Individual at Ranby

Investigation into the death of a man at Bassetlaw Hospital
whilst in the custody of HMP Ranby
in February 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2010
The man died at 7.15pm having suffered a heart attack in Bassetlaw Hospital while
in the custody of HMP Ranby. He was 50 years old. I offer my sincere sympathy
and condolences to those touched by the death of the man.
The investigation was carried out on my behalf by my investigator. A clinical review
of the man’s healthcare was undertaken by two clinical reviewers on behalf of
Bassetlaw Primary Care Trust. I am grateful for their review. I would also like to
thank the Governor of Ranby and her staff for their co-operation and assistance.
The man had been in custody for under a year. He had not complained to staff of
any serious medical issues and none were identified during his initial healthscreen
assessments. On 22 February 2010, the man became involved in an altercation in
the welding workshop. Staff intervened and separated the prisoners. However, the
man collapsed shortly afterwards. The post-mortem report confirmed that his
collapse was not directly related to the fight. He was taken to hospital but died later
that day.
There do not appear to have been any signs that the man was in danger of
collapsing and I find no fault in the response of Ranby healthcare staff. This was an
unexpected event that I do not believe could reasonably have been prevented. I
make one recommendation in this report regarding the collection of next of kin
details.
The 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 August 2010
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CONTENTS
Summary
The investigation process
HMP Ranby
Key findings
Issues
Recommendations
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SUMMARY
The man was remanded into HMP Hull on 29 May 2009. The initial healthscreen did
not reveal anything of concern. The man was transferred to HMP Leeds and then to
HMP Ranby in December 2009. No significant medical history was identified at his
first reception health screen. He told staff he was a smoker and did not raise any
concerns about his physical or mental health. He was located on an ordinary wing
and allocated work in the welding workshop. He did not report any significant
concerns about his health in the following eight months.
On 22 February 2010, the man was involved in a brief fight with another prisoner in
the welding workshop. After officers ended the fight, the man became unwell and
was taken to the healthcare centre. Staff telephoned for an ambulance as they were
concerned about his health. He was taken to Bassetlaw Hospital. Hospital staff
undertook a series of tests on him. They declared the man fit to leave the hospital
but, as he was preparing to go, he collapsed suffering from a heart attack. Despite
attempts to resuscitate him, he died at 7.15pm. Prison staff visited the man’s mother
the next morning to inform her of his death. The report contains one
recommendation regarding obtaining accurate next of kin details.
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THE INVESTIGATION PROCESS
1. One of the office’s investigators opened the investigation on 26 February on
behalf of the investigator appointed to consider the circumstances of the
man’s death. She met senior prison managers and took copies of the
documentation relating to the man. Notices of the investigation were issued
to staff and prisoners, inviting those who wished to provide information
regarding the man’s death to make themselves known to the investigator.
No-one came forward in response to the notices.
2. The investigator wrote to the Chief Executive of Bassetlaw Primary Care
Trust (PCT) to commission a clinical review. Bassetlaw PCT asked two
clinical reviewers to carry out a review of the care received by the man whilst
at HMP Ranby. The two clinical reviewers received a copy of the relevant
medical documents upon which they based their findings. The clinical review
can be found at the first annex to this investigation report. I am grateful for
their timely review.
3. One of my family liaison officers contacted the man’s family at the beginning
of the investigation. She explained the investigation and offered them the
opportunity to raise any questions or concerns they would like addressed
during the investigation. My investigator and another family liaison officer,
visited the man’s family on 24 June. They discussed the investigation
process and answered the initial questions that the man’s family had
concerning his death.
4. The Ombudsman’s investigation was initially suspended because
Nottinghamshire Police were investigating the death. Having concluded their
enquiries, the police confirmed that there was no criminal matter to pursue
with regard to the man’s death. The Ombudsman’s office was able to
continue the investigation. My investigator met Nottinghamshire police
officers to discuss the case and was provided with the evidence collected as
part of their investigation.
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HMP RANBY
5. HMP Ranby is a category C male adult training prison in North
Nottinghamshire. It contains prisoners who cannot be trusted in open
conditions but who are unlikely to try to escape. There are 11 residential
wings, of which four are on the ‘open’ side of the prison. It has an operational
capacity of 1,098. The prison does not have a hospital wing and does not
provide 24 hour healthcare.
Independent Monitoring Board
6. Each prison has its own Independent Monitoring Board (IMB) made up of
volunteers from the community. The Board’s role is to ensure that the prison
is properly run and that prisoners are treated fairly. Each Board produces an
annual report for the Secretary of State. The most recent report from the
Ranby IMB covers the period from 1 April 2008 – 31 March 2009. The board
commented positively on the progress in the education and skills facilities at
the prison, and noted how many prisoners are able to gain qualifications to
help their prospects once released.
