Individual at Forest Bank

Investigation into the circumstances surrounding the
death of a man at outside hospital
in July 2010, while in the custody of
HMP Forest Bank
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2011
This is the report of an investigation into the death of a prisoner at HMP Forest Bank.
The man died in July 2010 at outside hospital. I offer my sincere sympathy and
condolences to the man’s family and all those affected by his loss.
The man was sentenced to two years imprisonment at a crown court on 8 January
2010. He was taken to Forest Bank and, following a reception healthscreen, was
immediately admitted to the healthcare ward. He had several serious health
problems including diabetes, prostate cancer, heart disease and kidney failure, for
which he was prescribed a number of medicines. The man was physically frail and
largely confined to a wheelchair, although he could walk short distances with the
help of a Zimmer frame.
The investigation was carried out by two of my investigators. An independent review
of the man’s medical care in custody was carried out by a clinical reviewer on behalf
of Salford Primary Care Trust. I am most grateful to him for his assistance.
I would also like to thank the Director and staff of Forest Bank for their full and ready
co-operation during the course of the investigation. I am especially obliged to one
particular prison liaison for her help liaising with my investigators.
The man was found to be unresponsive in his bed in the morning of his death. Staff
attempted resuscitation and he was immediately taken to hospital by ambulance.
His death was pronounced just over an hour later. At the time of writing, I have not
had sight of the post mortem examination but I am aware that a preliminary cause of
death has been recorded as natural causes which could have been due to a number
of the man’s illnesses.
Both the clinical reviewer and my investigator have concluded that the man received
a high level of care, which was comparable to that which he would have received in
the community.
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
Acting Prisons and Probation Ombudsman June 2011
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CONTENTS
Summary
The investigation process
HMP Forest Bank
Key events
Issues
Conclusion
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SUMMARY
Having been sentenced to two years imprisonment on 8 January 2010, for offences
he had committed in the 1960s, the man was taken to Forest Bank. Once assessed
by a nurse, he was immediately admitted to a ward in the healthcare centre due to
his serious medical conditions and age. He remained as an inpatient throughout his
time at the prison, aside from a period of a few days when he was moved to a
residential wing.
The man had been diagnosed with prostate cancer, oedema, angina, diabetes, heart
disease and chronic kidney failure among other conditions. He was prescribed a
number of medications and was already physically very frail when he arrived at the
prison. He was able to walk only short distances with the assistance of a Zimmer
frame.
Throughout his time at Forest Bank, the man’s wife visited him regularly and he also
had regular contact with his personal officer. He had frequent appointments at
outside hospital and his diabetes was treated by a specialist nurse in the prison. The
man was also monitored every day as his mental health deteriorated due to frequent
urinary infections. He was often confused, believing himself to be in hospital and his
wife to be in the building.
Due to urinary retention, the man had a catheter and he sometimes needed the help
of nurses. Prison staff also helped him with some of his daily living tasks. His
physical illnesses also meant he was at risk of falling, which he did with increasing
frequency. As a result, in June, he was moved from a single cell to a four bedded
ward where he had more space to move around.
The man was admitted to outside hospital on 18 June, as an emergency, after falling
over. Prison staff asked the rapid response team to assess the man to determine
what equipment he needed in the prison to assist him. He returned to the prison four
days later after a toilet frame had been installed in healthcare. The rapid response
team assessed him again on 28 June and more equipment was obtained to make
him comfortable.
In the morning of the eve of the man’s death, he was found to be unresponsive on
his bed. Staff immediately telephoned an ambulance and paramedics arrived a short
time later. They treated the man with glucose as they thought he had suffered a
hypoglycaemic episode (related to his diabetes). Following further medical checks,
he was considered fit enough to remain in the prison.
The following morning the man was again found by staff to be unresponsive. He had
stopped breathing and staff tried to resuscitate him. Their efforts continued following
his transfer to hospital in an ambulance but at 7.19am a doctor confirmed his death.
