Individual at Manchester

Investigation into the circumstances surrounding the
death of a man, who died in April 2009 at hospital,
whilst in the custody of HMP Manchester.
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2009
This is the report of an investigation into the circumstances surrounding the
death of a man, who was a prisoner at HMP Manchester. He died in April
2009, at hospital, having been there since 28 February. He was 70 years old
when he died.
The cause of death, established after a post mortem, was given as chronic
obstructive pulmonary disease and ischaemic heart disease. I offer my
sincere sympathy and condolences to the man’s family, and to all of those
affected by his loss.
The investigation was carried out on my behalf by my colleague. A review of
the man’s medical care in prison was carried out by the clinical reviewer, on
behalf of the local Primary Care Trust. As ever, I am most grateful to her for
her assistance.
I would also like to thank the Governor and staff of Manchester for their full
and ready co-operation during the course of the investigation. My particular
thanks go to the Safer Custody Team for their work in liaising with the
investigator.
I conclude that the man was treated appropriately by staff at Manchester. My
report includes two recommendations from the clinical reviewer’s review
which I endorse along with recognising one area of good practice.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman November 2009
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CONTENTS
Summary
The Investigation Process
HMP Manchester
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was born in September 1938 and lived in the Manchester area. He
was convicted on 24 January 2008 of sexual offences committed many years
earlier and given a four year custodial sentence.
On his arrival at Manchester a Reception Health Screen check was conducted
by the prison doctor. He told the doctor that he suffered from diabetes and
angina. In addition he said that he had previously had a heart attack. He was
confused and uncertain about his diabetic medication levels. He was
admitted to the healthcare unit and remained there until 16 September. His
diabetes and general well being were monitored at least three times a day.
He was encouraged to attend to his personal hygiene and ensure that he
maintained an appropriate diet.
The man moved to the Vulnerable Persons Unit (VPU) and a mobility
assessment was conducted by a physiotherapist. He was unable to walk long
distances but was able to walk to the visiting area comfortably. He was seen
walking without any sign of unsteadiness even on quick changes in direction.
The diabetic nursing specialist saw him on 5 January 2009 as there were
concerns about how he was managing his diabetes. It was established that
he was not taking all his prescribed medication and so he was admitted to the
healthcare unit so that his diabetic treatment regime and medication could be
monitored. He remained in the healthcare unit until he transferred back to the
VPU on 1 February.
At 8.15am on 27 February a nurse was administering the morning treatments
when VPU staff asked that the man be seen. His cell mate had reported that
he had fainted earlier that morning. The nurse recorded that he had not taken
his medication and appeared pale and clammy. He was advised to have his
breakfast and see the doctor later that day.
The doctor went to see the man later in the afternoon but he was in the visits
centre with his family. The doctor eventually saw him at 6.28pm. He had no
chest pain or palpitations but was admitted to the healthcare unit for further
observations and for full blood tests to be taken the following day.
Later that same evening his condition deteriorated. He had difficulty breathing
and his legs and feet were severely swollen. It was decided to send him to
outside hospital and an ambulance was called at 11.07pm. He was taken to
the hospital.
In the early morning of 28 February a prison nurse spoke to the sister at the
hospital who said that the man’s organs were failing and he was in a critical
condition. At 1.00am on 15 April, hospital staff contacted his family and asked
them to come to the hospital. They arrived at 1.25am and the hospital doctor
confirmed that he had died at 1.33am.
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I find that overall the man received a standard of care whilst at Manchester
that was equitable to that which he could have expected in the community. I
also find that he was treated with dignity and respect in his final days. I do,
however, make two recommendations regarding the process for acting on
abnormal test results and urine testing protocol.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 18 April 2009 by the investigator. He
issued notices announcing the investigation to staff and prisoners. The
notices included an invitation to anyone who wished to submit information
relating to the man’s death to make themselves known. In the event one
prisoner came forward and was interviewed. The investigator also
studied all relevant prison records, which included the man’s main prison
record and his medical records. The investigator returned Manchester on
9 July and interviewed four members of staff.
2. The local Primary Care Trust commissioned a clinical reviewer, a nurse,
to carry out an independent review of the man’s clinical care. I am
grateful to her for undertaking such a thorough and timely review.
3. The investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the post
mortem report. Upon completion, this report will be sent to the Coroner to
assist his enquiries into the man’s death.
4. The Senior Family Liaison Officer contacted the man’s family. This gave
them the opportunity to discuss the purpose of the investigation and to
raise any concerns or questions that they wanted to be addressed. The
family raised the following concerns:
(cid:127) He was not looked after properly
(cid:127) His health and medical needs were not met
(cid:127) He was left in filthy clothes
(cid:127) The family were unable to contact anyone at the prison to take their
concerns for his health seriously.
