Individual at Glen Parva

Investigation into the circumstances surrounding
the death of a man in February 2007
at Queen’s Medical Centre, Nottingham,
whilst in the custody of HMP Glen Parva
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2010
This is the report of an investigation into the circumstances surrounding the death of
a man in February 2007 at the Queen’s Medical Centre in Nottingham. At the time,
the man – who was originally from Somalia – was a prisoner in the custody of
HMYOI Glen Parva. He had transferred from HMYOI Feltham to Glen Parva three
days earlier.
The man had complained of headaches and eye pain for several weeks and was in
severe pain when he collapsed in the holding room on unit 15 at Glen Parva in
February. He was taken to Leicester Royal Infirmary, and was subsequently
transferred to the Queen’s Medical Centre where he underwent surgery on the same
day. After a series of post operative tests, he was diagnosed with brain stem death.
He died at 11.10am. He was only 19 years old. The cause of death was determined
to be bleeding in the right side of his brain, caused by a ruptured ‘Berry aneurysm’.
The underlying cause of this type of aneurysm was most likely a congenital
weakness. In other words, he would have been born with an abnormal set of blood
vessels at the base of his brain.
.
I would like to extend my sincere condolences to the man’s family. To lose a family
member when they are as young as he was is difficult enough. That he died whilst
he was being held in custody only compounds the grieving process.
I must also apologise for the long, and frankly inexcusable, delay in issuing my
report. The investigation was originally led by one of my investigators. At the
request of the Coroner, work was suspended whilst expert neurological reports were
completed and a separate police investigation was conducted. Another of my
investigators then reopened the investigation in November 2007. She subsequently
left my office, having been unable to complete her inquiries. I am therefore grateful
to a third investigator who resumed the investigation in November 2008.
At the beginning of the process, I asked one of my family liaison officers to contact
the man’s family. She has remained in touch with the family’s solicitor and has twice
met the man’s relatives, alongside the first and third investigators, in March 2007 and
January 2009 respectively. I trust that, within this report, I have responded to all the
questions that the family have raised.
Also at the start of my investigation, I asked the local Primary Care Trust to
commission a clinical review of the treatment that the man received in custody. (The
principal purpose of the clinical review was to assess whether the care he received
was equivalent to that he could have expected in the community.) I am grateful to
the clinical reviewer for completing his review, which is annexed to my report. He
judges that, on the balance of probabilities, the man’s death could not have been
prevented. However, he expresses concern at some failures by healthcare staff at
both Feltham and Glen Parva.
I would like to thank the Governor of Glen Parva for appointing a liaison officer to
assist with my investigation. I am similarly grateful to the staff and management at
Glen Parva and Feltham for their co-operation.
My report includes six recommendations. I endorse a further six recommendations
made by the clinical reviewer. I am disappointed that two of these repeat those I
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have made in previous reports on deaths at Glen Parva. I draw this matter to the
attention of the Director of Offender Health as well as to the Chief Executive of the
Primary Care Trust.
My investigations into deaths from natural causes frequently raise as many issues as
those I conduct into self-inflicted deaths. This is certainly true here.
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 February 2010
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CONTENTS
Summary
The Investigation Process
HMP Feltham
HMP Glen Parva
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was born in Somalia in 1988. He came to the UK in 2002. In October
2006, he was remanded into custody by the Magistrates Court following his arrest for
two offences against the person. He was transferred to HMYOI Feltham after his
court appearance.
A fortnight later, the man transferred to HMYOI Glen Parva due to overcrowding at
Feltham. In October he received an Incentives and Earned Privileges (IEP) warning
because he had kicked his cell door. He was involved in a fight with another
prisoner in November. He sustained a fracture to his thumb during this fight, for
which he received treatment at the Leicester Royal Infirmary. He was subject to an
adjudication (prison disciplinary hearing) as a result of his behaviour.
The man assaulted an officer in December 2006 and was restrained by staff. He
was again subject to the adjudication process as a result. A nurse confirmed that he
had not been injured during the control and restraint procedure. In December and
January 2007, he reported suffering from headaches and was prescribed
paracetamol.
The man appeared at Crown Court in London in January 2007. He had been
reluctant to attend court, and received another IEP warning because of his refusal
earlier that morning. After his court appearance, he returned to Feltham. He then
returned to Crown Court for another hearing in January.
In January, the man was treated for a sore throat and neck ache. Four days later he
was prescribed paracetamol after complaining of a headache. The same month, he
felt faint and vomited in the prison gym. He was assessed by a doctor, and a nurse
checked on him later that day. During the course of January he reported a series of
headaches and was prescribed paracetamol on each occasion by three different
members of nursing staff.
It was thought that the man was experiencing a migraine at the end of January and
he was prescribed ibuprofen. In the early hours of in February, he told a nurse that
he had a severe headache and eye pain. He was referred to the doctor. During the
doctor’s examination later that day, the eye pain was not recorded or treated. It is
unclear whether he told the doctor about it.
The man was due to be transferred back to Glen Parva for a second time in
February, once again as a result of overcrowding at Feltham. However, he initially
refused to transfer and had stripped his clothes off. Officers used control and
restraint procedures to move him to the reception area. Once in reception he began
to co-operate. A nurse assessed him following the use of restraint and reported that
he had no injuries. She went on to authorise his transfer to Glen Parva. The nurse
claimed that she had spoken to a doctor to agree the transfer, but a subsequent
investigation revealed that she had not done so.
The man settled into unit 15 at Glen Parva after he arrived and shared a cell with the
young man with whom he had transferred from Feltham. He felt increasingly unwell
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overnight, and in the morning told an officer that he was experiencing a headache
and a pain behind his right eye.
The officer became increasingly concerned about the man and made two telephone
calls to staff in the healthcare centre in February. Despite the officer describing his
symptoms accurately, nursing staff did not come to the unit to assess him that day
as they were asked to do.
One morning in February 2007, the officer’s concern for the man escalated because
he was visibly suffering and in greater pain. She made two further phone calls to the
healthcare centre in an attempt to have him examined. At 10.30am, a senior nurse
performed a brief assessment of him in the entrance to his cell and gave him some
painkillers. She considered that he could wait to be examined by a doctor that
afternoon.
The man was unlocked after lunch and asked to wait in the unit’s holding room en
route to being taken to his appointment with the doctor. He collapsed in this room at
1.50pm. Healthcare staff arrived within five minutes, and an ambulance was called
at about 2.00pm. He was taken to Leicester Royal Infirmary where he underwent a
scan.
It was decided that the man needed surgery, and he was transferred to the Queen’s
Medical Centre in Nottingham later that afternoon. Surgery to remove a haematoma
(large blood clot) was performed shortly after his arrival. He was moved to the
Intensive Care Unit (ICU) and his family arrived during the night. However, he did
not recover, and he was pronounced dead at 11.10am. The cause of death was a
bleed in his brain as a result of a ruptured aneurysm.
My investigation has identified failings by healthcare staff at both Feltham and Glen
Parva. Whilst the clinical reviewer judges in his clinical review that, on the balance
of probabilities, the man’s death was not preventable, it is clear that certain staff
failed to carry out their duties as they should have done. The man’s family have
raised a number of other concerns about his time in custody which I address in my
report.
I make six recommendations, including one asking that consideration be given to a
disciplinary investigation into the actions of the senior nurse. I also endorse six
recommendations made by the clinical reviewer.
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THE INVESTIGATION PROCESS
1. The investigation was initially opened by an investigator in February 2007.
Notices were issued to both staff and prisoners at Glen Parva informing them of
the investigation process. They were given the opportunity to contact my
investigator if they felt that they could assist in providing any relevant
information.
2. In February, the investigator was asked to suspend his investigation by the
Leicestershire Constabulary whilst neurological reports were completed at the
Coroner’s request. The police completed their enquiries, and in November
2007 I appointed another investigator to continue the work. Unfortunately, she
was unable to see the investigation through to its conclusion before she left my
office in September 2008. Another of my investigators resumed the
investigation in November 2008. I must repeat what I have said in my foreword:
I sincerely regret the very long delay in issuing this report.
3. The original investigator wrote to the local Coroner’s office in February 2007 to
inform them of the nature and scope of my investigation, and to request a copy
of the post mortem report. HM Coroner will receive a copy of my report.
4. The clinical reviewer was appointed by the local Primary Care Trust to carry out
a review of the medical treatment which the man received at both Feltham and
Glen Parva. His review was somewhat delayed by the police investigation
conducted in 2007. He conducted interviews with staff at both Glen Parva and
Feltham in the spring of 2008. His report was received by my office in
September 2008.
5. One of my family liaison officers contacted the man’s family shortly after I
opened the investigation. She explained her role and that of my office and
provided information about the investigation process. She also gave the man’s
family the opportunity to meet and discuss their concerns. Both the family
liaison officer and the original investigator met his family in March 2007.
6. The family liaison officer subsequently wrote to the family to provide further
information and to acknowledge the concerns which had been highlighted
during their initial meeting. I trust I have answered these concerns within my
report. I also hope that my investigation gives the family a better understanding
of the events leading up to his death.
7. The family liaison officer met the man’s family again in January 2009, alongside
the third investigator and one of my Assistant Ombudsmen. They explained to
the family the reasons for the delay in issuing my report.
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HMYOI FELTHAM
8. Feltham is a young offenders institution (YOI), located in west London. It has a
maximum operational capacity of 764 remand and sentenced prisoners.
9. The YOI accommodates young people aged from 15 to 17 years who cannot be
held in secure local authority accommodation, and young adults aged between
18 and 21 years. They generally come from either London or the south east of
England. The majority of the accommodation at Feltham is in single cells.
10. Locked complaint boxes are located on each unit to allow prisoners to make
complaints. There are also two race relations managers in post at Feltham, as
well as an equal opportunities manager. Like all Prison Service establishments,
Feltham has implemented an anti-bullying policy.
11. My office has been responsible for the investigation of all deaths in prison
custody since April 2004. Since that time, no prisoners have died at Feltham.
12. The provision of healthcare at Feltham is the responsibility of Hounslow Primary
Care Trust. They commissioned Serco, a privately run company, to deliver
primary healthcare and the arrangement has been in place for the last three
years. There is a member of nursing staff on site at Feltham who can deliver
healthcare 24 hours a day. During the period when the man was at Feltham, a
doctor attended between 9.00am and 5.00pm from Monday to Friday, and
between 9.00am and midday at weekends. At other times, an out of hours
service was available, just as it would be in the community.
13. HM Chief Inspector of Prisons completed her most recent inspection of Feltham
between 4 and 8 June 2007. She found that:
‘Feltham has benefited from strong management, considerable investment
and protection from some of the more damaging effects of overcrowding.
Overall, staff have responded well, and it is a long way from the establishment
described … in the Mubarek inquiry.’
(The Mubarek inquiry refers to the death of a young man who was killed by his
cell mate. The tragedy exposed significant failings at Feltham.).
14. I have reviewed the report issued by the Independent Monitoring Board (IMB) at
Feltham relating to 1 November 2006 to 31 October 2007 and covering the
period when the man was there. (The IMB at each prison is made up of
members of the public who are both independent and unpaid. They monitor the
day-to-day life in their local prison and ensure that proper standards of care and
decency are maintained.) The IMB report indicates that the percentage of
prisoners from a black and minority ethnic background during this 12 month
period was consistently above 60 per cent. The Board recognises the progress
made at Feltham, but also expresses concern that the pressures experienced
by the prison estate as a whole may impact on those improvements:
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‘Given the recent rises reported in the number of deaths in custody nationally,
we take the opportunity of our annual report to [refer to] … the significant,
additional risks faced by Feltham given its high proportion of Foreign
Nationals, the number of prisoners on remand, their mental health needs, and
age profile …’
15. As regards the provision of healthcare at Feltham, the IMB says:
‘… bringing the NHS into Feltham five years ago has led, and is leading, to
considerable improvements in the healthcare being offered … overall we feel
the health services are generally improving, and many of the facilities being
offered to the prisoners are at least equal to those usually available from the
NHS outside prison.’
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HMYOI GLEN PARVA
16. Glen Parva is a young offenders’ institution located near Leicester. It has a
maximum operational capacity of 808 young men aged between 18 and 21
years. The establishment opened in 1974 and has always held young
offenders. All prisoners who arrive at Glen Parva spend their first six nights in a
dedicated induction unit. In total there are 12 residential units.
17. HM Chief Inspector of Prisons completed an inspection of Glen Parva between
25 and 27 June 2007. She made the following observations in the introduction
to her report of that inspection:
‘ … we were pleased to find that Glen Parva had progressed and was now
performing reasonably well across all the main areas that constitute a healthy
prison ... Reception, first night and induction were all satisfactory … staff-
prisoner relationships were much improved … Despite a challenging and
volatile population, Glen Parva remained an essentially safe place …
Considerable progress had been made in the management of … race equality
… however, there was still more to do to address bullying adequately …’
18. Since 2004, I have investigated three deaths at Glen Parva, all of which were
self inflicted. The clinical reviewer, who conducted the clinical review of the
man’s medical care, completed clinical reviews of two of the three previous
deaths. In relation to all three of the cases he has now reviewed at Glen Parva,
he has made the same recommendation relating to a failure to obtain a
prisoner’s records from their community doctor once they enter custody. There
is another recommendation, regarding poor record keeping by healthcare staff,
which was also raised in one of his previous clinical reviews.
