Individual at Risley

Investigation into the death of a man
at HMP Risley in May 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2009
This is the report of an investigation into the circumstances surrounding the death of
a man. He was 41 years old when he was found collapsed in his cell at HMP Risley
in May 2008. He was pronounced dead some 30 minutes later by paramedics. A
post-mortem revealed that he had severe coronary artery disease and this had led to
his death.
The man had struggled with substance misuse since his teens. After a two year
period of being drug-free between 2005 and 2007, he returned to heavy drug use
following difficulties in his relationship and the threat of losing his home. The man
leaves three children and two step-children. Fellow prisoners and staff commented
that his cell was full of pictures of his family, and that he spoke regularly to them on
the telephone. I would like to offer my sincere condolences to his family for their sad
loss.
The investigation was led by one of my investigators. One of my family liaison
officers spoke to the man’s partner on the telephone to tell her about my investigation
and to ask whether she had any particular questions about his time in Risley. In
addition, an independent review of his medical care was undertaken by the clinical
reviewer on behalf of the local Primary Care Trust. I am grateful to the clinical
reviewer for his assistance. I am also grateful to the prison’s liaison officer and to the
staff and prisoners at Risley for their co-operation.
The clinical reviewer has concluded that the care the man received in prison for his
chest pain compared favourably with the treatment he would have received in the
community. However, my report raises a number of issues about the prison’s
response to his collapse. I am pleased to record that Risley has already
implemented policies to address some of these matters. I make four
recommendations with the intention of further improving the prison’s ability to
respond to a first aid emergency.
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 April 2009
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CONTENTS
Summary
The investigation process
HMP Risley
The events leading up to the man’s death
Risley’s response to the man’s death
Issues considered during the investigation
- The clinical care given to the man at Risley
- The prison’s response to the man’s death
Recommendations
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SUMMARY
The man was aged 41 years when he died at HMP Risley in May 2008. He was
found collapsed in his cell by another prisoner. Despite the efforts of staff to revive
him, he was pronounced dead some 30 minutes later. A post-mortem revealed that
he suffered from serious coronary artery disease which had led to his death.
The man had transferred to Risley on 24 January 2007. He was located on the re-
integration unit and mixed well with his peers. He leaves a partner, three children
and two step-children. He was in close contact with his partner and all of his
children, and was waiting for a transfer to a prison closer to home so that he could
see them more regularly.
On 27 April 2008, the man complained of chest pains and numbness in his left arm.
He was taken to outside hospital but tests showed he had not had a heart attack and
so he was returned to Risley. He was examined the following day by the prison
doctor who referred him to an out-patient clinic at another hospital. His first
appointment at this clinic was scheduled for 14 May.
A clinical review of the man’s medical treatment while at Risley was undertaken by
the clinical reviewer. The clinical reviewer concludes that the care the man received
in prison for his chest pain compared favourably with the care he would have
expected to receive in the community.
I highlight a number of issues about the prison’s response to discovering the man
collapsed in his cell. The radio of the officer who first entered his cell failed, and he
was unable to use it to call for emergency assistance. The member of staff
designated first emergency response did not immediately hear the emergency radio
call. None of the discipline staff who responded to the alarm was trained in cardio-
pulmonary resuscitation. Two of the masks in the emergency medical kitbag were
defective, and the wrong leads were attached to the defibrillator making it unusable.
The clinical reviewer has advised that, given the extent of the man’s heart disease, it
is unlikely that any of this made a difference to his chances of survival.
Nevertheless, I endorse the recommendations made by the clinical reviewer and
make four of my own. I have been pleased to learn that Risley has already
implemented new policies designed to improve their response to medical
emergencies.
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THE INVESTIGATION PROCESS
1. I was notified of the man’s death in May 2008. The investigation was allocated to
an investigator the same day. Notices were issued to staff and prisoners at
Risley telling them that an investigation would be taking place, and inviting those
who wished to see the investigator to make themselves known. The investigator
wrote to the Coroner and to the local Primary Care Trust.
2. The investigator visited Risley on 16 May. He met the appointed liaison officer
and interviewed a prisoner and friend of the man. The investigator collected
copies of the man’s prison record and copies of other records associated with his
death. He visited the unit where the man lived and spoke informally to a number
of staff there. The investigator returned to Risley on 13 July when he interviewed
six members of staff.
3. A clinical review of the man’s medical care was commissioned from the local
Primary Care Trust (PCT). The review was undertaken by a clinical reviewer and
it appeared in full as an annex to the draft report.