(cid:127) In the last two weeks of his life, the number of visits allowed for the
family were reduced from everyday to once a week and had to be
booked. His family believed that this contributed to his failing
health.
The investigator has attempted to address the issues raised by the family
within this report. I hope that it provides the family with a better
understanding of the treatment given to the man before his death.
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HMP MANCHESTER
5. HMP Manchester is a Victorian local prison which takes people who are
remanded into custody from courts in Greater Manchester. It has been
part of the High Security Estate since 2003. The prison consists of two
blocks containing a total of nine wings with a mix of single and double
cells.
6. Healthcare at Manchester is provided by the local Primary Care Trust.
The healthcare centre provides 24 hour nursing care and medical cover,
and has beds for up to 38 patients. The Independent Monitoring Board
report for 2007-08 noted that a number of the beds in the healthcare
centre are used for non-clinical use, due to prison overcrowding. They
also report that at least half of the prisoners on Assessment, Care in
Custody and Teamwork (ACCT is used by the Prison Service to monitor
and support persons deemed to be at risk of suicide or self-harm) live in
healthcare, creating a time consuming amount of work for staff. Since
the man’s death the number of beds in healthcare centre has been
reduced from 38 to 20 and patients are now admitted on clinical need
only.
7. The IMB also expressed their concern that elderly prisoners with
complex mental and physical needs were being held in the healthcare
centre which had neither the appropriate facilities nor equipment to
respond to their needs. The IMB referred in their report to an inquest
into the death of a 75 year old prisoner when the Coroner commented
that the healthcare centre of a category A prison was not a suitable
environment for the care of the elderly and infirm.
8. Manchester was last inspected by Her Majesty’s Chief Inspector of
Prisons in May 2007. She also found that a number of prisoners were
inappropriately admitted to the healthcare centre. She recommended
that admission to the healthcare centre should be on the basis of clinical
needs alone.
9. The man’s death was one of 26 to occur at Manchester since April 2004,
when the Ombudsman began investigating all deaths in prison custody
in England and Wales. Eight of the previous 25 deaths were due to
natural causes. There has subsequently been a further death at
Manchester, which was not due to natural causes.
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KEY FINDINGS
10. The man was born in September 1938 and lived in the Manchester area.
He was convicted on 24 January 2008 at Crown Court of historical
sexual offences and given a four year custodial sentence.
11. On arrival at Manchester, the man had a Reception Health screen check
with the prison doctor. The man told the doctor that he suffered from
diabetes and angina. In addition he said that he had previously suffered
a heart attack. He was confused and uncertain about his diabetic
medication. Consequently, he was admitted to the healthcare unit so
that his diabetes could be monitored.
12. Confirmation was received the next day from the man’s doctor’s surgery
that he was prescribed:
(cid:127) Humulin (injectable insulin medication for treatment of diabetes)
(cid:127) Atenolol (for treatment of cardiovascular disease)
(cid:127) Isosorbide Mononitrate (for treatment of angina and blood pressure)
(cid:127) Pravastatin (for treatment of high cholesterol)
(cid:127) Lisinopril (for prevention of renal and retinal complications resulting
from suffering from diabetes)
(cid:127) Aspirin.
13. From 26 January to 16 September the man remained on the healthcare
unit and, during this period, was monitored at least three times a day by
either healthcare staff or prison doctors. He was encouraged to attend
to his personal hygiene and ensure that he ate an appropriate diet. He
was also made aware of the laundry facilities within the prison. On 16
September, healthcare staff were satisfied that he could move to a
normal location within the prison.
14. The man moved from healthcare to K wing on 17 September. He was
seen a week later by a nurse for a random blood sugar test. The result
of the test was high and his insulin was increased by two units. The
nurse recorded that he was to be reviewed in a further seven days. She
conducted the review on 30 September and recorded that his blood
sugar level was within normal limits and he was to continue with the
existing level of medication. He was also given advice regarding his diet.
15. On 10 October, the man moved to the Vulnerable Persons Unit (VPU)
which was thought to better suit his needs. Five days later he had a
mobility assessment conducted by a physiotherapist. He told her that he
was unable to walk long distances but was able to walk to the visiting
area comfortably. She saw him walk and recorded that there were no
signs of unsteadiness even on quick changes in direction.
16. The nurse saw the man for a diabetes review on 23 October and noted
that he was much better at controlling his diabetes and gave advice
about injection techniques. She also gave him an influenza vaccination.