Her Majesty’s Chief Inspector of Prisons
7. Her Majesty’s Chief Inspector of Prisons undertook an announced inspection
of Ranby from 12 – 16 March 2007. Her report said that healthcare facilities
offered a reasonable service. It also described the educational and
vocational training facilities as “good quality”.
Other deaths at Ranby
8. In the last five years, Ranby has only experienced one other death due to
natural causes. The death, which occurred in October 2009, was also due to
a cardiac arrest.
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KEY FINDINGS
9. The man was born in September 1959 in North Yorkshire. He had
convictions for violent behaviour and had previously been released from
custody in 2001.
10. He was remanded into HMP Hull on 20 May 2009, following a court
appearance at York Crown Court, for failing to surrender to bail for an alleged
offence of grievous bodily harm in 2004. A first reception health screen
document was completed by a nurse. He told the nurse that he was not
worried about his physical health other than an abscess on his tonsils which
had been removed six years previously. It had left a permanent tickle in his
throat and some sinus discharge. He was concerned that the abscess may
have returned. It was also noted that he smoked, had used cocaine
approximately a year before and was a social user of alcohol. The man’s
blood pressure was recorded at 110/70, (an average reading is 130/80 but
110/70 is considered an ideal reading), and his pulse rate measured 76 beats
per minutes, (an average is between 60 -100). He was not taking any
prescribed medication.
11. As part of the reception process, an officer conducted a cell sharing risk
assessment. This seeks to establish the level of risk a prisoner presents to a
cellmate. It contains a number of questions that are put to the prisoner. No
issues were noted and the man was assessed as being of low risk of
attacking a cellmate.
12. The following day the man was examined by the doctor. The doctor wrote
that the man had fallen from a ladder 18 months previously causing on-going
pain and restricted movement to his right knee and arm. The man also told
the doctor about his throat problems and his concerns that a second abscess
might be forming. On examination, his blood pressure reading was 118/84.
The doctor referred the man for remedial exercise in the prison gym to help
his knee and arm pain.
13. On 11 June, the man was seen on the wing with swelling to the right side of
his face and pain in his mouth. A nurse prescribed pain relief and he was
seen by the dentist that afternoon. He was diagnosed as having a tooth
infection and was prescribed antibiotics. The man was given Ibuprofen for
pain relief to ease shoulder pain when he seen by a second doctor on 27
July.
14. The man was transferred to HMP Leeds in October and subsequently
sentenced to four years in prison by Leeds Crown Court. He moved to HMP
Ranby on 30 December. Upon his arrival at Ranby, The man was again
assessed as low risk on the cell sharing risk assessment. At his first
reception health screen no significant medical history was identified. The
man told staff that he was a smoker and he did not raise any concerns about
his physical or mental health. He was located on an ordinary wing and
allocated work in the welding workshop.
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15. The man had no further significant contact with healthcare whilst he was at
Ranby. He attended a training course in welding, sheet metal work and
general engineering. This course led to a NVQ qualification. The morning
shift was from 8am to 11.30am and the afternoon shift lasted from 2.00pm to
4.30pm.
16. The man did not go to work on the morning of 22 February 2010 as he said
that he felt unwell. He attended work in the afternoon although he later said
that he had still felt unwell. The man did not bring this to the attention of staff.
Shortly after the start of the session, at approximately 2.15pm, he became
involved in a dispute with another prisoner in workshop 13. The other
prisoner claimed that he asked the man if he could use the station that the
man was working at as it had a light that he needed. The man refused and
the two began to push each other. They fell to the floor before they were
separated by staff. The other prisoner complained that the man had head-
butted him.
17. The healthcare department received a call from Workshop 13 advising that
the man had knee pain and could not walk. A wheelchair was sent to collect
the man with a healthcare support worker. During the move from the
workshop to healthcare, his condition deteriorated. Upon arrival at
healthcare, he was found to be in a collapsed state, and cold and clammy. A
second nurse examined him and noted that his blood pressure was low at
90/60, with an exceedingly weak pulse. He had a Glasgow Coma Score
(GCS) of five. (The GCS is a reliable, objective way of recording the
conscious state of a person. A score of five would indicate that the patient
was responsive to pain when touched.) The nurse administered oxygen
therapy and carried out an electrocardiograph (ECG) which indicated the
man’s had an abnormal heart rate. (An ECG measures the heart rate and
rhythm.) The man then became more responsive and complained of
tightness in his chest, pain and tingling in his arms with further pain going to
his neck. At this point it was decided to transfer him to hospital so an
ambulance was requested. A paramedic arrived within 10 minutes and
placed an intravenous cannula (tube) in the man arm to provide him with
fluids.