A debrief was held at the prison and the prison care team offered support to staff.
Both my investigator and the clinical reviewer conclude that the man received a level
of care comparable to what he would have received in the community. Staff made
good use of the resources they had and were very considerate of the man’s comfort
and health. Although the man’s wife was satisfied overall with the way she was
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treated, she asked why there was no one from the prison at the hospital to meet her
after her husband’s death. I believe this could have been handled more sensitively
and discuss this in the report. However, I make no formal recommendations.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 13 July 2010, when the investigator issued
notices to staff and prisoners. The notices announced the investigation and
included an invitation to those who wished to submit information related to the
man’s death to make themselves known to the investigator. No one came
forward as a result.
2. The investigator was given access to the man’s prison files, including the
medical record. She visited Forest Bank with another investigator on 10
August and interviewed one member of staff.
3. An independent clinical review of the man’s health needs whilst he was in
custody was carried out by a clinical reviewer on behalf of Salford Primary
Care Trust.
4. One of my family liaison officers wrote to the man’s wife on 21 July to advise
her of the investigation and invite her to raise any matters she wished to be
addressed. On 26 August, both my family liaison officer and my investigator
visited the man’s wife. She said that she had generally been treated very well
by the prison but she had three main concerns. She firstly wanted to know
why her husband was handcuffed when he was at the outside hospital.
Secondly, she asked why no one from the prison had waited for her arrival at
the hospital following his death, so she could better understand what had
happened that morning. Lastly, she wanted to know whether he had been
given the correct anti-cholesterol medication. This was because she was
aware that hypercholesterolaemia (high levels of cholesterol in the blood) was
listed on the preliminary post mortem report.
5. The man’s wife received a copy of the draft report as part of the consultation
process. I hope that the findings of my investigation address the initial issues
she raised and helps her to better understand the circumstances of her
husband’s death. His wife also made a number of observations after reading
the draft report to which I have responded by letter.
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HMP FOREST BANK
6. HMP Forest Bank accepts remand and sentenced adults and remand young
offenders from courts in North-West England. It is a category B prison. 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.
Category B prisoners are those for whom the highest security conditions are
not necessary but for whom escape must be made very difficult.
7. Forest Bank has an operating capacity of 1,424. It is privately run and has
been contracted to a private company, Kalyx, for 25 years. Forest Bank
Healthcare has a 20 bed in-patient facility, including two 4 bed wards and a 2
bed observation room. There is 24 hour nursing care and the general
practitioner (GP) service is provided by a local agency.
8. HM Chief Inspector of Prisons conducted an unannounced full inspection of
Forest Bank in September 2007. An unannounced full follow up inspection
took place between 29 June to 9 July 2010, in which the inspectorate found
that the standard of healthcare had improved since the previous inspection
and concluded, “Forest Bank is a good local prison and a number of
improvements were evident since our last inspection.”
9. An IMB is appointed to each prison by the Secretary of State for Justice. Its
members are independent of the National Offender Management Service
(NOMS) and the prison’s management team. Each IMB is required to
produce an annual report to the Secretary of State, highlighting good practice
and areas of concern.
10. Forest Bank’s latest IMB report covers the period December 2008 to
December 2009. The Board commented that it had been ten years since
Forest Bank first opened and they were impressed by the commitment of staff
to running a safe prison which reduced re-offending. However, they also
considered that there were problems with healthcare, particularly with
appointments to see the doctor, medication and prescriptions. They noted,
however, that waiting for routine appointments to see the GP had been
reduced.
11. NOMS is responsible for the management of prisons in England and Wales.
Every three months it publishes an assessment of each prison’s performance
against 34 measures. Prisons gain a rating of between one (serious
concerns) and four (exceptional performance). Forest Bank has scored three
(good performance) for the last four quarters.
