negative impact on
prisoners in a number of ways: induction on reception and first night
arrangements; the difficulty of arranging accumulated visits and
transfers of prisoners to their own locality; and transfer of prisoners
to other establishments to undertake the courses specified in their
sentence plan.
“Treatment clinics are held on weekdays in the outpatients' section
of Healthcare. There is a Mental Health In-reach Team within
Healthcare and a member will visit prisoners on the wings.”
HMP FOREST BANK
22. HMP Forest Bank is a privately managed prison operated by Kalyx. It is
situated on the outskirts of Salford. The prison opened in January 2000
and has an operational capacity of over 1,424 prisoners.
23. Healthcare facilities at Forest Bank are provided by Kalyx. General
Practitioner, pharmacy and dentistry services are contracted out and
are provided by local practitioners. Services provided by the Mental
Health In Reach Team are commissioned from, and delivered by the
Salford Primary Care Trust.
24. Forest Bank was last inspected by Her Majesty’s Chief Inspector of
Prisons in September 2007. In her report the Chief Inspector
summarised Forest Bank as follows:
”Forest Bank is a contracted-out local prison in Salford, run by
Kalyx. Its first inspection, in 2002, was relatively positive, though it
lacked sufficient activity. A follow-up inspection in 2005, however,
recorded significant concerns about safety, including the availability
of illicit drugs.
“This inspection found that safety had improved, and that overall
Forest Bank was not an unsafe prison. However, some
weaknesses remained, such as the arrangements for prisoners’ first
night in the prison and the management of bullying, which young
adults in particular reported to be a problem.”
25. On reviewing the healthcare services, the Chief Inspector’s summary
was:
“Healthcare was unacceptably poor, with staff shortages and some
unsafe reception screening and pharmaceutical practices. Primary
care, including primary mental healthcare, was weak, and inpatients
had a very limited regime. Secondary mental healthcare was,
however, reasonably good.”
26. The latest IMB report for Forest Bank was for the period December
2008 to December 2009 in which they made the following comment
regarding healthcare services:
“There is a Healthcare centre with both inpatient and outpatient
facilities
“There are a lot of issues concerning Health Care particularly with
appointments to see the doctor, medication and prescriptions. This
has been evidenced by the number of applications to the board.
We are pleased to report that the waiting times for routine
appointments to see the G.P have been reduced.
“A new clinical IT system has also been agreed which will in time
link directly to the NHS system so information can be shared. This
will be sited in the new building along with the IDTS wing this
should improve and make it easier to control and administer
methadone treatment times.”
KEY EVENTS
27. The man was born in June 1970 and lived in the Manchester area. He
was single and had two teenage children from a previous relationship.
The man had been unemployed since 1988 following an injury
sustained in a road traffic accident. He was a smoker, had a history of
using illicit drugs and had served previous custodial sentences.
28. On 18 February 2009, the man was remanded into HMP Manchester.
On arrival he had an initial healthscreen assessment conducted by a
Healthcare Assistant (HCA), who recorded that the man said that he
smoked and had used cocaine in the last month. A urine sample test
was taken and showed to be positive for cocaine and Subutex (an
opiate addiction treatment). Later the same evening a prison doctor
saw the man and recorded that he had an operation on the right femur
in 1988 and suffered nerve and tendon damage to the right hand in
2002. The man had previously been prescribed gabapentin (for
treatment of nerve pain). The doctor referred the man to the drug
detoxification (Detox) team.
29. The next day the prison Detox doctor saw the man and recorded that
he had taken 12mg of Subutex the previous day. The doctor also
recorded that the man said that there was a family history of
cardiovascular disease and diabetes. He told the doctor that he
smoked 10 to 19 cigarettes a day, and before he came into prison,
drank three to four cans of beer and used heroin and crack cocaine.
The prison Detox doctor authorised a Subutex dextoxification plan for
the man.
30. On 23 February, when a nurse issued the man his Subutex medication
he was observed to have tissue paper under his top lip and attempted
to manouver the Subutex into the tissue (this is a method known to be
used amongst prisoners so they can trade medication). When
challenged by an officer, the man swallowed the tissue and Subutex.
The nurse checked the man’s mouth to ensure that he had swallowed
the Subutex and that it was not hidden under his tongue, and referred
him to be seen by the Detox doctor.