19. Healthcare at Glen Parva is commissioned by the local Primary Care Trust.
The nursing staff are employed through the Prison Service. There is a
combination of registered general nurses (RGNs), mental health nurses (RMNs)
and nurses which specialise in learning disabilities, and a member of nursing
staff is on site 24 hours a day. From Monday to Friday, there is full nursing
cover from 7.15am until 8.00pm. During nights and at weekends, both a
qualified nurse (either an RGN or RMN) and a clinical support worker are
present. Both members of staff are trained to deal with basic emergency
situations.
20. A full time doctor’s surgery operates at Glen Parva on weekdays. There is a
lead doctor, supported by colleagues, all of whom are employed by the same
local provider. At the time that the man died, there was a locum doctor who
regularly provided this service. On weekends, a doctor runs a surgery in the
afternoons only. After 6.00pm on weekdays and at weekends, Primecare run
an out of hours service which staff can call if they need advice regarding a
prisoner’s health. There are ten in-patient beds in the healthcare centre.
21. The most recent annual report issued by the Independent Monitoring Board at
Glen Parva relates to the two year period from December 2006 to November
2008. The Board believes that Glen Parva is a prison that has continued to
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improve. However, they express concern that the Measuring the Quality of
Prison Life survey conducted in February 2008 produced results which the
Board considered to be ‘unpalatable’. They are also critical of the standard of
accommodation, some of which is uninhabitable.
22. The IMB considers that the issue of race equality is prioritised at Glen Parva.
New members of staff receive appropriate training, and meetings attended by
both staff and prisoners are held each month. A full-time race equality officer
has been appointed. The IMB believes that complaints procedures are well
publicised if any individual feels unfairly treated. Complaints forms and a
locked complaints box are located on each unit, and the instructions are clear.
23. If a prisoner wishes to make an application (or complaint) to the IMB, they must
put the relevant form in an envelope, which is then placed in the requests and
complaints box on the unit. Members of the IMB place blank forms in these
boxes occasionally to check that they are being delivered by prison staff.
24. Unit 15 functions as the induction unit when prisoners arrive at Glen Parva. The
unit is staffed by six officers and one senior officer. Prisoners are interviewed
before being located in a cell.
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KEY FINDINGS
Events at Feltham in October 2006
25. The man was remanded into custody at Magistrates Court in October 2006,
having been charged with committing two offences. His case was committed to
be dealt with at Crown Court in January 2007, and he was transferred to
HMYOI Feltham.
26. When the man arrived at Feltham shortly after 7.00pm, a nurse assessed him in
the reception area and completed a routine first reception health screening.
(This is a basic assessment of prisoners’ health issues which takes place every
time a person enters custody as a new reception.) He told the nurse he had not
experienced any prior episodes of ill health and he reported no current health
concerns. He told the nurse that, to the best of his knowledge, there was no
history of any recurring illness within his family.
27. The man said that he was a cannabis user and the nurse referred him to the
Counselling, Assessment, Referral, Advice and Throughcare Service
(CARATS) at the prison. (The CARATS team works with those offenders who
misuse drugs.) He was considered fit for normal location but, due to the nature
of his alleged offences, he was assessed as representing a high risk of harm to
other prisoners and was located in a single cell.
28. In October, the man’s Cell Sharing Risk Assessment was reviewed by a senior
officer. Following the review, the risk he represented to other young offenders
was reduced to the medium level, and he was moved to Swallow Unit. The
man spoke with his personal officer and told him that he had no concerns.
Events at Glen Parva from October 2006 to January 2007
29. The man was transferred to Glen Parva in October. His medical record
indicates that he was fit for transfer and that he was not taking any medication.
According to the investigation completed by the Leicestershire Constabulary, he
was transferred out as a result of overcrowding at Feltham. He left Feltham at
11.10am and arrived at Glen Parva at 2.05pm. Unfortunately, my investigator
has not seen the reception health screening form which was completed upon
his arrival. He should have gone through a similar reception process to the one
he had experienced at Feltham. He was located onto Unit 15 at Glen Parva, an
induction wing.
30. The man did not appear to settle well at Glen Parva. In October, he was given
an Incentives and Earned Privileges (IEP) Scheme warning by an officer after
he repeatedly kicked his cell door. (The IEP scheme is intended to encourage
and reward good behaviour. Additional entitlements, such as more visits, can
be gained in return for good behaviour. However, those entitlements can be
lost if behaviour deteriorates.) The officer made an entry in the man’s wing
history record describing him as a ‘… young man who needs help to understand
rules and regulations’. The man was moved to Unit 12 in November.
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31. At about 3.00pm in November, the man was involved in a fight with another
prisoner after interrupting a game of pool in the Unit 12 association area. The
man had insisted that he should be allowed to play with the others. He
sustained a fracture to his right thumb during the subsequent fight. As a result
of this incident, he was subject to an adjudication (a disciplinary hearing) as
was the other prisoner involved. After being found guilty of fighting, 50 per cent
of his earnings were withheld for 14 days. He was also stopped from
associating with other prisoners for five days and was not allowed to buy items
such as sweets and cigarettes for a week.
32. The man’s fractured thumb was examined by a doctor and he was referred to
Leicestershire Royal Infirmary (LRI) for treatment. His thumb was put in plaster
and he was discharged back to Glen Parva. He returned to the LRI in
December to complete the treatment for his injury.
33. At about 10.30pm in December, the man was being escorted back to his cell by
an officer after again disrupting a game of pool during the association period.
As they walked back to the cell, he tried to return to the association area. He
spun around and assaulted the officer, pushing into him with his shoulder,
causing the officer to stumble. He was restrained by the officer, placed in
ratchet handcuffs and relocated onto Unit 7 (the segregation unit).
34. The man was examined by a nurse as part of the safety algorithm process
which has to take place before a prisoner is placed in segregation. The aim of
this process, outlined within Prison Service Order 1700, is to see whether there
are any medical reasons for not placing the prisoner in segregation. The nurse
confirmed that he had not sustained any injuries as a result of the control and
restraint procedure which had been used.
35. In December, the man was subject to another adjudication as a result of his
behaviour two days earlier. After being found guilty, his earnings were reduced
by 50 per cent for two weeks, he was prevented from buying items such as
sweets and cigarettes for two weeks and he was not allowed to take part in
association periods for one week.
36. The man did not come to the attention of healthcare staff again until 21
December. At 11.30pm, he was examined by a nurse and complained of a
headache. He was prescribed paracetamol. He also reported a headache in
January 2007 and paracetamol was prescribed once more.
Events at Feltham from January to February 2007
37. The man received an IEP warning at Glen Parva regarding his behaviour early
on 9 January as he did not initially cooperate with being taken to a court
appearance in London. His warning sheet, completed by an officer, recorded
that the man was ‘in bed on court release’.
38. The man’s family told my investigator that on the day that he went to Crown
Court a member of the prison staff had thrown his copy of the Qur’an across his
cell.
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39. The man eventually left Glen Parva at 8.10am in January to appear at Crown
Court. He arrived at court at 11.40am. After his appearance, instead of
returning to Glen Parva, he was transferred to Feltham and arrived there at
5.15pm. He was screened by a nurse upon arrival and no new health concerns
were identified. Upon arriving at Feltham that evening, he spoke with his
mother on the telephone. The following day, he attended his offender
management reception interview.
40. The man appeared at Crown Court again in January. He underwent a routine
healthcheck before he left and was considered fit to appear at court. He arrived
at court at 8.40am. After his hearing, he was transferred back to Feltham.
41. A prison doctor assessed the man in January after he complained of a sore
throat and neck ache. The doctor found that he had a mild throat infection. He
was advised to take in more fluid. There is no record of him complaining of a
headache at the time.
42. A Cell Sharing Risk Assessment was completed in January 2007 in which it
was noted that the man did not wish to share a cell at the time because he
wanted first to address his quick temper. He reported having a headache on
the same day and was prescribed paracetamol. The next day he was located
on Partridge Unit.
43. During the daytime in January, the man vomited three times and fainted whilst
exercising in the gym. He was taken to the healthcare centre where he was
assessed by the prison doctor. The doctor instructed him to drink more fluids
because he was dehydrated, and to eat more. His blood pressure was taken
and he was prescribed prochlorperazine, a drug used to treat nausea. The
doctor also started him on a course of paracetamol. Both medications were
prescribed until 27 January.
44. The man returned to his residential unit after his examination. A nurse
subsequently checked on him in the evening and told officers on Partridge Unit
to let her know if he developed a rash, as he had complained to her that the
light was hurting his eyes.
45. In January, the man met his personal officer. Three days later he was still
feeling unwell so his personal officer completed a sickness application form for
him. He was assessed by healthcare staff later that day and was prescribed
paracetamol after complaining of a headache.
46. The man was again prescribed paracetamol by nursing staff at the end of
January after complaining of headaches each day. He was examined by three
different nurses.
47. The man was prescribed ibuprofen for pain relief as it was thought that he was
experiencing a migraine. On this occasion, he was assessed by the same
member of nursing staff who examined him previously.
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48. The man’s headaches continued. At 2.25am in February he rang his cell bell
after he had woken up with a severe headache and a pain behind his right eye.
At 3.00am, a nurse came to assess him. He reported his symptoms and the
nurse prescribed soluble paracetamol. An appointment was made for him to
see the doctor later that day.
49. The prison doctor carried out that consultation. In a written statement, he
recalled that the man had presented with a headache but with no other
significant symptoms or complaints. The doctor did not record in the medical
record (nor did he recall in his statement) that the man reported any eye pain
during the examination. An entry concerning the consultation was made in the
man’s medical record for the doctor by a nurse. The nurse recorded that the
man had denied having a migraine. The doctor wrote in his statement that the
man had not been in any apparent distress. He recalled that he had taken a full
and appropriate history from him. On the basis of the symptoms with which he
presented, the doctor prescribed pain relief medication and referred him to have
his ears syringed.
50. Later that day the man was told he would be transferring back to Glen Parva.
Once again, the investigation conducted by the Leicestershire Constabulary
indicates that overcrowding at Feltham necessitated the move.
51. In February, the man refused to be transferred to Glen Parva, claiming that he
had previously been subjected to racist bullying by its staff. Following his
refusal to comply with the transfer, officers went to his cell. He was standing
naked near the window in his cell when officers arrived to escort him to
reception area ‘B’. He had stripped himself and doused both himself and the
floor of his cell on Partridge Unit with water and what was probably shower gel.
He thought that this would prevent officers from moving him as the floor was
very slippery.
52. A Principal Officer (PO) recorded in the ‘Use of Force’ form that the man did not
behave aggressively, but that he did not comply with staff. A Senior Officer
(SO) wrote in his form that the PO had spoken at length with the man to
persuade him to get dressed and complete the transfer, but without success.
53. In the event, the man was restrained at about 10.30am on the instructions of
the PO, with the permission of the Governor who was also present. The SO
took hold of his head; an officer took his left arm and another officer his right
arm. The officers ended up slipping on the floor because it was wet but
managed to restrain the man as he lay prone on the floor. Despite several
requests to get dressed, he refused to comply. The officers then stood him up
under restraint. Contrary to the instructions issued in Prison Service Order
1600 relating to the planned use of control and restraint, a member of
healthcare staff was not present when the man was restrained and moved out
of his cell.
54. A blanket was sought to cover the man. In the meanwhile, he said he was
experiencing difficulties breathing whilst being held in the restraint position so
the SO released his head and he stood upright. The other two officers
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maintained their locks on his arms. The man continued to refuse to comply with
the transfer from his cell. A blanket was brought and he was covered up. His
shoes were put on his feet by one of the officers.
55. The man was placed in ratchet cuffs and moved from Partridge Unit downstairs
to the search room. He walked to the search room under the restraint of the
officers. Once he arrived, there was some prolonged negotiation before he
eventually agreed to comply. The cuffs were then removed, the officers’ hold
was released, and he agreed to dress himself. The PO wrote in his statement
that the correct control and restraint procedures were used when the officers
moved the man and that the minimum force required was used throughout. The
appropriate use of force forms were completed by the PO, the SO and both
officers.
56. The man complained of dizziness after the use of the control and restraint
procedure when he was assessed by the nurse. He told the nurse that he felt
unwell. She consulted his clinical records and noticed that he had been
assessed by both a nurse and the doctor the previous day. She recorded that
he had sustained no visible injuries, assessed him as being fit to transfer out of
Feltham, and told him to report sick to a nurse upon his arrival at Glen Parva if
he still felt unwell.