12. The man’s death was the seventh to have occurred at Forest Bank since April
2004, when my office began investigating all deaths in prison custody in
England and Wales. Two of the previous deaths were due to natural causes,
two were self-inflicted, one was due to a drug overdose and one was a result
of injuries inflicted during an assault. There are no significant similarities
between these deaths and that of this man.
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KEY EVENTS
13. Having left school at the age of 14, the man joined the Territorial Army and
later served in the army during the Second World War. Once he returned
from active service in 1945, he became an apprentice joiner and continued
working in this profession until his mid-seventies. He married his wife when
he was 28 years old and had three children, one of whom died at the age of
33. Prior to his imprisonment, he had been retired for a number of years and
had regular contact with his two surviving children and five grandchildren.
14. On 8 January 2010, the man was sentenced to two years imprisonment at a
crown court for offences which he had committed in the 1960s. He had no
previous convictions and had therefore never been in prison before. He was
taken to HMP Forest Bank and arrived at 7.30pm that evening.
15. Following a routine reception healthscreen with a nurse, the man was
immediately admitted to ward three in healthcare because of his age and
physical condition. The nurse also referred him to a doctor the following day
for a more detailed assessment.
16. The man had several serious medical conditions. They included type two
diabetes (a metabolic disorder characterised by high blood glucose), oedema
(fluid retention) in both legs, prostate cancer, ischaemic heart disease
(reduced blood supply to the heart muscle) with angina (chest pain), chronic
kidney failure, an abdominal aortic aneurism (swelling of the aorta) and
pancytopenia (reduction in red and white blood cells). As a result he was
physically very frail and mainly confined to a wheelchair.
17. Having been assessed by the doctor, the man was prescribed aspirin (an
analgesic and anti-inflammatory), atorvastatin (to lower blood cholesterol),
isosorbide mononitrate (to treat angina by lowering blood pressure), nicorandil
(also to treat angina), omeprazole (to block the production of stomach acid),
glycoside (to treat heart failure) and ferrous sulphate (an iron supplement).
18. Throughout his time at Forest Bank, the man received regular visits from his
wife. At her request, she was allowed to visit him three times a week for an
hour, rather than weekly for three hours as was usually the case. (I judge that
this was a kind arrangement which was sympathetic to the couple’s age.)
19. A Prison Custody Officer (PCO) who worked in healthcare was the man’s
personal officer. (The personal officer scheme was introduced so that
prisoners are given a named officer that they can approach for advice or
assistance.) He met the man regularly to discuss any concerns. On 17
February, he noted that the man’s mental health had deteriorated due to a
urine infection and he had been having visual and auditory hallucinations.
The man sometimes believed that he was in hospital and his wife was there.
Healthcare staff continued to monitor his condition daily.
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20. On 19 February, the man moved from the healthcare centre to G1 wing to
create some space for another prisoner. However, he returned two days later
as he was not considered fit enough to remain on a normal residential wing.
21. At the request of the criminal appeal office, a consultant psychiatrist assessed
the man on 8 March. He noted that he was suffering from:
“Myelodysplasia resulting in anaemia and thrombocytopenia (meaning
that he has low haemoglobin causing fatigue and an increase risk of
bruising). Myelodysplasia is a pre-leukaemic condition of the bone
marrow. He has carcinoma of the prostate gland causing urinary
retention, for which he self-catheterises. He suffers from type 2
diabetes mellitus which is controlled through medication and diet. He
has a 6cm aortic aneurism and generalised osteoarthritis affecting his
back, hands and lower limbs. He also suffers from
hypercholesterolemia.”
The doctor concluded that these multiple physical health problems resulted in
him being physically frail and at risk of falling. He also assessed him as
“globally cognitively impaired, suggestive of a dementing illness of moderate
severity”.
22. On 31 March, the man’s appeal against his conviction was dismissed. Staff
spent some time explaining this to him to ensure that he understood the
implications of the verdict and how long he had left to serve at the prison.