31. The prison Detox doctor saw the man on 2 March and recorded that
there was no evidence of drug withdrawal and informed him that,
based on the evidence available, there was no need for the
dextoxification programme to continue. The man’s solicitors wrote to
Manchester on 4 March stating that their client complained that he had
not received any detoxification care and had not been seen by a
doctor since his remand on 18 February. Manchester responded to
this letter outlining the medical interventions that had taken place since
the man arrived at the prison.
32. On 12 March, a third prison doctor saw the man as he complained of
pain in his right hand. The doctor recorded that the man had problems
with his hand since 2002 and preferred gabapentin for pain relief. The
doctor prescribed 100mg gabapentin capsules to be taken twice a day.
33. The man saw a fourth prison doctor on 23 March as the pain relief was
only partially effective. The doctor recorded that in addition to the
problems with his right hand the man also suffered from a shaving rash.
The doctor prescribed an increase of gabapentin to 300mg twice a day
and fusidic acid cream and hydrocortisone acetate cream (both for
treatment of skin infections) to be applied twice a day.
34. Due to breach of prison rules regarding the attempt to obtain unlawful
items via the post and on a prison visit on 7 April, the man was moved
to the segregation unit (single cell accomodation in the segregated part
of the prison where prisoners are closely monitored by staff) . On
arrival in the segregation unit, a nurse saw the man but he refused to be
examined or answer any medical questions. At interview the nurse
confirmed that it was the man’s right to refuse to be examined, but that
there were no visible signs of illness or injury.
35. The man remained on the segregation unit until 2 June, when he
returned to the a normal cell on K Wing. During this period he was
seen and checked regularly by healthcare staff but no issues or
concerns were raised.
36. On 10 June, a fifth prison doctor saw the man as he was still in pain
from his hand. The doctor recorded that other than his hand the man
had no other issues and the doctor increased the prescribed gabapentin
to 600mg in the day and 300mg at night. The doctor advised him to
return to healthcare if the pain did not ease.
37. Two days later a nurse responded to an alarm call from wing staff that
another prisoner had thrown a cup of hot water over the man. The
nurse recorded that the man said that he had no injuries or scalding and
that the cup of water had hit the wall and not him. He refused to allow
the nurse to examine him but the nurse recorded that there were no
obvious signs of injury.
38. Due to further breach of prison rules, on 16 July the man was again
taken to the segregation unit. For the next eleven days he was seen
each day by a member of healthcare staff and there were no issues or
concerns raised. He then returned back to a normal wing.
39. On 11 August, the man appeared at Crown Court, was further
remanded, and taken to HMP Forest Bank. On arrival a nurse
conducted a healthscreen which confirmed the man’s gabapentin
medication and his history of substance misuse from the medical
records from Manchester. The nurse recorded that the man had no
thoughts of self harm, his blood pressure was 116/78 with a pulse of 62
and his weight was 81kg. (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.) The nurse assessed the man as fit for normal
location and work
40. The next day a prison doctor saw the man and recorded that he said he
had purchased 2mg of Subutex from other prisoners on the wing since
his arrival. He had been offered and refused Britofex (for treatment of
opiate withdrawal). The doctor continued the prescribed gabapentin at
the level of 600mg in the day and 300mg at night.
41. Due to spitting on a member of staff, the man was moved to the
segregation unit on 17 August, where he remained until his court
appearance on 18 September. The following day a second prison
doctor tried to see the man as part of the assessment of prisoners in the
segregation unit. He said that he did not want to see a doctor.
42. On 21 August, a third prison doctor saw the man who said that he had
pain in his upper chest, in his collar bones and down both arms. The
doctor recorded that the man’s pain was not related to exertion and his
abdomen was not tender. The doctor prescribed paracetamol and
advised the man to ask to see healthcare if the pain got worse. Four
days later the man was reviewed by the second prison doctor, who
recorded that he said he did not want to see the doctor.
43. At the same time senior management at Forest Bank considered the
man’s categorisation assessment, to decide which prison would be best
suited to meet the needs of his sentence and rehabilitation prior to his
release back into the community. This was completed on 24 August
which assessed the man as a category C prisoner, suitable for the
prison regime available at HMP Risley, pending his future court
appearance.
44. A fourth prison doctor assessed the man on 30 August as he had
complained of pain in his upper chest and shoulders. On examination,
the doctor recorded that his chest was clear and that the man’s heart
sounds were normal. The doctor advised the man to continue with the
pain relief. The next day the same doctor checked on the man but he
said that he did not want to see a doctor.
