Individual at Bristol

Investigation into the circumstances surrounding the
death of a man at HMP & YOI Bristol
in June 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2009
This is the report of an investigation into the death of a man. He was a
prisoner at HMP & YOI Bristol and died in June 2008. He had been suffering
from diabetes, heart disease and schizophrenia for a number of years, and
was 70 years of age when he died.
The loss of a loved one is always distressing and I extend my condolences to
the man’s family. I know that his son has raised concerns that he was not
made aware of the seriousness of his father’s illnesses. I trust that my report
addresses this issue
The investigation into the man’s death was carried out by one of my
investigators. A clinical review was commissioned from the local NHS
Primary Care Trust and completed by a clinical reviewer. I thank him for his
observations and the recommendations drawn from his findings. I would also
like to thank the Governor of Bristol and his staff for their co-operation and
assistance. I am particularly grateful to the Healthcare Manager and the
prison liaison officer.
The man had a history of significant heart disease and ill health.
Unfortunately, he was also becoming more physically frail. My investigation
concludes that there was little that could have been done to prevent his death.
However, I make five recommendations for procedural improvements.
I must apologise for the delay in issuing this report and any additional distress
this may have caused.
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.
Stephen Shaw CBE
Prisons and Probation Ombudsman May
2009
CONTENTS
Summary
The Investigation Process
HMP & YOI Bristol
Key Findings
Issues
Recommendations
SUMMARY
The man was received into custody at HMP & YOI Bristol on 28 April 2006.
He was 68 years old at the time. He was a diabetic, suffered from significant
heart disease and had been diagnosed with schizophrenia in the past. As a
result of his medical history he was closely monitored by wing based
healthcare staff. He regularly attended the diabetic clinic and received routine
care for his heart condition. He was also regularly reviewed and monitored by
the Mental Health In Reach team.
In January 2007, the man complained of upper body tremors and had difficulty
walking. He was assessed by a specialist from the local Mental Health
Partnership Trust, who diagnosed a movement disorder, possibly Parkinson’s
Disease, although the diagnosis was never confirmed. A scan of his head
was arranged in April which showed a degree of cerebral atrophy that could
have been caused by cerebral vascular disease and smoking. (Cerebral
atrophy is when part of the brain dies or becomes non-effective. In his case, it
was attributed either to a stroke - that is, cerebral vascular disease - or his
smoking.)
The man had been complaining of being breathless and, after a heart scan
(ECG) in September 2007, he was diagnosed with heart failure. Over the
following months he started to experience further problems with his mobility
and became incontinent. This resulted in admission to the Royal Infirmary on
12 February 2008 where he remained until mid March.
The man continued to have problems with his mobility and was physically
deteriorating. He was readmitted into the healthcare centre at Bristol prison
on 12 May. He had been provided with a Zimmer walking frame and was
being given assistance with his personal care.
A full review of the man’s health took place on 28 May. His diabetes and
heart condition were recorded as stable on medication, and his incontinence
problems had been resolved. However, he was confused and still had
significant problems with mobility. Healthcare staff referred him to the Mental
Health In Reach team and a specialist physiotherapist.
On 4 June, it was recorded in the medical notes that there was a further
deterioration in the man’s mental state. He was confused and had become
incontinent again. It was decided to refer him for a psychiatric assessment
which was planned for 12 June. In the meantime, urine tests could be
completed and a course of antibiotics (if he was found to have a urine
infection) completed prior to the psychiatric assessment. The urine tests
proved negative for infection.
Three days later, on the morning of 7 June 2008, the man had breakfast and
was assisted to shower. A healthcare officer noticed a slight deterioration and
in the afternoon he asked a visiting doctor to see him. In interview, the
healthcare officer said that the doctor saw the man and was not concerned
about him. (This examination is recorded in the medical record but the entry
is not signed.) He spent most of the rest of the day in his room lying on his
bed, which was not unusual. He was given his medication and a cup of tea in
the evening. The evening duty staff, the healthcare officer and a nurse,
helped him into bed and thought that he was comfortable when they went off
duty. The nurse said that she asked the night staff, a second nurse and a
senior officer (who was acting as a Healthcare Assistant), to observe him
through the night but there is no record of this actually happening.
