Individual at Gartree

Investigation into the circumstances surrounding the
death of a man at HMP Gartree
In July 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
This is the report of an investigation into the circumstances surrounding the death of
a man, a prisoner at HMP Gartree. The man died on 6 July 2009. He was in his
early forties. A post mortem showed that the cause of his death was a heart attack.
I offer my sincere sympathy and condolences to the man’s family, as I do to all of his
friends and acquaintances who are touched by his passing.
The investigation was carried out on behalf of the Ombudsman by my one of
colleagues. Both he and I would like to thank the Governor of HMP Gartree and all
the staff, in particular one of his governor’s, for their full and ready co-operation
during the course of our enquiries. I also thank the doctor for the clinical review he
led on behalf of Leicestershire County and Rutland Primary Care Trust (PCT).
This report recognises that the clinical care and consideration given to the man by
the staff at Gartree was equitable to that expected in the community. I make no
recommendations, and I am pleased to recognise the professionalism of staff who
responded the emergency response and the good efforts of the staff who liaised with
the man’s family.
Jane Webb
Deputy Prisons and Probation Ombudsman January 2010
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CONTENTS
Summary
The Investigation Process
HMP Gartree
Key Findings
Issues
Conclusion
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SUMMARY
When the man was remanded in prison on 29 October 2007, he was sent to HMP
Leicester where a nurse conducted a First Reception Health Screen with him. He
told the nurse that he had seen his doctor for alcoholism and depression.
Confirmation of his medication was received from his general practitioner and the
man agreed to participate in the substance misuse programme.
On 9 November, he saw a prison doctor as he had a swollen right leg. The doctor
diagnosed deep vein thrombosis (DVT) (the formation of a blood clot in a deep vein)
and prescribed medication
In the following 11 months, the man had 19 separate reviews of his medication with
either the prison doctor or healthcare staff.
On 30 October 2008, the man appeared in court. He was sentenced to life
imprisonment, to serve a minimum of 18 years. By 20 January 2009, the man had
11 further reviews of his medication.
The man transferred to HMP Gartree on 23 January, and a nurse carried out a full
health review to confirm his medication, weight, height and blood pressure. He saw
the doctor on 26 January who recorded that he had thrombosis in the right leg and
high blood pressure, and requested blood tests to be taken.
Three days later a nurse saw the man to explain that the blood tests had to be
repeated. The man was unhappy at this and signed a disclaimer refusing further
treatment and all medication. The disclaimer was endorsed by the nurse to the
effect that he had been made aware of the severe implications of his decision.
A week later the man saw a nurse from the Mental Health Inreach Team who
confirmed that he was mentally capable of accessing healthcare services if he
changed his mind and that there was no need for any Inreach Team intervention.
There were no concerns about the man’s health until, at approximately 8.10am on 6
July, an officer unlocked his cell as usual. Attempts were made to wake him without
success and it appeared that he was not breathing. A call was made for urgent
medical assistance and an emergency ambulance. Healthcare staff started
cardiopulmonary resuscitation (CPR) until the paramedics arrived at 8.35am.
However, they judged that the man had died and his death was pronounced at
8.40am.
The man’s mother was visited later that morning by a governor and family liaison
officer from Gartree to inform her of his death. The governor arranged for her to visit
the prison two days later to see his cell and talk to staff. The prison also offered
financial assistance to meet the costs of the funeral expenses.
The clinical review highlights that the care he received at Gartree was equitable with
that expected in the community. Whilst I make no formal recommendations, I do ask
the Healthcare Managers at Leicester and Gartree to consider the findings of the
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clinical review. I do recognise the areas of good practice in the emergency response
and family liaison.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 7 July 2009 when the investigator issued
notices to staff and prisoners. The notices included an invitation to those who
wished to submit information relating to the man’s death to make them known.
No one came forward as a result.
2. The investigator visited HMP Gartree on 24 July. During his visit he was given
copies of all the documentation relating to the man, which included his main
prison record and medical records. He also visited the houseblock to see the
man’s cell. The investigator returned on 25 August when he interviewed four
members of staff.
3. Leicestershire County and Rutland Primary Care Trust appointed a doctor to
carry out a review of the man’s clinical care. The investigator and the clinical
reviewer discussed aspects of the man’s treatment and healthcare whilst he was
at Gartree. I am grateful to the clinical reviewer for providing such a thorough
and timely review.
