Individual at Durham

Investigation into the circumstances surrounding the
death of a man in September 2008
at a local hospital whilst
released on bail from HMP Durham
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2009
This is the report of an investigation into the circumstances surrounding the death of
a prisoner who had been released on bail from HMP Durham. I investigated the
circumstances of the man’s death under my discretionary powers.
The man died in September 2008 at a local hospital, where he had been an inpatient
for nearly three weeks. He was 68 years old. He had been in custody previously,
including three separate occasions in the course of 2008. I offer my sincere
sympathy and condolences to all those affected by his passing.
The investigation was carried out by my investigator. An independent review of the
man’s medical care was carried out by a clinical reviewer on behalf of the local
Primary Care Trust. I am most grateful to the clinical reviewer for his assistance.
I would also like to thank the Governor and staff of HMP Durham for their full and
ready cooperation during the course of the investigation. I am particularly grateful to
the liaison officers for their assistance to my investigators.
I make two recommendations, one of which repeats that made in a previous
investigation at Durham. I also highlight three examples 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.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2009
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CONTENTS
Summary
The Investigation Process
HMP Durham
Key Events
Issues
Recommendations and Good Practice
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SUMMARY
A man was remanded to HMP Durham in August 2008. He had been in prison
previously, including three separate occasions in 2008. The man was initially
located on the first night induction centre where he was assessed by prison and
healthcare staff. He had a long history of alcohol misuse but showed no symptoms
of alcohol withdrawal. However, his health was generally poor, and he had trouble
eating and had poor mobility.
The man remained on the first night induction centre for a week before moving to C
wing on 14 August. On 21 August, the man was moved to E wing because C wing
staff were concerned about his poor mobility and thought he would find it easier to
manage if located on the ground floor landing of E wing.
The following day (22 August), the man was seen by nursing staff who were worried
about his mental and physical condition and his inability to look after himself
properly. He was admitted to the inpatients unit where he could be helped to eat,
drink, wash and dress, with all of which he struggled.
The man’s physical and mental condition continued to deteriorate, and on 27 August
he was admitted to the local hospital. The prison’s healthcare team and the hospital
team agreed to keep the man in hospital for further assessments and medical care.
On 28 August, the Security Governor authorised the removal of the man’s restraints
because of his poor condition. The Security Governor instructed staff to “use
common sense” in their approach to restraining the man. He remained in hospital.
On 9 September, the County Court remanded the man in custody again until 30
September, pending a medical report. The report would address the question of his
fitness to attend court for sentencing. The same day the Consultant Respiratory and
General Physician at the local hospital wrote to the County Court and advised that
the man was not fit to attend.
Two days later, on 11 September, the court granted the man bail to “reside in
accommodation as directed by the local Primary Care Trust”. The man remained in
hospital but on bail and without prison officers present.
In the early hours of 15 September 2008, the man died on ward 6 at the local
hospital. The clinical team had taken the decision not to attempt resuscitation and
the man died peacefully. The Consultant Respiratory and General Physician said
the man died from multi-organ failure due to sepsis and chronic obstructive
pulmonary disease. (Chronic obstructive pulmonary disease is a disease of the
lungs in which the airways become narrowed, limiting the flow of air to and from the
lungs and causing shortness of breath.) Post mortem examination was not
requested by the Consultant Respiratory and General Physician. The Coroner was
informed of the man’s death but decided not to make any enquiries.
The man was aged 68 and in very poor health. He had misused alcohol over a
number of years, which sadly contributed to his death. Prison staff knew him to be a
quiet man who kept his own company but had a dry sense of humour. My
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investigator found that he had received impressive and humane care from a number
of prison staff in his last period of custody. This had provided him with some comfort
and dignity as he neared the end of his life.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 23 September 2008 when my investigator,
issued notices announcing the investigation to the staff and prisoners of HMP
Durham. The notices included an invitation to those who wished to contribute
to the investigation to make themselves known. No prisoners came forward
but a senior prison officer who had cared for the man asked to speak to my
investigator.
2. My investigator made a preliminary visit to the prison on 3 October. He met
the governing Governor, the chair of the local branch of the Prison Officers’
Association, and the Safer Custody Officers who had been deployed to assist
my investigator as his liaison officers. Unfortunately, it was not possible to
meet the chair of the Independent Monitoring Board (IMB) who left a note
explaining that the IMB at Durham had not been involved with the man and
had not received any applications from him. (The Prisons Act 1952 requires
every prison to be monitored by an independent board appointed by the
Secretary of State for Justice from members of the community in which the
prison is situated. The Board must satisfy itself as to the humane and just
treatment of those held in custody within its prison.)