In interview, the second nurse said that she checked the man several times
throughout the night as he had got out of bed on previous nights that week
and had to be helped back into bed. The records for the night state that he
appeared “to have slept through the night” and was still in bed at
approximately 5.15am when the early roll check was completed by the senior
officer.
An hour and a half later, at 6.50am, the man was found during a routine check
by a third nurse. He was kneeling on pillows on the floor with his head resting
on the bed. He had no pulse and his body was cold. His death was
pronounced at 7.20am.
The post mortem report carried out on 12 June 2008 concluded that the cause
of the man’s death was ischemic heart disease.
THE INVESTIGATION PROCESS
1. An investigator carried out the investigation into the man’s death on my
behalf. Notices were issued to staff and prisoners informing them of
the investigation and its terms of reference, and inviting them to contact
the investigator should they wish to do so. In the event no one came
forward.
2. The clinical reviewer of Bristol Primary Care Trust used the healthcare
records to carry out a full clinical review of the man’s mental and
physical healthcare whilst he was in custody.
3. The investigator visited HMP Bristol on 26 June 2008. He spoke
informally to staff and visited the healthcare centre where the man
spent the last few months of his life. He spoke with members of the
Independent Monitoring Board (IMB) and the Prison Officers’
Association (POA). He reviewed the prison records for the man and
arranged for copies of these and his medical record to be sent to him.
He also interviewed a nurse.
4. My investigator contacted HM Coroner’s office to inform him of the
investigation and ask for a copy of the post mortem report. A copy of
my report will be sent to the Coroner to assist in his enquiries into the
man’s death.
5. One of my family liaison officers contacted the man’s next-of-kin, his
son, to offer him and other family members the opportunity to
contribute to the investigation. There was some delay in making this
contact due to my office being given incorrect address details.
6. The man’s son was concerned that the family were not made aware of
his father’s deteriorating health and that their contact details were
incorrectly recorded. I have done my best to address their concerns. I
hope that my report helps the family better understand what happened
in the time leading up to his death.
7. On 2 December, the investigator returned to Bristol to interview three
additional members of staff. The nurse on duty in the inpatient unit on
the night of 7/8 June 2008, is not currently working in a prison. The
investigator conducted a telephone interview with her on 18 February
2009.
HMP & YOI BRISTOL
8. HMP & YOI Bristol is a category B local prison which first opened in
1883. It has accommodation for 600 prisoners and serves the local
courts in Avon, Somerset and Wiltshire.
9. The healthcare service is commissioned by the local NHS Primary
Care Trust (PCT). Primary care is provided by Bristol Community
Health (an arms length organisation from the PCT) and a mental health
in-reach service is provided by Avon and Wiltshire Mental Health
Partnership NHS Trust. The prison provides 24 hour primary
healthcare, which includes nurses who treat patients within the prison’s
wings. There is a 20 bed inpatient facility within the healthcare centre
(HCC), which is located in a two storey block shared with the
segregation unit. The HCC also has association/day room facilities for
inpatients, and consultation rooms where prisoners from other parts of
the prison can see a doctor. An exercise yard is shared with the
segregation unit.
10. Bristol received an unannounced inspection by HM Chief Inspector of
Prisons in June 2008. She wrote that she was “extremely encouraged
by the significant developments in all aspects of the health services”.
Primary care services were good, with wide range of nurse led clinics
in operation. Inpatient services were also good.
11. There had been eight previous deaths from natural causes at HMP &
YOI Bristol since 2004, when I was given responsibility for investigating
all deaths in prison custody, before that of the man. In a report I issued
in March 2005 I made a recommendation about resuscitation policies
for people who are terminally ill. Resuscitation is a feature of this
report too, albeit from a different perspective.