23. A healthcare report completed by a registered mental nurse (RMN)
summarised the man’s healthcare at the prison. His diabetes was being
monitored by a healthcare specialist diabetic nurse. His oedema made it
difficult for him to walk, although he managed short distances with the aid of a
Zimmer frame. He had regular appointments with the psychogeriatrician (a
psychiatrist specialising in the treatment of elderly people) at outside hospital.
Due to urinary retention, the man had a catheter to allow for the withdrawal of
urine from his bladder and sometimes needed the help of nurses. Prison staff
also helped him with some of his daily living tasks.
24. The man’s mental state was compromised by frequent urinary tract infections.
He also fell over on a number of occasions due to his ill health. He had
occupied a single cell which allowed him to move about by holding on to
furniture. However, this also meant that he often tripped over due to the lack
of space. Therefore, in mid-June, healthcare staff decided to move him to a
four bedded ward to allow him more room to move around. He did not share
the ward with any other prisoners.
25. Regular safety assessments and care plans were completed and documented
in the medical record. For example, by June, this included encouraging the
man to get out of bed in the morning to encourage him to dress, wash and
take care of his catheter. Daily observations of his oedema and wound
healing were also made at the same time by healthcare staff. The man was
encouraged to move around the healthcare centre to promote his flexibility
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and balance, help with fluid management and improve his confidence and
motor skills. He was also supported to undress himself at night when further
healthcare observations were made.
26. On 18 June, at around 9.00am, the man was admitted to outside hospital as
an emergency. He had fallen over in the prison, could not stand up and
appeared confused and drowsy. Prison staff were concerned that he should
not be discharged from hospital unless he was able to walk independently.
They asked the rapid response team to assess the man and recommend
equipment to assist him in prison. As a result, he returned to the prison four
days later, once a toilet frame had been installed in the healthcare centre.
The discharge medication no longer included atorvastatin, which had been
used to treat his high cholesterol levels. The decision to withdraw this
medication is discussed later in the report.
27. On 28 June, the rapid response team made another assessment of the man
at the prison and ordered a pressure sore mattress, cushion and shoes to
assist in making him more comfortable.
28. In a healthcare update report, the registered mental nurse (RMN) wrote that
the outside hospital’s physiotherapy department had recently carried out a full
needs analysis regarding the man’s ongoing treatment needs. The report
concluded that generally he could undertake daily living tasks on his own and
could walk with limited assistance. A specialist elderly care nurse completed
a more comprehensive assessment at the prison including updating the
Waterlow assessment (to assist care and prevent bed sores and ulcers).
29. Healthcare staff tried to transfer the man to a specialist elderly unit at HMP
Wymott. However, this could not be accommodated as Wymott did not have
24 hour nursing care.
30. On the eve of the man’s death, at around 8.00am, healthcare staff noticed
that the man was unresponsive in his bed, with drooping on the left side of his
face. They immediately telephoned an ambulance. Paramedics arrived a
short time later and assessed that he had suffered a hypoglycaemic episode
(related to his diabetes) and therefore treated him with glucose so that his
condition improved. They also carried out an electrocardiogram to measure
electrical activity in the heart) and once the man was stabilised, paramedics
decided that he did not need to go to hospital. Staff decided to monitor his
food and drink intake to determine the reason for the recent hypoglycaemic
episodes, since this had not been the first one, although it was the most
serious.
The day of the man’s death
31. The man’s personal officer began his shift at 8.00pm on the eve of the man’s
death. Since he was aware of the man’s medical difficulties, he checked him
every hour throughout the night until 5.15am. A prison custody officer began
his shift at 6.00am on the day of the man’s death. During a handover
between the two officers, the prison custody officer that had just begun his
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shift noticed that the man’s side bed rail was not correctly adjusted. When the
officers went to investigate further they found that the man did not respond
and the prison custody officer who had just began his shift immediately called
a registered mental nurse (RMN) to him. The nurse could not detect a pulse
and the prison custody officer therefore called a “code yellow two” over the
radio, which meant that a prisoner was unresponsive.
