Individual at Lewes

Investigation into the death of a man
at HMP Lewes in December 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2011
This is a report into the circumstances surrounding the death of the man, a prisoner
at HMP Lewes.
The man was found unconscious when his cell was opened so that he could collect
his evening meal. The officer who discovered the man called for healthcare
assistance, and staff and paramedics attempted to resuscitate him. Soon after,
however, the paramedics declared that the man had died.
I offer my sincere sympathy and condolences to the man’s family and friends for their
loss. I am sorry that my report has been delayed and for any additional distress this
may have caused.
The investigation was carried out by my colleague. A clinical review of the man’s
healthcare at Lewes was undertaken by a clinical reviewer on behalf of the East
Sussex Downs and Weald Primary Care Trust. I am grateful for his timely review. I
would also like to thank the Governor of Lewes and his staff for their co-operation
and assistance. Particular thanks go to the two Governor’s secretaries, and the
prison’s liaison officer, for their help throughout the investigation.
The man had served 12 years of a life sentence and had been at HMP Lewes for 18
months. He had been transferred there from an open prison following a change to
his security category. I understand he was frustrated by his re-categorisation.
However, while the man reported various minor ailments, there were no serious
concerns about his well-being until the day of his death.
Although the man’s death was due to natural causes (heart attack), I have
questioned the medical treatment he received in the hours leading up to his death.
Two of the nurses who attended to the man were also subsequently suspended by
the Head of Healthcare whilst a healthcare review was conducted. One has since
resigned from her position at Lewes.
I make eight recommendations regarding the response to a prisoner with chest
pains, life threatening emergencies and contacting the next of kin.
Jane Webb
Acting Prisons and Probation Ombudsman March 2011
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CONTENTS
Summary
The investigation process
The man
HMP Lewes
Key findings
Issues
Recommendations
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SUMMARY
The man was given a life sentence for murder. He had been in several prisons,
including those in the open estate, before transferring to HMP Lewes on 29 May
2008. He had a chronically painful left shoulder which was later diagnosed (in July
2007) as early degenerative arthritis. For this reason, the man took paracetamol and
ibuprofen daily. Aside from this long term shoulder injury, he did not have many
health problems.
Very quickly after arriving at Lewes, the man settled into the prison regime. Staff
had few concerns about him and he generally made the most of his time,
predominantly by attending computer based workshops. Up until 22 December
2009, the man had not reported having any chest pains to staff or any of his peers.
On 23 December at about 2.00pm, having left his cell on the fourth landing to go his
workshop, the man arrived on the second landing and complained of having chest
pains and tingling in his left arm. The officer on duty believed he did not look well
and immediately contacted healthcare. Soon after, two nurses attended the wing to
see the man.
Having explained his symptoms, the man’s blood pressure was checked several
times and found to be above normal. One of the nurses subsequently administered
a GTN spray (to treat angina). After approximately 15 minutes, his blood pressure
lowered to what was considered an acceptable level. This was around 2.50pm. The
nurse wrote in the man’s medical record that he should be reviewed by the prison
doctor as soon as possible. Soon afterwards the man returned to his cell to rest.
Around 3.00pm the man alerted staff by ringing his cell bell. He again complained of
chest pains and the officer summoned healthcare. Another different nurse attended
promptly.
The man was examined and told the nurse about the pain he was experiencing. His
blood pressure and pulse were initially high. The nurse talked to the man for a while
and he mentioned his old shoulder injury. The man did not display any of the
symptoms she expected from someone having a heart attack and believed his pain
stemmed from his usual shoulder pain. The nurse wrote in the man’s medical record
“I have reassured him that he is not having a heart attack”. Around ten minutes later,
the man’s blood pressure, pulse rate and the pain had all lessened. The man was
told he would see the prison doctor in the morning, but that he should let staff know
immediately if he experienced any further problems.
About two hours later, shortly after 5.30pm, staff began to unlock the wing to allow
prisoners to collect their dinner. When the man’s cell was opened, he did not
respond to the officer who called him. The officer went into the cell and found the
man lying on his top bunk facing the wall. He did not respond and a senior officer
was called immediately. They checked the man for any signs of life, but could not
find any.
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An “Urgent Message” call (which indicates a life threatening emergency) was radioed
through. Healthcare and other staff arrived quickly. The man was examined by the
nurses and no signs of life were found. The nurses immediately began cardio
pulmonary resuscitation (CPR), until the paramedics arrived and took over. The
paramedics continued CPR but the man was pronounced dead at 6.40pm.
I make eight recommendations in my report. They concern responding to a prisoner
with chest pains, life threatening emergencies and contacting the next of kin.
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THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened by one of my colleagues, on
13 January 2010 when he met the Governor of Lewes and some of his staff.
Notices of the investigation and terms of reference had already been sent
inviting anyone with any information to contact the investigator. One prisoner
responded to the notices and was interviewed by my colleague.
2. My colleague also met the Head of Healthcare, representatives of the Prison
Officers’ Association and a representative of the Independent Monitoring Board.
He visited all parts of the prison including the wing where the man lived, and
met the prison’s liaison officer.
3. The man’s prison records, including his medical record, were made available to
my colleague during his initial visit to the prison. Additional documents were
provided when he returned to conduct interviews at the prison.
4. Two of the nurses involved in the care of the man on the day of his death were
subsequently suspended from duty, to allow an internal healthcare investigation
to take place. Despite trying to contact both nurses, only one nurse responded
who was subsequently interviewed. After the interviews were completed, my
colleague fed back his initial findings to the Governor. During the course of this
investigation, the internal healthcare investigation was still ongoing.
5. A clinical review of the man’s medical care was commissioned from NHS
Hastings and Rother & NHS East Sussex Downs and Weald PCT. I am
grateful to the clinical reviewer for his review. As part of his review, the clinical
reviewer also chaired a Clinical Review Panel meeting at the Primary Care
Trust (PCT) Headquarters. He had sight of some of the interview transcripts
and the man’s medical records. I would like to extend my thanks also to the
Consultant Nurse Cardiologist employed by Brighton and Sussex Hospital trust,
who attended the Clinical Review Panel to provide an independent opinion into
some aspects of the care provide to the man.
6. One of the Ombudsman’s family liaison officers contacted the man’s family to
inform them of the investigation. Later the Ombudsman’s family liaison officer
met the man’s sister at her home to give her the opportunity to raise any
questions or concerns about the care her brother received. The man’s sister
wished to share the following information in respect of her brother.
(cid:127) The man’s said that her brother had never complained of heart
problems. She was aware that he suffered from shoulder pain which
she believed was arthritis. She said that the man would have asked
for help straight away if he knew something was wrong with him.
The man’s sister would also like to know if and when the man had
ever seen a doctor and if he had been diagnosed with angina.
