Individual at Hull

Investigation into the circumstances surrounding the
death of a man
at HMP & YOI Hull in May 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2012
This is the report of an investigation into the death of a man, a prisoner at HMP Hull,
who died in May 2010. The cause of death was acute cardiac failure, as a
consequence of arrhythmogenic and ischaemic heart disease, he was 53 years old.
I offer my condolences to those affected by the man’s death. I also apologise for the
additional distress caused by the delay in issuing this report.
The investigation was undertaken by an investigator. A clinical review of the
healthcare provided to the man during his time at HMP Hull was commissioned by
the local PCT and I am grateful to the clinical reviewer for his review. I would also
like to thank the Governor of HMP Hull and his staff for their co-operation throughout
the course of the investigation.
The man was remanded into custody at HMP Hull on 2 March 2009. He informed
the doctor during his reception health screen of his existing health conditions, which
included angina. The following day, he reported chest pain and was examined by
the prison doctor. He was admitted to hospital and underwent a coronary artery
bypass, a surgical procedure used to divert blood around narrowed or clogged parts
of the major arteries, to improve blood flow and oxygen supply to the heart.
Healthcare staff at the prison monitored his angina closely. They encouraged him to
take his medication and informed him of the consequences of not taking it. He was
admitted to hospital on three other occasions for treatment for his heart condition.
On an evening in May, the man’s cell mate called staff as he had found him
unresponsive on the cell floor. Staff responded and attempted to resuscitate him
until the arrival of ambulance staff. He was taken to hospital where further,
unsuccessful, resuscitation attempts were made and he was pronounced dead a
short while later.
I am satisfied that the man was given appropriate care at Hull and referred to
hospital specialists promptly for treatment. Also, when he was found in his cell
unresponsive, staff took the relevant steps to assist him. However, I make three
recommendations to improve the response to medical emergencies and these have
all been accepted.
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.
Thea Walton
Acting Deputy Ombudsman January 2012
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CONTENTS
Summary
The investigation process
HMP & YOI Hull
Key events
Issues
Conclusion
Recommendations
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SUMMARY
1. The man was born in November 1957 and died in May 2010 at hospital. He was
53 years old. He was remanded into HMP Hull on 2 March 2009, charged with
serious offences for which he was subsequently convicted. On reception to the
prison, he told staff that he had been diagnosed with angina. (Angina is a
syndrome (a collection of symptoms caused by an underlying health condition)
that is caused when the supply of oxygen-rich blood to the heart becomes
restricted. One of the common symptoms is chest pain.)
2. The day after he went into prison, 3 March 2009, the man reported chest pain
and was examined by the prison doctor. The doctor advised that he was to have
an electrocardiogram (ECG), a test that measures the electrical activity of the
heart). He then went to the Accident and Emergency department for further
assessment. He stayed in hospital, where he was diagnosed with heart disease
and underwent a coronary artery bypass on 23 March. (This is a surgical
procedure to relieve angina and reduce the risk of death from coronary artery
disease.) He returned to Hull on 13 April, where he had a brief stay in healthcare
before being discharged back to a residential wing.
3. The man was admitted to hospital again on 14 May 2009, with difficulty breathing
and unstable angina. He was discharged back to Hull on 3 June. He attended
various hospital and healthcare appointments during the course of the year, to
monitor his heart condition, back pain and his medication. It was noted that he
did not cooperate with taking warfarin (a medication that helps prevent blood
clotting.) He was also subject to suicide and self-harm monitoring under the
Assessment, Care in Custody and Treatment (ACCT) procedures after receiving
a lengthy sentence on 14 September.
4. On 21 January 2010, the man went into hospital for a radiofrequency ablation
(treatment that uses electrical energy to destroy tissues in the heart that are
causing rhythm disturbances) and stayed overnight. He then attended the
healthcare department regularly over the following months, but still refused to
take his warfarin. He was again admitted to hospital on 24 April with a racing
heart and difficulty breathing. He was diagnosed with atrial flutter (rapid, irregular
heart rate) and tachycardia (abnormal heartbeat) and discharged back to Hull on
29 April.
5. The man was seen by a nurse for an ECG on 10 May. During his appointment,
he mentioned to her that he felt depressed and was having thoughts of harming
himself. The nurse began the suicide and self-harm prevention procedures and
referred him to see the doctor and mental health team. He subsequently saw a
doctor, who prescribed an antidepressant. At a meeting with the mental health
team on 20 May, he said that although he was feeling low, he no longer had
thoughts of self-harm. He said he felt supported by wing staff and peers and was
attending education and art classes. The ACCT document was then closed.