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He saw the nurse again on 5 November, 7 November and 9 December
for diabetic reviews. He demonstrated to her satisfaction that he was
able to give himself the correct dose of medication and administer the
injection correctly.
17. On 17 December, a second nurse responded to a call for urgent
assistance at 7.02pm as the man had collapsed in his cell. The nurse
recorded that he was orientated and alert and there were no obvious
signs of injury. He was eating his tea and told her that he felt well. She
checked his vital signs (blood pressure, pulse and breathing) as stable
and said she would check again later. She returned at 8.25pm to find no
change in him and he said that he was feeling fine. She advised him
that if he felt unwell, he was to contact healthcare straight away.
18. The first nurse next saw the man on 5 January 2009 when she was
concerned about how he was managing his diabetes. The nurse
established that he was not taking his blood pressure tablets or his
tablets for cholesterol. She arranged for him to be admitted to the
healthcare unit so that his diabetic treatment regime could be monitored
and ensure that he took all his prescribed medication.
19. The man remained in the healthcare unit until he transferred back to the
VPU on 1 February. During this period he was monitored every day by
healthcare staff. Once back on the VPU, he had two further diabetic
reviews on 4 and 10 February. The first nurse recorded at the second
review that though his diabetes was controlled, he seemed generally
unwell. He should be referred to the prison doctor to assess whether he
should return to the healthcare unit.
20. On 13 February, the prison doctor saw the man who said that he had no
concerns or worries and was adamant that he felt well. The doctor
recorded the man’s blood pressure as 198/88 which was a very high
reading. (The normal range for blood pressure is 100/70 to 140/90,
varying throughout the day depending on the individual’s activities. A
blood pressure reading of greater than 140/90 is classed as high and a
reading of 90/60 or below is classed as low.) As a result the doctor
prescribed an increase in of Linisopril of 5mg to 10mg for a period of two
weeks at which point the man was to have his medication reviewed.
21. The man was assessed by a third nurse on 19 February at 6.30pm after
wing staff told her he had fallen off his chair and banged his head. The
nurse examined him and recorded that there was no sign of any injury
but referred him the doctor the next day. The following day a second
prison doctor saw him and concluded that no action was required.
22. On 27 February, at midnight. a fourth nurse received a phone call from
the staff on the VPU who expressed their concern about the man’s
physical and mental state, saying that his cell mate was also concerned.
She told the wing staff that he was due to see the doctor later in the day.
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23. A fifth nurse was administering the morning treatments at 8.15am when
E wing staff asked that the man be seen. The nurse was told that the
man’s cell mate reported that he had fainted earlier that morning. The
nurse recorded that he had not taken his medication and appeared pale
and clammy. She advised him to have his breakfast and said that he
would see the doctor later that day.
24. A sixth nurse saw the man at 10.41am in his cell as he was unable to
walk over to the clinic. The nurse found him sitting in his chair. He was
not sweating but appeared unkempt and his blood pressure reading was
134/78. He told the nurse that he was not in pain but he felt “knackered”.
She arranged for the doctor to see him in his cell later that afternoon.
25. At 11.05am a seventh nurse saw the man to give him his morning
medication. The nurse recorded that he administered his insulin as
prescribed. He had eight bottles of full sugar lemonade and also sauces
that were high in sugar. The nurse advised him not to eat or drink these
high sugar products.
26. The second prison doctor came to see the man later in the afternoon but
he was in the visits centre. The doctor eventually saw him at 6.28pm,
and noted that he had no chest pain or palpitations, his blood pressure
was 120/88 and pulse was 66. The doctor admitted him to the
healthcare unit for further observations and for full blood tests to be
taken the following day.
27. Later that evening, at approximately 9.20pm, the fourth nurse grew
concerned about the man. He was lying on his right side, struggling to
breathe, his lips were blue and he was cold to the touch. On further
examination, it was found that his legs and feet were severely swollen.
She called for the assistance of an eighth nurse. Together, the nurses
used extra blankets and used pillows to elevate his feet. After a period
of close observation his condition had not improved so the decision was
taken to send him to outside hospital.
28. An ambulance was called and arrived at 11.30pm and the man was
taken to the hospital. He was escorted by two officers with the
instruction that the long restraint chain was to be removed at the request
of hospital staff at the hospital to assist their treatment.
29. The eighth nurse spoke to the sister at the hospital in the early morning
of 28 February and was told that the man was suffering multiple organ
failure and was in a critical condition. Later the same day, following a
bedwatch risk assessment, the Governor authorised the removal of all
restraints until such time as there was an improvement in the man’s
condition. Two officers remained with him. The risk assessment
permitted visits from the man’s family. The Governor authorised that
family visits to the hospital could be allowed at anytime, without the need
to contact the prison in advance.