(cid:127) The man’s sister was concerned at the accuracy of information given
to her about the circumstances of her brother’s death. She was
initially led to believe by the prison’s family liaison officer that the
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man had died suddenly. Shortly after this, following a visit from the
Governor and the family liaison officer, it emerged that the man had
actually been unwell on the day of his death and had been attended
to by healthcare staff.
(cid:127) The man’s sister was also concerned that her brother had been given
GTN spray (normally used to treat angina) when he had felt unwell
and she queried if the nurse believed that her brother had angina.
Furthermore, it was written in the man’s medical record that he was
assured that he was not having a heart attack. The man’s sister
wanted to know if her brother had asked the nurse if he was having a
heart attack and why this comment was made.
(cid:127) The man’s sister wanted to know how many nurses saw her brother
on the day of his death, and whether they were permanent or
temporary nursing staff. She also wanted to know why an
ambulance was not called earlier and if the man’s cell door was
locked.
(cid:127) The man’s sister asked if the clinical reviewer would comment on
whether, if the man had received earlier treatment, or if an
ambulance had been called by the nurses when they first visited him,
the man might have survived his heart attack.
7. Following the issue of the draft report of this investigation, feedback was
received from the man’s next of kin, the Prison Service and East Sussex
Downs and Weald Primary Care Trust. This has been acknowledged and
where appropriate the final report has been amended to reflect the feedback
received.
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The man
8. The man was born in London. He was the youngest of four siblings and worked
as a plasterer. He gained qualifications in plastering and an NVQ in bricklaying
until an injury in 1997 made him unfit to work.
9. He was married for around 17 years before the marriage broke down. The man
had no children.
10. During the man’s imprisonment, he attended Creative Writing classes and
subsequently went on to achieve Open College Network Certificates. He was
popular with his fellow students and was someone who eagerly supported and
encouraged others in the group. His classroom teachers described him as
always very focussed on his writing and said that he produced insightful and
imaginative work. He was awarded two prizes in the short story category in the
2009 Koestler Awards.
.
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HMP LEWES
11. HMP Lewes is a category B local prison serving the courts of East and West
Sussex. It accepts both adult men and young adults, and has an operational
capacity of 723.
12. In her most recent inspection report, following an announced inspection in
August 2007, the HM Chief Inspector of Prisons described Lewes as
“reasonably safe”, but with weaknesses in anti-bullying and suicide prevention
measures. Drug and alcohol work was described as effective and as having
good links with the local community. The HM Chief Inspector of Prisons report
particularly commended the extremely good relationships between staff and
prisoners. Healthcare provision was described as undergoing a “significant
modernisation programme”, with new staff being recruited to provide a broader
mix of skills and experience. Primary care was “developing well”.
13. Each prison has an Independent Monitoring Board (IMB) made up of members
of the community. The Board’s role is to ensure that the prison is properly run
and that prisoners are treated decently. The Board produces an annual report
for the Secretary of State. The most recent report from the Lewes IMB
commented on how population pressures across the prison estate had resulted
in the retention of life sentenced prisoners due to the lack of capacity at lifer
centres. The Board said that lifers were waiting a long time at Lewes before
moving to an appropriate lifer unit. The Board praised the healthcare unit and
detoxification regime.
Clinical provision
14. Since April 2009, healthcare at HMP Lewes has been provided by East Sussex
Community Health Services (ESCHS), an arms length organisation from East
Sussex Downs and Weald PCT. The current Head of Healthcare of Lewes is
seconded to ESCHS, where he is responsible for 38 nursing staff who provide
24 hour care to prisoners. Medical input is provided by a consortium of five
doctors (GPs) who provide one to two doctors each morning. These doctors
provide primary care clinics, visit the inpatient unit (which has 19 beds) twice
daily and give 24 hour on-call cover.
15. General mandatory nurse training is provided by the PCT as part of its historical
relationship with ESCHS and specific prison related training is provided in-
house. All the nurses receive annual refresher training on emergency
response, cardiac emergency response and use of a heart-start (defibrillator)
machine.
16. The first nurse (who is mentioned later in this report) completed Extended Life
Support training on 21 October 2009, and the second nurse (also mentioned
later in this report) attended and completed the same course on 10 June 2009.
All staff have annual appraisals.
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17. The clinical reviewer comments that staffing levels are generally good with a
minimum of four nurses/health care assistants in both outpatients and
inpatients from 7.00am to 3.00pm. (In addition there are two specialist nurses
from the IDTS (drug treatment) Team and three for the Mental Health In-reach
Team from Monday to Friday.) From 3.00pm each day six nurses/healthcare
assistants are in duty. On the day of the man’s death, the Head of Healthcare
confirmed to the investigator that there were six on duty with a good skill mix
and grades from three to seven. Of the three nurses that attended to the man
on the day and prior to his death, two were permanent members of staff and the
other was an agency employee who had worked at the prison for about a year.
Category of prisoners
18. On arrival into prison, prisoners are risk assessed and given a category based
on their offence and the risk that they pose to the public should they escape.
There are four levels of category which are A, B, C and D, with Category A
prisoners presenting the highest risk.
Multi-Agency Lifer Risk Assessment Panels (MALRAPs)
19. The Prison and Probation Services have an agreement with the Association of
Chief Police Officers for the provision of information regarding prisoners serving
life sentences for offences of homicide in England and Wales. The MALRAP
meeting is a crucial part of the risk assessment process and enables officers
involved in the investigation to review and exchange information about the lifer
and to highlight areas of concern at an early stage of sentence. The MALRAP
members must include the following staff:
lifer manager
wing lifer officer/personal officer
home probation officer
police investigating officer(s)
Incentives and Earned Privileges (IEP)
20. The IEP scheme was introduced in 1996 to encourage and reward good
behaviour by prisoners. There are three levels: Basic, Standard and Enhanced.
Incentives include access to in-cell television, more private cash to spend,
being able to wear their own clothes, more time out of cell and access to extra
and enhanced visits. Each prison sets its own criteria to reach each level.
Previous deaths in Lewes
21. Since April 2004, the Ombudsman became responsible for investigating deaths
in prison custody, I have investigated ten deaths at Lewes before the man. Six
were a result of natural causes and the remaining were four self inflicted. I refer
to a previous recommendation made in one of these investigations in this
report.
10
.
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KEY FINDINGS
Prior to the man’s arrival at HMP Lewes
22. The man was arrested and convicted for the offence of murder committed on 28
January 1998. He was later sentenced to life imprisonment with a tariff of 11
years.
23. He began his prison sentence at HMP Wandsworth. He later went on to be
held in nine different prisons before transferring to HMP Lewes in May 2008.
During this time, he fully co-operated with his sentence plan, completing
programmes designed to address his offending behaviour (such as Anger
Management, Enhanced Thinking Skills and Emotive Behaviour Therapy) and
meeting the targets set for him by staff. He made positive steps to address his
offender behaviour and received good reports from prison staff. The man also
used his time constructively by attending a number of workshops and achieving
enhanced Incentive and Earned Privileges status.