6. In May the man’s cell mate called staff using the emergency bell in the cell.
Discipline and medical staff responded. The nurses assessed the man and
attempted to resuscitate him while the officers obtained emergency equipment
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7. Prison Managers contacted the man’s family shortly afterwards and offered their
assistance. A prison family liaison officer was appointed. A debrief was held and
both staff and the man’s cell mate were offered support. The Governor and
prison family liaison officer attended the funeral on 7 June.
8. The pathologist found that the cause of death was acute cardiac failure, as a
consequence of arrhythmogenic and ischaemic heart disease. This is a condition
in which fatty deposits build up in the linings of the walls of the coronary arteries
and causes a narrow artery and reduced blood flow to the heart muscle. The
inquest concluded that the man died from natural causes.
9. The investigation has found that the man was given appropriate care by prison
staff in respect of his medical conditions. However, I make three
recommendations for improvements in aspects of the response to medical
emergencies.
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THE INVESTIGATION PROCESS
10. The investigation was opened at Hull on 9 June 2010, by an investigator, who
met the Governor and representatives of the Independent Monitoring Board (IMB)
and Prison Officers’ Association. The prison provided copies of all the
documentation relating to the man. Notices of the investigation were issued to
staff and prisoners, inviting those who wished to provide information regarding his
death to make themselves known to the investigator. No one came forward.
11. The investigator wrote to the local Primary Care Trust (PCT) to commission a
review of the clinical care given to the man at Hull. The PCT appointed a clinical
reviewer to conduct the review. He received copies of relevant medical
documentation, upon which he based his findings. He also conducted interviews
with relevant staff, jointly with the investigator.
12. The investigator also contacted HM Coroner for the East Riding and Kingston
upon Hull District to inform him of the nature of the investigation. She
subsequently gave him information gained from the investigation to assist the
inquest, which was held at the beginning of April 2011. The verdict was that the
man died from natural causes.
13. One of my family liaison officers wrote to the man’s family at the beginning of the
investigation. She informed them of the investigation and offered them the
opportunity to raise any questions or concerns they would like to be addressed.
The family raised no issues of concern at that time, they will however have an
opportunity to receive and comment on the report if they should chose to do so.
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14. HMP Hull is a category B local prison holding remand and sentenced adult male
prisoners and young offenders. Prisoners are risk assessed when they come into
prison and given a category based on their offence and the risk that they pose to
the public should they escape. There are four categories: A, B, C and D, with
category A prisoners being the most dangerous. Category B are prisoners for
whom the highest security conditions are not necessary but for whom escape
must be made very difficult.
15. Since 2002, Hull has undergone a period of expansion and now holds over 1000
prisoners. The expansion included a purpose built healthcare centre offering 24
hour healthcare and a multi-bedded inpatient ward and cellular accommodation.
In 2009, a terminal care suite was adapted. Medical services are contracted out
to Hull Teaching Primary Care Trust.
16. The prison accepts prisoners sentenced to Imprisonment for public protection
(IPP) as well as those given the conventional mandatory life sentence. (IPP
prisoners have no automatic right to release at the end of their sentence). Hull
runs a number of offence-related courses and prisoners are often re-categorised
to lower security categories once they have completed them.
17. Each prison has an Independent Monitoring Board. The IMB is appointed to
each prison by the Secretary of State for Justice. They are not members of the
Prison Service, nor are they part of the management team. They are required to
produce an annual report on the prison to the Secretary of State, highlighting
good practice and flagging up areas of concern. The IMB report for 2008
highlighted the problem of moving prisoners around an overcrowded prison
system. In common with other category B prisons, Hull also contains a number of
category C and even category D prisoners who are waiting for spaces at lower
category prisons.
18. In late 2008, Hull scored positively in the Measuring Quality of Prisoner’s Life
(MQPL) survey and attained ‘Best in class for Diversity’. It was rated as a “safe
and decent prison”. The National Offender Management Service (NOMS) is
responsible for the management of prisons in England and Wales. Every three
months it publishes an assessment of each prison’s performance against 34
measures. Prisons can gain a rating of between one (serious concerns) and four
(exceptional performance). At the time of the man’s death, the NOMS rating was
level four – awarded to “excellent establishments that are delivering exceptionally
high performance”.
19. Her Majesty’s Inspectorate of Prisons last inspected Hull in an announced
inspection in November 2008. The inspection report, published in March 2009,
complimented Hull on staff prisoner relations, activities, diversity, resettlement
and time out of cell. The healthcare offered was judged to have “improved
considerably” since the previous inspection.
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Previous deaths at Hull
20. Since the Ombudsman was given responsibility for investigating all deaths in
custody for England and Wales in April 2004, there have been seventeen deaths
at Hull, eleven of which were due to natural causes. The last death was in April
2009. There are no similarities in relation to this investigation and any of the
previous deaths at Hull.