4. The investigator contacted HM Coroner to inform him of the nature and scope of
the investigation and to request a copy of the post mortem report. Upon
completion, this report will be sent to the Coroner to assist in his enquiries into
the man’s death.
5. One of the family liaison officers (FLO) from the Ombudsman’s office contacted
the man’s mother to inform her of the investigation. The FLO and investigator
later met her and she raised the following concerns:
(cid:127) Why did the man have repeated blood tests and why were some tests
lost?
(cid:127) In view of his mental health history, was the man in the right state of mind
to make the decision to sign the medical treatment disclaimer?
(cid:127) When did the man stop taking his medication?
6. I have attempted to address the issues raised by the man’s mother within the
report and I hope that it provides her with a better understanding of the treatment
he was given. His mother expressed her gratitude to the prison family liaison
officer for her sympathetic and professional manner.
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HMP GARTREE
7. HMP Gartree opened in 1966, originally as a category C prison. Within a year, it
was converted to a top security dispersal prison and maintained this function for
approximately 25 years. In the early 1990s, Gartree was re-categorised to a B
category training prison for adult male life sentenced, and now indeterminate
sentenced, prisoners. Typically, it holds prisoners in the early stages of their
sentence for up to five years and can told 575 prisoners.
8. The prison’s purpose is to help prisoners come to terms with their sentences, to
assess their individual needs and to provide specific interventions, such as
offending behaviour programmes, until such time that they can move through the
prison system towards eventual release.
9. Gartree has four residential wings (A to D) with B wing being the induction unit.
There is a therapeutic community unit, a healthcare unit and a supervision and
assessment unit.
10. Her Majesty’s Chief Inspector of Prisons carried out an unannounced inspection
at Gartree in April 2008 as a follow up to a full inspection in August 2005. She
noted that a healthcare recommendation made in 2005 had been achieved. The
recommendation had said:
“The healthcare staff skill mix should be reviewed to ensure appropriately
qualified and graded staff are available to meet the clinical needs of patients,
particularly those with mental health problems.”
This had been achieved by:
“The skill mix had been reviewed in February 2007 and several changes had
been made. Nursing staff were appropriately qualified with a good range of
skills, including in mental health. There were two full-time on-site pharmacy
technicians. GPs from a local practice ran morning surgeries every weekday.
The healthcare team was almost at full strength and offered a comprehensive
service to prisoners.”
11. In her summary of the unannounced inspection Her Majesty’s Chief Inspector of
Prisons commented:
“Of the 49 recommendations in this area, 15 had been achieved, 12 partially
achieved and 22 not achieved. We have made 33 further recommendations.
On the basis of this short follow-up inspection, we considered that the prison
continued to perform reasonably well against this healthy prison test.”
Healthcare centre
12. Gartree delivers both primary and secondary healthcare services, akin to a
doctor’s surgery and an inpatient facility. The healthcare centre is over 40 years
old. The Independent Monitoring Board (IMB) commented in 2006/07 that
refurbishment plans were currently under discussion at senior and area
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management level. Despite appearances, the IMB report said that the healthcare
centre delivered an “excellent service”.
13. When new prisoners arrive, they are seen by a member of the healthcare team in
reception who assesses their needs. The healthcare centre employs a number of
registered mental nurses, general nurses, one counsellor and a visiting
psychiatrist who carries out, on average, one session every two weeks. The
inpatient facility has 14 beds, one of which is reserved for prisoners at risk of
suicide who require continual observation. It is fitted with closed circuit television.
14. The IMB commented that numerous prisoners located in the inpatient wing
should be accommodated in more appropriate accommodation, such as secure
hospitals, where the necessary treatment could be provided.
15. There have been 12 previous deaths at Gartree since 2004. There are no
similarities between those deaths and the man.
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KEY FINDINGS
16. The man was born in July 1966 and lived in Leicestershire. He had a daughter
but was divorced. He had a history of alcohol dependency, depression and was
a smoker. He was remanded into custody at HMP Leicester on 29 October 2007.
HMP Leicester
17. When he arrived at Leicester a nurse conducted a First Reception Health Screen.
Health Screens are conducted to obtain a brief confidential medical and
psychiatric history from the prisoner to ensure that he receives the appropriate
medical treatment. The man told the nurse that he had seen his doctor before
coming into prison for alcoholism and was prescribed medication of Fluoxetine
(antidepressant medication), Chlordiazepoxide (for alcohol withdrawal syndrome)
and Zopiclone (for insomnia).