24. In May 2006, the man was awarded category D status. This followed a Parole
Board review where he was given credit for the offending behaviour work he
had completed. It was acknowledged that he presented a reduced level of risk
to the public. The man subsequently transferred to HMP Blantyre House in
February 2007 and was granted regular periods of release on temporary
licence (ROTL). These included overnight resettlement releases (where he
was allowed to remain away from the prison overnight), all of which were
completed without incident.
25. The man’s past medical history included a chronically painful left shoulder
which he had for many years. He saw an orthopaedic surgeon on 4 July 2007,
who diagnosed early degenerative arthritis of his left acromioclavicular joint.
The man took paracetamol 500mg two tablets four times daily and ibuprofen
400mg one tablet three times daily.
26. Following an incident on 15 March 2008 whilst the man was on a period of
ROTL, the police investigated an allegation of threatening behaviour and affray.
His ROTL was suspended whilst the police made their enquiries. He was
subsequently charged.
27. On 17 April, having attended Lewes Crown Court, the man was acquitted of the
charges against him. However, the Parole Board still had concerns about his
conduct. He was returned to closed prison conditions and transferred to
Lewes.
The man’s arrival at HMP Lewes
28. The man returned to Lewes on 29 May 2008 where he went through the normal
reception screening process. A cell sharing risk assessment (CSRA) and a
health assessment were completed. As a prisoner serving life, he was
allocated a single cell.
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29. The health assessment screening included completion of a questionnaire by the
nurse which captured information such as his past history, family history, social
history and immunisations. His blood pressure was135/82, he weighed 99kg,
measured 6foot 2inches and his girth was 36inches. There is no record of a
urine screening despite there being a space for it to be recorded. The nurse
also completed a medical statement as “fit” and signed in the space ‘signature
of medical officer’. In the section on current symptoms, the nurse circled ‘chest
pain’ and added coughing. Despite the form stating that any ‘yes’ responses
should result in a referral to the doctor/relevant clinic, there is no evidence to
suggest this was done.
30. The assessment identified no concerns that the man might be at risk of harming
himself. He had started a series of dental treatments whilst at Blantyre House
which were scheduled to continue in Lewes. It was noted that the man felt
frustrated that he had been returned to closed prison conditions, which was
also away from his family and friends. Most of the man’s health screening was
hand written and although sometimes unclear, raised no concerns about his
general wellbeing other than those mentioned already. (The investigator
established that the healthcare department now keeps its records electronically
and record keeping is now clearer and referrals easier to monitor.)
31. No further risks were identified during the man’s First Night Centre interview.
He told the induction staff that he was an experienced prisoner and wished to
opt out of receiving the full prison induction. He again expressed that he was
upset at being returned to closed prison conditions.
32. The man was located on C wing. He settled into prison regime well with staff
reporting no issues. Comments in his wing history sheet included “the man is a
polite chap who is keen to get on with his time using the regime well” to “ the
man has had a good two weeks, follows wing routine, mixes with select few on
wing, and attends education and PICTA (computer education classes)
regularly”.
33. The man’s personal officer (a prisoner’s first port of call if they have any
questions, complaints or need any advice) on C wing up until late October
2009. At interview with the investigator, she described the man as not a
talkative man, but “very opinionated”. He mixed with a select few prisoners and
regularly attended his PICTA workshops. He never complained of any health
problems to her.
34. The first officer concurred with the man’s personal officer’s perception of the
man. She worked on C wing and had frequent contact with him. At interview
with the investigator, the first officer said the man was a “very quiet man, didn’t
really mix with many people and stayed in his cell quite a lot of the time and
liked art work”. He had been unhappy at being returned to closed prison
conditions which was followed by disappointment at being refused parole in
November 2009. At The man’s request, the first officer had attended the parole
review board with him. She noted how upset he was about the decision. The
man had mentioned on quite a few occasions to the first officer that he did not
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get along with his probation officer, whom he believed was not assisting him
effectively.
35. The first Senior Officer (SO) was interviewed by the investigator. The SO said
that his role at Lewes was that of the Lifer/IPS manager. This involved
managing prisoners who were given either life or indeterminate prison
sentences (IPS). As part of his role he would set up and conduct the Multi
Agency Lifer Risk Assessment Panels (MALRAP). His responsibility also
extended to lifer prisoners who had been recalled to prison after breaching their
licence conditions, when he would liaise with the Parole Board as necessary.
36. As a licence recall prisoner, the man spoke with the first SO each week. When
The man’s parole was refused, the Parole Board identified a number of
rehabilitation programmes that he should undertake to address his offending
behaviour. Once these were completed, he could apply to return to open prison
conditions. In particular, the panel identified a programme called the Healthy
Relationships Programme as they judged that the man displayed a lack of skill
in handling of relationships and emotional issues. When the SO met the man,
they discussed this and his sentencing planning. He described the man as
generally a quiet prisoner who did not mix with a lot of the other prisoners. He
said he could be a difficult prisoner who questioned everything the Prison
Service tried to do for him. The SO said he had not known the man to have
had any previous health problems.
37. The man made approximately ten telephone calls to friends and family between
16 December and 21 December. (These were not listened to by the Prison
Service until after the man’s death). He was in good spirits during each and
only mentioned a concern he had regarding his health on 16 December. During
this call to a female friend, the man said he was “getting this pain in the
shoulder and it’s you know where I injured my shoulder”. This was followed by
him saying “It’s where the arthritis, what it is it stretches and goes across my
chest and it’s like the muscles”. The man said he had taken ibuprofen pain
killers. He made no further reference to his pain in this or any of the
subsequent telephone calls.
Events on the day of the man’s death
38. The third nurse who was on duty on the morning of the man’s death. He told
the investigator that the man attended the healthcare hatch around 8.00am to
collect paracetamol and ibuprofen for his back and shoulder pain. The nurse’s
contact with him was short and once he confirmed his identity, the man was
given his medication. The nurse said the man made no reference to
experiencing chest pains to him. The nurse had no further contact with The
man.
39. The man should have attended his PICTA workshop in the morning, but the
workshop was cancelled and so he stayed in his cell on C wing. There were no
entries in his wing history sheet denoting any concerns raised about him that
morning.
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40. At interview with the investigator, a fellow prisoner said he had been in Lewes
since March 2009. He first met the man at the PICTA workshop and they
became good friends. Although they were on different landings, the man would
regularly visit the man and they would have cups of tea together. The prisoner
described the man as a “very quiet person” who was sometimes abrupt and did
not talk to or trust many others. The prisoner was not aware of the man having
any previous or ongoing health problems. He said he did not see the man on
the morning of the man’s death.