45. On 8 September, the fourth prison doctor saw the man, as he reported
experiencing pain in his shoulders and arms for a few days but not that
particular day. The doctor recorded that there was no typical cardiac
chest pain, but requested that an electrocardiograph (ECG) (to measure
and diagnose abnormal rhythms of the heart) was to be completed
when possible.
46. The fourth prison doctor tried to see the man on two further occasions,
13 and 15 September, but on each occasion the man said that he did
not want to see the doctor. There is no record that the request for an
ECG was actioned by this doctor or any other clinician.
47. At interview the fourth prison doctor said that it was his understanding
that it was the responsibility of other healthcare staff to arrange and
conduct the ECG. He further commented that when he saw the man on
the 13 and 15 September, as the man said he did not wish to see a
doctor, he assumed that the chest pain problem had resolved itself.
48. The investigator interviewed the Healthcare Manager at Forest Bank to
establish the procedure for healthcare staff following up clinical
requests. The Healthcare Manager said that if a prisoner had been
seen in healthcare any clinical request would usually have been acted
on straight away. In cases where a prisoner was in the segregation
unit, as this man was, he said the prisoner would be taken to healthcare
for further treatment by healthcare staff.
49. On 18 September the man appeared in Crown Court. The Person
Escort Record Form (PER) was completed which indicated that there
was a risk of violence and drugs and the man was to be kept separate
from a fellow prisoner with whom there was a history of trouble. The
section on health risks was completed by a nurse who recorded that
there were no medical or mental health risks.
50. The man was sentenced to four and a half years in custody and sent to
HMP Manchester. On arrival at the prison he was seen by a nurse who
recorded that all his details were still held from his previous stays and
that there had been no change. At interview the nurse confirmed that
the man told her that there had been no changes since he was last at
Manchester, and that all he wanted was his gabapentin. The nurse told
the investigator that the man did not mention that he had chest pains
whilst at Forest Bank. Later the same day a doctor saw the man and
authorised the prescribed level of gabapentin. There is no record that
either the nurse or the doctor reviewed the medical records from Forest
Bank or made reference to the fourth doctor at Forest Bank’s
recommendation for an ECG.
51. Three days later a further categorisation assessment was completed by
senior management at Manchester which confirmed the earlier
assessment made at Forest Bank, which included the proposed transfer
of the man to Risley.
52. A nurse saw the man on 22 September and recorded that he smoked
20 to 39 cigarettes a day, weighed 82.55kg, and had a family history of
cardiovascular disease and diabetes. The nurse gave him health
advice regarding smoking cessation and testicular cancer.
53. A fellow prisoner told the investigator that he had been friends with the
man from childhood and they were on the same wing at Manchester.
The fellow prisoner told my investigator that the man had requested to
see the doctor on two occasions because he had chest pains. He
explained the system to have an appointment with healthcare was that
prisoners completed an appointment slip and then were later told when
their appointment had been made. The fellow prisoner was unaware if
the man had been told when his appointments were due. He went on to
say that both he and the man were on the exercise yard together when
staff went to the man’s cell to take him over to healthcare. This meant
that the man did not have his appointment with the doctor.
54. The investigator interviewed the healthcare manager who confirmed
that the appointment system worked as described by the fellow
prisoner, and that prisoners were told the time of their appointment.
The healthcare manager said that prisoners were aware that it was their
responsibility to be in their cell and wait to be escorted to healthcare by
uniformed staff in time for their appointment. She explained that
prisoners who required urgent medical attention would either raise the
alarm directly with a uniformed member of staff or press their cell bell.
Prison records show that the man had been in Manchester on several
occasions since 2004 and therefore it is reasonable to expect him to
have known the procedure for arranging a healthcare appointment as
the appointment system had been in place for many years.
55. The only other entries on the man’s medical records were on 28
September when a nurse issued paracetamol for a headache, and on
21 October when a further nurse recorded that he appeared fit for
transfer. There is no evidence available that shows that the man was
seen by a doctor after he saw the first prison doctor on 18 September,
nor any evidence that the earlier request for an ECG had been
actioned.
56. The nurse who had earlier recorded he appeared fit for transfer
confirmed at interview that in assessing the man as fit for transfer there
was a check for outstanding hospital appointments or specific ongoing
treatment. The nurse then printed off the man’s medical record which
was placed in a sealed envelope marked ‘confidential’ ready to be taken
to the next establishment.