57. This nurse later claimed that she had consulted the doctor by telephone when
she was deciding whether the man was fit to transfer. She stated that the
doctor had told her on the telephone that he had examined the man on the
previous day, and that he could be transferred. The doctor was attending to
other prisoners on Albatross Unit at the time. The nurse claimed that she had
assessed the man as fit to transfer on the basis of her conversation with the
doctor. (This situation is addressed in the ‘Issues’ section of this report, as it
has since emerged that the nurse had not consulted the doctor as she claimed
to have done.)
58. After the nurse had assessed him, the man was escorted from reception area
‘B’ to the van for transfer. He was no longer protesting and seems to have
made his way peaceably to the van. The prisoner escort record (PER) was
completed to indicate that he had not sustained any visible injuries as a result of
the control and restraint procedures which had been used. The van left
Feltham at 11.05am.
59. The Prisoner Escort Record (PER) completed prior to the van’s departure
makes no mention of the man having to be handcuffed during the journey to
Glen Parva. A governor has been the Deputy Head of First Days in Custody at
Feltham since April 2006, dealing with the reception and induction process. He
told my investigator that prisoners are not normally cuffed when they are
transferred between prisons. He said that such an event would be exceptional,
and that he cannot remember it ever happening during the time that he has
worked in the reception and induction group. He has worked at Feltham for 12
years.
16
60. The governor said that because nothing was marked on the PER to indicate
that the man was handcuffed for the journey, it can be presumed that this did
not happen. Such an unusual course of action would warrant an explanation on
the PER.
61. The governor said that prisoners who are being transferred out of Feltham are
walked to the van without cuffs. They are then each locked in a separate
cellular compartment in the body of the van. Some vans have six
compartments, but those used for the journey to Glen Parva usually have ten.
There is, on average, one transfer each week from Feltham to Glen Parva.
62. One of the man’s fellow prisoners travelled in the same van to Glen Parva in
February. He said in his police statement that the man claimed to have been
‘jumped’ by staff at Feltham when he had refused to transfer out. (The prisoner
has since been released from custody and, unfortunately, it has not been
possible for my investigators to either locate or interview him.)
Events at Glen Parva from 2 February
63. The man was transferred to Glen Parva and arrived at 1.35pm. The prisoner
said in his statement to the police that, when they got off the van, the man told
him that he was getting a headache. He recalled that the man’s left eye was
starting to close up at this point (it was in fact his right eye that was causing him
pain).
64. An officer who was working in the reception area that afternoon, recorded in the
Cell Sharing Risk Assessment document that the man wanted to share a cell
with the prisoner and that both men had seemed pleased to do so. He also
noted that he did not report any problems or concerns to him when this
assessment was completed. During the reception process, the officer informed
the man of the first night procedure for prisoners. Four days after the man died,
the officer made a statement recalling that he had been ‘in a good mood, quiet
and polite’ when he entered Glen Parva.
65. Whilst in reception, the man complained of ‘dizziness’ to the nurse during the
routine health screening. She prescribed paracetamol. He was then placed on
Unit 15, which is an induction unit. None of the staff involved in his reception
process recorded that there was anything unusual about his eye.
66. An officer collected the man from the telephone room on Unit 15 and took him
to his cell. During interview, she told my investigator that he had neither
complained to her of feeling unwell in February, nor had seemed unwell to her
on that evening. She observed nothing in his appearance or behaviour at this
stage which caused her concern. As part of the process of settling him into the
unit, the officer asked him if he was okay. She did not recall observing that he
was still upset or agitated after the use of control and restraint procedures at
Feltham earlier that day, although she was not aware that force had been used
at the time. Nonetheless, whilst she would subsequently become concerned
about him, she indicated that there was nothing remarkable about his
presentation on the day of his arrival at Glen Parva.
17
67. The prisoner said in his police statement that, during a night in February, the
man had asked for the light to be turned down because his eye was overly
sensitive. The prisoner also told the police that the man’s left eye began
pointing outwards at this point, away from his nose. He said that the man had
made a patch for his eye out of material.
68. The prisoner said that he rang the cell bell several times during the night
because he was worried about the man. He recalled that the night patrol staff
had said that they would contact the healthcare centre. However, he told the
police that the man was not seen by healthcare staff during the night.
Unfortunately, there is no record of the events described by the prisoner. My
investigator requested the relevant cell bell records, but staff at Glen Parva
have been unable to retrieve this information from their computer.
69. The entries made in the observation book kept on Unit 15 do not include any
mention of either the man or the prisoner until the man collapsed. (Any areas of
concern or significant incidents are supposed to be recorded in this book.) An
officer wrote that it had been a ’quiet evening’ on 2 February. During the
handover to the day staff a member of staff noted in the book that it had been a
‘quiet night’ and that there was nothing to report.
70. During morning unlock the man spoke to the officer. He told her that he had a
pain behind his right eye. He said that he wanted to be examined by a doctor,
and she showed him where to fill in the appropriate application form. A little
later, she spoke with him again. He told her that his eye was sore and that his
head hurt. She observed that his eye was visibly swollen or ‘puffed up’, as if he
might have had an eye infection.
71. The officer was worried about the man because he was evidently in pain and
discomfort at this point. She was not unduly alarmed, but could see that he was
unwell. From her personal experience, she considered that he might be
suffering with a migraine.
72. Out of concern, the officer telephoned the healthcare unit at about 9.00am to
ask if the man could see a doctor. She hoped to speed up the appointment
process. However, she was told that he could not be assessed that day by a
doctor as there were no more appointments available. The officer told my
investigator that she spoke with a female member of the healthcare team at this
stage, although she could not recall exactly who it was.
73. Later that day, the man pressed his cell bell. The officer went to see him and
he complained again of eye pain and a worsening headache. The officer
telephoned the healthcare centre for a second time at about 2.30pm, but was
told that a doctor was no longer on site and that nobody else was available to
come to Unit 15 to assess him that day. The officer was told that an
appointment would be made for him to be examined by a doctor the next
morning. When my investigator spoke with the officer, she said that, to the best
of her recollection, she believed that she had spoken with the senior nurse on
18
this occasion. The senior nurse has confirmed that she did speak to the officer
when she rang the healthcare centre for the second time that day.
74. The officer advised the man that healthcare staff would not assess him until the
next morning. She advised him to place a cold flannel on his head to help
relieve the pain in the meantime. He said that he would lie down on his bed to
try and relieve the pain.
75. The man was assessed by a substance misuse worker. It would appear he did
not discuss any health problems with him.
76. The prisoner told the police that, the man complained of blurred vision, had not
eaten and had slept a lot. He said that they continued to ring the cell bell. He
indicated that no healthcare staff were brought to assess him until Sunday, by
which time the prisoner said that the man was in a great deal of pain, rolling
around and clutching his eye.
77. The observation book kept on Unit 15 is similarly unable to confirm the
prisoner’s recollection of the night in February. During the handover to the night
staff, the comment that it had been a ‘quiet’ evening is recorded in the
observation book. When the night staff went off duty the next morning, they
again noted that it had been a ‘quiet night’. An incident involving other
prisoners during the course of the night is fully detailed, but there is no mention
of the man until he collapsed later that day.
78. Shortly after morning unlock, the officer spoke with the man. He complained of
both a headache and experiencing eye pain overnight. He was holding his right
eye and was visibly suffering. The officer described in interview how his eye
had been both red and swollen, as if it was infected. When the officer spoke
with the clinical reviewer she could not recall whether on that Sunday morning
the eye was pointing in its normal direction.
79. The officer checked the appointment list and found that the man had been given
a doctor’s appointment in the afternoon. Having been under the impression that
he was going to be assessed in the morning, and feeling increasingly
concerned about his wellbeing, she was not satisfied that the examination
would be further delayed. She telephoned the healthcare centre and was told
by the senior nurse that no doctor’s appointments were available until the
afternoon. In interview, the officer said that she continued to press for a nurse
to examine the ma in the interim and was told that nursing staff were due to visit
Unit 15 later that morning. The senior nurse has confirmed that she spoke to
the officer on the telephone that morning.
80. The officer told my investigator that, as the weekend progressed, she became
increasingly frustrated by the failure of healthcare staff to come to Unit 15 and
examine the man. She described how her concern for his welfare grew from
Saturday to the Sunday. As time went on, she said that he was evidently in
more pain. She thought that she had accurately described the distress that the
man was in when she spoke with the healthcare team on the telephone. The
19
senior nurse has denied that the officer was ‘quite insistent’ when asking for him
to be assessed.
81. A little later that morning, the man pressed his cell bell again. The officer went
to see him and observed that he was in more pain than the previous day. His
eye was still puffy and swollen; he was in a heightened state of physical
distress and was complaining loudly. She told him that a nurse was on the way,
and she then telephoned the healthcare centre for the second time that morning
to ensure that a nurse was shortly due on Unit 15. The man’s cell mate also
spoke with the officer at this stage. She recalled that he had told her that the
man was ‘really struggling’. The officer tried to reassure him that a nurse would
arrive imminently.
82. The senior nurse arrived on Unit 15 shortly after the officer’s second telephone
call to the healthcare centre. The officer escorted her up to the man’s cell at
about 10.30am. He was lying down on the bed with a towel over his eyes to
shield them from the light. During interview, the officer told my investigator that
she and the senior nurse had stepped just inside the cell, but that the nurse had
not examined him either standing by his bed or sitting down next to him. The
man had got up off his bed and met them just inside the entrance to his cell.
The senior nurse handed him some pain relief medication, which he swallowed.
She told him that he would be examined by a doctor that afternoon.
83. The officer had reported the man’s symptoms of eye pain and a headache to
the nurse over the telephone. She recalled during interview that he had also
described his symptoms himself when the nurse visited his cell. The officer
said that his eye pain and distress were readily apparent to her, especially
because he had placed a towel over his eyes.
84. The officer told my investigator that the senior nurse had not examined the
man’s eye when she visited his cell, nor had she asked to do so, and she did
not remember him refusing to let the nurse look at his eye. The officer said that
the nurse spent approximately two minutes with him and she did not consider
that the nurse had conducted a thorough examination.
85. The senior nurse said in interview that the man told her of both his eye pain and
the fact that he had had a headache since the previous day. She said that she
had asked him a number of questions to determine what was wrong. She also
said that she had asked him to get up, walk to the sink and drink some water, in
order to observe his brain function and co-ordination. She said that these had
appeared to be normal.
86. Contrary to the officer’s recollection of events, the senior nurse said that she
had tried to examine the man’s eye, but that he had been reluctant to let her do
so. She indicated that she had therefore not done so, because she was
concerned that she might be accused of assaulting him if she went against his
wishes. She observed that his right eye was ‘tightly closed’. The nurse
assessed that his eye pain was the main problem, and that his headache was
not as severe. In her assessment, he did not present with any other symptoms
at that time.
20
87. There was no doctor in the prison on the Sunday morning. At weekends, a
doctor will attend Glen Parva in the afternoons to assess emergency cases that
healthcare staff have referred to them. The senior nurse said that she had
been concerned that the man should see a doctor later that day because his
headache had lasted more than 24 hours, and because she said that he would
not let her examine his eye.
88. Again contrary to the officer’s recollection, the senior nurse did not consider that
the man had been ‘unduly distressed’ at the time she examined him, and she
therefore judged that he could wait until the doctor arrived in the afternoon to
perform a full assessment.
89. The man’s cellmate collected lunch for them both at about 11.30am and
returned to the cell. A second officer later said in his statement that he
remembered the man seeming too unwell to get his own lunch. At 1.10pm, a
further officer responded after the man rang his cell bell. He observed that he
appeared unwell, and that his eye had ‘puffed up’. He assured him that
arrangements had been made for him to be examined by the doctor that
afternoon.
90. At around 1.35pm, the second officer went to the man’s cell and told him to get
ready for his doctor’s appointment. The officer found him lying in bed with ‘a
towel wrapped round his head’. He observed that he was visibly unwell at this
stage. The man got dressed and made his way downstairs from the third
landing to the ‘holding room’, or ‘phone room‘, on the ground floor. (This is a
room containing telephones and a television where prisoners wait for officers to
escort them off the wing to the healthcare unit.)
91. Whilst the second officer finished his unlocking duties, the man made his own
way down to the holding room. The first officer told my investigator that other
prisoners were present in the holding room when he collapsed. A third officer
confirmed that he had been the first member of staff to reach him after his
collapse. He said that, at about 1.50pm, he had been half way up the stairs
near the holding room when one of the other prisoners had come out and
shouted, ‘He’s been sick.’
92. The third officer went into the holding room and saw the man sitting with his
back to the wall. He described how his eyes had glazed over and said that he
seemed unresponsive. Although the prisoner who raised the alarm had
referred to him having been sick, he did not seem to have actually vomited at
this point. He was seated but very unsteady, and the third officer caught hold of
him when he began to roll to one side and lose his balance. It seemed to this
officer that the man was going to keel over. He lowered him to the floor and
placed him in the recovery position to keep him safe.