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KEY EVENTS
21. The man was remanded into custody at HMP Hull on 2 March 2009, charged with
serious offences. He had previously committed a number of minor offences and
had been in prison 30 years before. New prisoners go through the reception
process, including risk and health assessments. During his first reception
healthscreen, he told the prison doctor that he was a smoker, suffered back pain
from an old laminectomy (a spine operation to remove a portion of the vertebral
bone), had angina for which he used glyceryl trinitrate (GTN) spray (medication
that helps to make veins and arteries relax and widen) and suffered from
depression.
22. The following day, 3 March, Prison Doctor A examined the man as he had chest
pain. The doctor recorded in the medical notes that his chest was clear, but he
had an irregular pulse. He took one dose of his GTN spray, however this did not
relieve his symptoms and so the doctor decided to perform an electrocardiogram
(ECG) (a test that measures the electrical activity of the heart) in the healthcare
centre. After the ECG, the doctor sent him to hospital for further assessment.
23. The man was admitted to hospital, where he was diagnosed with cardiac
changes – infarction (an area of tissue that dies due to a local lack of oxygen
caused by obstruction of the tissue's blood supply) and atrial fibrillation (abnormal
heart rhythm) for which he was prescribed warfarin, a medication that thins the
blood to prevent and treat the formation of harmful blood clots. He stayed in
hospital and underwent a coronary artery bypass on 23 March.
24. The man was discharged back to Hull on 13 April. He was initially admitted to
healthcare before being transferred back onto a residential wing on 17 April. Staff
put in place a care plan to ensure appropriate care and assessment of him during
his recovery from surgery and to monitor his angina. The clinical reviewer
commented that this was “good practice in potential vulnerable patient”.
25. Staff made regular, daily observations of the man and recorded them in his
medical record. Healthcare staff began weekly monitoring of his international
normalised ratio (INR) – (a procedure used to monitor the level of anticoagulant in
the blood) to establish the correct dosage of warfarin to be prescribed.
26. On 23 April, the man attended an appointment with a dietician, who recorded that
his body mass index (ratio of height to weight) was 20, which is thin. He was
prescribed Fortisip liquid (a supplement drink) to help build up the weight that he
had lost and also to help promote wound healing from his recent surgery. It was
noted that once he had increased his weight, the supplements were to be
stopped. A smoking cessation referral was made for him, although there is no
evidence of this being arranged, or him attending this appointment. He was to be
reviewed by a doctor on 6 May.
27. Nurse A assessed the man on 27 April. He was suffering from shortness of
breath, a racing heart as well as pins and needles in his right arm. She found his
blood pressure to be low and spoke to Prison Doctor B regarding his symptoms.
The doctor also examined him and diagnosed paroxysmal atrial fibrillation
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(irregular heart rhythm). He advised that his medication did not need to be
increased, however if his symptoms became more disabling he would need a
cardiology assessment.
28. It is noted in the man’s medical record on 1 May that he was seen by a
cardiologist (a doctor who specialises in treating diseases of the heart and blood
vessels). The cardiologist reviewed his medication and asked for him to be
reviewed again in six weeks time.
29. The man appeared at Crown Court on 6 May, in relation to the offences for which
he had been remanded. His trial was scheduled for 7 September. The following
day, Nurse A assessed his weight and noted that there had been no further
weight loss since April and that his weight was to be monitored at every INR
appointment.
30. A week later, on 14 May, Nurse A examined the man as he was suffering from
breathlessness on exertion. He had previously complained of breathlessness at
night with palpitations and had seen a doctor, who advised that if it worsened he
was to be reviewed by a cardiologist (heart specialist). She discussed his
symptoms with Prison Doctor C and it was decided to send him to hospital for
further assessment. He underwent further tests and a 24 hour tape of his heart
showed no signs of abnormal electrical activity. He was discharged back to Hull
on 28 May, with a follow up review scheduled for six weeks later. He was given
amiodarone (medication used to treat irregular heart beat) for a trial period,
however this affected his ECG results and so it was discontinued.
31. The man attended an appointment with a doctor at the hospital on 10 June.
Arrangements were made for him to have a radiofrequency ablation (treatment
that uses electrical energy to destroy tissues in the heart that are causing rhythm
disturbances) and he was also referred to a remedial gym. Healthcare staff were
informed of this on his return to Hull.