57. On 22 October the man transferred to Risley and a PER was completed
that indicated security risks but no risks regarding medical or mental
health. The health assessment had been signed by a nurse from
Manchester.
58. The man was transferred from Manchester to Risley by G4S, inter
prison transfers. Two prison custody officers (PCOs) confirmed at
interview that they were the officers that were on duty and responsible
for the transfer of the man. One PCO was the driver and the other PCO
the escort officer. The escort officer also confirmed that he signed for
all the documentation and property for the six prisoners to be
transferred, which included this man. The escort officer said that this
included the sealed medical records for each prisoner and he had to
record this on the G4S documentation accordingly. The transport
vehicle left Manchester at 2.10pm.
59. En-route to HMP Risley, the escort officer was required to check the
prisoners whilst in transit. He confirmed that he checked on the man on
three separate occasions during the journey and recorded that on each
occasion he was looking out of the window.
60. On arrival at Risley at 2.45pm, the escort officer said that he handed all
the documentation and property over to the prison uniformed reception
staff. The escort officer then allowed the prisoners off the transport
vehicle into the custody of the prison reception staff.
61. At approximately 4.00pm a healthcare assistant (HCA) conducted a
healthscreen assessment and noted that the man said he was pleased
to be at Risley, had no thoughts of self harm and was a smoker. The
HCA recorded his blood pressure as 125/75 with a pulse of 82, that he
was prescribed gabapentin and that there was no immediate action
required. He offered the man smoking cessation advice. At interview
the HCA said that no medical records had been transferred with the
man.
62. A cell sharing risk assessment was completed and the man stated that
he was prepared to share a cell as long as it was not with anyone from
an ethnic minority background. Due to this declaration the assessment
was made that he should initially be located in a single cell until a
further indepth review could be undertaken.
63. A fellow prisoner who had transferred with the man from Manchester told
the investigator at interview that later that same evening the man had
purchased cocaine on the wing. The fellow prisoner said that he saw
the man smoke the drugs at approximately 7.00pm and the next
morning was told by the man that he had chest pains.
Events on the day of the man’s death
64. At approximately 6.10am, as part of his duties, an officer conducted a
cell check on the wing when the man called for assistance. He told the
officer that he had pains in his chest and in both arms and wanted to be
seen by someone from healthcare. The officer contacted the
healthcare centre by telephone to ask for a nurse to come and see the
man.
65. The orderly officer in charge of the prison received a telephone call at
approximately 6.15am from a nurse to say that the man had chest pains
and felt unwell. The orderly officer went to healthcare and collected the
nurse and they then went to the man’s cell. During the night all prisons
are in patrol state and nurses would not have cell keys.
66. The nurse, accompanied by the orderly officer and the officer who had
contacted healthcare to ask for a nurse, entered the man’s cell at
approximately 6.27am. The man told the nurse that he had pain across
his upper chest and it was tender to the touch. He also told the nurse
that he had experienced the same pain in a previous prison and had
been waiting to have an ECG. The nurse recorded that he had a good
colour, was not short of breath, and did not feel sick or dizzy. The
nurse recorded his blood pressure as 148/99 with a pulse of 72,
prescribed paracetamol and ibuprofen. The nurse advised the man to
attend healthcare later that morning for an ECG but to ring his cell bell if
the pain relief did not reduce his symptoms.
67. At interview the nurse said that a very classic sign of a heart attack
would be a central chest pain that might move to the left side of the
chest, sometimes down to the left arm and sometimes up into the jaw.
The nurse was aware that these symptoms are not always present with
a cardiac pain. The nurse said that the man complained of pain around
the collar bone area which was tender to the touch; otherwise he did not
appear unwell.
68. The orderly officer told the investigator at interview that he recalled the
man told the nurse that he had pains in his chest and down his arms
and that he had waited for an ECG whilst at Forest Bank. The orderly
officer said that he was aware that the nurse had made an appointment
for the man to see the doctor later that morning. The orderly officer also
said that if the nurse had told him that the man needed to go to hospital
an emergency ambulance would have been called straight away.
69. The man reported to healthcare at 9.01am to have the ECG; however
the ECG was not conducted until 10.25am. An HCA took the ECG
result to a prison doctor. In light of the results, and having spoken to
the man in the consultation room to obtain the history of his chest pain,
the prison doctor immediately asked for an emergency ambulance.
From the prison control room log, the 999 call was made at 10.42am.