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30. Throughout the man’s stay in hospital, healthcare staff maintained daily
contact with the hospital to obtain update information about his condition.
On 3 March, a further bedwatch risk assessment was completed. The
Governor judged that the officers should remain but restraints were only
to be used in the event of the man being moved from hospital or
discharged back to prison
31. The man’s condition suddenly deteriorated in the early hours and nursing
staff at the hospital contacted his family at 1.00am to come to the
hospital straight away. They arrived at his bedside at 1.25am and the
hospital doctor confirmed that he had died at 1.33am. The family
remained at the hospital until 2.00am.
32. The family were visited twice by the Family Liaison Officer and prison
chaplain. The prison also provided financial assistance towards the
funeral costs.
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ISSUES
Clinical care
33. The clinical review showed that the man had long standing heart disease
and diabetes which was not monitored closely when he was in the
community and he did not attend clinics or the doctors very often.
34. On coming into custody the man’s medical problems were identified and
he was admitted immediately as an in patient in the healthcare unit. His
diabetes was monitored medication was given in a controlled and safe
environment. He remained in the healthcare unit for nine months as it
took some time to achieve a reasonable level of control of his diabetes. I
believe that he was treated in an appropriate and timely manner for his
diabetes. The clinical reviewer makes the following recommendation
which I endorse:
The Head of Health Care should develop, in conjunction with
Manchester PCT diabetic nurse specialist, a urine testing
protocol for diabetics seen in reception.
35. The man also suffered from hypertension and his blood pressure was
monitored regularly. It was recorded as high on many occasions but no
action was taken until February 2009 when the prison doctor increased
his hypertensive medication and it reduced quickly. The clinical reviewer
makes the following recommendation which I endorse:
The Head of Healthcare should review the process for acting on
abnormal blood pressure levels to ensure that results are
promptly acted upon so that prison doctors can make timely
documented clinical decisions.
36. During February 2009 the man’s health gradually deteriorated he
returned to healthcare. The healthcare staff acted appropriately and in a
timely manner when addressing his acute medical problems and
admitted him to hospital.
Use of restraints
37. Unfortunately there have been too many reports where I have been
critical of the use of restraints when prisoners are under escort in outside
hospital. It is pleasing therefore to recognise the good practice adopted
by Manchester to ensure that the man was treated with dignity and
respect during his final weeks in hospital. Risk assessments authorised
the removal of his restraints and allowed his family unrestricted time with
him.
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Family issues
38. One of the issues raised by the man’s family, which has not been
addressed elsewhere in the report, was that they felt they were unable to
contact the prison to raise their concerns over his health. The
investigator has studied all the prison documentation relating to the man
and had been able to establish that, in addition to weekly visits made to
the prison, his brother wrote to the Governor at Manchester during 2008
on 31 January, 29 May and 26 September raising concerns about his
wellbeing.
39. On each occasion the prison responded in writing, both from healthcare
and general prison operational perspectives, addressing the issues that
the man’s brother raised. In addition to writing to the prison, families with
concerns over a prisoner’s wellbeing can also contact the Safer Custody
Department whose number is displayed in the Visitor Centre along with
freely available leaflets giving visitors prison contact details.
40. I acknowledge that the frustration that families feel in understanding the
care that their loved ones receive whilst in prison. I do believe that
Manchester made sufficient effort to respond to the man’s family.
Ultimately he was an independent adult able to deal with his health and
personal needs without his family’s involvement.
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CONCLUSION
41. I recognise the concerns of the IMB regarding the location of older
prisoners in Manchester, however I judge that attention was paid to the
man’s health needs and appropriate treatment was provided. The
standard of care that he received whilst at Manchester was equitable to
that which he could have expected to receive in the community.
42. I believe that the man was treated with dignity and respect during the
time he was at hospital. Following his death Manchester appropriately
followed the guidance given in PSO 2710, “Follow up to death in
custody”.
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RECOMMENDATIONS
1. The Head of Healthcare should review the process for acting on abnormal
blood pressure levels to ensure that results are promptly acted upon so
that prison doctors can make timely documented clinical decisions.
Accepted
The Head of Healthcare, in conjunction with the GPs, will put into place
guidelines for any clinical observations taken, which will include blood
pressure, temperature, pulse and respiration. To be completed by
February 2010.
2. The Head of Health Care should develop, in conjunction with Manchester
PCT diabetic nurse specialist, a urine testing protocol for diabetics seen in
reception.
Partially Accepted
Blood glucose will be monitored on all diabetics coming into reception and
referrals will be made to the Diabetic Nurse Specialist. To be completed
by February 2010.
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