18. The man was taken to Bassetlaw Hospital at approximately 3.30pm. This
was later than intended as the first ambulance broke down. The ambulance
notes recorded that his blood pressure remained low. Two officers escorted
the man using a single-cuff chain. (This is a restraint made from 1.8 metres
of chain with one cuff attached to the prisoner and the other cuff to an officer.)
the man was examined by doctors when he arrived at the hospital at
approximately 4.05pm. He had a blood test, followed by an X-ray at
approximately 4.15pm. At 4.30pm, officers accompanied the man to the x-
ray department and then returned to the accident and emergency
department. At 4.50pm the two officers were relieved of their duties and two
other officers took over responsibility for the escort.
19. The result of the blood test was normal and the hospital subsequently
permitted the man to return to the prison. At approximately 6.50pm as he
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began to fasten his shoes, the man collapsed onto the hospital floor. Hospital
staff immediately responded and the third officer removed the restraint.
Despite the efforts by hospital staff, the man died at 7.15pm.
20. A senior prison officer was appointed as family liaison officer that evening.
The man had not nominated a next of kin, and the prison confirmed that he
had not received any visits from a family member since arriving at Ranby.
His telephone account indicated that he had spoken to his mother the
previous day. The police liaison officer was able to find an address for the
man’s mother.
21. The prison family liaison officer noted that if staff left the prison immediately
to break the news of the man’s death to his family, it might be as late as
midnight before they arrived at their destination. (This was due to the
distance and location of the man’s mother’s home.) Therefore, it was
decided to travel early the next morning. The prison family liaison officer and
the prison governor broke the news to the man’s mum and, due to her
distress, telephoned her daughter to come and be with her. The family
liaison officer explained what would happen next, and offered to contribute to
the costs of the funeral.
22. A notice was issued to prisoners informing them of the death of the man. I
understand that the care team was available to any staff who required their
support, and the Governor and Duty Governor met with the escort officers on
their return from the hospital.
23. The man’s property was returned to his family on 5 March. Prison staff
attended the funeral, provided a wreath and conducted a memorial service for
the man inside the prison. The man’s family told the investigator that they
were very grateful for all the support they received from the prison following
his death.
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ISSUES
Clinical care
24. The man had very little contact with healthcare services while in prison. No
significant medical history or concerns were raised during his initial
healthscreen interviews in the prisons he entered. Although the man’s
collapse followed an altercation in the workshop, the post-mortem report said
that he died as a consequence of a thrombotic occlusion of his left coronary
artery. This resulted in him having a heart attack. The pathologist said that
the collapse of the man appeared to be a coincidental event rather than an
event directly linked to the fight in the workshop. The pathologist was of the
opinion that a thrombus cannot form and be associated with an argument or
fight, so the two events were not directly linked.
25. The clinical review described the clinical care received by the man as
equitable to what he would have received had he been in the community.
The care received by the man prior to his collapse was described as
satisfactory. The clinical review went on to say the care provided on the day
of the man’s death was equitable to what he would have received in the
community. The assessment and actions were described as comprehensive
and commendable.
26. I understand that the clinical reviewer asks some further questions regarding
the treatment the man received at Bassetlaw Hospital. However, his time at
hospital is outside the Ombudsman’s Terms of Reference. However, I
understand that a serious untoward incident investigation is to be undertaken
by the PCT to consider this aspect further.
Next of kin details
27. Next of kin details are recorded when a prisoner arrives at a prison, and I
consider it important that staff attempt to gather full information. The lack of
an address for the man’s family was one of the factors in the decision to
break the news the following morning.
The Governor should remind reception staff to record the full address
and telephone number of the next of kin for all new receptions into
prison. If it is not possible to attain accurate details on reception,
efforts should be made to obtain them as soon as possible.
Liaison with the man’s family
28. PSO 2710 (Follow-up to a death in custody) says that the news should be
broken as soon as possible. The prison took the decision to travel up early
the following morning to avoid reaching the man’s mother’s house late at
night. Although it is nearly always best to break the news as quickly as
possible, I understand why the prison took the decision they did. The man’s
family were very grateful that the prison did so as they confirmed that their
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mother would have been distressed had prison staff arrived at her home late
at night.
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RECOMMENDATIONS
1. The Governor should remind reception staff to record the full address and
telephone number of the next of kin for all new receptions into prison. If it is
not possible to attain accurate details on reception, efforts should be made to
obtain them as soon as possible.
The National Offender Management Service accepted this recommendation:
“Reception managers and staff instructed to ensure that all F2050 page 2
details are routinely and comprehensively completed.
Head of Residence to conduct ad hoc spot checks to ensure compliance.
LSS amended to include this recommendation.”
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