41. That afternoon, prisoners were unlocked for free-flow about 2.00pm. This is
when prisoners go to and from their working activities, attend visits and
appointments. A second officer who was working on the second landing
(ground floor) working at the gate controlling the flow of prisoners through and
off the wing. Two members of staff normally staff each landing. A third officer,
who started his shift at lunch time, also assisted with free-flow with a fourth
officer.
42. The man left his cell on the fourth landing and began to make his way to his
PICTA workshop. He arrived on the second landing carrying some library
books in his hand. He approached the first prisoner who was outside his cell,
and greeted him. The first prisoner told the investigator that the man did not
appear to be his normal self. He looked unwell, was very pale, complaining of
chest pains and pins and needles sensation in his arms.
43. The first prisoner said he told the man that he looked unwell and was “greyish”
in colour. He sat him down on a box near to his cell that was used to store
library books. He went to fetch a cup of water for the man. He asked the man
if he was alright, and the man responded ”oh my chest, my chest”. His eyes
were rolling back and he looked uncomfortable.
44. The first prisoner immediately called the second officer and informed him of The
man’s condition. Having noticed the man sitting down on the wing, the second
officer approached him and asked if he was going to his workshop. The man
said he was not as he had chest pains and pins and needles in his arms. The
second officer told the investigator that he immediately telephoned the
healthcare unit so that they could send someone to attend to him.
45. Registered mental health nurse (RMN) who was on duty on that day. She had
been working at Lewes as an agency nurse for approximately one year. At
interview with the investigator, the RMN said that she was in the outpatients
department when she received a telephone call from an officer on C wing. The
officer reported that a prisoner on the wing, the man, had complained of having
chest pains. The first nurse who was in charge was a registered general nurse
(RGN) who was in the healthcare office. The RMN informed her of the
telephone call from the officer. The first nurse retrieved the man’s medical
notes and had a quick look through them. The two nurses then made their way
to C wing.
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46. The second nurse did not respond to my request to be interviewed. In her
statement to the police following the man’s death, the nurse said that she took
the lead in asking the man about his health. The RMN stood beside her. The
man said that he had a pain in his left shoulder and some discomfort in his
chest. Whilst the nurses were attending to the man, the second officer
continued to supervise other prisoners. The first prisoner said that the nurses
had not arrived straight away when called, but thought they arrived at around
2.25pm. By this time, free-flow finished and he was taken back to his cell.
47. The first nurse checked the man’s blood pressure. (It is recorded in the man’s
medical records that his blood pressure was taken at 2.35pm.) She described
the reading as “normal and gave no cause for concern”. The RMN told the
investigator that the nurses considered the man’s blood pressure to be raised.
The RMN said that the first nurse repeated the measurement a few times and
the man’s blood pressure still remained “raised”. The RMN suggested they try
another sphygmomanometer (a blood pressure device used to measure blood
pressure) so that the accuracy of the first readings could be checked. She
therefore proceeded to retrieve another device from the C wing treatment room.
The man told the first nurse that he had had a similar pain in his shoulder six
weeks ago but had not reported it, and the pain then went away. He also said
he had taken some paracetamol (pain killers) around 12.00pm that day.
48. Having obtained the second sphygmomanometer, the first nurse rechecked The
man’s blood pressure. The RMN said that the man’s blood pressure was
slightly lower than the previous readings, but was still considered high. The first
nurse continued to check the man’s blood pressure. She told the RMN that she
would give The man a dose of glyceryl trinitrate (GTN spray, used to treat
angina), and left to get this from the healthcare outpatients department. The
RMN said she was not aware whether the nurse asked the man if he had ever
used a GTN spray before or if he had a history of angina.
49. The RMN remained with the man. He told her that he had chest pains radiating
to his left arm which he associated with an injury he received some years
earlier. She asked if he had any problems or worries and he replied “Of course,
Miss, this time of the year (meaning Christmas) you know you tend to be
worried and stressed out”.
50. On the first nurse’s return, she administered two puffs of GTN spray to the man.
(A GTN spray provides rapid relief to the blood vessels in the heart and can
relieve angina/cardiac pain.) This was confirmed at interview with the Head of
Healthcare. However, the Head of Healthcare told the investigator that it was
not policy in Lewes for any nurse to use a GTN spray or GTN tablets without
them being prescribed by a doctor in advance.
51. The second officer returned and checked on the man while the nurses were still
present. Asked whether he was okay and comfortable, the man said he was
fine. The officer offered to get him a cup of tea and left the nurses checking
The man’s blood pressure whilst he went to make it. Although the first prisoner
was locked in his cell, he could see the nurses attending to the man through the
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flap in his door. He shouted towards the man and asked him if he was okay, to
which he received the response “I’ll be alright”.
52. After a few minutes, the man told the nurses he felt slightly better. He remained
seated on the box on the landing for a short while before the first nurse
suggested that she and the RMN take him back to his cell to lie down.
However, the man said he was comfortable where he was and wanted to
remain there. The nurse agreed and told the man that he would be seen the
following day by the prison doctor. She said that if his pain began to worsen,
he should communicate with healthcare through the landing staff. The man
was content with this. This information was passed onto the second officer as
the two nurses left the wing. The nurses also said they would send someone
back in the afternoon to check on the man. (This was recorded in the man’s
medical record at around 2.50pm.)
53. The second officer went and spoke to the man. He asked him if he wanted to
stay out on the landing, something the officer was happy for him to do, so he
could be monitored more easily. The man said that he wanted to return to his
cell. The officer said that was fine but he should ring his cell bell if he wanted
staff assistance. It would appear that the man then made his way back to his
cell on the fourth landing shortly after 2.50pm.
54. The SO told the investigator that he walked around during the afternoon
showing a new probation officer the layout of the prison. He had not gone
specifically to C wing to see the man but, having glimpsed him on the fourth
landing (he believed it was around 3.20pm although there is some doubt which
I consider later) he decided to introduce the new probation officer to him. The
man had just come onto the landing. The SO and the new probation officer
approached the man and the SO introduced them. The man did not
acknowledge her. By this point, they were standing opposite the man’s cell,
which was locked. The SO asked the man if he had been out somewhere, to
which he responded “healthcare”.
55. The SO described the man’s normal attitude as always “very sharp and curt”.
He was a tall man (over six foot) and would “stand in somewhat of a stooped
position” with one hand underneath the opposite arm. On this occasion, the
SO said the man did not look well and so he asked him if he was alright. The
man responded with words to the effect of “my blood pressures up again,
thanks to you bastards”. The SO asked the man again if he was okay to which
he replied “yes, yeah I’m alright, I’m alright”. The man went on to question the
SO about the programme that he was to undertake soon, something he was not
happy about.