32. On 20 July, the man went to see Nurse B as he was experiencing anginal attacks
much more frequently. He had felt unwell over the weekend, was breathless on
exertion, and was experiencing dizziness, numbness and tingling down his left
arm. He said that his GTN spray was not always effective and that he was taking
his medication as prescribed. She referred him to Prison Doctor D, who noted
that he looked very pale, his pulse was racing and dropped very low. The doctor
promptly sent him to hospital for further assessment, where he was diagnosed
with muscular pain and no further cardiac changes. He was discharged back to
Hull.
33. A doctor examined the man on 14 August as his chronic back pain had become
worse and he was concerned about his circulation as his legs felt ‘dead’ whilst
lying in bed. The doctor noted that he had good reflexes, his pulse was normal
and he was able to put his shoes on and off. He advised him to have five days
bed rest and take two 500mg paracetamol tablets four times a day to help
manage the pain.
10
34. Healthcare staff continued to monitor the man’s INR level on a weekly basis,
giving his results to the anti-coagulation team to enable them to prescribe the
correct dosage of warfarin. On 20 August, it was noted in his medical record that
he had not taken his warfarin for eight days, stating that he was unable to climb
the stairs to the medication hatch due to back pain and vertigo (condition where
the environment around you seems like it is moving or spinning). Healthcare and
discipline staff were persistent in encouraging him to take his warfarin and
informed him of the health risks involved if he did not. The clinical reviewer
recorded this as “evidence of good team work” within his clinical review.
35. The man’s medical records show that Nurse C received a phone call from an
employee from the Crown Prosecution Service (CPS) on 3 September regarding
his upcoming trial. The employee informed her that he had told the CPS that he
was suffering from short term memory loss. The nurse noted that he had also
reported this to healthcare staff on a daily basis. The employee asked for him to
have an urgent assessment for fitness to stand trial. The nurse checked his
medical history and found that there were no reported mental health issues and
no reference to memory defects. She spoke with the Head of Custodial
Sentences, who agreed to contact the employee directly.
36. Nurse D assessed the man the next morning, prior to leaving for court. He made
no reference to memory loss, but said that he was unable to attend the
medication hatch on his wing to collect his warfarin. She pointed out that he had
just climbed as many stairs to come to reception and did not appear to have any
symptoms of anxiety. It was noted that he did not reply and went to court.
37. The man’s trial started on 7 September. He attended court daily and was
sentenced to 19 years and six months imprisonment on 14 September. Nurse E
spoke to him on his return to Hull. He said that he felt terrible and was
dumbfounded by his sentence, as he was not expecting it. He was also worried
about his wife’s welfare as she had been diagnosed with cancer. He became
tearful and said that he was unsure whether he would “do something” and that he
needed time to adjust. She opened an ACCT document and admitted him as an
inpatient in the healthcare centre for further assessment and to see the mental
health team.
38. The man was observed hourly throughout the day and night. He expressed that
he had no suicidal intent, but said that he could not guarantee his safety. He
remained low in mood and he was to remain subject to monitoring under the
ACCT procedures until he came to terms with his sentence. Prison Doctor A
reviewed him on 15 September and discussed his life circumstances. The doctor
advised him to think of positive things that had happened to him recently, for
example his heart operation and explained things would become easier once he
accepted his sentence.
39. Staff continued to regularly observe the man and by 18 September he was
engaging in activities on the healthcare wing and was eating and drinking well.
He still hadn’t come to terms with his sentence and needed regular support. He
went back to his wing on 21 September, but staff continued to monitor him whilst
he settled back in.
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40. A mental health worker held an ACCT review with the man on 24 September. He
spoke about negative experiences over the previous few years. He said this had
contributed to his anxiety and depression for which he had been prescribed
medication in the past. He added that he did not leave his cell much and did not
attend education or work. He explained that he was suffering from nightmares
and flashbacks, which was affecting his sleep. He told her that his wife visited
and wrote to him regularly. She noted in his medical record that he had suicidal
thoughts, but would not act on them due to the impact it would have had on his
family. She closed the ACCT however he was to receive further mental health
reviews.
41. The man attended appointments with the mental health worker on 7 and 16
October where they discussed coping strategies and self-help information. He
kept occupied by reading, so she set him a goal to start attending the library.
42. As the man was still not cooperating in taking his warfarin and adamant that he
could not use the stairs, healthcare staff admitted him to the healthcare centre on
20 October to review his health and well being. They looked at strategies to help
him have better access to his medication. This included arranging for one of the
nurses to deliver his warfarin to him and also moved him up a level on the wing
so that he had only one flight of stairs to climb to the medication hatch. He was
also reminded that he could use the lift. He was discharged back to the wing
three days later.
43. It was noted in the man’s medical record that he was able to use the stairs to
attend visits and collect his meals. This was discussed with him and he began to
attend the treatment hatch again to collect his medication, however he still did not
do so on a regular basis and missed several doses over the next few months.