3. My investigator made a tour of the prison to see where the man had been
located and met the healthcare team and wing staff. My investigator spoke
with a number of staff, which gave him the opportunity to learn about the man
as an individual, about aspects of his care and custody, and to see first hand
the custodial and care environment. He talked to the nurses about how
nursing care was organised in the inpatients unit in relation to the man.
4. My investigator was given access to the man’s prison and clinical records and
reviewed these by constructing a chronology of significant events. He
reviewed all relevant prison and clinical documents available, which included
the inmate locations log, EMIS (the information technology system that
healthcare staff use to record clinical information about prisoners), first night
induction and first reception health screening assessments, the cell sharing
risk assessment, clinical assessments and clinical records, escort and
bedwatch risk assessments, bedwatch log reports, court orders, and
correspondence between professionals about the man’s care.
5. My investigator returned to Durham on 12 and 13 November and interviewed
a number of prison staff who were involved in caring for the man. He
interviewed Senior Officer (SO), Principal Officer (PO), Security Governor,
Clinical Director, a prison doctor, a Mental Health Lead, two prison officers
and 2 prison nurses.
6. The local Primary Care Trust commissioned an independent medical
practitioner to carry out a review of the man’s medical care. I am grateful to
the clinical reviewer for carrying out the review expeditiously.
7. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to discuss the case with the responsible
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coroner’s officer. A post mortem was not requested by the man’s Consultant
Respiratory and General Physician at the local hospital, and the coroner’s
officer told my investigator that the Coroner would not be investigating this
case.
8. One of my Family Liaison Officers contacted the man’s sister on 20 October
2008. This gave the man’s family the opportunity to discuss the purpose of
the investigation and to raise any concerns or questions. The man’s sister
raised the following issues that she wanted the investigation to address:
(cid:127) The family wanted to know why they had not been notified earlier that the
man was ill and in hospital.
(cid:127) She could not understand how the man had become ill so quickly,
particularly as she had seen him just a few weeks previously and, although
somewhat confused, he had appeared to be in good health.
(cid:127) She confirmed that the few belongings the man possessed had been
returned, but she was surprised to see only a bus pass and a photo in his
wallet. The man’s sister wondered where his pension book and bank
cards were.
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HMP DURHAM
9. Durham is a local prison which serves the courts and areas of Tyneside and
Cumbria and houses sentenced, convicted and remand male prisoners over
21 years old. Built in the early 19th century, it has been undergoing a major
refurbishment programme during the last ten years. The prison has an
operational capacity of 981 prisoners and has seven wings, plus healthcare
and segregation. All cells have integral sanitation and in-cell electricity.
10. The local Primary Care Trust commissions and provides primary care health
services and Tees, Esk and Wear Valley NHS Trust provides specialist
mental health services. There is 24 hour healthcare provision, which includes
a clinical director and a general practitioner, supported by a primary care
nursing team. Inpatient facilities in the prison are located on E wing, although
when the man was there the inpatients unit had been temporarily relocated to
B1 wing because of re-wiring work in the Healthcare Centre.
11. Since 2004, my office has investigated eight deaths due to natural causes at
Durham. There was no link between the circumstances surrounding this
investigation and the previous deaths.
12. Her Majesty’s Chief Inspector of Prisons last inspected Durham in September
2006. The inspection found that the new management team was “driving
forward some significant and much needed improvements,” that “relationships
between staff and prisoners were good,” and that the prison was an
“improving establishment”.
13. The Independent Monitoring Board’s report for 2006/07 said that healthcare
staff provided “high quality healthcare” but the Board were concerned at the
“continued failure of the Prison Service to invest in a new Healthcare Centre
for HMP Durham”. The report’s executive summary said that, “HMP Durham
operates under a range of severe constraints. These relate particularly to the
fact that the predominantly Victorian buildings are tightly confined within the
city centre site which provides little scope for improvement” When my
investigator visited Durham the re-wiring work had been completed the
previous weekend, so staff and prisoners had been able to return from B wing
to the Healthcare Centre.