18. The man told the nurse that, prior to coming into prison, he consumed a litre of
whisky daily and suffered from alcohol induced fits. He also said that he smoked
and did not intend stopping. He said that he had never used illicit drugs in the
past. His blood presssure was taken and recorded as 159/116. (The normal
range for blood pressure is 100/70 to 140/90, although the pressure does vary
throughout the day depending on the individual’s activities. A blood pressure
reading of greater than 140/90 is classed as high and a reading of 90/60 or below
is classed as low.) The nurse referred the man to the detoxification nurse as it
was evident that he was withdrawing from alcohol.
19. The following day the man saw the specialist detoxification nurse. The nurse
recorded that he suffered from tremors, shivers, insomnia and anxiety. His blood
pressure was recorded as 141/98. He agreed to take part in the substance
misuse programme and the nurse authorised the 30mg Chlordiazepoxide with a
plan to reduce this amount over a 12 day period.
20. Later the same day, healthcare staff requested confirmation of the prescriptions
from the man’s general practitioner. The general practitioner responded on 1
November, confirming that the man was last issued Fluoxetine and Zopiclone on
10 October.
21. On 3 November the man saw the triage nurse in healthcare. He asked to see the
doctor and did not want to discuss his concerns with the nurse. An appointment
was made with the doctor on 9 November when the man saw a prison doctor.
The doctor recorded that the man had a swollen right calf and ankle. He told the
doctor that he had previously suffered from Deep Vein Thrombosis (DVT). The
doctor recorded the man’s blood pressure as 117/78 and prescribed Dalteparin
(for DVT) and Naproxen (non-steriod anti-inflamatory for moderate to severe pain
relief) and the use of support stockings.
22. The man next saw the triage nurse on 21 November when he asked for another
appointment with the doctor. He was seen the following day by the doctor and
blood samples were taken. The reason for taking the samples was to test for his
international normalised ratio (INR) indicates whether the blood clots adequately.
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The result was that the man had a low INR of 1.1. (A high INR level, such as
five, indicates that there is a high chance of bleeding. An INR of 0.5 shows that
there is a high chance of a blood clot. The normal range for a healthy person is
0.9 –1.3 and 2.0 – 3.0 for people who are prescribed Warfarin.). Due to his
history of DVT, the doctor prescribed Warfarin of 8mg a day to prevent
thrombosis.
23. Over the next 11 days the man saw the doctor on five separate occasions to
review his INR. On 8 December the doctor decided that the man’s prescription
for Warfarin needed to be increased to 9mg. Due to his low mood he should stop
taking Fluoxetine and take Mirtazapine (antidepressant) instead at a dose of
15mg per day.
24. Between 14 December 2007 and 7 May 2008 the man had ten separate reviews
of his INR, eight of which were with the doctor. His medication remained the
same although it was noted that his mood had not improvedand so the dosage of
Mirtazapine was increased to 30mg.
25. On 9 May, the man saw a nurse from the Mental Health In-reach Team. He told
the nurse that he heard voices in his head which he was unable to describe. He
said that he was taking his antidepressants and had no thoughts of harming
himself.
26. The man next saw the doctor on 11 June. The doctor recorded that his INR was
1.9 and that the dose of Warfarin should remain at 9mg. The man had five more
INR reviews with nursing staff up to 4 August. At this last review a nurse
recorded that his blood pressure was 147/107 and advised that he needed to see
the doctor. However he told the nurse that he did not want an appointment with
the doctor.
27. The doctor did see the man on 9 September and reviewed his INR which was
2.3. The doctor advised continuing with 9mg of Warfarin. The doctor saw him
again seven days later as he had been concerned about his blood pressure. The
man had not been sleeping and felt stressed due to his forthcoming court
appearance. The doctor prescribed Propranolol (beta blocker used to treat high
blood pressure) and Promethazine (to treat insomnia).
28. Between 22 September and 21 October the man made 19 separate court
appearances at Leicester Crown Court. On each occasion a nurse recorded that
he was fit to attend court.
29. On 29 October, the man saw the doctor who reviewed his INR which was
recorded as 1.4. The doctor increased the daily dose of Warfarin to 10mg to be
reviewed in seven days. The man appeared in court on 30 October where he
was was convicted and sentenced to life imprisonment, to serve a minimum of 18
years. Six days later the doctor saw him and reduced the dose of Warfarin to
9mg.
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30. The man had three more reviews of his INR with nursing staff before he saw the
doctor again on 10 December. The doctor recorded that his INR level was 2.4
and that a daily dose of 8mg Warfarin would be appropriate.