56. Their conversation lasted for a few minutes and ended with the man asking the
SO if he could unlock his cell so he could go in. The man went in and turned
back to face the SO who was stood at the door. The man continued his
conversation about the programme. Whilst doing this, he bent over and the
expression on his face gave further cause for concern to the SO. He asked the
man if he was sure he was alright and whether there was anything he could do
for him. The man again said he was fine. Their conversation ended with the
17
SO saying he would look further into the man’s queries regarding the
programmes they had talked about. The SO then locked and left the wing. The
new probation officer did not speak to the man.
57. As 3.00pm approached, the first nurse and the RMN finished their shift for the
day. Before leaving, the first nurse gave a handover to the late duty second
nurse and gave her the prison radio.
58. At interview with the investigator, the third officer said he had not seen the man
since he was assessed by the nurses. At approximately 3.00pm, the officer
responded to the man’s cell bell. He answered it immediately and found him
sitting on his chair (which was normal) at the back of his cell. The man said he
was experiencing pains on the left side of his chest and arm.
59. The third officer said he would contact the healthcare department straightaway
and left the man’s cell door open. He offered to put the man’s chair outside on
the landing to make it easier to keep an eye on him. The man refused and said
he would be okay in his cell. The officer immediately went to the office and
telephoned the healthcare department. He informed them that the man had a
problem again and needed someone to attend the wing straightaway. The
officer said that the second nurse arrived quickly at the man’s cell.
60. At interview with the investigator, the second nurse said she knew that the
nurses had earlier visited C wing to see the man. He had complained of having
“some pain mostly in his shoulder but some general chest pain”. He had been
examined and his blood pressure taken and the first nurse had updated his
medical records. The second nurse knew that the man’s blood pressure had
been taken but did not know that he had been given GTN spray. The two
nurses said that, when they saw the man, he was okay.
61. At 3.00pm, the second nurse received a telephone call from an officer on C
wing, requesting her to see the man. She was the only nurse in the out-
patients department at the time and, after locking away the medication, made
her way to the wing.
62. When the second nurse arrived (at approximately 3.05pm), the man was initially
quite agitated at having to explain his symptoms again with another nurse. He
said he had just had a chance meeting with the lifer officer and he was not
happy about this. He calmed down and began to engage in conversation. The
second nurse told him that, because she had been called to the wing in an
emergency, she had not had time to read his medical notes. The second officer
who had stayed in the cell in case his assistance was required, described The
man as unwell and grey. After a minute or so, the officer left to continue with
his other duties.
63. The man told the nurse that he had pains in his left shoulder and chest. The
second nurse examined him and took blood pressure and pulse readings. They
were 173/102, and 90 respectively. The nurse told the investigator that she
considered this blood pressure reading as “a bit on the high side”. Although
she considered whether his chest pain was heart related, she dismissed this as
18
the man had not displayed some of the common symptoms of a heart attack,
such as being clammy, short of breath or complaining of nausea. He also did
not complain of any radiation of pain in his neck or in either arm. The nurse
said that the man described his chest pain as an epigastric pain (the area of
central abdomen) than a pain in his chest.
64. The second nurse sat and talked to the man. His speech was normal and he
smoked whilst walking about in his cell. The nurse said they discussed
attendance at smoking cessation courses. In their discussions, she told the
man that he was not having a heart attack and he said that it was his shoulder
injury, not his heart that he was worried about.
65. After being with the man for ten to 15 minutes, the second nurse checked his
blood pressure again (timed at 3.10pm) and noted that it had lowered to 160/92
with his pulse reading at 65. His pain had also reduced. The nurse believed
that the man’s pain related to the shoulder pain he had told her about. She told
the man that “he will see GP in the morning and to call if any more problems”.
As the nurse would visit the wing around 7.30pm, she intended to check on the
man again at that point.
66. Upon leaving the wing at about 3.15pm, the second nurse went to the wing
office. She informed an officer that if the man had any further problems,
healthcare should be contacted immediately. The man’s wing history sheet
was updated by wing staff, reading “the man had chest pains today, healthcare
came”. Shortly after returning to the healthcare department, the nurse updated
the man’s medical record. She included his blood pressure and pulse readings
and further added, “I have reassured him that he is not having a heart attack”.
67. Should the time that the second nurse said she examined the man be correct,
then it would mean that the SO actually spoke with him just before 3.00pm and
not 3.20pm as he estimated. This would seem more likely as the man told the
second officer that he would return to his cell after seeing the first nurse and the
RMN around 2.50pm. He then spoke to the SO before the second nurse was
called. The investigator was unable to check the prison’s cell activation log to
confirm the time the cell bell was pressed as this information is not recorded.
68. The third officer returned to check on the man about 20 minutes after he left his
cell. The man’s cell door was still open and he was lying on his bed. The
second nurse had left by this time. The officer had been quite busy, and did not
know when the nurse had left the wing. He asked the man how he felt and
received the response “yes, I’m fine”. The officer again said to the man that he
was happy to leave his cell door open or he could sit out on the landing. He
specifically said this because he had a number of tasks to undertake on the
wing, and it would be easier for him to monitor the man if he could see him on
the landing. There were also a number of wing cleaners who were carrying out
cleaning duties on the landings who would also be able see the man. The
man’s response however was “No Gov, I’m fine. I just want to sort of get my
head down”. The officer then continued with his wing duties.
19
69. At 4.15pm, the process of free-flow begins again as prisoners return from their
activities. This usually takes around 15 minutes during which prisoners are
counted in by staff as they return to their cells. Staff then conduct the tea time
roll check of the entire wing to ensure that every prisoner is present. All cell
doors are locked during this time.
70. The third officer carried out the roll check on C wing. When he arrived at the
man’s cell, he looked in and saw him lying on the top bunk of the bed. He
believed that he was resting. Having completed the roll check, the officer and
other staff went for their tea break. When the staff returned, they had a quick
briefing meeting and then began to prepare the wing for serving the evening
meal.
71. Confirmation was given that the roll check was correct and prisoners could be
unlocked to collect their evening meal. The third officer began unlocking cells
from the fourth landing, starting with cell number 30. As the man was in cell
number 31, his was the second cell that the officer opened. This occurred at
5.45pm.
72. When the third officer opened the cell door, the man still appeared to be resting
on his bed. The officer called to the man, saying “dinner”. He received no
response and so repeated his words. As the man again failed to respond, the
officer went inside the cell to check him. As he stood beside the bed he could
see the man’s hands “clutched” and that his face was blue in colour. The man
still did not respond when called. The officer quickly left the cell closing the flap
and cell door behind him. He was conscious that other prisoners were now on
the landing as their cells had been unlocked. He shouted immediately to a
second SO who was downstairs, to come up to the man’s cell.
73. At interview with the investigator, the second SO said that he was in charge of
C wing. Staff had informed him earlier during the day that the man had
experienced chest pains. He was aware that the third officer had kept the
man’s cell door open to keep an eye on him. The SO said he responded to the
third officer’s shout by running up the stairs to the fourth landing, arriving at The
man’s cell within seconds.