70. At interview the prison doctor explained that when prisoners arrive in
healthcare for appointments they are seen by the Out-Patient Nurse
who books them in on the system and they are usually seen in the order
that they arrived. However the prison doctor said that all the clinics
were listed on the computer screen and staff could enter an
administration note below the prisoner’s name to ask for someone to be
seen first or request a certain treatment.
71. The prison doctor gave the man 300mg aspirin and three puffs of
glyceryl trinitrate (GTN) spray (for treatment of angina and heart failure)
which greatly relieved the pain. The HCA bought an oxygen cylinder
into the room and assisted the doctor to give the man a full flow of
oxygen. The doctor left the room to fetch the cannulation equipment (to
allow medicines to be administered direct into the blood stream), whilst
the HCA remained with the man.
72. The doctor returned within sixty seconds to find that the man’s
breathing was slow and erratic and had become blue in colour. The
doctor checked for a pulse and heart beat but there was no response.
The doctor, assisted by the HCA and a visiting physiotherapist,
commenced cardio pulmonary resuscitation (CPR) and used an
automatic external defibrillator (AED) (portable electronic device that
diagnoses heart rhythm and gives electrical therapy to allow the heart to
re-establish a normal rhythm). The healthcare staff continued with the
CPR until the paramedics arrived.
73. A paramedic arrived at 10.52am and took over the CPR, assisted by an
ambulance crew who arrived two minutes later. The prison doctor also
assisted the paramedics in the treatment given to the man. After a
period of emergency treatment the paramedics took the decision to
transfer the man to hospital. The ambulance left the prison for outside
hospital at 11.22am. After arrival at the hospital and further emergency
treatment, the hospital doctor pronounced the man had died at
11.40am.
74. The prison family liaison officer and the prison chaplaincy left Risley at
12.35pm to inform the man’s nominated next of kin, his sister, of his
death. They arrived at the man’s sister’s address at 1.15pm to find that
she was not at home. A neighbour said that she was at work. The
prison family liaison officer contacted a governor to pass the information
on, and the prison was able to contact the man’s sister via her mobile
phone and she returned home, with her husband, to meet the prison
family liaison officer and the prison chaplaincy.
75. Later that same day a Governor held a hot debrief for all the staff
involved in the emergency, which included the officers that
accompanied the man to hospital. (A hot debrief offers staff involved
the opportunity to discuss the incident. The purpose is to offer
reassurance, information and support). A member of the care team and
chaplaincy was available to offer support to staff and prisoners affected
by the man’s death.
76. In the days that followed, the prison chaplaincy maintained contact with
the man’s sister by phone and personal visit to offer support as well as
organising the funeral arrangements. The prison offered financial
support towards the cost of funeral expenses.
ISSUES
Clinical care
Initial remand period at HMP Manchester
77. On his remand into custody in February 2009, the man was
appropriately assessed by healthcare staff at Manchester. Due to his
family history of cardiovascular disease and diabetes and along with the
detail that he smoked, used alcohol and illicit drugs, he was a young
man with a moderate to high risk of developing heart disease. The
clinical review made the following comment concerning the man’s
treatment for drug misuse:
“On the information available to me l take the view that the man’s
illicit substance misuse problem was managed in an appropriate
manner. It appears that he was no longer using the illicit
substance/s for which he had received the detoxification treatment
at the time of his transfer to HMP Risley.”.
Second remand period at HMP Forest Bank
78. The man moved to Forest Bank following his court appearance on 11
August. It was whilst at Forest Bank that he complained of chest pain
on three separate occasions over a two week period from 21 August to
8 September. On each occasion the man was seen by a prison doctor,
firstly by one doctor and on the second and third occasion by the same
doctor. That doctor requested an ECG to be undertaken, but this was
not followed up by healthcare staff or by the doctor who saw the man
twice more on 13 and 15 September.
79. Although clinicians use their physical assessment skills to identify
deteriorating health and clinically assess patients into the most
appropriate care locations, there is evidence that this did not occur in
this man’s case. Whilst it is unknown whether the immediate
investigation by an acute specialist would have made a positive
difference to the man, the failure to holistically assess and seek the
guidance of specialists or to apply best practice guidance are serious
lapses in care.
80. The clinical review carefully considered the assessment of the
symptoms presented to the doctors at Forest Bank by the man and
stated:
“ he had symptoms which needed a careful analysis to determine
whether or not they pointed to the presence or absence of ischemic
heart disease.”
81.