KEY FINDINGS
12. The man was received into custody at HMP & YOI Bristol on 28 April
2006 having been sentenced to 14 years imprisonment. During his
initial health screening it was noted that he suffered from heart disease
and diabetes and had suffered from schizophrenia in the past. He was
referred to the mental health team, diabetes nurse and a chiropodist.
13. The man was located within the main prison where he was monitored
regularly by wing based healthcare staff. He attended the diabetic
clinic where his condition was monitored and received treatment from
the visiting podiatrist. Throughout his time at Bristol his mental health
was reviewed by the Mental Health In Reach team and he received
regular routine care for his heart condition.
14. In January 2007, the man was assessed by a Specialist Registrar at
the West of England Forensic Mental Health Service after complaining
of upper body tremors and difficulty with everyday movement. The
Specialist Registrar diagnosed him as having a movement disorder,
which was possibly Parkinson’s Disease. A head scan was carried out
in April 2007 which showed a degree of premature cerebral atrophy
that could be due to cerebral vascular disease and smoking, but a
definitive diagnosis was not reached.
15. The man started to complain of breathlessness. On 5 September
2007, he was given a heart scan following which a doctor, from the
cardiology department of Bristol Royal Infirmary, diagnosed heart
failure.
16. In February 2008, the man was experiencing problems walking and
controlling his bowels. He was admitted to the Royal Infirmary on 12
February. He returned to Bristol HCC on 11 March and to his wing on
29 March. While he was being looked after in the HCC, his medical
notes record that on 16 March staff were asked to make contact with
HMP Norwich, where there is an elderly prisoners unit, with a view to
arranging a transfer. However, my investigator was unable to find out if
an application was ever made.
17. Close monitoring by healthcare staff continued during April. The man
was assessed for a Zimmer frame walking aid, and his hearing aid was
sent for repair. He was readmitted to the HCC on 12 May as his
mobility had deteriorated and he was becoming frail. He needed
assistance to look after himself including washing, dressing and eating.
A routine external hospital appointment was cancelled as he was not
well enough to attend.
18. The man’s health was reviewed on 28 May when he was referred to
the Mental Health in Reach team for a review of his symptoms of
schizophrenia. He was also having problems with mobility and was
referred to an outside hospital’s physiotherapy department. His
diabetes and heart condition were stable due to the medication he was
taking, and his incontinence problems had been resolved. He was
experiencing pain in his feet for which he was prescribed additional
medication. He had an optometry assessment on 2 June and new
glasses were ordered.
19. By 4 June, there was deterioration in the man’s memory, he was
confused and also experienced further incontinence. Urine tests were
taken and an appointment for a psychiatric assessment was planned
for 12 June, once the results of the urine tests were received and any
infection had been treated. (The test results showed that he did not
have an infection.) Healthcare staff noted that he was slightly brighter
and more mobile the following day.
20. Two days later, on the morning of 7 June 2008, the man had his
breakfast and the staff assisted him to shower. The healthcare officer
noticed a slight deterioration and asked a visiting doctor from Brisdoc,
the out of hours service, to see him. The doctor examined him and,
according to the healthcare officer, was not concerned about his
condition. My investigator could not find the identity of the visiting
doctor in the written, unsigned, record of this examination.
21. The evening duty staff on 7 June were a nurse and the healthcare
officer. The man spent most of the evening on his bed, which was not
unusual. He was given his evening medication by the nurse. The
healthcare officer and the nurse then gave him a cup of tea and helped
him into bed, ensuring he was comfortable for the night.
22. Talking to my investigator, the nurse recalled asking the night staff to
keep an eye on the man as he had been “slow” during the evening. My
investigator could not find any written record of the discussion nor any
evidence to suggest that the request was acted on.
23. The night staff on 7 June were a senior officer (SO), who was acting in
the capacity of a Healthcare Assistant, and a second nurse. The
segregation officer also patrolled the HCC regularly during the night.