74. The second SO found the man lying face down on the top of the bunk with his
head facing the cell door. He looked asleep. He checked his pulse, but could
not find one. He immediately used his radio and called through ‘Urgent
message” and that immediate medical attention was required. The SO
repeated this message to ensure the officer in the Communications Unit was
aware of the seriousness of the call. He gave further information including the
cell location and the fact that the prisoner inside did not respond.
75. Although both officers were first aid trained, neither had received any recent
refresher training. Neither commenced CPR. The second SO said that he
thought about attempting CPR, but was interrupted by a number of prisoners
approaching the man’s door to see what was happening inside. As he tried to
ensure that “panic and unrest” did not unfold on the landing, staff from
20
healthcare arrived. On observing the man, the third officer said that from his
colour, it looked as if the “life had already drained out of him”.
76. The Principal Officer (PO) was the Oscar 1 (the officer in charge of the running
of the prison) when he heard the message “urgent medical assistance required”
over his radio. He told the investigator that he immediately made his way to C
wing and was quickly directed to the man’s cell. He was briefed by the second
SO on the events that had occurred and was told that the man appeared to
have died. Oscar 1 immediately went to the wing office and alerted the duty
governor. Oscar 1 also requested that an ambulance was called, just as the
healthcare nurses arrived.
77. The second SO said that within two minutes, the second nurse and a third
nurse arrived with medical emergency equipment. The second nurse had been
in the healthcare unit when she received the emergency call at 5.45pm and
collected the red emergency bag to take to C wing. (The red emergency bag
contains a number of pieces of emergency medical equipment including oxygen
and is quite heavy.)
78. The third nurse was working on C wing when she saw the second nurse
coming through with the medical bag. Having been informed by other officers
that an emergency call had been reported, the third nurse quickly made her to
the fourth landing. She was beckoned to the man’s cell by staff and quickly
updated on the situation. The second nurse (because she was carrying the
heavy medical equipment) went into the cell as the third nurse was being
briefed on the situation. The second nurse said that CPR had not been started
at that point.
79. The third officer and the second SO assisted the second nurse and the third
nurse put the man into the recovery position. The nurses checked the man for
signs of life. He had no pulse and so the second nurse entered an airway and
administered oxygen. The third nurse continued to check for a pulse and a
blood pressure reading throughout. The man remained unresponsive. The
second nurse said that the man was not breathing and his face was mottled.
She immediately asked the healthcare assistant, who had now also arrived, to
collect the defibrillator (a machine that that detects the electrical activity in the
heart and gives automated instructions to the user on what to do) from
healthcare and bring it to the cell.
80. The man was still on the top bunk bed. The nurses were aware that they
needed a hard surface, such as the floor, in order for CPR to be most effective.
The cell was already short of space and the man was a big man and this made
the nurses believe it would be difficult to lower him to the floor. Wanting to start
CPR quickly, the third nurse jumped onto the top bunk bed whilst the second
Nurse continued administering oxygen. The nurses continued to administer
CPR whilst they awaited the arrival of the ambulance. The third nurse said that,
during the time that CPR was being administered, the man showed no signs of
life.
21
81. Oscar 1 said that, as C wing had just been unlocked, it was very busy on the
wings. Aware that the nurses were carrying out CPR, he wanted to ensure
some privacy was maintained around the man’s cell. The second SO and the
third officer cordoned off the area around the cell with some screens. The
prisoners were locked back into their cells.
82. By the time a member of staff had brought the prison’s defibrillator to the man’s
cell, the first paramedics had also arrived (at 5.57pm) and taken control of the
situation. A second ambulance crew arrived at 6.05pm. With assistance from
those in the cell, the man was lowered to the floor. The third nurse then left the
cell. The paramedics assessed his condition and used their own defibrillator.
Resuscitation attempts continued for a further 30 minutes before the man’s
death was confirmed at 6.40pm.
After The man’s death
83. The death in custody contingency plans was immediately instigated by Oscar 1.
The paramedics remained on the scene for the arrival of the police and the
man’s cell was sealed to await their arrival. Arrangement was made to contact
all the necessary agencies to inform them of the man’s death.
84. The police started to arrive at the prison quickly and began to conduct their
investigations. They noted that no-one had been appointed as a log keeper (to
record details of those entering and leaving the cell), and so arranged for this to
be done.
85. Later that evening, a hot debrief was conducted chaired by the Governor of
Lewes. The events were discussed and staff were given the opportunity to talk
about their involvement. The staff care and welfare team were also in
attendance to offer staff support.
86. Around 7.00pm, the Head of Healthcare was informed of the man’s death. He
later spoke with the healthcare staff involved and also informed the managing
director of the ESCHS. Over the next two days, both the first and the second
nurses attended the man before his death, were suspended from duty. This
was in order that an investigation could be conducted by ESCHS and the
Provider Integrated Governance Committee could consider the events leading
to the man‘s death.
87. At interview with the investigator, the third nurse confirmed that although the
prison had a defibrillator machine, it was not initially brought to the man’s cell
when the emergency was raised. The prison also has an electrocardiogram
(ECG) machine which is used to measure the electrical activity of the heart.
The Head of Healthcare told the investigator that the ECG was not working at
the time of the man’s death and a replacement was being sought. However, he
said that generally nurses at Lewes were not proficient to use an ECG which
would be left for a doctor.
22
Contact with The man’s family
88. At interview with the investigator, the officer who was appointed as the prison
family liaison officer (FLO) said she was contacted at home at around 7.45pm.
The FLO was informed that she might be needed to visit that evening to break
the news to the man’s next of kin. (Later that evening, she was asked to attend
the prison the following morning.)
89. As soon as the man’s death was confirmed, staff began the task of collating his
prison records. The man’s next of kin details were checked and appeared to be
incorrect. Staff spent the evening through to the night checking the details
before being able to identify the man’s sister his next of kin, although no contact
telephone number was available.
90. The following morning (24 December), the FLO went to the prison and was
briefed by the Governor of Lewes and a second Governor. Given that the
man’s family lived in London and wanting to ensure his sister was told as soon
as possible, the prison FLO asked the Metropolitan Police to break the news.
This was done almost immediately and at 9.45am, the man’s sister telephoned
the FLO at the prison.
91. The FLO said she passed on the information that she had been given that
morning about the circumstances surrounding the man’s death. This was that
the man was unlocked for dinner at about 5.45pm and was found lying on his
bed. Healthcare and paramedics were called and his death was confirmed at
6.45pm. It was suspected that the man had had a heart attack.
92. The FLO said that she offered to visit the man’s sister later that day. However,
the man’s was very upset and declined. Nonetheless, the FLO said she would
contact her each day to update her on any further information that came to
hand. The FLO also spoke with the man’s brother and the coroner to try and
arrange for the family to view the man’s body. This caused some difficulty as
the coroner’s office was closed for a number of days for the Christmas period.