32. Whilst the mental health nurse went to get the resuscitation bag and
defibrillator, a further nurse also arrived at the ward, collecting the emergency
bag on her way. (A defibrillator is a portable electronic device which
measures electrical activity in the body and advises on the action to be taken.)
The nurses attached the defibrillator to the man which advised that no shock
should be given. They immediately began cardiopulmonary resuscitation
(CPR). Other staff, including the night orderly officer and his assistant, who
were carrying radios Oscar One and Oscar Two, respectively, also arrived in
the ward. (The night orderly officer is in charge of the prison at night and
Oscar One and Two are the emergency response radios). At 6.13, Oscar
One used his radio to ask for an ambulance and the communications
department did so immediately. Further nursing staff attended. They
continued CPR on the man in rotation, so that no one became tired.
33. The paramedics arrived at 6.27am and continued CPR. The man was taken
by ambulance to outside hospital Accident and Emergency Department.
Following a routine risk assessment, he was escorted by two officers, without
any handcuffs.
34. The person in the prison who was carrying radio Victor One (which meant he
had managerial responsibility for dealing with any emergencies), arrived in the
command suite by 7.00am. Having been made aware of the man’s condition,
he telephoned the Prison Chaplain at home and asked him to go to the
hospital. Victor One told my investigator that he chose this chaplain as the
family liaison officer (FLO) as he was an experienced member of staff. He
was also the chaplaincy manager and had recent contact with the man and
his wife.
35. Hospital staff continued CPR until 7.19am, when a doctor pronounced the
man’s death. The Prison Chaplain arrived at 7.35am. He went to see the
man’s body, collected his personal belongings and then returned to the prison
with the two escort officers. On his arrival back in the prison, he telephoned
the man’s wife. He told her of her husband’s death and advised her to take a
taxi to the hospital. She did so and was met by the police. The Director wrote
a letter of condolence to the man’s wife later that day.
36. A debrief was held and the prison care team attended the healthcare
department and spoke to all the staff involved.
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ISSUES
Clinical care
37. The clinical reviewer concludes the following regarding the man’s clinical care:
“It appeared to be obvious from admission that [the man] had on-going
serious health concerns. During his stay at Forest Bank, [the man] had
been seen extensively by multiple members of the healthcare team on
an extremely regular basis. He had also been seen by specialist
clinicians including Haematology, Urology, Diabetes and Psycho-
geriatrics from secondary care services.
“He had attended on several occasions outside hospital both as an
inpatient and as an outpatient to address his multiple health concerns.
I note also that staff at Forest Bank had attempted to relocate [the man]
to a setting more appropriate to someone with severe health concerns.
However, this unfortunately could not be achieved as appropriate local
accommodation was not available. It would have been inappropriate to
place [the man] further afield as this would have made it very difficult
for his wife to visit him.
“I do not have any specific concerns regarding the immediate care prior
to death and the attempts at resuscitation … The care that [the man]
received was appropriate and would compare extremely favourably
with what he would have received in the community.”
38. The man’s wife asked whether he had been given the correct medication for
his high cholesterol levels. Having originally been prescribed atorvastatin
when he arrived at the prison, when the man was discharged from outside
hospital on 18 June, this medication was withdrawn by hospital specialists.
The clinical reviewer concludes that this decision was appropriate since statin
medications are linked to pancytopenia, with which the man had also been
diagnosed.
39. My investigator concurs with the clinical reviewer’s opinion and believes that
the man was afforded a good level of care which met his complex health
needs whilst at Forest Bank. A great deal of individual attention was given to
his health, comfort and welfare whilst at the prison.