31. On 2 January 2009, the man saw a nurse who recorded his INR level as 5.7 and
noted that a doctor should review the dose of Warfarin. Two days later he saw
another nurse who recorded that he wished to see a doctor because he was
concerned over “being overloaded with body fluids”. (No appointments were
made with the doctor after either of the consultations with the nurse.)
32. A nurse saw the man on 9 January and recorded his INR level as 1.6 and again
requested a review by a doctor. Four days later he saw a nurse who recorded
the INR level as 1.9 and made a further request for a review by a doctor as the
last time he had seen one was on 10 December 2008.
33. On 19 January, the man was seen in healthcare by a nurse because he felt
generally unwell. The nurse recorded that he was to be referred to the blood
clinic and an appointment was made for him to see the doctor three days later.
34. The following day a nurse saw him and recorded his INR level as 4.2 and also
noted that he was to be transferred to HMP Gartree. The nurse also recorded
that the doctor needed to prescribe sufficient Warfarin to allow Gartree healthcare
time to assess and continue his treatment. (There is no record that a doctor saw
the man, as arranged on 22 January.)
HMP Gartree
35. On 23 January, the man transferred to Gartree where he was seen by a nurse
who did a full health review to confirm his medication, weight and height. The
nurse offered smoking cessation advice as he smoked 40 cigarrettes a day, but
he said that he would not give up. His blood pressure was recorded as 174/117.
The same nurse saw him the next day to check his blood pressure which was
160/94 and that he was to see the doctor in two days time.
36. The man saw a doctor on 26 January. The doctor recorded that he had
thrombosis in the right leg and had high blood pressure since he arrived at
Gartree. He told the doctor that he smoked and confirmed that he would not give
up. The doctor recorded that he was short of breath on exertion, had an
occassional chest wheeze and a swollen right ankle. The doctor prescribed
Glucosamine (for arthritis) and requested full blood tests. The doctor noted that
the aim was to achieve a stable INR and monitor his blood pressure over the next
two weeks.
37. The blood samples were taken the following day by a nurse and the results were
reviewed and recorded by a doctor. In relation to the INR it was recorded that the
incorrect sample bottle had been used which meant that the test had not been
completed. The test results also showed that the man had a high potassium level
of 5.7. (The normal serum level of potassium is 3.5 to 5 but a higher level can
indicate potential risks such as fatal abnormal heart rythems or kidney disease.)
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38. On 29 January, the man saw a nurse who explained the reason and the need to
repeat the INR tests. The man was unhappy that problems had arisen and told
the nurse that he would decline any further procedures or medication. The nurse
made him aware of the serious implications of his decision and he signed a
disclaimer refusing further treatment and medication. The disclaimer was counter
signed by a nurse confirming that he had been made aware of the implications.
39. Seven days later the man saw a nurse from the Mental Health Inreach Team.
The nurse recorded that he was a physically and mentally capable individual. He
told the nurse that he did not want to see healthcare as he had no faith in them
due to the numerous blood tests. The nurse’s assessment was that he was
mentally capable of accessing healthcare services if he felt he needed to and that
there was no need for Mental Health Inreach Team intervention. This was the
last contact the man had with medical staff.
40. In the six months that followed, prison records show that the man continued with
prison life and there were no concerns or incidents recorded by wing staff. From
the 29 January he did not take any medication, nor did he have any prescribed.
Events of 6 July
41. At approximately 8.10am an officer unlocked the man’s cell as usual. On looking
through the observation flap the officer saw him lying in his bed apparently
asleep. The officer called out the man’s name and said good morning but
received no response. He called several more times but still got no response and
went into the cell. The officer said that he gently shook the man at the same time
as calling his name in an attempt to wake him but still got no response. The
officer visually looked for signs of movement and saw that his chest was not
rising and falling.
42. The officer called to a Senior Officer (SO), who was just outside the man’s cell,
and said that he did not think the man was breathing. The SO entered the cell
and checked for a pulse but did not find one. He immediately made a Code Blue
call (emergency response call for a prisoner found not breathing) over the radio
network.
43. At approximately 8.20am a Healthcare Senior Officer (HCSO) and a Healthcare
Officer (HCO) were in the healthcare centre when they responded to the Code
Blue call. (Healthcare Officer is a title given to prison service staff who are
qualified nurses who work for the healthcare centre). The HCSO collected the
emergency resuscitation bag out of the cupboard on the wing and arrived at the
man’s cell at approximately 8.23am. Having visited Gartree the investigator was
able to confirm that at quick walking pace it takes up to five minutes to get from
healthcare to H wing. It would not be unreasonable for someone running to take
two to three minutes to cover the same distance.