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KEY EVENTS
14. On 6 August 2008, the local County Court remanded the man into custody
because he had breached a court order from 7 July prohibiting him from
entering a specified address and the area surrounding that address. The man
was taken into the custody of Durham Constabulary. Later that evening he
was examined by a police doctor who found that he had a “significant alcohol
history but no evidence of withdrawal, no treatment required”.
15. The next day, on 7 August, the man was received at HMP Durham and
initially located on E wing, which is the first night, induction and initial
assessment unit. He went through the usual reception process and was seen
by first night officers and reception nurses who carried out first night induction
and initial assessment, cell sharing risk assessment, health screen
assessment and housing assessment. The man told reception staff that his
mother was his next of kin but he had not seen her for some time.
16. My investigator found that the first reception health screen documents had
been only partially completed. In interview, the nurses who undertake
reception duties explained the health screening process. The registered
nurse interviews each new prisoner and partially completes the first reception
health screen document, whilst a healthcare assistant inputs more detailed
clinical information into the clinical IT system (EMIS). This was the case when
the first reception health screen was completed for the man.
17. The man had a long history of alcohol misuse and dependence but did not
show any signs or symptoms of alcohol withdrawal when received into prison.
His past medical history was not identified at the first reception health screen
at any of the man’s three admissions into Durham during 2008 (on 5 June, 25
July or 7 August). The clinical IT system (EMIS) stores prisoners’ medical
histories and clinical information from previous periods in custody, but the
nurses did not search his electronic clinical record to source relevant
information about the man’s past medical history and particularly his history of
alcohol misuse.
18. The health assessment identified that “due to age has limited mobility”, but no
specific healthcare issues or alcohol problems were identified at this point by
either the first night induction staff or healthcare staff. When my investigator
interviewed medical staff, they confirmed there were no signs of alcohol
withdrawal or related problems. The clinical reviewer, has found that, “his
alcohol problem was not clear at his reception on 7 August. He showed no
signs of alcohol withdrawal thereafter and the problem only came to light
when the GP records became available – too late for any action by the prison
team.”
19. On 7 August, the reception nurses completed the health screen assessment
documents. They also inputted the same information and additional clinical
information into EMIS (as described in paragraph 19 above). The clinical
record documents that the man had trouble eating and drinking, had poor
mobility and a history of alcohol misuse.
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20. The man remained on E wing for a week before moving to C wing on 14
August. A week later, on 21 August, the man moved to E wing because C
wing staff were concerned about his poor mobility. They thought that he
would find it easier to manage if he was located on the ground floor landing on
E wing. The man’s health and general condition quickly deteriorated, and he
was seen by the nurses and referred to the Clinical Director and the prison
doctor for further examination.
21. On 22 August, the man was seen by a Staff Nurse who found that he was
“disorientated in time, place and person and was living in squalor with non-
existent self-care” in his cell. Food left uneaten from the previous day was
found in the cell. The Staff Nurse arranged for the man to transfer
immediately to the inpatients unit for observations and care. He was admitted
to the inpatients unit on B1 wing, which was temporarily being used for
inpatient beds because the Healthcare Centre was being re-wired at the time.
Nursing staff helped him to eat, drink, wash and dress, as he struggled to do
this for himself.
22. The man was due to appear at the local County Court on 26 August but, after
the Staff Nurse saw the man in reception, she wrote to the court to say he
was unfit to attend. He was returned to B1. The court adjourned sentencing
and he was remanded in custody until the next hearing, scheduled for 9
September.
23. The man’s physical and mental condition continued to deteriorate and, on 27
August, he was admitted to the local hospital. The prison’s healthcare team
and the hospital team liaised and agreed that he should remain in hospital for
further assessments and medical care.
24. The Clinical Director wrote to the man’s hospital doctor on 27 August, saying
that the prison medical team considered the man “might be at the start of a
dementia; he is confused, disorientated and incontinent of urine and faeces”.
The Clinical Director had by this time received medical history summaries
from the man’s GP in the community. The clinical reviewer has found that,
“there was some difficulty in retrieving these records, as he had not been
registered with a GP at all for one year. They did not become available to the
clinical team until after his admission to hospital.”