4. One of my family liaison officers spoke to the man’s partner on the telephone.
She explained the nature and purpose of my investigation and asked his partner
if she had any questions about his treatment in Risley. His partner did not raise
any specific concerns at that time. However, she expressed her shock as she
had been talking to him on the phone a short time before representatives from
Risley arrived at her home to tell her of his death. His partner was aware that he
had experienced chest pains some two weeks prior to his death, but said he had
not mentioned feeling unwell during their conversation on the day he died. I hope
my report helps his family better understand what happened in the time leading
up to his death.
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HMP RISLEY
5. HMP Risley is a male category C training prison in Cheshire. It has an
operational capacity of 1,085, and offers a variety of work, vocational training
courses and a comprehensive education programme. It has 24 hour healthcare
provision. Primary healthcare is provided by the local Primary Care Trust (PCT).
6. B1 re-integration unit, where the man was located, is a small residential unit for
prisoners who have had problems in the mainstream prison population. The aim
is to provide access to courses and activities for those prisoners who have been
previously removed from the regime, so that they can progress to a normal
residential unit.
7. Risley received an unannounced inspection by HM Chief Inspector of Prisons in
April 2008. In her report she wrote that Risley was a jail that simply had to
improve, particularly in respect of keeping prisoners occupied and improving how
safe they felt. There were also shortfalls identified with respect to healthcare
provision, but none that has direct implications to the man’s care. Similarly, the
prison’s Independent Monitoring Board (IMB) in its annual report for 2008
mentioned concerns about mental health services for prisoners, but nothing that
applied to the man’s care. (The IMB is an independent, lay body. Each prison
has an IMB appointed to consider the humane and just treatment of prisoners
and the range and adequacy of programmes preparing them for release.)
8. Prior to the death of the man, there had been three previous deaths at HMP
Risley since 2004 when I was given responsibility for investigating all deaths in
prison custody. The circumstances of the man’s death are different from those
earlier investigations and none of my earlier recommendations has any bearing
here.
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THE EVENTS LEADING UP TO THE MAN’S DEATH
9. As noted, the man was transferred to Risley on 24 January 2008. On 8
February, he was transferred to C wing. On 28 February, he was found in
possession of a mobile phone and later the same day asked staff if he could be
moved to the care and separation unit (CSU – the segregation unit) for his own
protection. He said he owed money to the prisoner who had supplied him with
the phone and that he had been threatened. He was relocated to the CSU. He
said he was keen to be transferred to a prison on Merseyside so he could keep
in better contact with his family.
10. On 13 March, the man was moved to B1, the re-integration unit. He was
reviewed every two weeks and it was recorded that he complied with the regime,
was polite to staff and mixed well with his peers. He had been placed on the
transfer list for a Merseyside prison. He hoped to go to HMP Altcourse so that
he could attend their ‘STOP’ programme (Substance Treatment and Offending
Programme - an offending behaviour course).
11. Shortly after midnight on 26 April, the man pressed his cell bell and complained
of chest pains and numbness in his left arm. He was seen by healthcare staff
who performed an Electro Cardiogram (ECG) test using a defibrillator. As a
result, an ambulance was called and he was taken to North Cheshire Hospitals
NHS Trust. He was given two TnI tests (blood tests which determine if a patient
has had a heart attack) that showed negative and was returned to Risley at
6.30pm on 27 April. The following day he was seen by the prison doctor who
prescribed aspirin and referred him to hospital for a tread mill stress test to detect
any undiagnosed coronary artery disease. His hospital appointment was
scheduled for 14 May.
12. At about 2.55pm on an afternoon in May, two Officers noticed that the man and
two other prisoners had set up a ‘mini-gym’ using overturned tables and chairs in
one of the association rooms. Both Officers said in interview that they told the
prisoners to stop what they were doing because the activity had not been risk-
assessed and they were not being directly supervised. The first Officer said the
prisoners stopped and went off to have a shower. He then spent some minutes
ringing around to see if he could set up a gym session for the three prisoners.
On finding out that it might be possible for them to attend the gym on a Friday
afternoon, he went into the shower area and told the man and the other two
prisoners. The Officer said that all three men seemed fine.
13. One of the prisoners exercising with the man at interview said that he was doing
some press-ups and sit-ups with him and another prisoner when the Officer told
them to stop. The prisoner said they stopped and went for a shower. He said he
was talking to the Officer on the landing when the man came out of the shower
and went into his cell. Not long afterwards he heard some noise, and looking
into his cell he saw him collapsed on the floor. The prisoner called for help and
officers came to the cell.