Consideration for early release on compassionate grounds (ERCG)
40. Prison Service Order (PSO) 6000 says ERCG may be considered when
“a prisoner is suffering from a terminal illness and death is likely to
occur soon. There are no set time limits, but three months may be
considered to be an appropriate period. It is therefore essential to try
to obtain a clear medical opinion on the likely life expectancy. The
Secretary of State will also need to be satisfied that the risk of re-
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offending is past and that there are adequate arrangements for the
prisoner’s care and treatment outside prison.”
41. Although the man had multiple health concerns, he had not been diagnosed
with a terminal illness or given a likely life expectancy and therefore ERCG
could not be considered.
42. Staff tried to transfer the man to a specialist elderly unit at HMP Wymott, but
were unsuccessful since the prison did not have the necessary 24 hour
nursing care. The man’s wife visited her husband three times a week and it
would therefore not have been appropriate to consider a transfer to a prison
further away than Wymott. In the circumstances, I conclude that staff met the
man’s needs as best they could.
Family Liaison
43. The man’s wife asked why no one from the prison was at the hospital to meet
her, after she had been told of her husband’s death over the telephone. She
said that she would have appreciated speaking to a member of staff from the
prison about what had happened that morning before her husband was
admitted to hospital.
44. Victor One appointed the Prison Chaplain as the FLO as he was a Roman
Catholic Chaplain and had contact previously with the man and his wife. The
Chaplain had not been trained as a FLO and my investigator has not had
access to a family liaison decision log. Prison Service Order (PSO) 2700 has
supplementary guidance for FLOs. It says:
“Traditionally Governors have asked a Chaplain to break the news of a
death to a family. Chaplains are trained and experienced in
bereavement issues and are ideally suited to this task. There is
nothing in this guidance to prevent this practice continuing … It would
not usually be appropriate for a Chaplain to take on all of the tasks of
the Family Liaison Officer set out in this guidance document (returning
property, attending the inquest etc) and in drawing up their contingency
plans Governors should consider how to make best use of the
Chaplaincy team following a death in custody.”
45. The PSO goes on to say that a prisoner’s next of kin should be informed face
to face as soon as possible following their death and that:
“Using the telephone is too impersonal to use in delivering news of a
death to the family and should be used only as a last resort. There
may be no one nearby to support the family ... However the news is
broken and especially if this is not done face to face by the prison,
there should be an early follow up by the prison.”
46. Appointing the Prison Chaplain to break the news of her husband’s death to
his wife seems an appropriate decision in the circumstances. Given the
man’s ill health, I can also understand that it would have been difficult for the
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Prison Chaplain not to explain the circumstances of his call when he
telephoned the man’s wife. He advised her to take a taxi to the hospital which
was good practice. However, given that she was not told of her husband’s
death in person, it would have been preferable for someone from the prison to
meet her at the hospital, to offer support role as well as provide answers to
any questions. Furthermore a trained FLO should also have been appointed
to assist her, as per the above guidance. However, aside from not being met
at the hospital, the man’s wife said she had been treated well by the prison
and I make no criticism of the Prison Chaplain’s contact with her.
47. Although I do not make a formal recommendation in this regard, I suggest that
the Director ensures that staff appointed as FLOs are given the relevant
training and that appropriate support is offered to a prisoner’s next of kin.
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CONCLUSION
48. The man went into prison when he was elderly, with a number of serious
health concerns, already frail and largely wheelchair bound. He was
immediately admitted to the healthcare ward and, aside from brief periods of a
few days on a residential wing in the prison and a four day admission to
outside hospital, he remained there until he died around six months later.
49. Both the clinical reviewer and my investigator have found that the man
received a high level of care, which favourably compares to what he could
have expected to receive in the community. My investigation has found
several examples of sensitive arrangements being made for the man and his
wife, which I hope made their separation at the end of their marriage easier to
bear. I trust that the Director of Forest Bank will look sympathetically at the
comments of the man’s wife about the family liaison and so I do not make any
formal recommendations.
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