Individual at Styal

Investigation into the circumstances surrounding the
death of a woman
in March 2010 at outside hospital,
while in the custody of HMP & YOI Styal
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2011
This is the report of the investigation into the death of a woman who died in
March 2010 at outside hospital while in the custody of HMP & YOI Styal. She
was 42 years old. I extend my sincere condolences to her family and friends.
The investigation was undertaken by two of my investigators. Her Majesty’s
Coroner for Cheshire held a post mortem into the woman’s death, which
found that she died of natural causes, as a result of irregular heartbeat.
Further examination of the woman’s heart, by specialists at outside hospital,
noted that the woman was a victim of Sudden Adult Death Syndrome (SAD).
This affects up to 500 young adults per year.
The woman had a history of intravenous drug misuse, alcohol and self harm.
For two days, 18 and 20 March, she was taken to outside hospital for heart
related problems and discharged herself back to Styal. During the early hours
of a day in March 2010, the woman was found collapsed in her cell and an
emergency ambulance was called. Members of healthcare staff attended to
the woman with cardio pulmonary resuscitation (CPR). She was escorted to
hospital and her death was confirmed by hospital staff at 4.48am.
A review of the woman’s healthcare was commissioned with Eastern Cheshire
Primary Care Trust (PCT). I am grateful to the clinical reviewer for carrying
out that comprehensive review. I would like to thank the Governor of Styal
and his staff for their help and assistance with this investigation. I would also
like to thank the liaison officer for her assistance.
I endorse one recommendation made by the clinical reviewer to the PCT and
the Prison Health Partnership Board that relates to the woman’s clinical care.
I also make my own recommendation for the Governor to review systems
whereby relatives can raise concerns about prisoners.
This version of my report, published on my website, has been amended to
remove the names of the woman who died and those of staff and prisoners
involved in my investigation.
Jane Webb
Acting Prisons and Probation Ombudsman January 2011
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CONTENTS
Summary
The investigation process
HMP & YOI Styal
Key findings
Issues
Conclusions
Recommendations
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SUMMARY
The woman was sentenced to 12 years imprisonment in 2002 for conspiracy
to supply drugs. She served three years of her sentence, before absconding
from HMP Askham Grange on 22 September 2005, and returned to custody
three and a half years later, on 20 March 2009.
On her arrival at HMP Styal it was recorded that the woman had a history of
intravenous drug and alcohol misuse and chest pain. She had attempted
suicide during her previous custodial sentence. Her blood pressure reading
was above the normal range. She was assessed by a doctor who prescribed
a stabilising programme of methadone, along with Librium to help her cope
with withdrawal symptoms.
Nine days later, officers started the Assessment, Care in Custody and
Teamwork (ACCT) procedures for the woman. (The ACCT procedures are
used by prison staff to identify, assess and support prisoners at risk of suicide
or self-harm.) She was assessed to be at risk whilst she was detoxifying and
because she spoke of personal problems. The ACCT was closed five months
later, when she was no longer vulnerable and felt better.
The woman was supported by the Counselling Assessment Referral and
Throughcare Service team (CARATs). (The CARATs team is a specialist
service used in prison to support prisoners who have a history of substance
misuse.) She went regularly to the substance misuse clinics and was referred
to the mental health in reach team, although she did not always cooperate
with them.
On 18 March 2010, the woman was taken to hospital as an emergency. Her
heart rate was low, her breathing rapid and she was sweating. The following
day she was discharged from hospital and returned to Styal without further
medical interventions or treatments.
During the afternoon, the woman was assessed by a doctor as she had a fast
heart rate and high blood pressure. The doctor told the woman she needed to
return to the hospital. However, she refused to go and said she was scared of
hospitals. After contact with the cardiology department, arrangements were
made for her to return to hospital the following morning which she agreed to.
In the early hours of the next day, at 3.00am, the woman was transferred to
hospital as her condition had deteriorated through the night. She was taken in
a taxi as she was unhappy going by ambulance. Later that day she
discharged herself against medical advice and returned to Styal at 11.30am.