My investigator interviewed the SO and conducted a telephone
interview with the nurse. The SO remembered the man having a
settled night on 7 June. He said he checked on him periodically
through the night and had no cause for concern.
24. The nurse said that at approximately 10.30pm the man was talking to
himself and waving his hands in front of his face. She spoke to him
and gave him a cup of tea through the hatch in the door. She
remembered that he was slow to collect his cup of tea from the hatch,
and she left him to make his way there at his own pace. She returned
to her other duties, but recalled seeing him use his Zimmer frame. She
noticed that the cup of tea was gone when she next looked in and that
he was back in bed. A short time later she remembered waving to him
as she left the inpatient area, and that he waved back.
25. The nurse also remembered checking on the man several times
throughout the night. He had got up during preceding nights and
needed help to get back into bed, which necessitated calling for the
night orderly officer (the person in charge of the prison at night) in order
to unlock his cell. She did not think that he got out of bed during the
rest of the night of 7/8 June, as he did not require help to get back into
bed.
26. The SO conducted a roll check at approximately 5.15am on 8 June and
checked on all the inpatients in the HCC. At 6.00am, 45 minutes later,
he reported by telephone to the Control Room that all the inpatients
were accounted.
27. The SO and nurse handed over to the day staff, a third nurse, who is a
Registered General and Registered Mental Nurse, at 6.40am. The
handover was verbal and no problems were reported. The man was
reported to have had a quiet night.
28. The nurse opened the observation hatch on the door of the man’s cell
to check on him at 6.50am. He saw him kneeling on pillows on the
floor by his bed, with his head on the bed. He went into the cell and
examined him. As he had no pulse and was cold to the touch, the
nurse decided not to attempt resuscitation. An ambulance and Brisdoc
(the out of hours doctors service) were called. The man was
pronounced dead by the paramedics at 7.20am.
29. The prison’s Family Liaison Officer and Duty Governor attempted to
visit the man’s next of kin, his son, at the documented address later
that day. Unfortunately, the address recorded was wrong. The
prison’s Family Liaison Officer eventually made contact with the man’s
son at 4.40pm and arranged to visit the following day.
30. The post mortem conducted by a pathologist on 12 June concluded
that the cause of the man’s death was ischemic heart disease.
ISSUES
Clinical care
31. In his clinical review, the clinical reviewer concludes that the man’s
chronic conditions of diabetes, heart disease and schizophrenia were
appropriately cared for by staff at HMP Bristol. He was regularly
reviewed and appropriate consultant assessments were carried out.
The clinical reviewer is satisfied that best practice was followed in
regard to prescribing for heart failure, diabetes and ischaemic heart
disease.
Record keeping
32. There are a number of discrepancies between the documentation and
evidence given at interview for this investigation. It was often difficult to
establish who was responsible for entering comments on the records
and who was the named nurse responsible for care at any particular
time.
I recommend that all staff be required to print their names next to
any entry on official documents and that all staff are reminded of
the need to document all significant contact with prisoners.
Resuscitation
33. The man’s body was cold when he was found at 6.50am. Whilst no
precise time of death is known, it is probable that he had been dead for
some time before he was discovered, the previous check having taken
place at 5.15am. The current roll check procedures do not require a
check to be made by the oncoming day staff prior to the departure of
night staff. Whilst this would not have prevented the man’s death, it
might have resulted in him being found earlier.
I recommend that the Governor review the roll check procedures
within the inpatient unit of the healthcare centre.
34. There may be some who read this report and question why no attempt
was made to resuscitate the man. To answer this issue, Annex C of
Prison Service Order (PSO) 2700 clearly states that resuscitation
should not be attempted when rigor mortis has set in. The clinical
reviewer in his clinical review concludes that the nurse’s decision not to
resuscitate was appropriately taken. I agree. It is respectful neither to
the person conducting resuscitation nor to the memory of the deceased
to attempt to revive someone when their body is already cold.