93. The first officer had been in the unit office when the third officer raised the alarm
over the radio. She arrived in the holding room to find the man unconscious
and supported in the officer’s arms. She recalled that, amongst other staff, two
other officers were present.
21
94. An SO, who was acting up as a temporary principal officer at the time, was in
the control room. He answered a telephone call which said that the man had
been found collapsed in the holding room. He was instructed that the unit’s
senior officer should be informed. The SO asked the communications officer in
the control room to put a call out for the unit’s senior officer.
95. At this point, the call came over the radio from the holding room requesting
medical assistance, indicating that a ‘code blue’ emergency was underway on
Unit 15. (A ‘code blue’ emergency indicates that a prisoner is experiencing
breathing difficulties.) The SO went to the holding room to assist. En route, he
held open the gates to allow healthcare staff to make their way through.
96. A PO, who was the duty manager, subsequently arrived in the holding room to
find officers in attendance, along with the SO and two governors. One was the
duty governor on the day.
97. During interview, the first officer recalled that the other prisoners present in the
holding room when the man collapsed were quickly relocated by staff. This
ensured him more privacy, and allowed him to be treated without interruption.
She also said that, once healthcare staff were asked to attend, their response
was very quick and efficient. She estimated that the senior nurse arrived within
at most five minutes, shortly followed by other members of the healthcare team.
98. The senior nurse received the emergency call at just after 1.50pm and went
straight from Unit 14 to Unit 15. She was the first member of healthcare staff to
arrive. She recalled that the man had been placed on his left side in the
recovery position. Once the third officer was relieved by her, he resumed his
task of taking prisoners to the visitors centre.
99. The nurse checked the man’s pupils, and found them to be unequal and
unreactive. She recalled in interview that he was unresponsive at this stage.
She noticed that he was salivating from the right side of his mouth and that his
breathing was laboured and shallow. He had also now vomited.
100. Two staff nurses then arrived bringing oxygen equipment with them. The senior
nurse administered oxygen to the man and inserted an airway into his throat.
She also checked his pulse and blood pressure, and found them to be within
normal limits.
101. After assessing the man, the senior nurse asked the first officer to organise for
an ambulance to be called as a matter of urgency and requested that the
paramedics be told that he was unconscious. The officer contacted the control
room and asked that an ambulance be called. Both the prison’s records and
the East Midland Ambulance Service’s Patient Report Form (PRF) confirm that
an ambulance was requested at 2.00pm.
102. The senior nurse noticed that the man had spat out his airway. She continued
to maintain his breathing manually. She decided to move him to the healthcare
centre at this stage, to provide more privacy for him and to have more
22
equipment on hand if it was required. She did not think that she could best
continue to care for him in the holding room.
103. A Healthcare Officer (HO) arrived bringing a trolley from the healthcare centre
to help move the man. The HO and the SO then assisted the senior nurse
place him onto a stretcher. Accompanied by the two nurses they proceeded
with him to the treatment room in the prison’s outpatients’ department. This
took approximately ten minutes, and was necessarily slower than usual as the
senior nurse had to maintain his airway throughout.
104. The senior nurse remained with the man in the healthcare centre, monitoring
him until the paramedics arrived. He became restless and irritable. He tried to
cough his airway out and the nurse assisted him to remove it. He moved his
right arm and leg, but it was noticeable that there was no movement from the
left side of his body.
105. According to the PRF, the ambulance arrived at the prison gates at 2.07pm.
The SO went to meet it and he brought the paramedics up to date as regards
the man’s condition. He escorted them to the healthcare centre and the PRF
confirms that the paramedics reached the man at 2.10pm. Meanwhile, an
officer had gone to collect the escort bag which the officers escorting the man to
hospital would have to take with them.
106. Whilst staff and paramedics were responding to the man’s collapse, the PO put
the arrangements in place to escort him to hospital. The PO instructed two
officers to escort him. A risk assessment was carried out and it was designated
an emergency escort. The governor oversaw the restraint arrangements,
indicating that a ‘double cuff’ should be used initially. In his statement, the SO
said that he discussed the use of a closeting chain with the governor. (A
closeting chain allows a ratchet cuff to be attached to both the prisoner and the
escorting officer, with a length of chain in between. This allows medical
treatment to continue during an escort out of the prison without the officer
obstructing the procedure.) Once the governor had authorised the use of the
closeting chain until the man’s condition improved, the SO attached one cuff to
the man and the other to the officer.
107. A second PO explained during a conversation with my investigator that double
cuffing is standard practice on all escorts out of Glen Parva. He said that a
closeting chain would be used when a prisoner is semi-conscious. He was the
dispatching officer for the man’s escort. The dispatching officer checks that the
escort is properly staffed and that staff have all of the necessary equipment as
they leave the prison. He could not recall the specific details of his checks that
day.
108. However, the SO recalls that the dispatching officer checked the application of
the cuffs to the man and the officer and then authorised the ambulance’s
departure from Glen Parva, with both officers escorting. In interview, one officer
recalled that he had volunteered to accompany the man to provide him with
some comfort and continuity of care.
23
109. The PRF indicates that the ambulance left Glen Parva at 2.32pm. It arrived at
Leicester Royal Infirmary (LRI) at 2.40pm.
Events at Leicester Royal Infirmary
110. The closeting chain used during the journey from Glen Parva was removed
from the man in the hospital at 3.15pm after he had been anesthetised. The
escorting officer noted in the bedwatch log that the dispatching officer had
authorised the chain’s removal over the telephone. No restraints were
reapplied at any point during the rest of the man’s time in hospital. At 4.00pm,
the man had a computerised tomography (CT) scan before returning to the
Accident and Emergency Department’s resuscitation area.
111. Just after 4.15pm, the escorting officer spoke to the medical staff and was told
that the man had suffered a ‘large bleed’. A short while later, medical staff
confirmed that he would be transferred to the Queen’s Medical Centre (QMC) in
Nottingham in order to undergo surgery. The escorting officers were told that
his condition was such that he might not recover, and medical staff advised that
the prison should contact his next of kin. The other escorting officer telephoned
the governor and indicated that the man’s family should be contacted.
112. Having received permission for a single officer escort, the first escorting officer
travelled in the front seat of the ambulance with the man in the rear with the
medical staff. The second escorting officer travelled separately in a taxi
because there was insufficient space in the ambulance for him. The ambulance
left the LRI at 5.43pm, travelled under a ‘blue light’ (meaning that the journey
was treated as an emergency), and arrived at the QMC at 6.14pm.
113. At about 6.00pm, staff at Glen Parva spoke with the man’s family. They wished
to visit him at the hospital and made preparations to set off from London. They
would subsequently telephone Glen Parva again later that evening in order to
obtain directions to the QMC in Nottingham.
Events at the Queen’s Medical Centre
114. The man underwent an operation in theatre at the QMC. It began at about
6.30pm, only minutes after his arrival. The operating neurosurgeon performed
an emergency craniotomy. This meant entering the man’s brain via his skull in
order to evacuate the haematoma (large blood clot) which had formed as a
result of the bleeding in the right side of his brain. However, the operation
would ultimately prove unsuccessful.
115. The escorting officers had been told that the man’s prognosis was poor. They
passed the information onto the duty governor during a telephone conversation
at 6.50pm, at which point it was confirmed that the next of kin were on their
way.
116. The officers were relieved at 8.15pm and a further two officers took over the
bedwatch. The man was located in the Intensive Care Unit (ICU) at the QMC
after his operation. The escorting officers were asked to wait outside, as there
24
was no room for them in such a busy ward with other patients present. Having
contacted the prison at 9.10pm, and with the duty governor’s permission, the
escorting officers spent the rest of the night in or around the family room, away
from the ICU.
117. The bedwatch log indicates that the man’s family arrived at the QMC at
11.30pm. They remained at the hospital throughout the night and were based
both in the family room where the prison officers also sat, and in another room
close by. These rooms were situated just down the corridor from the ward
where the man was located. The main waiting room was fairly large, with about
20 chairs in it. Staff spoke with members of his family on several occasions
during the night.
118. At 1.05am, staff at the QMC explained to the man’s relatives both the
seriousness of his condition and its rarity. They answered questions from the
family. Between 5.00am and 6.00am, a consultant reviewed his condition. At
about 8.00am, a further two officers took over the bedwatch. At 9.15am, the
prison and the hospital discussed the need for officers to remain on bedwatch,
and the Governor confirmed that both officers should stay with the man.
119. Shortly after 9.30am, the officers on the bedwatch were informed by medical
staff that the man had been diagnosed with brain stem death, and that
consequently his family would be asked to consider switching off his ventilator.
His pupils were dilated and unresponsive. The situation was explained to the
family with the aid of an interpreter at 10.45am, and their permission was
sought. The ventilator was switched off shortly afterwards, and the man was
declared dead at 11.10am.
120. At 1.40pm, the Governor and Glen Parva’s family liaison officer arrived at the
hospital to speak with the family and answer their questions.
121. The cause of death was subsequently found to be the development of a
spontaneous intracerebral haematoma. This means that a blood clot had
developed within the right side of the man’s brain. The post-mortem completed
by a Professor found that the bleeding resulted from a ruptured Berry
aneurysm. (This type of aneurysm is found at the base of the brain, and can
grow in size and then spontaneously rupture. The underlying cause of the
aneurysm was most likely a weakness that the man was born with, namely an
abnormal set of blood vessels in the brain.)
122. A consultant neuropathologist, found the rupture of the aneurysm had resulted
in extensive bleeding within the man’s brain. The pressure exerted by the
haematoma (or blood clot), which was 4cm by 5cm in size, caused his brain to
die probably even before he was operated on. The damage was sadly
irretrievable and, in the assessment of the consultant neurosurgeon who
completed a medical report with regard to the man’s case, surgery was
probably futile.
25
The police investigation
123. A police investigation of the man’s death by Leicestershire Constabulary took
place, during which time my own investigation was suspended. The police
found that no individual had been neglectful in their duties to such an extent
that they had either contributed to or failed to prevent his death. The police
concluded that he died of natural causes.
26
ISSUES
Clinical care
124. When my Family Liaison Officer and my investigator at the time visited the
man’s relatives in March 2007, the family expressed a number of concerns
about his death which I address within this section of my report. The clinical
review of his case, conducted by the clinical reviewer, has been of particular
assistance in answering many of the family’s questions. The review is annexed
in full to my report. The investigator who completed this report visited the man’s
family again in January 2009. He provided the family with a copy of the clinical
review, and has taken account of the issues that the family still felt needed to be
addressed.
Response to the man’s headaches
125. The family are concerned that medical staff in Feltham and Glen Parva ignored
the man’s headaches and did not treat them with due concern. He complained
of a number of headaches in the weeks before his collapse. He told his family
about these headaches and that he did not feel that his symptoms were being
taken seriously enough. His mother was sufficiently concerned about her son
to consult a solicitor in February 2007. She was already worried about him
before he collapsed.
126. The clinical reviewer explains why the headaches the man reported would not
have been particularly exceptional, and places his rare condition into context.
He stresses that only one or two per cent of headaches about which people
complain to healthcare staff, either in the community or in prison, actually have
a serious cause. Approximately 98 per cent of headaches referred to a clinician
are not the result of a serious or potentially fatal condition. This is why patients
are invariably prescribed paracetamol or a similar drug.
127. Whether in the community or in custody, the clinical reviewer considers that it is
not usually possible for a nurse or doctor to address what presents as a simple
headache as a possible symptom of a very serious illness, unless other
symptoms are reported in addition.
128. When he spoke with my investigator, the clinical reviewer commented that, in
the community if a patient presents with ongoing headaches but no ‘red
flag symptoms’ (signs that might suggest a serious underlying cause for the
headache), there are a number of steps that the doctor might take. They
include ongoing observation, the keeping of a ‘headache diary’, and the
prescription of different medications.
129. The clinical reviewer estimated that a General Practitioner would realistically
manage the treatment of these headaches for up to three months in the
community before considering referring the individual to hospital. The doctor
might try out different types of pain relief and medication in order to resolve the
headaches. Only after these options were exhausted or if the symptoms
27
changed to suggest a different diagnosis, would the patient be referred to
hospital.
130. The clinical review highlights the rarity of the man’s condition within the
population as a whole. The clinical reviewer comments that the type of bleed in
his brain which he suffered is experienced by about one person in every 10,000
each year. It is particularly rare and unfortunate to find this condition in
somebody so young. This type of aneurysm is predominantly associated with
individuals aged between 40 and 50 years.
131. The consultant neurosurgeon who reviewed the man’s case, commented that,
with the benefit of hindsight, the headaches which he reported were
undoubtedly the result of an enlarging aneurysm. However, he concurred that
these types of aneurysms are exceptionally rare, particularly in someone as
young as the man. As a result, it was not reasonable to expect healthcare staff
at the prison who examined him to have diagnosed his condition until other
symptoms presented themselves - something which did not occur until the
weekend that he died.