During that afternoon, her pulse rate was still low and her blood pressure was
high. An on call doctor, in the prison to assess reception prisoners, declined
to see the woman telling prison staff that she should be taken to hospital if her
clinical observations were a cause for concern.
Despite the staff efforts to convince her, the woman refused to go back to
hospital and night duty staff arranged to check her wellbeing during the night.
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At about 3.00am, a nurse went into the woman’s cell to take her clinical
observations but she did not respond. Emergency medical staff and an
ambulance were immediately called. The responding medical staff started
CPR. The woman was taken to outside hospital and her death was confirmed
at 4.40am.
I endorse the recommendation made by the clinical reviewer for the attention
of the PCT and the Prison Health Partnership Board. I make a further
recommendation about dealing with prisoners’ families concerns when they
contact the prison.
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THE INVESTIGATION PROCESS
1. I appointed one of my senior investigators to conduct the investigation
into this woman’s death. He opened the investigation on 22 March
2010 by telephone when he contacted the Deputy Governor at Styal.
My investigator outlined the terms of reference for the investigation and
asked for the woman’s prison file and medical records to be forwarded
to him. My investigator had recently investigated another death at
Styal and was familiar with the prison and its regime.
2. The Ombudsman’s terms of reference and notices to staff and
prisoners were sent to the Governor. My investigator’s contact details
were made available to members of the Independent Monitoring Board
(IMB) and the Prison Officer’s Association. (The IMB are volunteers
who monitor the day to day life of the prison to ensure that proper
standards of care and decency are maintained.) At the time of
publication of the draft report, there has not been any response to
these notices.
3. A review of the woman’s healthcare was commissioned with Central
and Eastern Cheshire Primary Care Trust. The review was undertaken
by a clinical reviewer.
4. One of my family liaison officers contacted the woman’s mother
outlining the process of the investigation. On 30 April, my family liaison
officer spoke to the woman’s mother on the telephone and noted her
questions and concerns about her daughter’s care.
(cid:127) The use of restraints and her daughter’s fear of hospitals.
(cid:127) A telephone call made by the woman to her mother the afternoon
before she died concerned about taking anti-depressant
medication with her heart condition. Her daughter asked her
mother to contact the doctors so the prison could have access to
her medical history.
(cid:127) Her daughter felt the prison did not have full information about her
past medical history.
(cid:127) Her mother’s effort to contact the healthcare unit at Styal on 20
March.
(cid:127) Breaking the news of her daughter’s death to her mother.
I trust that I have addressed these concerns in the Issues section of
this report.
5. My investigator visited Styal on 25 May and interviewed two doctors, a
nurse and an operational support grade officer. On 15 July, my other
investigator with conduct of this case visited Styal and interviewed two
further officers and a nurse.
6. Solicitors acting on behalf of the woman’s mother contacted one of my
investigators on 20 July. The solicitor asked for certain medical issues
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to be included in the clinical review. These issues were passed to the
clinical reviewer who has addressed them in his review. In response to
the draft report, in a letter of 19 November 2010, the solicitor acting on
behalf of the woman’s mother raised a number of additional issues.
These are addressed at the end of the issues section of my report,
paragraph 97.
In response to the draft report the National Offender Management
Service (NOMS) makes reference to Annex 1, executive summary of
the clinical review. They sate that the woman arrived at Styal on 20
March 2009, and not on the 21 as stated in his report. NOMS also
note that the clinical reviewer refers to the Keller Unit as a “specialist
unit for prisoners with extreme psychiatric problems”. They state that
the Keller Unit provides enhanced levels of support to prisoners with
complex needs.
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HMP & YOI STYAL
7. Styal is the only local prison for women prisoners serving the North
West of England and North Wales. It mainly accommodates women
serving short sentences or those on remand. The prison has an
operational capacity of 460. Waite wing has the capacity for 135
women in cellular accommodation.
8. Healthcare services at Styal are commissioned by the Central and
Eastern Cheshire PCT. A doctor is based in the healthcare centre
during weekdays and evenings. An on call service is available
overnight and at weekends. There are nurses on site 24 hours a day.