25. The Clinical Director wrote a second letter on 27 August outlining the relevant
clinical information that he had just received from the GP. The information
from the GP was that the man suffered from:
“chronic obstructive pulmonary disease, but did not appear to
have been on recent treatment, essential hypertension, his
blood pressure noted to be of the order of 136/89 and no
medication, past history of heavy alcohol usage although he did
appear latterly (2006 onwards) to cut down on this; at one time
was noted he was drinking 122 units per week, in November
2003 his haemoglobin was noted to be 9.9; he appears to have
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been treated with ferrous sulphate but there does not appear to
have been any investigation of this”
26. This is medical information which makes reference to the man’s blood
pressure, his red blood cell count, and the medication he was given to help
his medical problems arising from heavy alcohol use.
27. The prison’s Security Governor authorised the removal of restraints on 28
August because of the man’s poor condition. Two officers continued to
provide an escort for the man and also assisted with his personal care, such
as at mealtimes. The Security Governor instructed staff to “use common
sense” in their approach to restraining him. An entry in the bedwatch log for
the same day recorded that the man had “lashed out” when female nurses
attended him.
28. The man’s condition remained poor over the following days but restraints
were not re-applied by prison staff. On 4 September the Principal Officer
undertook a routine “management check”, as is required when a prisoner is
on a hospital bedwatch. The Principal Officer wrote to the Security Governor
to report that the man was:
“lying on a pressure relieving bed, was doubly incontinent; two
nurses were attending to him; could not sit up in bed; appeared
very frail; had lost weight, around seven stone; skin showing
signs of pressure sores around the ankles and elbows. Staff
reported that the man had been asleep for most of the day; not
able to communicate more than an occasional few words which
were often inappropriate. He was in a confused state but could
respond to simple commands; deteriorating health. Not likely to
be fit for court proceedings or adjudication for foreseeable
future; is not mobile; is not presenting an immediate risk to staff,
patients or the public in the current nursing environment; not
currently able to contact any victimised parties or those subject
to restraining order.”
29. The Principal Officer recommended to the Security Governor that, “bail may
be considered as appropriate considering the man’s current physical and
mental state and his restricted access to the victim of his offences. A
multidisciplinary case review needed to consider the possibility of long-term
elderly mentally ill care.”
30. On 5 September, the local County Court decided that the hearing on 9
September would be cancelled and that the man’s solicitor should file a report
from a doctor about his fitness to attend court for sentencing.
31. The Security Governor also wrote on 5 September to the Governor and
requested permission to pursue an application for bail, “as he [the man] is
extremely unwell at present … As he is a remand prisoner, I have no option
other than to man the hospital with two staff 24 hours per day … His condition
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would not allow him to get off his bed without assistance.” The Security
Governor could not obtain either probation or legal advice at that time.
32. Over the course of the next few days the nurses and prison officers continued
to look after the man. Prison staff noted in their bedwatch log during the
second week of September that he was restless or sleeping for much of the
time. He was also very agitated at times, and refused to cooperate with
nursing care or take his medication. On some occasions he was aggressive
and needed to be restrained by prison staff.
33. The Security Governor asked the court to clarify the man’s custodial status
from 9 September because the court date had been cancelled and the prison
needed legal authority to continue detaining the man. The same day, the
local County Court remanded the man in custody until 30 September, pending
a medical report to address the question of his fitness to attend court.
34. The man remained in the local hospital. Bedwatch prison staff wrote in their
reports during the second week of September that he was “very agitated, not
sleeping, deteriorating, drip fitted, refusing to drink, and not communicating”.
Hospital staff explored options to provide care for the man in the longer term,
but thought that was not possible to arrange a nursing home placement if he
remained in custody.
35. On 10 September the prison’s Mental Health Lead and Staff Nurse visited the
hospital to review the man’s condition. They received a comprehensive hand-
over from the ward sister. They noted that there had been, “significant
deterioration in the man’s condition that morning, potentially life threatening.
He remained in a frail and poorly condition, receiving oxygen therapy and
intravenous fluids, unable to mobilise, receiving direct care from his bedside.”
The prison’s Mental Health Lead requested a brief medical report from the
hospital team to summarise the man’s condition, his care and his treatment
needs. The prison’s Mental Health Lead also noted that the two bedwatch
prison officers demonstrated a “high level of professionalism, care and
empathy”, for example he observed one “officer encouraging and assisting the
man with his drink and lunchtime meal”. The prison’s Mental Health Lead
described how the prison staff’s kindly assistance and interaction promoted
the man’s comfort and dignity during his last few days.