44. On 13 November, the man had a mental health review with the mental health
worker. They discussed recent events and his progress. He told her that the
move to the second floor had helped to overcome his feelings of anxiety.
Although he did still feel anxious at times, he was able to collect his medication.
He said he was gradually pushing himself to do more and he had had a visit from
his wife who was feeling better, which helped to relieve some of his concerns. A
follow-up appointment was made and she discussed discharging him from the
mental health service.
45. The man’s next mental health review was held with the mental health worker on
27 November. She recorded that he was managing well and was continuing to
collect his medication from the third floor, although he was anxious whilst getting
it. He had been attending the library and was engaging with others on the wing.
This had helped him to feel less anxious, so she discharged him from the service
as she considered that no other action was needed at this time. She advised him
to ask if he felt that he needed the service in the future.
46. The hospital telephoned the prison on 3 December to advise that the man was
booked to have his radiofrequency ablation treatment on 21 January 2010, with
one overnight stay. He was also required to attend the hospital on 18, 19 and 30
12
47. The man had a meeting with the Offender Manager and Offender Supervisor on
15 December. It was recorded in his sentence plan document that they explained
the meetings occur every twelve months. He told them that he was finding it hard
to cope with his time in custody whilst his wife was terminally ill and that he had
suffered with depression in the past. The support available to him was discussed
as well as the possibility of him completing a sex offender treatment programme
(SOTP). He stated that he could not see the benefits of completing the
programme.
48. Healthcare nursed gave the man the Fragmin injections and he was admitted to
hospital on 21 January 2010 to undergo the radiofrequency ablation procedure.
He stayed at hospital overnight and was discharged the next day.
49. The man started experiencing chest pain and palpitations at night and went to
see Prison Doctor A on 2 February. The doctor admitted him to healthcare and
advised an ECG to be done whilst he was experiencing the chest pain. His pulse
was regular, he had good colour and was moving around well with no shortness
of breath. He experienced pain during the night, however he said his GTN spray
quickly eased this. The doctor advised that he was to remain in healthcare for a
second night and continue to be observed. He had no further chest pain and
stated that he felt good from reducing his smoking. He returned to the wing on 4
February.
50. As the man was still experiencing chest pain during the night, he attended a
cardiology appointment at hospital on 22 April. He was prescribed sotalol (to
treat rhythm disturbances in the heart) as he had relapsed back into an abnormal
heartbeat after the radiofrequency ablation and an ECG was scheduled for the
end of May.
51. On 24 April, the man went to the healthcare centre. He was experiencing a
racing heart and difficulty breathing. His medical notes show that the out of hours
doctor was contacted and staff were advised to send him to hospital, given his
observations and his past medical history. He was admitted to a cardiology ward
at hospital and further ECGs were taken. Healthcare staff issued the ward with
his INR results form the last six months. He was diagnosed as having atrial flutter
and tachycardia, (an irregular and fast heartbeat). He was discharged on 29
April.
52. Nurse F performed an ECG on the man on 10 May. He told her that he was
feeling very low and had thought about harming himself. He said that he felt
physically unwell and that eighteen months ago he was fit and well, apart from his
back pain. He felt that everything had gone wrong at once. She opened an
ACCT document to begin monitoring him under the suicide prevention and
management of self-harm procedures and discussed her concerns with an officer
on his wing.
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53. The man attended an appointment with Prison Doctor E on 17 May, where he
discussed his mood and current feelings. He told the doctor that he would like to
start Prozac (an antidepressant) again, and that it had been prescribed in the
past. The doctor explained the cardiac side effects of Prozac. However, he
agreed to prescribe it, advising the man that if he felt chest pains or palpitations
he was to see a doctor.
54. Nurse F, who had opened the ACCT procedures the previous week, reviewed the
man on the morning of 20 May. He told her that he felt more supported by wing
staff and his peers and was feeling much better. She then closed the ACCT
monitoring. The mental health worker went to see him on the wing that afternoon
and spoke to him about how he was feeling. He repeated that he was still feeling
low regarding his wife’s illness and not being able to support her. However, he
was attending education and art class everyday and finding it very beneficial.
May 2010
55. The man was in his cell one evening in May. At 6.00pm, his cell mate pushed the
cell bell. (Each cell is fitted with a bell to enable prisoners to request assistance.)