During the night nursing staff are based in the first night centre, as
there are no inpatient facilities at the prison.
9. HM Chief Inspector of Prisons conducted a full announced inspection
of Styal in September 2008. The Chief Inspector reported that:
“Women had reasonable access to most health services, but there
was significant pressure on services and staff struggled to meet
women’s considerable mental and physical health needs.”
10. In their annual report for 2007/2008, the IMB noted difficulties recruiting
and retaining nursing staff. They related the high turnover in staff to
the challenges entailed in dealing with a “demanding population” of
prisoners. The IMB also noted that the healthcare budget was
significantly under spent during the year 2007/2008, as it had been the
previous year. They made the following comment:
“Bearing in mind the nature of the Styal’s prisoner population and
their unique and varied health issues, it is unacceptable that the
budget is not managed in such a way to ensure all the resources
needed by the prison are acquired.”
11. The woman’s death was the fourth death due to natural causes to have
occurred at Styal since April 2004, when my office began investigating
all deaths in prison custody in England and Wales. There are no
similarities between the issues raised in this report and those
addressed in previous investigations.
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KEY FINDINGS
12. The woman was born in June 1967, and was the mother of two
children who were looked after by other members of her family. She
was unemployed and had recently lost her partner in a car accident.
She used cocaine intravenously, misused alcohol and had a number of
previous convictions, for which she had served several custodial
sentences.
12.1 In response to the draft report the woman’s mother asked for the
following paragraph to be added. “[The woman] loved her two sons
and that although she had suffered drug addiction all her life, she was
addressing the issues arising from her illness. She is missed terribly
by her family and had many positive qualities including loving animals
and being very creative.”
13. On 29 April 2002, the woman was sentenced to 12 years imprisonment
at a crown court for conspiracy to supply drugs. Following transfers to
HMP Durham and HMP Buckley Hall, the woman was moved to HMP
Askham Grange in York on 22 September 2005. Six months later, she
absconded from custody.
March to October 2009
14. Three and a half years after she escaped, the woman was arrested in
Blackpool on 20 March 2009. Following a court appearance, she was
returned to custody at Styal. A first reception health screen document
was completed by a nurse. The nurse wrote that the woman had a
history of epilepsy, intravenous drug use, misuse of alcohol, a history
of chest pain and had attempted suicide during her previous time in
custody. She told the nurse that she had no thoughts of self harm, nor
had she been in receipt of any medication for mental health problems
in the community. It was further noted that she had been homeless. A
high blood pressure reading of 143/108 was recorded (an average
blood pressure is 130/80). She had a normal pulse rate of 72 beats
per minute (bpm) (an average is 60 - 100 bpm).
15. The woman was assessed by one of the prison doctors. He recorded
that she was dependent on alcohol and opiates, with recurrent drug-
induced fits. (A urine test indicated that she had taken methadone and
cocaine.) She was prescribed a stabilising programme of methadone,
40 millilitres (mls) and Librium. ((These drugs are used to relieve drug
withdrawal symptoms.) The following day, her blood pressure reading
had fallen to within a normal range (137/74). It was further recorded
that she had obsessive compulsive disorder (OCD) which was reflected
in her fixation with cleaning and hygiene.
16. The healthcare centre made a request for the woman’s previous
medical records. However, it was noted that they had been lost within
the prison system.
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17. On 29 March, the self harm prevention measures Assessment, Care in
Custody and Teamwork (ACCT) procedure were put in place by wing
officers. The woman had told the officers that morning of her previous
suicide attempt, which she said was due to issues with her medication
while she was detoxifying. The woman said she was having similar
concerns about her current medication and might attempt to hurt
herself as a result. Additionally, she said her partner had recently been
killed in a car accident and her father had cancer. For her own
wellbeing, the woman was checked hourly during the day and twice
each hour at night.
18. Regular ACCT case reviews to monitor the woman’s progress were
held over the next five months. The reviews noted that she progressed
well. Her detoxification programme was supported through the
substance misuse clinic, she had attended bereavement counselling
and worked as a wing cleaner. The woman’s ACCT document was
closed on 12 August. She told the reviewing staff she had no intention
of hurting herself and felt well.