When the FLO eventually managed to speak with the coroner on 29 December,
she arranged for the family to view the man’s body on 31 December. This
information was relayed to the family.
93. On 30 December, the FLO telephoned the man’s sister and arranged to visit
her with the Governor of Lewes on 5 January 2010. On 31 December, the FLO
met two of the man’s brothers to view his body. They were informed that, once
the coroner had released the man’s body, preparations for his funeral could be
made. They offered financial assistance from the prison.
94. The FLO and the Governor of Lewes arrived at the man’s sisters’ home at
around 10.30am on 5 January. The Governor told them that the man had felt
unwell in the morning and staff had kept him off work and had made him a cup
of tea. The man returned to his cell where the door had been kept open.
Healthcare were called and came to see the man. The man’s cell door was
then locked about 4.30pm following the return of prisoners from various
workshops. He was discovered when his cell was unlocked by staff for tea.
23
The man’s sister was very upset at hearing this further information about her
brother and felt she should have received full and accurate information from the
start.
95. The FLO told the investigator that she did not know this additional information
until the Governor said it at the family meeting. She agreed to find out as much
information as possible and spoke to the man’s sister again the next day. She
gave her further information about the man’s Parole Board and probation
contacts, as well as discussing the release of her brother’s body so that his
funeral could take place. The FLO spoke with the man’s sister again a number
of times, mainly to arrange his funeral.
96. Due to the Christmas period and the varying staff shift patterns, the FLO was
unable to contact the landing staff who had contact with the man on the day
that he died as quickly as she wanted. When she eventually did so, she was
able to obtain additional information regarding the circumstances surrounding
the man’s death. She contacted the man’s sister by telephone on 18 January
to give her the additional information. The man’s sister was also informed that
the nurses who examined the man had been suspended from duty pending an
investigation.
97. The man’s sister was again very upset at receiving additional information. The
FLO told the investigator that it was unfortunate that she did not have all the
information to pass on to the man’s sister when she first contacted her. Had
she gone to the prison immediately she was informed of his death and been
included in the hot debrief, the FLO said she would have known more that she
was originally told.
Post mortem
98. A post mortem examination concluded that the man died from Acute Myocardial
Infarction (heart attack) due to Coronary Artery Atheroma (an accumulation of
deposits in the wall of the artery). A toxicology examination performed by
Brighton and Sussex University Hospitals found no evidence of alcohol,
opiates, benzodiazepines, cocaine, benzoyledgonine (a metabolite of cocaine)
or cannabinoids in his blood. Paracetamol was present but not in excess.
24
ISSUES
Clinical care
99. It was agreed by the Clinical Review Panel that, overall, the medical care
provided to the man prior to 23 December 2009 was appropriate. The clinical
reviewer makes six recommendations in his report and I refer to the most
pertinent in my report. The clinical review will be shared however in its entirety
with the PCT and is attached as an annex to this report. In addition, I make two
further recommendations related to healthcare issues.
Reception healthcare screening
100. On arrival at Lewes, the man’s reception health screening was carried
appropriately. The clinical reviewer highlighted a few discrepancies such as the
legibility of the nurse’s handwriting and some missing information. Although
none of this appears to have been related to the man’s later symptoms, it is
important that initial health screening information is recorded in full, accurately
and clearly. I am pleased to note that such problems have now been reduced
by the introduction of a new computerised medical records system which has
also improved the referral process.
Healthcare response to the man’s symptoms
101. Prior to 23 December, he man’s prison medical records do not indicate that he
had any signs of any heart related problems. It was, however, clear that he had
suffered from long term shoulder pain.
102. The RMN and the first nurse first attended the man on 23 December at 2.00pm
and ascertained that he had chest pain and raised blood pressure. Against
prison policy, an un-prescribed medication (the GTN spray) was administered
by the first nurse. The clinical reviewer comments that the fact that the nurse
administered the spray suggests that she suspected he had angina. If this was
the case, she should have arranged his urgent admission to hospital or at least
have sought advice from the emergency doctor.
103. Given the nature and purpose of GTN spray, the clinical reviewer also suggests
that the first nurse should have realised that the drug could lower the man’s
blood pressure. Indeed, it appears that although the pain reduced, after he saw
the nurses, he was still in pain as he made his way back to his cell. This is
supported by the description of the man from the lifer manager who saw him on
the wing.
104. Administering un-prescribed medications can have serious implications for a
patient and is a breach of medical practice. I am aware that the nurse was
suspended from duty and subsequently resigned from her position at Lewes.
Nevertheless, it is of the utmost importance that all healthcare staff are
reminded of their responsibilities with regard to dispensing medication.
25
The Head of Healthcare should remind all healthcare staff of the protocols
in place, and their responsibilities with regard to, the correct dispensing
of medication.
105. At the clinical review panel meeting held on 20 April 2010, a consultant nurse
cardiologist employed by Brighton and Sussex hospital said that the symptoms
described by the man sounded fairly typical of someone having heart problems.
In a hospital setting, an ECG would have been carried out and in a community
setting such as a patient’s home or GP surgery, a 999 call would have been
made.
106. An ECG recording would normally only take place at the request of a doctor. It
is used as a diagnostic aid for medical staff. Unless nursing staff use the
machines regularly, they would not have the skills to read and interpret
accurately. Paramedics however do have the skills. HMP Lewes does have an
ECG machine but, on the day in question, it was out of action. At an interview
with the Head of Healthcare, on 20 April 2010 it still had not been repaired or
replaced. Although, having said that, there is no evidence to suggest that the
nurses even considered using the ECG to possibly assess the man’s condition.
Furthermore, it cannot be assumed that using an ECG would have necessarily
altered the outcome for the man.
107. In a previous investigation the Ombudsman carried out at Lewes in 2006, the
following recommendation was made:
“A review of when to undertake an electro cardiogram (ECG) recording and
establish a subsequent protocol must be developed in terms of complaints of
chest pain or angina. This would also empower nursing staff as part of their
triage and management roles following agreed algorithms, as medical staff
are not always onsite.”
108. I am disappointed to repeat the recommendation here. It is also important that
equipment such an ECG is regularly maintained so that it is available for use in
these circumstances.
The Head of Healthcare should conduct a review of the use of electro
cardiograms (ECG) and establish a protocol for action that should be
taken to deal with complaints of chest pain or angina.
The Head of Healthcare should ensure that medical equipment is checked
regularly and in full working order.
109. Although I cannot be certain whether, had an ambulance been called when the
first nurse assessed the man, he would have survived the heart attack, his
chances of survival would certainly have been better. This can also be said
about the second nurse’s later contact. It is imperative that the healthcare
department has procedures which provide clear guidelines to staff responding
to prisoners complaining of chest pain. Following receipt of the draft report,
The man’s next of kin felt it was it was important to highlight that a key
26
component of any chest pain protocol is the requirement that an ambulance is
called.