132. The clinical reviewer believes that, again with the benefit of hindsight, the
vomiting and possible faint or collapse which the man experienced in January
might have been linked to an early, much smaller bleed in his brain. He cannot
be sure what happened in the gym on that day, as the recorded entries do not
make this episode of ill health entirely clear. It is possible that the vomiting was
unconnected to the eventual aneurysm which caused his death. Equally, it
could be that this was a collapse brought on by a small bleed in his brain.
133. The man’s family have said that, despite fainting, he was forced to go to the
gym and was told that he would be deprived of visits if he did not do so. My
investigator has found no supporting evidence in the prison records.
Unfortunately, the passage of time since my investigation started has meant
that there is now no realistic means available of determining whether this was
the case.
134. The development of eye pain from 1 February onwards at Feltham may well
have been associated with an expansion of the aneurysm in the man’s brain.
The clinical reviewer considers that it would not realistically have been possible
to have diagnosed the man’s underlying condition prior to his reports of eye
pain. This newly reported symptom, following a series of headaches, correctly
resulted in a referral to a doctor by a nurse at Feltham. The referral was made
when the nurse assessed him in the middle of the night after he reported a
severe headache and a pain behind his right eye.
135. However, when the man was examined by the prison doctor later that same
day, it seems that the doctor did not make a further referral or prescribe any
significantly different medication. He treated the man for a headache and said
that he did not find him to be in any obvious distress. In his notes, which were
actually made for him by the nurse (something I go on to discuss below), the
doctor did not make reference to any eye pain. He maintained in a written
28
statement that he had taken a full history from the man during the examination,
and that he had not presented with any other significant symptoms.
136. The clinical reviewer says that the headaches which the man reported will have
been experienced by between 25 and 50 per cent of patients with his condition
in the weeks before they suffer a brain haemorrhage. However, this history of
headaches is usually only identified retrospectively and does not help medical
staff to diagnose the condition at the time. This is because the pain reported is
often indistinguishable from everyday headaches. Unfortunately, it is therefore
usual for an aneurysm, such as the one the man experienced, only to come to
light when a sudden bleed results in brain damage.
137. The consultant neurosurgeon considered what would have happened had a
member of healthcare staff made a connection between the man’s headaches
and a possible aneurysm, and decided that the headaches therefore warranted
further investigation. On the balance of probabilities they would most likely
have made a referral to a neurologist. Given average waiting times, an
appointment with the neurologist would then have been scheduled for four to six
weeks from the date of the referral. Having been assessed by a neurologist,
the man would probably have been sent for a CT scan or a magnetic resonance
imaging (MRI) scan. This would have taken a further four to six weeks to
complete. Given that the aneurysm in his brain ruptured a couple of weeks
after he first presented with a succession of headaches, even a remarkably
accurate suspicion on the part of a nurse or doctor within prison healthcare
could not, in all likelihood, have prevented his death.
138. Nonetheless, I note that the consultant neuropathologist who completed the
autopsy report following the man’s death, did remark that:
‘… if the patient had been referred earlier, the aneurysm could have been
detected and different management and treatment would have been followed
… ‘
However, he asked a neurosurgeon to comment of the likely success of any
such management or treatment of the aneurysm. The consultant neurosurgeon
who operated on the man in February after his collapse, completed a medical
report with regard to his condition. He concluded that it was unlikely that the
bleed in his brain could have been prevented.
139. The Professor, who completed the post-mortem report, commented that the
bleed in the man’s brain was the result of a ruptured Berry aneurysm. (He said
that the headaches which he experienced before he died were likely to have
been linked to small leakages of blood from the aneurysm prior to the major
bleed in February.) This type of aneurysm is particular to blood vessels at the
base of the brain. It can expand and then spontaneously rupture. The rupture
can occur without prior warning and is highly likely to result in death.
140. The man’s family point out that he had been an apparently fit and healthy young
man. However, the medical experts who have explored his condition found that
he died as a result of an undiagnosed aneurysm. It appears to have been a
29
condition with which he was born. The only significant indication of there being
anything seriously wrong appeared three days before he collapsed, when his
eye began to hurt, and then deviated away from its normal position.
141. The clinical reviewer discussed current surgery trends with the consultant
neurosurgeon. He was told that a recent audit of time from diagnosis to
operation showed that the most common time to operate on this condition was
around three days after diagnosis in the United Kingdom.
142. In layman's terms, there is a balance to be struck between the risk involved in
early intervention in an unstable ongoing condition and the risk of delaying the
operation, possibly resulting in a complete rupture of the aneurysm. The
consultant neurosurgeon explained that surgeons have to strike the right
balance between preparing adequately for what is a very delicate operation,
and not waiting so long that the aneurysm may bleed catastrophically. If a
surgeon was to enter the brain too quickly, without the appropriate preparation,
this could be hazardous, just as waiting too long could also be dangerous.
143. The man collapsed two to three days after his right eye first started pointing
outwards (this is referred to as a deviated eye in medical reports). This was the
first significant indication, coming after a succession of headaches, of the
expanding aneurysm which caused his death. The rupture of this aneurysm
occurred at about the same time as the likely start of any surgery, had an
accurate diagnosis of his ‘deviated eye’ been made on 1 or 2 February and had
he been immediately referred to hospital.
144. The clinical reviewer also indicates that medical intervention in a case like the
man’s does not offer the patient a significant chance of survival. Had surgery
taken place before the aneurysm ruptured, then he would have faced a distinct
possibility of either dying during the operation, or sustaining brain damage if he
survived.
145. The man’s family wanted to know why he was not seen more often by a doctor,
despite telling staff about his headaches. Having spoken with medical staff, the
clinical reviewer ascertained that he usually presented with a generalised
headache. It was only three days before his collapse that he began to complain
of an additional symptom, namely the eye pain. As I have already outlined,
staff would not have had any reason to believe that a more serious illness lay
behind his headaches until his condition deteriorated further. Consequently,
they prescribed paracetamol during the January consultations, a reasonable
decision at the time.
146. The man’s requests for medical assistance and his reports of headaches
usually took place in the out of hours periods, when a doctor was not in the
prison. On these occasions, the clinical reviewer has satisfied himself that staff
would advise the man to ask for an appointment with a doctor if the problem
persisted. However, it would seem that these were predominantly episodic
headaches, which were not so severe at the time as to cause the nurses to call
upon the out of hours service. The man was assessed by a number of different
healthcare staff towards the end of January in Feltham. It is unfortunate that
30
one particular nurse did not build up a more cohesive or continuous picture of
the headaches he was experiencing. When he was assessed by the prison
doctor in February, after complaining of a headache and eye pain the previous
night, the doctor did not recall him saying that he had any eye pain during their
appointment.
Whether the man sustained an injury whilst he was held in custody which
might be linked to the cause of his death
147. Whilst the man was held in Feltham, he suffered a fracture to his thumb after
fighting with another prisoner in November 2006. He was also restrained by
staff on two occasions, in December 2006 and February 2007. The clinical
reviewer has concluded that the man did not suffer any significant injury as a
result of any of these incidents. He found that he died as a result of an
undiagnosed and unrelated condition. In his assessment, the aneurysm the
man experienced was neither triggered nor aggravated by an external event
such as a fight, nor by the use of control and restraint procedures by prison
staff.
148. As regards the fracture to his thumb, sustained in November 2006, the man
visited the Leicester Royal Infirmary on two occasions to have the injury
properly treated. After the use of control and restraint procedures in December
2006, he was assessed by a nurse later the same day. The nurse confirmed
that he had not suffered any injury as a result of the restraint used.
149. Perhaps the most pertinent incident was the use of control and restraint by staff
at Feltham in February 2007, two days before the man collapsed. He had taken
off his clothes and doused himself and the floor in water and shower gel to try to
prevent officers from transferring him to Glen Parva. In these circumstances,
staff used control and restraint procedures to facilitate the transfer. I examine
this incident in detail later in this report.
150. The Professor’s post-mortem report identified ‘a considerable number of old
injuries’. However, he confirmed that these injuries were not linked to, and
neither caused nor contributed to, the man’s death.
151. Finally, as I have already outlined, the investigation by the Leicestershire
Constabulary found that no individual had been neglectful in their duties to such
an extent that they contributed to the man’s death. The police concluded that
he died of natural causes.
Whether the man was fit to be transferred from Feltham to Glen Parva in
February 2007
152. The clinical reviewer expresses concern about the actions of the nurse who
assessed the man as fit to transfer to Glen Parva in February. She did so after
the use of control and restraint procedures by officers at Feltham. She had not
actually consulted with the prison doctor during her assessment, even though
she claimed to have done so at the time. The man complained of feeling dizzy
to her.
31
153. The clinical reviewer considers that the nurse was probably placed under some
pressure by prison staff to deem the man fit for transfer, due to overcrowding
problems at Feltham on the day. He also believes that officers would have
been reluctant to have had their decision to transfer him undermined by having
to return him to his cell, given the effort involved in removing him from it in the
first place.
154. Consequently, when she failed to reach the prison doctor by telephone, the
nurse deemed that the man was fit to be transferred anyway. She
subsequently made a statement in which she claimed that she had spoken with
the doctor. The doctor has always denied that he was consulted about the
transfer. This matter has since been investigated by Serco, the provider of
healthcare at Feltham. A copy of the investigation, conducted by a Senior
Investigations Officer is annexed to this report.
155. The Senior Investigations Officer found that the nurse had made a telephone
call to Albatross Unit where the doctor was working. However, from the
evidence provided by the doctor, an officer who took her telephone call and
another nurse who was also present, the doctor never came to the telephone to
speak with her.
156. The officer spoke with the nurse and relayed information to the doctor. He did
not ask him to come to the phone, and he did not pass him the handset. The
investigation established that the nurse did not consult directly with the doctor in
February regarding the man’s fitness to transfer to Glen Parva. There was
some suggestion that the other three professionals involved had essentially
formed a coalition against the nurse. The Serco investigation found that this
was not the case.
157. As a result of the complaint made against her by the doctor, the nurse was
suspended from work in February 2007. Following the conclusion of the
investigation by the Senior Investigations Officer, a disciplinary hearing was
held in July 2007. As a result of the hearing, the nurse was issued with a final
written warning. Her conduct in February was considered to be seriously below
the standards of normal nursing practice. The warning lasted for a period of 12
months. (The nurse returned to work in August 2007 and continues to work at
Feltham. The doctor has since left Feltham.)
158. In spite of these events, the clinical reviewer believes that the man would have
been fit to transfer (even if the doctor had examined him) and that there was no
reason for him not to have been moved in February. He does not believe that
the use of force and the transfer had a negative effect on his long term health.
He confirms that there were no ongoing or planned hospital appointments or
medical tests which he would have missed as a result of leaving Feltham.
159. From the evidence available, the clinical reviewer concludes that, had a doctor
examined the man before he left Feltham, there would not, at that stage, have
been any illness evident which would have led to the transfer between prisons
32
being blocked. There is no evidence that the man himself told staff that he was
too unwell to transfer that day.
160. An officer told my investigator that the man did not appear either particularly
agitated or upset when she settled him into Glen Parva later that day. She
asked him how he felt, and he made no complaint to her at that time. The
officer who was the reception officer at Glen Parva also recalled that the man
presented unremarkably when he arrived at the prison. However, he did
complain of dizziness to the nurse in reception and was prescribed
paracetamol.
161. With regard to the use of control and restraint in February at Feltham, this was
properly documented by all the members of staff involved. The correct
procedure is described, and restraint was stopped when the man agreed to co-
operate. Control and restraint procedures are used by prison staff when a
prisoner refuses to comply with reasonable instructions. In this instance, he
was being told that he had to move to another prison. It is not unusual for
prisoners to be transferred out at short notice in order to ease overcrowding.
Few welcome that fact, but prisoners cannot choose where they are located.
162. Because Feltham is the only young offenders’ institution in the London area, it
feels the population pressures most acutely. Feltham receives a large number
of young adults from the courts every day, and its operational capacity is
routinely tested. For these reasons, and because staff cannot be seen to allow
a prisoner to disobey an order to transfer without good reason (in case this
encourages further ill discipline), I do not believe it was unreasonable that force
was used to move the man to the reception area.
163. Prison Service Order (PSO) 1600 states that:
‘When healthcare staff (registered nurse, hospital officer or doctor) are on
duty in the establishment they MUST attend a planned C & R intervention.’
None of the statements made in the ‘Use of Force’ forms by the officers
involved indicates that a member of healthcare staff was either requested or
present during the control and restraint process used to transfer the man to the
reception area. The incident took place on a Friday morning, at a time when
several nurses would have been in the prison.
The Governor of Feltham should ensure that all staff are reminded of the
requirements of Prison Service Order 1600. The planned use of force
should always involve the attendance of a member of healthcare staff.