19. The woman was referred to the Counselling Assessment Referral and
Through Care Service team (CARATs) for support with her misuse.
She was seen in the substance misuse clinic six times during this
period. A member of the CARATs team referred the woman to the
mental health in reach team, as he was concerned about her “low
mood”.
20. The notes of the woman’s first attendance at the substance misuse
clinic on 26 March indicate that she showed signs of withdrawal by
shaking, sweating and aches and pains. She told the nurse that she
had been using illicit drugs since coming to Styal. Three days later,
she tested positive for cocaine, benzodiazepine (a tranquiliser) and
methadone. Over the next few weeks, the dose of the woman’s
methadone was increased twice to 60mls. She was advised against
using illicit drugs whilst taking the increased dose of methadone.
Subsequent drug tests indicated that she was no longer using cocaine
or benzodiazepines. CARATs case conferences were held to discuss
her progression with her drug withdrawal symtoms and well being. It
was agreed that she should be supported by both nursing staff,
including the mental health in reach team and the CARATs team.
21. During one of the woman’s substance misuse clinic appointments it
was recorded that she had a poor appetite and insomnia. She was
prescribed zopiclone to aid sleep and encouraged to eat and drink
plenty of fluids. Support from the mental health in reach team
continued. However, the woman did not always engage with them.
22. Despite some difficult times, mainly addressing her withdrawal
symptoms and feelings of low mood, the woman settled on Waite wing.
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She was noted to be a “willing and able worker” in the servery and as a
wing cleaner.
October 2009 – February 2010
23. The woman was due to have a blood test to check her thyroid levels as
she was experiencing mood swings, sweating and hair loss. She was
concerned by this and told a nurse at a substance misuse review that
she was worried about giving a blood sample. The nurse suggested
relaxation techniques. The woman then attended the healthcare unit
and the blood sample was taken.
24. In early November, another routine blood sample proved negative for
any thyroid abnormality, however her potassium level was high. The
doctor asked for an electrocardiogram (ECG) to be taken and a further
blood sample. (An ECG measures the electrical activity of the heart to
determine its rate and rhythms.) The ECG indicated that the woman
had a slow heart rate.
25. A prison doctor spoke to the woman as she had become abusive to
healthcare staff whilst they tried to take a second blood sample. The
doctor explained the urgency of the second blood sample and the
potential dangers to her health of a high potassium level in her blood.
(High levels of potassium can indicate potential serious heart
problems.)
26. The woman refused the blood test and admission to hospital despite
encouragement from the doctor. The doctor also noted that the woman
had full mental capacity to make this decision, and could not be forced
to accept medical care against her will. She signed a disclaimer
refusing medical treatment. The doctor made arrangements for close
observations to be made on the woman and for staff to encourage her
to re-consider her actions. Several weeks later, she consented to a
blood test. The result indicated that she had no further health issues in
relation to her potassium levels.
27. In January 2010, whilst attending a substance misuse clinic
appointment, the woman told the nurse she still had a poor appetitie
and was not sleeping well. She would only eat food that had been
wrapped as she was worried about food hygiene. Her concerns were
attributed to her OCD.
28. A nurse met the doctor to discuss the woman’s symptoms. She had a
history of eating disorders and OCD since her partner died and
declined any help from the mental health in reach team. She was
prescribed Ensure, a food supplement to help her maintain and
improve her weight.
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29. Following a further assessment, the woman was prescribed citalopram,
an antidepressant, in February. Three weeks later she was noted to be
brighter in mood and managing well on a 60ml dose of methadone.
18 March to the day of the woman’s death
30. A nurse was called to see the woman in her cell on 18 March at
6.45pm. She told the nurse she had woken that morning feeling unwell
and dizzy, and therefore she had rested throughout the day. An ECG
was taken and analysed by telephone using Healthwatch.