The Governor and Head of Healthcare, in conjunction with the Primary
Care Trust should implement a chest pain protocol across the prison for
all staff.
110. The man complained of being unwell and was assessed for a second time
between 3.00pm and 3.30pm, and it is likely that this was due to chest pains of
a similar or greater level to those he experienced earlier. The second nurse
who examined this time, appears to have assumed it was the man’s old
shoulder injury that was causing the symptoms. However, the man again had
high blood pressure, which she appears to have disregarded.
111. The second nurse knew that the man had been seen by other nurses that
afternoon. I believe that she should have read their notes before assessing the
man. Whether, had she known that his blood pressure had been high and he
had been given GTN spray, this would have altered her assessment, is
unknown.
112. From statements from prison officers and another prisoner, it would appear that
the man’s ‘grey’ colour and distress were noticeable. Although both received
annual refresher training on emergency response, cardiac emergency response
and the use of a heart-start machine (defibrillator), neither nurse sought advice
from a doctor and they were content that he would be seen by the doctor the
following day. I am satisfied that the ESCHS took immediate steps to
investigate the nurse’s conduct and so make no recommendation here.
Cardio pulmonary resuscitation
113. The first two officers who discovered the man did not attempt CPR. The clinical
reviewer comments that administering CPR as soon as possible increases the
possibility of lives being saved. The officers were conscious of a number of
prisoners being out on the landings and wanted to make sure that there was no
panic on the wing. Both officers were CPR trained, but neither had recent
refresher training. It is important that front line staff have their CPR skills
updated regularly so that they feel confident to intervene in an emergency.
114. The healthcare nurses arrived extremely quickly and CPR began initially on the
top bunk bed because the nurses were unable to lower the man to the floor,
where CPR would be more effective. Although the speed of CPR intervention
is to be commended, there were enough discipline and nursing staff who could
have lifted the man to the floor before the paramedics’ arrived.
115. Although the emergency response from the nurses was timely, they did not
bring a defibrillator with them. It is essential that necessary equipment is
immediately taken to a life threatening situation to assist resuscitation.
116. All three issues are part of general first aid and life support training and so I
recommend the following.
27
The Governor should review the need for first aid or basic life support
training, including refresher training for staff on frontline duties.
All emergency equipment should be brought to the scene as soon as an
emergency code call is made.
Log sheet
117. Prison Service Order (PSO) 2710 section 2.6 states that,
“Once death has been verified by a qualified person, a member of staff must
be posted to remain at the scene and keep a record of the names of all
those entering the cell, which must be limited only to those directly involved
with the incident. Pending the arrival of the police, all relevant evidence
must be preserved”.
This is a mandatory instruction but was not carried out by staff and was initiated
by the police. This is an extremely important task and staff should be reminded
of their responsibilities.
The Governor should remind staff of the importance of creating a log of
events following a death in custody as required by PSO 2710, section 2.6.
Contact with the man’s family
118. PSO 2710 also states that the Governor should
“Arrange notification to the next-of-kin and any other person reasonably
nominated by the prisoner as soon as possible in a suitable manner giving
an accurate factual account of what has happened.”
119. The man’s sister was very upset at not being told the full circumstances
surrounding the death of her brother at the outset. She received further details
some 13 days later during the visit from the Governor of Lewes. About a week
afterwards, further and clearer information was provided by the FLO. This
caused great distress to the man’s sister. However, although she was
concerned about the amount of information the FLO had provided at the outset,
she was pleased with the way the officer carried out her family liaison role. This
was demonstrated in the high level of contact the FLO had with the man’s
family and her support following his death.
120. The FLO was not instructed to attend the prison on the evening of the man’s
death. Had she been required to do so, it is possible that she would have had
access to more information and been able to speak to the staff on duty. It is
important that prison staff who speak to the bereaved family have all the
available information about the circumstances surrounding the death.
121. In other death in custody investigations the Ombudsman has conducted, a
summary of the circumstances has been produced very soon after the event by
the duty governor and a wing manager, which has then been used by the FLO.
28
Lewes might find it useful to consider using a similar system should another
death occur.
The Governor and Family Liaison Officer should ensure that following a
death in custody there is a system in place to accurately record all
relevant information prior to a family visit.
29
CONCLUSION
122. The man had a history of shoulder pain which may have influenced his own
view of the pain he experienced. There was no evidence to suggest any
previous chest, cardiac or angina history. By administering GTN spray, the
nurse implied that his symptoms were heart related. An immediate referral to
the prison doctor should have been the next step. It was not. The second
nurse who examined the man failed to review his medical records and was not
fully aware of his symptoms or the treatment he received in the preceding hour.
123. If the nurses had assessed the man properly and called for a doctor or
emergency ambulance earlier, I believe that his chances of survival might have
been higher. I recognise that he had no known history of cardiac symptoms,
but consider that the nurses should have realised the nature of his illness. The
man’s prognosis was not helped by the first nurse administering,
inappropriately, the GTN spray. Her error was compounded later by the delay
using the defibrillator. I am satisfied that there was no deliberate attempt to
withhold this information from the man’s family. I believe that the omission
began because the family liaison officer was not required to go to the prison the
night that the man died. It was compounded by staff absences over the
Christmas period. Nevertheless a delay of 13 days before the man’s family fully
understood the problem is, I believe, inexcusable.
30
RECOMMENDATIONS
1. The Head of Healthcare should remind all healthcare staff of the protocols in
place, and their responsibilities with regard to, the correct dispensing of
medication.
The Prison Service has accepted this recommendation.
2. The Head of Healthcare should conduct a review of the use of electro
cardiograms (ECG) and establish a protocol for action that should be taken to
deal with complaints of chest pain or angina.
The Prison Service has accepted this recommendation
3. The Head of Healthcare should ensure that medical equipment is checked
regularly and in full working order.
The Prison Service has accepted this recommendation.
4. The Governor and Head of Healthcare, in conjunction with the Primary Care
Trust should implement a chest pain protocol across the prison for all staff.
The Prison Service has accepted this recommendation.
5. The Governor should review the need for first aid or basic life support training,
including refresher training for staff on frontline duties.
The Prison Service has accepted this recommendation.
6. All emergency equipment should be brought to the scene as soon as an
emergency code call is made.
The Prison Service has accepted this recommendation.
7. The Governor should remind staff of the importance of creating a log of events
following a death in custody as required by PSO 2710, section 2.6.
The Prison Service has accepted this recommendation.
8. The Governor and Family Liaison Officer should ensure that following a death
in custody there is a system in place to accurately record all relevant
information prior to a family visit.
The Prison Service has accepted this recommendation.
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