36. Prison and hospital staff continued to liaise. On 10 September, hospital staff
told prison healthcare staff that the man’s blood pressure, blood glucose and
oxygen saturation levels were poor, and they were concerned that he might
be dying. The hospital staff asked the prison for permission to contact the
man’s next of kin so that the issue of resuscitation could be discussed with
them. The hospital consultant ultimately took the decision not to attempt
resuscitation.
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37. The Consultant Respiratory and General Physician at the local
hospital wrote to the local County Court on 11 September to advise
that the man was not fit to attend court. The prison doctor and the
Consultant Respiratory and General Physician noted their “clinical
impression that the man is suffering from dementia as [they] could
find no evidence of malignant disease”. It was recorded that the
man was “still not eating and required a lot of care from nursing
input”. The hospital intended to have the man assessed by a
psychiatrist specialising in the care of older people. The Consultant
Respiratory and General Physician reiterated that prison “is not a
suitable place for the man at the present time”.
38. The same day (11 September), following successful representations by the
Security Governor made directly to the judge, the local County Court granted
the man bail to “reside in accommodation as directed by the local Primary
Care Trust (hearing listed for 15 September to remain on list) as set out on
the court order”. Later that day, a second Senior Officer arrived at the
hospital with the relevant bail papers but the man was unable to sign them
due to his poor condition. The bedwatch was discontinued from this point and
the man remained in the hospital on bail.
39. Four days later, on the morning of 15 September, prison healthcare staff
received a telephone call from ward 6 at the hospital to tell them that the man
had died peacefully during the early hours of that morning. The man had
been in hospital for nearly three weeks.
40. Two days after the man died, the Consultant Respiratory and General
Physician wrote to the Clinical Director at HMP Durham, with the medical
summary of the man’s case:
“68 year old man was admitted to UHND from prison for severe
confusion, general deterioration and weight loss; severely ill; evidence
of severe sepsis, hyponatraemia and hypoalbuminaemia; ultrasound
and T scans showed gallstones and paralytic ileus, but no evidence of
cancer; severely under nourished; deficient in B12 and folic acid;
treated with blood transfusion, broad spectrum antibiotics, multiple
vitamin replacement and (shortly before death) had cortisone, but
deteriorated inexorably. Decided not to attempt resuscitation by other
means. He died peacefully, and post mortem examination was not
requested.”
41. The prison staff that cared for the man were supported by the prison’s care
team. The bedwatch officers were commended by the Governor for their care
and support of the man.
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ISSUES
Clinical care
42. As noted earlier, the clinical review was conducted by the appointed clinical
reviewer on behalf of the local Primary Care Trust. The clinical reviewer
concludes that:
“The man was suffering from multiple pathologies and he deteriorated
and died very rapidly. It is likely that his mental state had been
deteriorating for some time (months at least, possibly years) before his
admission to prison. His poor physical health probably resulted, at
least in part, from his lack of self-care due to mental infirmity and
chronic alcoholism. (It is possible that his intellectual deterioration and
its accompanying aggression contributed to his offending behaviour.)
The early symptoms of dementia are very difficult to recognise,
particularly in the absence of information from relatives or carers and I
do not consider that, if present, they would have been easy to spot
during his very brief stay on remand in 2007. His alcohol problem was
not clear at his reception on 7 August 2008.
He showed no signs of alcohol withdrawal thereafter and the problem
only came to light when the GP records became available – too late for
any action by the prison team.”
Durham’s healthcare team
43. The man suffered from numerous and serious health problems. I judge that,
as soon as the man’s needs were recognised by the prison’s healthcare team,
he received competent and timely care throughout his remaining time in
custody at Durham. After admission to hospital, the prison’s healthcare team
continued to work with hospital staff to ensure that his needs were met as well
as possible. All of this was good practice. This conclusion is supported by
the clinical reviewer in his independent clinical review.
Completion and recording of clinical information on reception
44. My investigator found that the first reception health screen documents were
only partially completed and were not of the required standard. The nurses
explained that during the health screening process, a registered nurse
interviews the prisoner and partially completes the first reception health
screen document, whilst a healthcare assistant inputs more detailed clinical
information directly into the clinical IT system.
45. Although the man had a long history of alcohol misuse and dependence, he
did not show any signs or symptoms of withdrawal when he arrived at
Durham. His past medical history had not been identified at the first reception
health screen by the nurses on any of his previous admissions during 2008.