(Healthwatch is a telephone medical monitoring service which enables
healthcare professionals to seek advice including the interpretation of
ECGs.) In turn, Healthwatch advised the nurse that the woman should
be taken to hospital as her heart rate was low. Whilst arrangements
were being made to transfer the woman, she became sweaty, clammy
and pale and started to breathe rapidly. She was given oxygen via a
mask and an ambulance was called.
31. The woman was taken to outside hospital. She was escorted by two
officers and was hand cuffed to one of these officers by the use of an
escort chain. She underwent medical tests and returned to Styal later
that evening. A nurse telephoned the hospital the following day, at
6.45am, as a discharge letter had not been sent back with the woman.
The nurse was told by hospital staff that the woman had not had a
heart attack and no further treatment was necessary. The hospital
advised the nurse that the woman could see the prison doctor for any
further treatment.
32. At 3.09pm, a locum doctor examined the woman and noted she had an
episode of ventricular tachycardia (fast heart rate). She told the doctor
that she was scared of hospitals. However, she agreed to be referred
to a cardiologist. As a result of her high blood pressure (137/111) and
an irregular heart rate, the locum doctor told the woman that she
needed to go back to hospital. The doctor contacted the cardiology
unit at outside hospital and arranged for the woman to be admitted.
However, she refused to go, saying she would go the next day. The
woman again signed a disclaimer refusing medical treatment.
33. At about 3.00am on 20 March, a nurse saw the woman in her cell. She
told the nurse that she had pins and needles in her fingers with pain in
her left arm. The nurse was unable to obtain a blood pressure reading.
In view of her symptoms, the nurse decided that the woman needed to
be admitted to hospital. The woman agreed and was transferred to
hospital by taxi as she was unhappy going by ambulance. She was
escorted by two officers and a restraint, in the form of handcuffs, was
applied.
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34. The woman was examined by a nurse in the accident and emergency
department. It was written in the escort record that she was upset
about being in handcuffs. The escort officers contacted the prison and
it was agreed that the handcuffs could be removed and an escort chain
was applied. (An escort chain is 1.8 metres long with a cuff at one end
attached to an officer and a cuff at the other to the prisoner.)
35. At 7.15am, the woman was seen by a cardiologist who told her that she
would be in hospital for at least 24 hours to undergo further tests. She
was unhappy about this and told the doctor she would discharge
herself at lunchtime. However, it was noted that she was “well-
mannered” and “in good spirits”.
36. At 10.00am hospital staff told the woman she would return to Styal at
some stage during the day, that her blood tests were normal and she
may have suffered postural hypotension (a drop blood pressure caused
by a change in body position). The plan was to use a five day heart
monitor at a later date to monitor her condition. Hospital staff also told
the woman she was suffering from bradycardia (a slow heart rate). At
11.30am, the woman returned to Styal after discharging herself from
the hospital.
37. A nurse saw the woman at 12.17pm and noted that her blood pressure
was 175/91 with a low pulse rate of 42bpm. She recorded that the
woman had discharged herself from the hospital. The woman told the
nurse that doctors at the hospital had advised her not to take her
antidepressants and she therefore declined them at medication time.
Two hours later, her blood pressure was taken again and read 171/95
with a pulse rate of 38 bpm.
38. At some stage during the day the woman wrote a note listing her
symptoms and referring to the antidepressant medication she had been
advised not to take. She did not address the note to anyone in
particular. (It was found in the woman’s possessions following her
death.)
39. The woman telephoned her mother before the evening meal. Her
mother said afterwards that her daughter sounded concerned about
her health however, she was able to have a positive conversation with
her. The woman told her mother that she had been in hospital for an
irregular heart beat and had discharged herself. She said the
antidepressants had slowed her heart beat and she had told doctors
that she had been seen by a heart specialist in Blackpool. The woman
asked her mother to contact the hospital in Blackpool so they could
send her notes through to the outside hospital she was currently
attending. Her mother explained that she was doubtful that the hospital
staff would speak to her. The woman then spoke to her mother about
her fear of hospitals. However, although anxious, she would return to
outside hospital the following Monday (22 March).
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40. During the t
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