35. There is no documentation to evidence that regular nursing checks
were carried out throughout the night of 7/8 June on those prisoners
who did not require special observations. Again, this would not have
prevented the man’s death, but it would ensure that all prisoners are
regularly monitored and any problems quickly identified.
I recommend that the Governor review the night patrol procedures
for the inpatient unit of the healthcare centre.
Contact with the family
36. When a prisoner dies, PSO 2710 states that prison managers must:
“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.”
PSO 0500 further states that, on reception into the prison, staff must
ensure that the next of kin is accurately recorded. The address
recorded for the man’s next of kin was out of date which resulted in an
unnecessary delay in informing his son. The Duty Governor and
prison’s Family Liaison Officer did attempt to visit the family to break
the news face to face but had the wrong address. This resulted in the
family being advised by telephone. The incorrect contact details were
also passed to my own Family Liaison Officer which again led to delays
in initiating contact.
I recommend that the Governor ensures the accuracy of every
prisoner’s next of kin details and puts in place an annual check of
these details.
37. The man’s son has expressed concern that the family were not kept
informed about his father’s deteriorating health. There is no direct
requirement on prison staff to keep next of kin updated on the health of
prisoners. However, in the light of the man’s increasing frailty, such
contact would have been good practice.
I recommend that the Prison Service reminds Governors of the
need to communicate with the next of kin when a prisoner’s
health deteriorates significantly, subject to consent being given.
The Prison Service responded to the following recommendations with an
Action Plan, the detail of which I have incorporated into this report.
RECOMMENDATIONS
1. I recommend that the Governor reviews the roll check procedures
within the inpatient unit of the healthcare centre.
Accepted: The staff are aware that the roll check must be a full roll
check where each prisoner must give a response to staff when checks
are made.
2. I recommend that the Governor reviews the night patrol procedures for
the In Patient unit of the healthcare centre.
Accepted: A full review of the night patrol procedures will be reviewed
[sic] to ascertain if any best practices can be adapted to ensure that
[sic] safety of all patients located in the healthcare centre (target date
for completion is November 2009).
3. I recommend that all staff be required to print their names next to any
entry on official documents and that all staff are reminded of the need
to document all significant contact with prisoners.
Accepted: A notice to staff will be issued to inform all staff when they
make entries in the prisoner/patients documents i.e. wing file, ACCT
documents, IMR etc that they must print their name so it is legible
(target date end April 2009).
4. I recommend that the Governor ensures the accuracy of every
prisoner’s next of kin details and puts in place an annual check of these
details.
Accepted: All prisoners are asked for next of kin details in reception
when they first enter the prison; on Induction which is within the next 24
hours of reception; and when an ACCT document is opened. A
prisoner may also request to change their next of kin details. A notice
to staff will be issued to remind staff to ensure that they ask the
prisoner for this information. An annual check will be completed by the
Safer Custody Team on ACCT documents. First night and Induction
staff will inform Safer Custody of those prisoners who have refused to
give this information out (target date for completion is February 2010).
5. I recommend that the Prison Service reminds Governors of the need to
communicate with the next of kin when a prisoner’s health deteriorates
significantly, subject to consent being given.
Accepted: National response – There is no mandatory requirement for
Governors to keep next of kin updated on the health of prisoners.
However, it is good practice to appoint a Family Liaison Officer (FLO)
where a terminal illness is diagnosed. This enables the prison to
develop a relationship with the family and provide support at this
difficult time. A recent edition of Safer Custody News reminded
Governors of this and consideration will be given to including it in the
review of PSO 2710.
Local response – With regards to HMP Bristol, they will ensure that the
next of kin details will be used to contact those family members when
health of a prisoner deteriorates. A working party will be set up to look
into the safe provision of older prisoners whose health may deteriorate
whilst in prison, and this recommendation will be included in this group
(target date for completion is February 2010).