164. I also note that the incident was not taped using a video camera. This is
recommended in PSO 1600 during the planned use of control and restraint.
However, in this situation, given that the man was undressed, it might have
been deemed inappropriate to video the use of force.
33
Reasons for the man’s transfer to Glen Parva
165. When my investigator spoke with them, the man’s family could not understand
why he was transferred out of Feltham where he was closer to them. According
to the police investigation conducted into his death, he was transferred out of
Feltham on both occasions as a result of overcrowding. His transfer was
apparently an operational decision and not a reflection on his conduct. As I
have already outlined, the clinical reviewer concludes that his health was not
affected detrimentally by the transfer. (I do of course sympathise with the view
that transferring a young man a hundred miles from his family is thoroughly
undesirable.)
166. The family also recall that the judge at Crown Court indicated at the man’s
hearing that he should remain at Feltham, and should not be transferred away
from the London area where his relatives were close by. However, as my
investigator told the family during his visit in January 2009, a judge’s comments
do not place the Prison Service under any obligation. The pressures of
overcrowding supersede such opinions as a judge may express. However
unwelcome the practice may be, it is an unfortunate fact that even young
offenders may be located at some distance from their families because of
prison overcrowding.
Sharing a cell
167. The man’s family have said they wanted him to share a cell with another
prisoner so that someone could check on his health. A Cell Sharing Risk
Assessment was completed at Feltham in January 2007 in which it was noted
that he did not wish to share a cell at the time because he wanted to address
his quick temper. However, he did subsequently ask to share a cell with
another prisoner when he arrived at Glen Parva in February. This was agreed,
and staff noted that both prisoners seemed pleased with the arrangement. The
prisoner provided the police with a statement regarding his friend’s health. He
seems to have assisted him whilst he became progressively more unwell during
his final weekend at Glen Parva, bringing him meals and such like.
Use of restraints
168. The man’s family wanted to know if he was transferred to the Queen’s Medical
Centre in cuffs. I can confirm that this was not the case. He was initially cuffed
to one of the escorting officers using a closeting chain (which consists of a
length of chain with cuffs at either end) for the journey from Glen Parva to the
Leicester Royal Infirmary (LRI). The closeting chain was removed soon after
his arrival at the LRI, and he remained uncuffed from that point onwards,
including during the journey to the Queen’s Medical Centre (QMC). Two
officers remained with him until he died. They did not stay at his bedside
throughout as this was not deemed either necessary or appropriate.
The journeys from Glen Parva to the LRI and then from the LRI to the QMC
34
169. The man’s family wanted to know whether the ambulance journeys from Glen
Parva to the LRI, and then from the LRI to the QMC, took longer than they
should have done. The timings regarding the calling and arrival of an
ambulance differed slightly, depending on the various statements and
documents provided. My investigator therefore obtained a Patient Report Form
(PRF) from the East Midlands Ambulance Service. This is likely to be the most
accurate record of events available. It is kept by the paramedics themselves as
a matter of routine during every emergency call out.
170. The PRF confirms that the ambulance was requested at 2.00pm. The
ambulance began its journey to Glen Parva at 2.01pm and arrived at the gates
at 2.07pm. The paramedics reached the man at 2.10pm. Having prepared him
for the journey, the ambulance departed Glen Parva at 2.32pm and arrived at
the LRI at 2.40pm.
171. Having undergone tests at the LRI during the afternoon, it was decided that the
man would be operated on at the QMC in Nottingham. He left the LRI in an
ambulance at 5.43pm, and arrived at the QMC at 6.14pm. A blue light was
used by the ambulance driver to ensure the quickest journey possible. By
6.30pm, he was in the operating theatre.
172. Consulting the Automobile Association (AA) website, my investigator has
ascertained that the journey from Glen Parva to the LRI is a distance of 3.4
miles, and should take about nine minutes to drive. This seems to correspond
with the time it took the ambulance to reach Glen Parva, given that an
ambulance was called at 2.00pm and reached the prison seven minutes later.
The journey from the prison to the LRI took a comparable eight minutes.
173. As regards the later journey from the LRI to the QMC, this is a distance of 26.9
miles, and is estimated to take an average 34 minutes to travel. The
ambulance actually made the journey in slightly less time in February 2007,
probably due to its ‘blue light’. I believe therefore that I can reassure the family
that the times taken to transfer the man in the ambulance were reasonable.
Whether the man’s treatment at Glen Parva was discriminatory
174. One of the concerns which the man’s family has about his treatment in prison is
the possibility that he was the victim of possible discriminatory treatment (racist
bullying) perpetrated by staff at Glen Parva. Unfortunately, when my
investigator and family liaison officer spoke with the family on two separate
occasions, they were unable to identify any specific officers. Indeed, whilst they
said that one unnamed officer at Glen Parva had apparently bullied him,
another had treated him with respect.
175. The man’s family told my investigator that an officer had thrown his copy of the
Qur’an across his cell in January, the day of his transfer from Glen Parva to
Crown Court. I have passed this allegation to the Governor of Glen Parva and
ask that he bring it to the attention of the Race Equality Officer so that the
matter can be investigated further.
35
The Governor of Glen Parva should commission further investigation into
the allegation made by the man’s family concerning events in January
2007.
176. It is certainly true that the man was reluctant to return to Glen Parva in
February, and became so agitated that he refused to transfer out. As we have
seen, he stripped himself and doused his cell in water and shower gel. Officers
at Feltham used control and restraint procedures to take him from his cell to the
reception area.
177. The Deputy Head of First Days in Custody at Feltham has confirmed that
around the time the man was transferred out, staff were observing a
considerable degree of reluctance on the part of black prisoners to transfer from
Feltham to Glen Parva. Prisoners were telling staff at Feltham that, as black
men originating from the London area, they did not feel at ease in Glen Parva.
The Deputy Head of First Days commented that this was a recognised problem
which was probably at its worst around the time that the man died. It would
seem that he was not alone in his reluctance to transfer to Glen Parva.
178. The Head of Diversity at Feltham confirmed that complaints from prisoners from
a black or minority ethnic background reached a peak in January 2007. Their
complaints related to their concern at the prospect of being transferred to Glen
Parva where they perceived that they would receive differential treatment.
179. In liaison with staff at Glen Parva, staff at Feltham took steps to address this
problem. The Head of Diversity visited Glen Parva in April 2007 to explore with
the Diversity Manager at Glen Parva at that time how the situation could be
improved. The Head of Diversity visited Glen Parva for a second time, and the
Diversity Manager also visited Feltham. Their co-working led to both members
of staff receiving a Performance Recognition Award from REAG (Race Equality
Advisory Group) for building a dialogue between the two prisons. The then
Director General of the Prison Service, now Director General of NOMS,
presented both men with the award in late summer 2007.
180. When the Head of Diversity spoke to my investigator, he explained that his co-
working with Diversity Manager had discovered the cause of the prisoners’
discontent. The strong feelings black prisoners had been expressing resulted
largely from the perception of life at Glen Parva rather than the reality. There
had been a lack of awareness of the particular circumstances at Feltham on the
part of staff at Glen Parva, and vice versa. A failure in communication,
seemingly now largely rectified, was deemed to be at the heart of the problem.
181. For example, staff at Glen Parva could not understand why Feltham was
sending them an apparently disproportionate number of prisoners from a black
or minority ethnic background. However, they failed to understand that
approximately 80 per cent of prisoners at Feltham fall into this category. The
situation is entirely reversed at Glen Parva, where a minority of prisoners define
themselves as having a black or minority ethnic background.
36
182. The Head of Diversity commented that prisoners perhaps had false
expectations of life at Glen Parva when they were transferred out of Feltham, as
Feltham is relatively well resourced. Black prisoners perceived that they were
being deprived of showers, food and such like at Glen Parva. However, the co-
working by the two YOIs found that these conditions were a result of generally
poorly equipped facilities, rather than a consequence of racial discrimination.
Black and minority ethnic prisoners had been interpreting a less well resourced
regime as receiving differential treatment.
183. A governor told my investigator that the situation has greatly improved and he
estimated that the resistance from black prisoners transferring from Feltham to
Glen Parva is now ‘a tenth’ of what it once was. There are still some
complaints, but not to anything like the same degree. The Head of Diversity
confirmed that he has only received one complaint about transferring to Glen
Parva since May 2007.
184. The Head of Diversity told my investigator that the man had not, unlike several
of his fellow prisoners, made any complaints in relation to racial discrimination
at Glen Parva whilst he was held at Feltham on either occasion.
185. I have confirmed that the man never made a complaint to my office about his
treatment. The Chair of the Independent Monitoring Board at Glen Parva in
2008 told my investigator that he never submitted any applications to the IMB
either. She also indicated that, in 2007, the IMB at Glen Parva received no
complaints from any prisoners specifically with regard to alleged racist
treatment by staff.
186. The Race Equality Officer at Glen Parva has further confirmed that the man
made no formal complaints using a prisoner complaint form, either of a general
nature or relating to racial discrimination, whilst he was held at Glen Parva on
either occasion. Over the 2006-2007 period, 58 prisoners at Glen Parva made
complaints about racial discrimination. This was apparently a comparable
figure to previous years.
187. The Race Equality Officer has provided my investigator with additional
information which helps to illustrate life as it would have been for a young adult
in Glen Parva in 2006 and 2007. I hope that this will be useful to the man’s
family.
188. There were 29 members of staff from a black or minority ethnic background
when the man was a prisoner at Glen Parva, which equated to 5.9 per cent of
the overall staffing. This compares with around 8 or 9 per cent of the population
of the East Midlands as a whole (and with about 38 per cent of the population of
Leicester).
189. At the time the man was held at Glen Parva, 28.6 per cent of prisoners
described themselves as being from a black or minority ethnic background.
The average percentage of adjudications against prisoners from a black or
minority ethnic background was almost identical to the proportion of the
population which they constituted during the months he was there. This
37
certainly does not indicate a pattern of racial discrimination in the adjudication
process. More detailed figures are provided in the table below:
38
Percentage of adjudications which
Month Involved prisoners who defined
themselves as black or minority ethnic
October 2006 30.25%
November 2006 29.1%
December 2006 25.42%
January 2007 35.25%
February 2007 23.37%
Average 28.68%
190. My investigator has also spoken with the man’s criminal solicitor. He confirmed
that the man never asked him to make a formal complaint on his behalf to either
Feltham or Glen Parva in relation to racial discrimination, or indeed any other
matter. The solicitor said that he would have written a letter to the Governor of
the relevant prison if he had asked him to.
Record keeping at both Feltham and Glen Parva
191. The clinical reviewer has examined the man’s clinical records. He notes that
entries made at both prisons were difficult to decipher, and that some entries
made by nursing staff were too brief. He believes that healthcare staff may well
benefit from training relating to record keeping. However, he notes that both
prisons were due to implement an electronic patient records system imminently,
and that this development should improve standards. In general, he considers
the man’s records to have been ‘of a reasonable standard’. However, he
makes the following recommendation, which I endorse.
The Heads of Healthcare at both Feltham and Glen Parva should ensure
that medical records are correctly signed and dated and that all relevant
details of the examination and plans for management of the patient’s
health are recorded. The member of staff should also print their name.
192. I note that the clinical reviewer has previously made a very similar
recommendation in relation to the self-inflicted death of a prisoner at Glen
Parva in June 2006.
193. In regard to record keeping, he highlights the fact that, just before the man was
transferred to Glen Parva in February, an entry was made by a nurse to record
actions taken by the prison doctor when he assessed the man in February.
Although the entry seems to accurately reflect the decisions made about the
man’s healthcare by the doctor, staff should record their own actions and
findings. Healthcare professionals should not make entries for other members
of their team in retrospect. However, the clinical reviewer does not consider
that the nurse’s actions had a negative impact on the care the man received. I
endorse his recommendation.
39
The Head of Healthcare at Feltham should ensure that staff make their
own records, and do not record the actions of colleagues. The Head of
Healthcare should address the action of the nurse.
194. The nurse had the opportunity to read my draft report during a period of
advance disclosure. (Any members of staff who are directly criticised during an
investigation are entitled to correct any factual errors within 21 days before the
report is sent to the man’s family.) The nurse said that she could not recall
making any notes of the doctor’s assessment. However, his medical record
indicates that she did make such an entry for the doctor in February. I have not
therefore amended my recommendation.
The failure to request the man’s medical records from his doctor
195. In the man’s case, neither Feltham nor Glen Parva obtained a copy of his
medical history from his community General Practitioner. The clinical reviewer
has reviewed a summary of his previous medical history prior to entering
custody provided to the Leicestershire Constabulary by his doctor following his
death. The clinical reviewer has confirmed that there was no significant
relevant medical history contained within the clinical records which the prisons
overlooked to the man’s detriment.