The clinical IT system stores prisoners’ medical histories and clinical
information from previous custodial episodes, but reception nurses did not
scrutinise the man’s electronic clinical record to retrieve relevant information
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about his medical history, especially his history of alcohol misuse and
dependency.
The Head of Healthcare at HMP Durham should review procedures to
ensure that all clinical and health information is accurately and
comprehensively recorded on one integrated system so that a
prisoner’s medical history can be retrieved during the first reception
health screen.
Meal checking system
46. On 22 August, the man was seen by a Staff Nurse who observed that he was
“disorientated in time, place and person and was living in squalor with non-
existent self-care” in his cell. Food left uneaten from the previous day was in
the man’s cell. I made a recommendation following a previous death in
custody investigation at Durham in December 2007 that a “meal checking
system” should be implemented by September 2008. A meal checking
system was subsequently established but this should include closer
monitoring of whether food is eaten, especially in relation to vulnerable,
disabled or elderly prisoners.
The Governor should ensure that my recommendation in a previous
investigation in December 2007 is fully implemented with a meal
checking system fully established.
Contact with the man’s family
47. Although the man was in hospital for nearly three weeks, his health
deteriorated quickly in the last few days. The prison’s healthcare team and
prison management were unable to confirm for my investigator the date when
they contacted the man’s sister.
48. The clinical reviewer has confirmed the prison doctor’s assessment that the
man, “was suffering from multiple pathologies and he deteriorated and died
very rapidly. It is likely that his mental state had been deteriorating for some
time before his admission to prison. His poor physical health probably
resulted, at least in part, from his lack of self-care due to mental infirmity and
chronic alcoholism.”
The man’s property
49. The man’s wallet and other personal items were given in a sealed packet to
his sister by the prison’s Safer Custody Liaison Officer after the funeral. After
further checks, the prison confirmed that there was no more property at the
establishment which belonged to the man. I regret that I am unable to provide
any more information to alleviate the family’s concern.
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Conduct of the officers on bedwatch duty
50. I believe that Bedwatch Officers demonstrated a high level of professionalism
and care towards the man. This included encouraging and assisting him to
eat and drink and remain safe and comfortable whilst in hospital, and also
ensuring that the hospital nurses were fully assisted while attending to him.
This kindly assistance and interaction promoted the man’s comfort and dignity
during his last few days.
Conduct of the Security Governor
51. I have judged that the Security Governor showed a high level of
professionalism and leadership. This was demonstrated by his authorising
the removal of the man’s restraints because of his poor condition and
instructing staff to “use common sense” in their approach to restraining the
man and through making representations directly to the judge to request that
bail was granted.
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RECOMMENDATIONS
1. The Head of Healthcare at HMP Durham should review procedures to ensure
that all clinical and health information is accurately and comprehensively
recorded on one integrated system so that a prisoner’s medical history can be
retrieved during the first reception health screen.
Durham have accepted this recommendation. A clinical IT system is in place
and the introduction of a new clinical IT system (SystemOne) is under
negotiation.
Reception screening tool templates have been developed and are being fully
implemented. The target completion date for this is July 2009.
2. The Governor should ensure that my recommendation in a previous
investigation in December 2007 is fully implemented and a meal checking
system is fully established.
GOOD PRACTICE
Durham’s healthcare team
1. As soon as the man’s needs were recognised by the prison’s healthcare team
he received proactive, competent and timely care throughout his remaining
period of custody at Durham before he was admitted into hospital. The
prison’s healthcare team continued to work with hospital staff to ensure that
the man’s needs were met as best and as fully as practicably possible.
Conduct of the officers on bedwatch duty
2. The Bedwatch Officers demonstrated a high level of professionalism and care
towards the man. This included encouraging and assisting the man to eat
and drink and remain safe and comfortable whilst in hospital, and also
ensuring that the hospital nurses were fully assisted while attending to him.
This kindly assistance and interaction promoted the man’s comfort and dignity
during his last few days.
Conduct of the Security Governor
3. The Security Governor showed a high level of professionalism and leadership.
This was demonstrated by his authorising the removal of the man’s restraints
because of his poor condition and instructing staff to “use common sense” in
their approach to restraining the man and through making representations
directly to the judge to request that bail was granted.
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