44. On arriving at the man’s side the HCSO checked his vital signs but found no
pulse or sign of breathing. An emergency ambulance was requested at 8.24am.
The HCSO, assisted by the HCO, commenced cardio pulmonary resuscitation
(CPR) and a doctor arrived with the defibrillator. No output was identified by the
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defibrillator and so the HCSO and HCO continued CPR until the paramedics
arrived.
45. The paramedics arrived at the prison at 8.32am and were at the man’s side at
8.35am to take over CPR. They assessed that he had died and the doctor
confirmed his death at 8.40am.
46. A Governor held a debrief for all staff at 9.05am to go through the events of the
emergency response and offer support to those staff affected by the man’s death.
47. At 11.00am that morning a Governor and the prison family liaison officer visited
the man’s mother to inform her of his death. The prison also offered financial
assistance towards the cost of funeral expenses. Arrangements were also made
for his mother to visit the prison on 8 July to allow her to see his cell and speak to
staff. She was given flowers on behalf of the Governor and staff.
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ISSUES
Clinical care
48. The clinical review undertaken by the doctor considered the care that the man
received whilst at Leicester and at Gartree. The review concluded that his death
could not have been avoided as his lifestyle, particularly his smoking, made him
vulnerable to heart disease. The review specifically stated “Many people have a
fatal heart attack as the first evidence of their heart disease and die unexpectedly
and unseen by others”.
49. The clinical review considered the care that the man received whilst at Leicester
and made the following comments:
“He was noted to have high blood pressure on several occasions and tried on
medication briefly but this was not followed up systematically with a review of
all his risk factors such as his smoking or cholesterol levels.”
“I also note he continued to be on Warfarin for a deep vein thrombosis for
more than the usual six months but no reason for this is included in the notes I
have seen. There may be good reasons for this such as it being a recurring
problem for him or him having a problem with his blood clotting that made him
more susceptible to blood clots.”
“He was also prescribed an anti-depressant called Mirtazapine which can
enhance the Warfarin. Regular blood tests meant that this was relatively safe
as he was on a stable dose of the Mirtazapine.”
50. In considering the care the man received at Gartree, the clinical review found it to
be equitable to what would be expected in the community. The review also
considered the effect of his refusal of treatment from 29 January 2009 onwards,
and stated:
“The man’s signing of the disclaimer refusing further treatment could,
therefore, have had a bearing on his death. There may have been other
interventions that would have prolonged his life but for how long it is
impossible to say and he would have had to have more blood tests which he
clearly did not feel happy with and so may not have complied with.”
“Continuing Warfarin may have reduced his risk as it prevents clots building
up and part of the process leading to a heart attack is a clot in one of the
arteries supplying the heart”
“The man’s choice not to continue medication was correctly assessed and it is
clear he had a right, and was allowed to exercise that right, to decline
treatment given sufficient information to make an informed decision.”
51. The clinical review highlights that, now that the Prison Service uses computerised
clinical records, consideration could be given to use integrated dosage testing
software. This would have to be evaluated to establish if it would be cost
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effective to introduce. Whilst I make no formal recommendation I do draw this to
the attention of the Primary Care Trust.
Emergency response
52. An officer raised the alarm and CPR was started and a defibrillator was being
used within tree minutes. The staff continued CPR as directed by the
defibrillator, until the paramedics arrived and took over the attempt to resuscitate
him.
53. I believe that the staff who responded to the man’s need for emergency
assistance acted with speed and professionalism. This is an example of good
practice
Family liaison
54. Gartree appropriately followed the guidance given in PSO 2710, “Follow up to
death in custody”. The man’s mother told my Family Liaison Officer that she was
very impressed with the after care service offered by the prison and I recognise
the good practice of an officer as family liaison officer.
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CONCLUSION
55. During his time at Leicester the man did have well document regular interventions
with doctors and other healthcare staff. Despite these, however, there were
some examples of omissions in arranging doctor appointments.
56. I am satisfied that the care that the man received at Gartree was equitable to that
expected in the community. He had a responsibility for his own health and could
have accepted medical attention but insisted he exercised his right to refuse
treatment for the last six months of his life. The clinical review confirms that
continual medical treatment might well have prolonged his life.
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