14. The second Officer said he was sitting at a desk about five yards from the man’s
cell when he heard a prisoner calling him. He said he tried to call for emergency
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assistance but his radio battery was dead. The second Officer entered the man’s
cell and saw him lying on his left hand side convulsing. He said his face was
blue and his arms were out in front of him. The man was breathing, but in a
laboured way. The Officer tried to get a response from him but could not. He
held the man’s head and noticed that he had vomited and urinated. The Officer
said he was not trained in cardio-pulmonary resuscitation and, because the man
appeared to be breathing, he did not attempt any life support. He said that
healthcare staff arrived within two or three minutes of the alarm being raised.
15. The first Officer said he heard a shout for help and went into the man’s cell. He
saw the second Officer trying to revive him and two prisoners moving furniture to
create space. The Officer used his radio to call for emergency assistance.
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RISLEY’S RESPONSE TO THE MAN’S DEATH
16. The control room log sheet shows that the call from B1 asking for emergency
medical response (the person carrying the radio with call sign Hotel 1) was made
at 3.15pm. The Deputy Head of Healthcare was Hotel 1 on that day. She said at
interview that she was in a meeting in the Healthcare Centre and did not
immediately hear the call. A Nurse was carrying the radio with call sign Hotel 2,
which meant that she was to offer support to Hotel 1 in an emergency. She said
at interview that she did not hear Hotel 1 respond to the call so she contacted the
control room to say that she was responding. Hotel 1 heard Hotel 2’s response
and realised that she must have missed the call for Hotel 1. She said that she
left her meeting and met Hotel 2 coming out of a treatment room. Hotel 2 was
carrying two emergency bags. They did not know what type of emergency they
were responding to, so Hotel 2 asked the Head of Healthcare to collect a
defibrillator and follow them to B1. Hotel 2 and Hotel 1 went immediately to the
scene of the emergency.
17. Hotel 2 said that when she arrived at the man’s cell an officer told her that he
was “navy blue”. She immediately asked for oxygen and an ambulance to be
called. Hotel 2 began mouth to mouth resuscitation using a Laerdal mask (a
mask used for resuscitation with a one-way valve to prevent transfer of fluids).
Hotel 1 checked for a pulse. When she found none she started chest
compressions. Hotel 1 said she checked the man’s eyes with her pen torch and
found that his pupils were fixed and dilated. Head of Healthcare arrived with the
defibrillator but the correct leads were missing and they were unable to use it.
The prison doctor also arrived and inserted an airway into the man’s mouth. The
man was given oxygen using an Ambu-bag (a bag valve mask used to give air to
a patient with breathing difficulties).
18. The paramedics arrived at the prison at 3.35pm. They went to the man’s cell and
attached their defibrillator to him. The machine showed a flat line indicating that
there was no electrical activity in his heart. They confirmed that he had died at
about 3.40pm.
19. All the relevant agencies were notified of the man’s death in a timely manner.
Staff told the other prisoners on the wing that he had died and arranged for a
Listener (Listeners are trained by Samaritans to provide confidential emotional
support to fellow prisoners in distress) to go to the wing later that same
afternoon. The care team offered support to staff involved in responding to the
man’s death. All prisoners who were deemed to be at risk of self harm were
checked. The same evening there was a meeting (known as a ‘hot debrief’) for
the staff involved to discuss the response to finding him collapsed.
20. A Principal Officer was nominated Family Liaison Officer. He and the Roman
Catholic Chaplain went to the home of the man’s partner later that afternoon and
broke the sad news of his death to her.
21. The Roman Catholic Chaplain attended the man’s funeral and the prison sent a
wreath. A service was also held for him at the prison. This was attended by his
friends and fellow prisoners from B1.
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ISSUES CONSIDERED DURING THE INVESTIGATION
The clinical care offered to the man at Risley
22. The clinical reviewer’s clinical review at Annex 1 provides a comprehensive
account and analysis of the man’s clinical treatment at Risley. I draw the
attention of the local PCT and the Governor and Head of Healthcare at Risley to
his findings and comments. I discuss the main points from the review below.
The clinical reviewer has made a number of recommendations which I endorse.
23. The clinical reviewer finds that the man’s key health problems were identified
during his reception medical screen at Risley. He comments that more clinically
relevant information could have been ascertained about his smoking history.
There was also an issue about whether he had suffered a heart attack
previously. There was some indication (but no objective evidence) in his record
that he had, but a direct question was not asked at the reception screen and the
man did not volunteer the information. It should be noted that when he attended
hospital on 27 April the consultant commented there was no convincing evidence
that he was suffering from heart disease.
24. The clinical reviewer says that the man’s mental health history was identified and
recorded at screening and that his needs were met appropriately while at Risley.
He judges that the man was attended to in a prompt and appropriate manner
when he complained of chest pain. The prison doctor assessed him on his
return to Risley and acted appropriately by referring him to the rapid access
chest pain clinic at North Cheshire Hospitals NHS Trust. Unfortunately, he died
before his appointment there.