The Senior Officer (SO) attended to the cell bell from the wing orderly office,
along with Officer A, who attended from his office. The officer talked to the cell
mate, through the door hatch, who said he could not get a response from the
man. The officer saw him on the bottom bunk and due to his appearance called a
code blue over the radio. (Most prisons use a code system to indicate a medical
emergency. Blue indicates that a person has breathing/respiratory problems and
red that the person is bleeding. The codes allow the medical staff to respond with
appropriate equipment.) The officer said during his interview with the investigator
and clinical reviewer:
“When I got to the cell I opened the hatch and I think his cellmate was there
saying he could get no response from the man… so I immediately got onto
our radio system and called what’s called a code blue. That alerts Oscar 1
who’s in charge of the prison at that time and the nursing staff that we need
urgent, urgent assistance really.”
56. The officer opened the cell door approximately a minute later when Nurse G and
Officer B arrived. The nurse went into the cell and conducted a rapid
assessment. The man appeared unresponsive, bradycardic (slow heart rate),
cyanosed (blue colouration of the skin due to lack of oxygen) and had a
respiratory rate of four (amount of breaths taken in one minute). She immediately
asked Officer A to get the emergency bag and Officer C to call a “blue light”
ambulance and a second nurse to assist. The clinical reviewer said in his clinical
review that it was “proper triage and a good set of commands by team leader –
Nurse G.”
57. Officer A ran to get the emergency bag from the wing orderly office then helped
Officer B move the man to the floor of the cell to perform cardio pulmonary
resuscitation (CPR). The nurse showed Officer B how to do chest compressions
whilst she then provided oxygen to the man using an Ambu-bag (self-inflating
resuscitator). CPR was performed at a rate of two breaths to thirty compressions.
14
“Although I’m not medically trained it was obvious that things had sort of
stepped up a bit and I was thinking about the effects on the cell mate so I
asked him if there was anyone he’d like to go and sit with and we arranged for
that.”
58. At approximately 6.09pm, another nurse went to the cell and took over from
Nurse G, who left the cell to talk to the ambulance control and inform them of the
man’s critical condition. She then went back to the cell and assisted the nurse in
performing CPR.
59. At 6.19pm the ambulance crew arrived. They noted that the man had no
respiration or blood pressure and was unconscious. The ambulance crew took
over the resuscitation attempt, using a defibrillator (machine used to give the
heart an electric shock to restore rhythm) and giving intravenous drugs to help
increase heart rate. Two officers made an escort bag and collated all relevant
paperwork ready to escort him to hospital in the ambulance. He was taken by
ambulance to hospital at approximately 6.56pm, with ambulance crew still
attempting to resuscitate him. He was not handcuffed.
60. The ambulance arrived at approximately 7.10pm and the man was taken to the
resuscitation ward, where medical staff attended to him. The escort officers were
relieved by two more officers at approximately 7.50pm and stood back whilst
medical staff continued to resuscitate him.
61. Despite extensive resuscitation efforts, the hospital doctor informed the officers of
the man’s death at 7.55pm. One officer then informed the prison by telephone
and one of the senior officers there contacted the duty governor.
62. At approximately 8.05pm, resuscitation ward staff gave one officer the man’s
belongings, which consisted of a watch, comb, prison ID, his ring and clothes.
The officer asked the doctor to supply a letter to confirm that he had died. He
was moved from the resuscitation ward to a side room at 8.50pm, where both
officers stayed in attendance outside. At 9.20pm, the duty governor and the
Head of Custodial Services arrived at the hospital and all staff returned to HMP
Hull.
63. The Governor informed the man’s next of kin, his son, of his death at 9.20pm by
telephone due to the distance to the home address. The Governor then spoke to
the man’s wife at 9.45pm and arranged for her to travel to Hull to view his body.
During the morning, another Governor spoke to the man’s wife, who asked him
some questions about events leading to his death and what would happen next.
Once he had the information she had asked for, he spoke to the man’s son. He
told him that his mother had been very upset during the call. He asked the
Governor to give him the information, saying he would pass it to his mother.
64. A family liaison officer was appointed and kept regular verbal contact with the
man’s wife and son. She relayed relevant information regarding the
15
65. On 23 May, a member of the chaplaincy included prayers for the man in the
morning worship service and stated that these were well received. He also spent
time with the cell mate, who talked about the events of the previous night and was
assured he had done all that he could.
66. A hot de-brief was held that morning by a Governor. (A hot debrief is a meeting
for staff to discuss issues and any lessons learned following serious events such
as deaths in custody, hostage situation or escape attempt. The meeting should
focus on reassurance, information sharing and how staff can support each other.)
All staff were offered support from the care team and reminded that they could
also speak to their line managers or any other manager. Staff then each spoke of
their part in the incident and were asked to make any suggestions or
recommendations. All the staff involved thought that the response was excellent
and that both discipline and healthcare staff had worked well together. When
asked at interview if she had been supported after the incident, Nurse G stated “a
lot yes, the support in the prison is great for anything like that”.