196. Nonetheless, it is of concern that there was the potential for an oversight with
serious consequences to have occurred. The clinical reviewer has ascertained
that both prisons now intend to request medical summaries from doctors when
a new prisoner enters custody. I note that he has completed two previous
clinical reviews in relation to the deaths of prisoners at Glen Parva. In both
those reports, he identified the same failing to obtain the prisoner’s medical
records and made the same recommendation.
The Heads of Healthcare at both Feltham and Glen Parva should ensure
that medical summaries are requested from community GPs in the case of
every new prisoner.
The care the man received in January
197. The clinical reviewer is satisfied that the man was examined after he felt unwell
and vomited in the gym in January. He was taken directly to the healthcare
centre to be assessed by the prison doctor. However, the clinical reviewer
remains unsure from the records available whether the man only vomited on
this occasion (as a result of a less serious illness), or if he actually collapsed as
well. If he did collapse in January, then it may have been as a result of an initial
bleed. This possible collapse might have been the first indication, aside from
headaches, of the more serious condition that would eventually cause his
death.
198. It is encouraging that a member of the healthcare staff visited the man on his
unit in the evening to check on his wellbeing. They also advised officers on the
unit to observe him and to call the healthcare team if he developed a rash. It is
unfortunate that they did not identify themselves in his medical record.
40
The care the man received after arriving at Glen Parva in February 2007
199. The clinical reviewer considers that the man did not present with any symptoms
of a significant illness when he underwent the reception process at Glen Parva
in February. It is persuasive that the officer, who helped the man to settle into
Unit 15 once he had left the reception area, could not recall there being
anything obviously wrong with his eye on the day of his arrival. She confirmed
that the man had not complained about his health on that first day, and there
was nothing in either his behaviour or appearance which gave her cause for
concern at that time.
200. The man’s health seems to have deteriorated rapidly from February onwards.
The clinical reviewer believes that he became increasingly unwell during the
night. As I have already described, his cellmate observed that he became
sensitive to light and noise. He also said that the man experienced eye pain,
and that one of his eyes began to point outwards, away from the other.
201. The man’s cellmate said he rang the cell bell during the night and alerted staff,
who told him that they would ask a member of the healthcare team to attend.
However, nobody attended to him during the night, and there is no record of
any of the events described by the cellmate. He has subsequently been
released from custody and my investigator has been unable to contact him.
202. The clinical reviewer believes that the cellmate was describing a clear sign that
a more serious condition was causing the man’s headaches, namely the
deviation in his eye. He believes that, had a medically qualified member of staff
made this observation on the night and linked it to a history of headaches, they
might well have been alerted to the seriousness of his condition.
203. During the next two days, the officer, who had inducted the man onto the unit,
observed his deteriorating health and repeatedly asked a member of the
healthcare team to assess him as quickly as possible. The clinical reviewer
commends the persistence of this officer in trying to secure an assessment of
the man by a doctor or nurse.
204. When she spoke with my investigator, the officer expressed her frustration
regarding the provision of healthcare at Glen Parva over that weekend. In all,
she made four telephone calls to the healthcare centre asking that the man be
examined. It was only as a result of her persistence that the senior nurse
eventually came to assess him. I endorse the clinical reviewer’s commendation
of the officer and would be grateful if the Governor could bring my comments to
her attention.
205. However, it would have been good practice if the officer had noted her
escalating concerns about the man in the unit’s observation book and thus have
kept night staff and other unit staff informed of the developing situation. She did
not do this. As the officer told my investigator, she was a relatively
inexperienced officer at the time, and she has reflected since on what occurred
41
over that weekend at Glen Parva. She recognises that there were aspects of
her own practice that could have been improved upon.
The Governor of Glen Parva should remind all staff of the importance of
writing relevant information in the wing observation book so that other
staff on the wing / newly arriving staff are aware of events.
206. The officer told my investigator that the senior nurse was, to the best of her
recollection, the member of nursing staff with whom she spoke when she called
the healthcare centre for the second time. The nurse confirms this. The officer
was increasingly concerned about the man’s symptoms, but was told by the
nurse in the early afternoon that nobody would come to Unit 15 to assess him
that day.
207. Although a formal triage policy was not introduced at Glen Parva until
December 2007, nurses were expected to assess prisoners once they had filled
in the appropriate application form requesting an assessment. The man had
made an application with the officer’s help early that morning. The officer had
also communicated her concern about him over the telephone twice. The
current Head of Healthcare has confirmed that 24 hour nursing cover at Glen
Parva meant just that at the time. A nurse should have been able to
competently assess a prisoner, having been informed of symptoms of eye and
head pain. In failing to visit Unit 15 on the Saturday and assess the man, I am
sorry to say that the nurse failed to fulfil her professional duties as the team
leader in the healthcare centre that day.
208. When the nurse did visit the man in his cell, the officer felt the examination was
cursory and said that the nurse did not examine his eye. She told my
investigator that the nurse did not actually make an attempt to do so, contrary to
the nurse’s own assertion. The officer does not remember any refusal on the
man’s part to allow the nurse to look at his eye. On the contrary, she said that
he had complained of eye pain repeatedly across the weekend. She
remembered that the assessment was carried out in the doorway to the cell and
lasted less than two minutes.
209. In his clinical review, the clinical reviewer is critical of the nurse’s failure to
examine the man’s deviated eye when she visited him in his cell in the morning.
The nurse told the clinical reviewer that she feared being accused of assault if
she examined his eye against his wishes. She maintained that he had been
reluctant to let her examine his eye, and had kept it tightly shut. The nurse did
not include this information in her statement to the police nor in her staff
statement made shortly after his death.
210. The clinical reviewer considers the nurse’s failure properly to examine the man
to be ‘extremely disappointing’. He comments that examination of his eye was
clearly warranted, given the pain he was reporting. He believes that such an
examination would have alerted the nurse to the fact that his condition was very
serious. I concur with the clinical reviewer when he suggests that a medical
examination, conducted in the presence of the officer, would have been in the
42
man’s interests, and would not realistically have resulted in disciplinary action
being taken against the nurse.
211. At a meeting with the man’s family in January 2009, their representative
expressed the family’s incredulity to my investigator that he would refuse to
have his eye examined by the nurse after he had been experiencing such pain
over the weekend. They called into question the nurse’s version of events.
Contemporaneous accounts are usually to be preferred to those submitted
subsequently, and I note that in neither her initial statement to the police, nor in
her staff statement, did the nurse recall the man’s refusal to let her look at his
eye.
212. Whilst the nurse by all accounts acted quickly and efficiently in response to the
man’s collapse that afternoon, there is criticism to be levelled with regard to her
professional conduct prior to the emergency response. Her failure to triage him,
despite the officer communicating her growing worries for his health during her
telephone messages, was a serious error of judgement. She should have
ensured that either she or a colleague examined him in February after speaking
with the officer. Had she performed a thorough examination that Saturday, she
would undoubtedly have identified the man’s deviated eye. This should then
have prompted either an immediate hospital referral or calling the out of hours
doctor.
213. When the nurse did assess the man on the morning of Sunday, it would seem
that her examination was not comprehensive and that no proper assessment of
his eye was attempted. Whilst any referral at this late stage would not, in the
clinical reviewer’s opinion, have changed the eventual outcome, the nurse’s
actions appear to have been below the standard expected.
214. My investigator interviewed the officer and received the clinical review from the
clinical reviewer after the nurse was interviewed by an Assistant Ombudsman in
July 2008. To ensure fairness, the investigator therefore wrote to the nurse in
March 2009, outlining the criticism that would be made of her actions as a result
of the new evidence and offering her the right to reply.
215. In her response dated March 2009, the nurse confirmed that she had spoken
once on the telephone with the officer on the afternoon of Saturday. She said
that she had not taken another telephone call from the officer that day. If
another call had been made to the healthcare centre earlier on, she had not
been made aware of it. The nurse denied that the officer had been insistent
about the need for the man to receive medical attention during the telephone
call in February. She commented that, had the officer been insistent, she would
have attended his cell as soon as she was able.
216. Regardless of whether the officer was insistent or not, the nurse accepts that
she was told by the officer over the telephone that the man required
assessment. It was therefore her responsibility as team leader to ensure that
either she or another nurse examined him on the same day.
43
217. The nurse suggested in her response that the officer should have brought the
man to the healthcare centre in February if she was so concerned about him.
Indeed, had the nurse asked the officer to bring him to her during their
telephone call, this might have been a reasonable course of action. However, I
do not think it is reasonable to expect an officer (with no medical training) to
decide that a patient is so unwell that she should take him to the healthcare
centre. The responsibility for assessing the man lay with the nurse (who had
been told of his symptoms) rather than the officer. Additionally, taking him to
the healthcare centre after being told that he would not be assessed that day
could have meant bringing an unwell prisoner into a potential conflict between
two members of staff.
218. In a letter dated April, the nurse provided my investigator with a further
statement. She said that it was ‘accepted practice’ at the time that healthcare
staff did not always assess prisoners on the same day as they asked to be
examined. She commented that staffing levels and the number of prisoners
meant that this was ‘simply not possible’. She indicated that healthcare staff
therefore relied on information from the officer requesting the assessment in
order to assign priority to the examination. She said that she could not recall
why she was unable to attend Unit 15 to assess the man in the afternoon, but
said that she would have given a reason to the officer at the time.
219. The nurse’s assertion that it was ‘accepted practice’ at the time that prisoners
were not assessed on the same day as they made an application is at odds with
the opinions of the clinical reviewer and the Head of Healthcare at Glen Parva.
Both consider that a prisoner reporting symptoms of eye pain and a headache
should have been assessed on the same day.
220. I have already made reference to the Head of Healthcare’s comments in this
regard in paragraph 208. The clinical reviewer remarks in his clinical review
that the officer was not qualified to make medical decisions and that it was
inappropriate for the nurse to rely on the opinion of a prison officer when
prioritising medical assessments. He thinks that a nursing assessment of the
man should have occurred as a matter of routine. He considers that it is
‘alarming’ that the nursing staff did not proactively examine a prisoner who
reported symptoms of eye pain and a headache.
The Head of Healthcare at Glen Parva should consider whether a
disciplinary investigation should be carried out into the actions of the
nurse in February 2007.
221. The nurse had the opportunity to read my draft report during a period of
advance disclosure. (Any members of staff who are directly criticised during an
investigation are entitled to correct any factual errors within 21 days before the
report is sent to the man’s family.) She submitted the following response:
‘I cannot accurately recall or even remember any specific events of February
2007. I only vaguely recall a phone call from the officer on that day.
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I will comment though if an officer states they are concerned seriously about a
prisoner I never hesitate to respond. It is my opinion that the officer has more
insight into the prisoners as they see them on a daily basis so will pick things
up even if they are unaware of any severity. They are aware if a prisoner is or
is not always complaining about medical problems. I always value their input
and concerns and will act accordingly.
I have never refused to go and see a prisoner if the officers say they have
concerns as I am aware they do not have medical insight so need support
from Healthcare.
I do not recall any insistence from the officer regarding the man - that is why I
dealt with going to see him when I did on the Sunday after a phone call. I
cannot recall any urgency either being stated.
I have no recollection of any conversation pertaining to the doctor going on on
the Saturday or that an appointment had been refused until the following day.
I was unaware at the time of seeing the man that an appointment had been
made for Sunday. I went on my own visit to decide this.
My recollection of Sunday morning is that I spoke to the officer because she
said that the man was still unwell with a headache and eye pain.
I went to visit him on my rounds and went on what I observed at the time and
what I was presented with. He had his eye tightly shut I noticed but I do not
recall him having it covered with anything.
I observed him get up off his bunk watching for any abnormal leaning to one
side or any lack of coordination. I also observed his gait and the colour of his
skin. Black people visibly pale when they are seriously poorly. All of this
seemed normal. There was no mention of any vomiting. I recall wanting to
look in his eye but the expression on his face and not being given verbal
agreement stopped me doing this. I gave pain relief to see if this would help
before he came to see the doctor.
On reading the report and my own feelings regarding the incident I would
certainly be more thorough and ask more accurate questions as I never want
to be put in a position where I could have done more. My career has always
been about helping the sick and early intervention.
I am also considering returning to Accident and Emergency to bank in order to
keep my skills updated. I am also reading my Minor injury book to read up on
Red Flags and problems that mimic other things.’
222. I have not amended my original recommendation as a result of receiving the
nurse’s letter. However, any disciplinary hearing should take into account her
response, which I felt it was important to include in its unedited form.
223. The clinical reviewer believes that there was a clear failing with regard to the
out of hours healthcare provision at Glen Parva over the weekend of 3 and 4
45
February. The prison’s healthcare policy clearly states that all medical
problems will initially be triaged by nursing staff when a doctor is not on site.
However, when the officer rang the healthcare department and reported the
man’s ill health on a morning in February, no assessment by a nurse took
place. Instead, he was offered an appointment with the doctor on the following
day.
224. When the officer persisted, and again spoke with a member of the healthcare
team (the nurse) in the afternoon, a nurse was still not sent to assess the man.