25. The clinical reviewer concludes that, in respect of the man’s heart disease, he
received care which compares favourably with what he would have received had
he been in the community.
The prison’s response to finding the man collapsed in his cell
26. The first officer to enter the man’s cell once the alarm had been raised by the
prisoner was originally located in the office. The officer tried to use his radio to
call for emergency assistance but the battery was dead. Fortunately, another
officer arrived within seconds and was able to use his radio to call for
assistance. It was explained at a post-incident de-brief that new batteries had
been received by the prison but there were still some old batteries in circulation.
In this case, I consider that the number of other staff on duty meant there was
not an unacceptable delay in calling for emergency assistance and no impact on
the attempts to revive the man. However, I am concerned that had the man
been taken ill during the night, or at another time when fewer staff were on the
wing, the unreliability of the radio battery might have had more serious
consequences.
I recommend that the Governor of Risley reviews the status of the radio
batteries in the establishment and satisfies himself that discipline staff
and healthcare staff are equipped with effective radio batteries.
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27. None of the discipline staff who went to the man’s cell was trained to give cardio-
pulmonary resuscitation (CPR). As a result, some minutes elapsed before
healthcare staff began trying to revive him. A few more minutes elapsed before
the defibrillator arrived. Unfortunately, it was found that the correct leads were
absent and staff were unable to use the machine. The clinical reviewer has
concluded that, because his pupils were already fixed and dilated and because
of the serious nature of his coronary artery disease, neither of these
circumstances played a part in his death. The issue of training staff in CPR was
raised at the post-incident de-brief and it was agreed that it should be considered
whether all principal and senior officers should receive basic CPR training.
28. I consider that this is a sensible way to proceed. At a time when prison budgets
are restricted it is not practicable for me to recommend that all staff are trained in
CPR. However, given that the first few minutes are crucial in any attempt to
revive a person who has suffered cardiac arrest, it is imperative that a
reasonable proportion of staff on duty at any one time (and all healthcare staff
who are expected to take the role of emergency response) are trained in CPR.
I recommend that the Governor and the Healthcare Manager provide
emergency first aid training for all healthcare staff who are required to
act as emergency response nurses.
I also recommend that a sufficient number of discipline staff are trained
to ensure that, at any one time, at least one member of staff on any wing
can give emergency first aid.
29. The notes from the de-brief also suggest that, as well as the defibrillator being
fitted with the incorrect leads, two of the masks in the emergency bag were
faulty. I am pleased that Risley now has a protocol for checking all emergency
equipment. The defibrillator is checked daily and all other emergency equipment
is checked daily or weekly.
30. At interview, both Hotels 1 and 2 commented that they were unaware of the
nature of the emergency that they were required to attend. This made it difficult
for them to judge what equipment they needed to take with them. A code system
was not in operation at Risley at the time of the man’s death but I have been
pleased to learn that one has since been implemented. This is the practice in
most prisons and in my view should be the practice in all prisons. I draw this to
the attention of Offender Health.
31. A Nurse was the designated emergency response nurse and carried the radio
with call sign Hotel 1. At interview, she told my investigator that she was in a
meeting when the call for Hotel 1 came across the radio and did not immediately
hear it. She was not sure whether her radio was turned down or whether she
simply did not hear the call. Another Nurse heard the call for Hotel 1 and
responded in her capacity as Hotel 2. I do not believe that there was a serious
delay in the healthcare response to the emergency call. However, it clearly does
not make sense for the person tasked with responding first to emergencies to
have their radio turned down. Although Hotel 1 could not say whether she had
turned her radio down or not, I judge that this is a sufficiently important issue for
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the Governor to remind those staff who are designated as emergency response
of the importance of being able to hear their radios at all times.
I recommend that the Governor ensures that emergency response staff
are aware of the importance of being able to hear their radios at all
times.
32. I have been pleased to note that two members of staff from Risley travelled to
the home of the man’s next of kin to break the sad news of his death in person.
33. I am satisfied that, despite the difficulties with some of the equipment, staff made
a sustained and committed attempt to revive the man after he was found
collapsed.
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RECOMMENDATIONS
1. I recommend that the Governor of Risley reviews the status of the radio
batteries in the establishment and satisfies himself that discipline staff and
healthcare staff are equipped with effective radio batteries.
2. I recommend that the Governor and the Healthcare Manager provide
emergency first aid training for all healthcare staff who are required to act as
emergency response nurses.
3. I also recommend that a sufficient number of discipline staff are trained to
ensure that, at any one time, at least one member of staff on any wing can
give emergency first aid.
4. I recommend that the Governor ensures that emergency response staff are
aware of the importance of being able to hear their radios at all times.
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