67. The man’s wife rang the prison in the evening as staff had not telephoned her as
they said they would. The duty governor telephoned her and said that another
governor had passed the information to her son. However, his son had not
passed on the information. The governor then answered the questions and
offered her condolences on behalf of the Governing Governor and the prison.
68. A governor sent a letter of condolence to the man’s wife, also informing her that
all his property and monies would be returned to her. He advised that if she had
any questions or, she was welcome to contact another governor or the family
liaison officer.
69. The family liaison officer and a governor visited the man’s wife at her home on 26
May and returned his property and money. The family liaison officer offered her a
visit to the prison after the funeral which took place on 7 June. They both
attended and the prison provided a financial contribution to the cost of the funeral.
The man’s wife and daughter sent letters of thanks and kind regards to all staff
involved in the attempts to save his life and for all the help and support offered to
them after his death.
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ISSUES
Timely and appropriate clinical care
70. The clinical reviewer judges that the overall level of clinical care given to the man
whilst he was at HMP Hull “was entirely appropriate and a good standard”.
General
71. Throughout his time at Hull, the man attended regular appointments with
healthcare staff and received treatment at an outside hospital for his angina. Both
healthcare and discipline staff monitored his health and wellbeing on a regular
basis, documenting all relevant information in his medical and wing records.
Good communication and care planning is evident from his prison documents.
Warfarin
72. The man was prescribed warfarin for his angina. Staff monitored his INR weekly
to be able to prescribe an appropriate dose. He refused to take his warfarin. He
said that he suffered from anxiety and vertigo and that this, including his back
pain, was preventing him from climbing the stairs to collect his medication from
the treatment hatch. However, staff observed that he was able to climb the stairs
to collect his meals, go to visits and also to go to reception.
73. Both healthcare and discipline staff discussed this with the man and arranged for
him to be moved to a more accessible location on the wing and also for a nurse to
bring his medication to him. Although he stated that he still suffered from anxiety,
he began to collect his medication. Staff encouraged him to take his warfarin and
reminded him of the risks involved in not taking it. Both healthcare and discipline
staff showed evidence of good communication and team work in trying to ensure
he cooperated with taking his medication.
Suicide prevention and self-harm management procedures at HMP Hull
74. In his first reception healthscreen, the man said that he had suffered from
depression in the past and had previously been on antidepressants. He was first
subject to monitoring under the ACCT suicide prevention procedures in
September 2009, when he received a lengthy sentence. Staff monitored him
appropriately and put in place a careplan for him. They offered him support and
encouragement to help him come to terms with his sentence and the ACCT was
closed soon after. He still received regular reviews from a member of the mental
health team until late November.
75. The man spoke to Nurse F about his feelings during an ECG check-up in May
2010. He had begun to feel depressed and was having thoughts of self- harm.
He said that he was innocent and everything had seemed to go wrong at once.
The nurse promptly opened an ACCT plan, relayed her concerns to staff on his
wing and referred him to see a doctor and the mental health team. He was
prescribed Prozac. The ACCT document was closed ten days later.
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76. The opening of the ACCT plans was clearly appropriate on both occasions, given
the circumstances and mood presented by the man. The clinical reviewer
considered that this was good practice.
Discovery and resuscitation attempt
77. Staff were alerted to the man being unresponsive when his cell mate pressed the
cell bell. When Officer A arrived at the cell, he radioed for assistance indicating a
“code blue”. Nurse G and the Senior Officer responded quickly to the alert. The
nurse took charge of the situation giving appropriate commands to others and
making quick and relevant decisions, such as the need for a blue light ambulance
and for another nurse to attend. Timely and appropriate resuscitation was given
as the incident developed.
78. After the nurse examined the man, she asked an officer to fetch the emergency
medical bags and for an ambulance to be called. The clinical reviewer raises two
issues about these actions and makes recommendations, which I endorse, to
speed up the process of emergency treatment.
First aid training
79. The clinical reviewer notes that the nurse did not collect the emergency
equipment before going to the cell. Therefore, although she began CPR
immediately, she did not have the full range of equipment available. However,
the bags were in the wing office and the officer returned shortly. She then used
an ambu bag to give the man oxygen while an officer carried out the chest
compressions. She did not ask for a defibrillator and so it was not available.
80. During his investigation, the clinical reviewer spoke to the inpatient manager
about what the emergency response nurses are expected to do. She said that
the nurse should attend a code red/blue call with the emergency equipment and
defibrillator.
The Head of Healthcare should remind all staff where the defibrillator is kept
and that the emergency bags should be taken to all code blue alerts.