I share the clinical reviewer’s criticism of the provision of healthcare at Glen
Parva in this instance. Without question, a nurse should have made an
assessment of the man at some stage after the officer twice reported his
symptoms and asked to have him examined.
225. When she spoke to my investigator, the officer expressed her frustration
regarding the failure to send a nurse to examine the man. In total, she made
four telephone calls on two days to the healthcare centre before a nurse came
to see him. The officer said that she accurately described his symptoms to the
nursing staff she spoke to, including his worsening headache and eye pain.
Like the clinical reviewer, I am alarmed that nursing staff did not prioritise a
patient who they were told was experiencing this combination of symptoms.
226. As an officer with only a few months experience at that stage, the officer did not
feel she was in a position to contest the decision made by the member of the
healthcare team. She was unaware at the time that nursing staff had an
obligation to come and perform an initial assessment on the man the same day,
even if a doctor was not in the prison. She told my investigator that, had she
both had a little more experience and been aware of the relevant policy, she
would have insisted that a nurse came and assessed him.
227. The clinical reviewer unfavourably compares the prison’s response to the man’s
symptoms (as described to the healthcare team by the officer) to that available
in the community. To illustrate this, he telephoned the local nurse triaging
service in the community, presenting them with a theoretical patient with the
general symptoms of eye pain and headache which he was experiencing.
228. The triaging service said that they would carry out a medical assessment of the
patient within one hour. The clinical reviewer believes that, following such an
assessment, the man would have been referred to hospital. Furthermore, had
the severity of the eye pain or the altered vision been reported, then it is likely
that an ambulance would have been called. The clinical reviewer concludes
that the prison fell short of the standard of healthcare expected in the
community.
The Head of Healthcare at Glen Parva should ensure that nursing staff
triage all prisoners if ill health is reported during the out of hours period.
If the combination of eye and head pain are reported, then nursing staff
should triage the patient within one hour.
A review of the failure to triage the man in February should be carried out.
46
229. The clinical reviewer also notes that few of the nurses who are responsible for
triaging prisoners in Glen Parva are as well qualified as their counterparts in the
community. Few have the necessary qualifications and training in the
assessment of general illness and the delivery of primary care.
230. Glen Parva used to have one nurse from a mental health background and
another from a general nursing background in attendance overnight if prisoners
became ill. The clinical reviewer is concerned that this staffing level has now
been reduced to one nurse, potentially exposing a mental health nurse to a
situation where they are unqualified to treat a condition such as the man’s. I
endorse his recommendation regarding the recruitment of nurses at Glen
Parva.
The Head of Healthcare at Glen Parva should ensure that nurses who are
responsible for the assessment of prisoners’ health during out of hours
periods either have the necessary training in general illness, or are
working towards the relevant qualifications.
231. Conversely, the clinical reviewer commends the delivery of healthcare at
Feltham, where mental health services are delivered by separate nursing staff.
Only nurses trained in general illness are involved in the delivery of primary
care to prisoners. He praises this model, and I endorse his remarks.
232. Despite the failings of healthcare staff at both Feltham and Glen Parva
highlighted by the clinical reviewer, he believes that any insight into the man’s
condition in the days prior to his collapse could not, on the balance of
probabilities, have prevented his death. Had a member of the healthcare staff
properly examined his deviated eye in February, then the clinical reviewer
considers that he would likely have been admitted to hospital. However, as
both the consultant neurosurgeon and neurologist have also concluded, the
aneurysm in his brain would still have ruptured.
The response to the man’s collapse in February
233. The clinical reviewer is of the opinion that the staff’s response to the man’s
eventual collapse was ‘prompt and appropriate’. He commends the third officer,
who arrived first in the holding room, for being able to place the man in the
recovery position until nursing staff attended. When my investigator spoke with
the first officer, despite her frustration with their failure to examine him earlier in
the weekend, she praised the response of the prison’s healthcare team to his
collapse as being both quick and efficient.
234. Whilst my investigator was provided with some statements prepared by staff at
Glen Parva shortly after the man’s collapse, they were not comprehensive. The
incident was not properly documented. Not all staff who attended the holding
room gave a statement, and consequently some details were not recorded. For
example, no log appears to have been taken to record the chain of events
minute by minute.
47
The Governor of Glen Parva should ensure that all staff involved in an
emergency prepare a written statement recording their actions as soon as
is practicable after the event. The Senior Officer overseeing the incident
should also ask an officer to record a log of events as they happen.
The care for the man’s family
235. The man’s relatives told my family liaison officer at their initial meeting that they
had felt frustrated with the lack of information forthcoming from the prison after
he died. They said that the Governor had rung his mother a month after his
death to ask if she had any questions, but the family felt that this was too late
and no longer wanted direct contact at that stage.
236. My investigator has been provided with a copy of the prison family liaison
officer’s log. This details actions taken with regard to the man’s family. There
are no entries in the log after the day he died. This would seem to lend
credence to the family’s feeling that they did not receive any follow up contact
from staff in the weeks after he died. If this is indeed the case, it is extremely
disappointing.
The Governor should review his contingency plans for a death in custody
to ensure that they emphasise the duty of care to the bereaved family.
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CONCLUSION
237. I recognise that the man’s death at such a young age has had a profound
impact on his family. That his death took place whilst he was in prison has
caused the family still further grief and has given rise to a number of questions
which they needed to be answered fully. I hope that my report has provided his
relatives and friends with a greater understanding of the events which took
place.
238. My investigation has discovered failings in the healthcare which the man
received at both Feltham and Glen Parva. I also recognise that other staff
clearly had his welfare at the forefront of their minds. I hope that the family will
gain some degree of consolation in knowing that lessons will be learnt from my
investigation.
239. I conclude that the man died of natural causes, almost certainly the result of a
congenital weakness.
240. Finally, I would like to repeat my apology that this report of my investigation was
delayed for so long.
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RECOMMENDATIONS FOR GLEN PARVA
1. The Governor of Glen Parva should commission further investigation into the
allegation made by the man’s family concerning events in January 2007.
The prison accepted this recommendation. The Governor commissioned the
Head of Healthcare to carry out an investigation of the events as alleged.
2. The Governor of Glen Parva should remind all staff of the importance of
writing relevant information in the wing observation book so that other staff on
the wing / newly arriving staff are aware of events.
The prison accepted this recommendation. The Governor agreed to publish a
Notice to Staff reminding them that accurate up to date information must be
recorded in the observation books on all units.
3. The Head of Healthcare at Glen Parva should consider whether a disciplinary
investigation should be carried out into the actions of the nurse in February
2007.
The prison accepted this recommendation. The Governor agreed to
commission the Head of Healthcare to carry out an investigation in relation to
the nurse’s conduct in February 2007 in consideration as to whether
disciplinary action should take place.
4. The Head of Healthcare at Glen Parva should ensure that nursing staff triage
all prisoners if ill health is reported during the out of hours period. If the
combination of eye and head pain are reported, then nursing staff should
triage the patient within one hour.
The prison accepted this recommendation. The Head of Healthcare agreed to
issue a Notice to Staff stating that clinical triage should take place within a
one hour period when prisoners report both head and eye pain. This
requirement will also be reflected in the annual appraisal process for
healthcare staff.
5. A review of the failure to triage the man in February should be carried out.
The prison accepted this recommendation. The review will be carried out as
part of the investigation into the nurse’s conduct.
6. The Head of Healthcare at Glen Parva should ensure that nurses who are
responsible for the assessment of prisoners’ health during out of hours
periods either have the necessary training in general illness, or are working
towards the relevant qualifications.
The prison partially accepted this recommendation and gave the following
response:
50
‘Given the wide range of skills expected for nursing in this environment it is
expected that all registered nurses would have a basic competency in
assessing prisoners’ healthcare needs. However it is not feasible for all
nurses to have an additional qualification other than that required to become a
registered nurse. This is due to the requirement to have a good cross section
of mental health and general trained nurses. If there is any doubt in relation
to a prisoner’s ill health then the registered nurses are able to access a doctor
24 hours a day. All nurses are offered minor injury training and also basic life
support training.’
7. The Governor of Glen Parva should ensure that all staff involved in an
emergency situation prepare a written statement recording their actions as
soon as is practicable after the event. The Senior Officer overseeing the
incident should also ask an officer to record a log of events as they happen.
The prison accepted this recommendation and gave the following response:
‘Procedures are currently in place to ensure this action takes place through
the security incident reporting process and also through the documents
completed when control and restraint procedures are used. However, a
notice will be published to staff reminding them. Contingency plans will be
amended to require log keeping in the event of an incident.’
.
8. The Governor of Glen Parva should review his contingency plans for a death
in custody to ensure that they emphasise the duty of care to the bereaved
family.
The prison accepted this recommendation. The death in custody contingency
plan will now require that a trained Family Liaison Officer is involved in
supporting the bereaved family.
RECOMMENDATIONS FOR FELTHAM
9. The Governor of Feltham should ensure that all staff are reminded of the
requirements of Prison Service Order (PSO) 1600. The planned use of force
should always involve the attendance of a member of healthcare staff.
The prison accepted this recommendation. A Governor’s Order has been
issued to all staff reminding them of the procedures laid out in PSO 1600.
Training for all nursing staff who might be involved in planned removals has
been provided by control and restraint instructors.
10. The Head of Healthcare at Feltham should ensure that staff make their own
records, and do not record the actions of colleagues. The Head of Healthcare
should address the actions of the healthcare nurse.
The prison accepted this recommendation. The introduction of the electronic
patient record keeping system means that staff cannot make entries on behalf
of their colleagues. The actions of the healthcare nurse have been addressed
by her employers, Serco Health.
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RECOMMENDATIONS FOR GLEN PARVA AND FELTHAM
11. The Heads of Healthcare at both Feltham and Glen Parva should ensure that
medical records are correctly signed and dated and that all relevant details of
the examination and plans for management of the patient’s health are
recorded. The member of staff should also print their name.
Glen Parva accepted this recommendation and gave the following response:
‘Glen Parva has an electronic patient record keeping system in place that is
now used by all nursing staff in place of manual records ensuring that all
entries are legible and easily identifiable.’
Feltham gave the following response:
‘Each member of healthcare staff has a unique password to access and
maintain the electronic patient record keeping system. This ensures that their
name is correctly recorded against each entry they make in the clinical record.
All electronic clinical records are audited.’
12. The Heads of Healthcare at both Feltham and Glen Parva should ensure that
medical summaries are requested from community GPs in the case of every
new prisoner.
Glen Parva accepted this recommendation and gave the following response:
‘All prisoners arriving at Glen Parva are asked for their doctor’s details.
Requests for medical information are actioned by the reception healthcare
team at the earliest opportunity.’
Feltham gave the following response:
‘With an average of 50 to 60 new prisoners each night this has proved
impractical. Any prisoner with a disclosed medical condition or previous
medical history will be assessed by a doctor who will request their medical
notes from their community doctor.’
THE FAMILY’S RESPONSE TO THE DRAFT REPORT
The man’s mother’s solicitor provided a response to the draft report on behalf
of the family in December 2009.
The family were disturbed to read about the use of control and restraint
procedures in February 2007 at Feltham without the presence of a member of
healthcare staff. The man’s mother thought that, had a nurse been present,
they might have alerted the officers to her son’s recent headaches. She
considered that this information might then have influenced the use of force.
The family are upset that the proper procedures were not followed.
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The man’s family expressed their concerns about the actions of the reception
nurse at Feltham. They were upset that the prison doctor did not have an
opportunity to assess him before he was transferred. The family also
expressed their concerns about the actions of the senior nurse at Glen Parva.
They did not accept her explanation of events.
The man’s mother accepted my explanation for the delay in producing the
draft report. However, she reiterated that the length of time it took to
complete the investigation was unacceptable. She expressed particular
concern that the delay in producing the report prevented my investigator from
being able to interview the cellmate.
The man’s mother asked what attempts were made during the investigation to
contact the cellmate. Unfortunately, when the investigator inherited the
investigation in November 2008, the better part of two years had passed. The
investigator had no forwarding contact details for the cellmate. He relied on a
police statement taken from him at the time of the man’s death.
The man’s family asked my investigator to provide the cellmate’s forwarding
address so that they could pursue their own investigation. As I have
indicated, the investigator does not possess up to date contact details. The
cellmate wrote on his police statement that he would not have a fixed address
following his release in March 2007.
My investigator checked the Prison Service’s Inmate Information System (IIS)
but no discharge address was recorded. The name of a probation officer was
mentioned, and my investigator telephoned him. The probation officer
confirmed that he has not supervised the cellmate for several years. IIS
indicated that he was represented by Hodge, Jones and Allen, the same
solicitors who represent the man’s mother. The investigator has passed this
information on to the solicitor.
Finally, the man’s family took the opportunity in responding to my report to
confirm that they felt let down by the lack of contact from the prison following
his death.
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