81. In some prisons, a code blue call automatically leads to control room staff
requesting an emergency ambulance. This is not the case at Hull. The records
show that the nurse asked for an ambulance four minutes after the man’s cell
mate pressed the cell bell. The control room called for an ambulance five
minutes after later, at 6.09pm. The clinical reviewer discusses this,
“I recognise that if the control room were to trigger off an alarm to the
ambulance service for every code blue then there might be a number of false
calls. The request can always be cancelled and the crew stood down. Rapid
and prompt assessment of the situation by the first attender should be the aim
to minimise any delays. The crucial time for restoration of a good heart rhythm
and a successful outcome- life and minimal impairment is in the first few
minutes.”
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He concludes, “I do not feel in this case the patient was put at risk as the
ambulance in fact arrived promptly.” The Governor and Head of Healthcare may
wish to discuss this with the local ambulance service.
82. The clinical reviewer notes that none of the officers were confident enough to
carry out CPR. However, the nurse showed an officer how to do chest
compressions and he carried on while she gave the man oxygen. The officer’s
willingness is commendable. The clinical reviewer suggests that wing officers
could be trained as “first responders”, allowing them to spot a heart attack or
similar collapse and perform basic life support until trained help arrives. He notes
that members of the public are trained in this role and that it is readily available in
the city.
The Governor and Head of Healthcare should consider reviewing basic life
support training and ensure that on every shift there are wing staff trained
to carry out life support.
83. Whilst the nurse was carrying out CPR, the ambulance service controller asked
to speak to her, calling her away from the man’s side. Fortunately, by that time,
another nurse had arrived and she felt able to go to the office to inform the
controller of the man’s condition. The clinical reviewer suggests that rather than a
trained nurse leaving a patient, he or she should relay the facts via an officer. He
suggests to healthcare managers that:
“Consideration be given to a few direct commands being used to the
Ambulance service which will allow them to give proper priority to the case.
E.g. patient not breathing- nurses are performing cpr- request urgent
paramedic support.”
The Head of Healthcare should consider training emergency response
nurses to pass a summary of the patient’s condition to the ambulance
service via an officer.
Support for staff
84. A hot de-brief took place the following morning. All staff involved in the incident
were reminded that they could talk to the care team, or any manager should they
wish to do so. All staff were given the opportunity to talk about their role within
the incident and whether they thought anything could have been done better or if
any recommendations needed to be made. Everyone involved stated that
healthcare and discipline staff had worked well together and that they had done
all that they could to try and save the man.
Family liaison
85. When the man’s wife telephoned the prison after she learned of her husband’s
death, she was, understandably, very distressed. Nevertheless, she had
questions about his death and practical details such as the post mortem. When
the governor explained what had happened, she said that she appreciated that
another governor had not wanted to add to her distress. However, it meant that
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CONCLUSION
86. The man was reviewed regularly by various staff within the healthcare centre. He
was diagnosed and managed appropriately according to his condition and was
referred to a specialist at an outside hospital to help control his angina. Staff
were encouraging and supportive throughout his time at Hull, putting in place care
plans and reviewing strategies to help him receive his medication. The clinical
reviewer considered that “he received better care in some ways when compared
to community care”.
87. Although staff did not take a defibrillator with the emergency bag the resuscitation
procedures were quick and controlled. Extensive attempts to revive the man
were made by all staff, including ambulance and hospital staff.
88. I am satisfied that the man’s care was at least the equivalent of that which he
could have expected in the community and that when he was discovered
unresponsive, staff generally followed the appropriate procedures in an effort to
resuscitate him.
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RECOMMENDATIONS
1. The Head of Healthcare should remind all staff where the defibrillator is kept and
that the emergency bags should be taken to all code blue alerts.
The recommendation was accepted and the response was:
“All healthcare staff are aware that there are emergency bags available on all
wings, and an emergency bag is taken to all code blues.
“We provide regular up date training and have added the location of each
defibrillator to all emergency bags.”
2. The Governor and head of Healthcare should consider reviewing basic life
support training and ensure that on every shift there are wing staff trained to carry
out life support.
The recommendation was accepted and the response was:
“All healthcare staff has yearly training updated on basic life support. This is
via the prison training department.
“The prison has a number of unified staff trained in first aid across the whole
establishment. trained HCC staff are on duty 24 hours a day which include
nights.”
3. The Head of Healthcare should consider training emergency response nurses to
pass a summary of the patient’s condition to the ambulance service via an officer.
The recommendation was accepted and the response was:
“The nurse attending the prisoner will handover to ambulance staff and
explain what has been completed. We also use the same IT system which is
accessible at the main hospital where all patients are taken.”
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