Individual at Forest Bank

Circumstances surrounding the death of a prisoner
at HMP/YOI Forest Bank, in November 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2006
This is the report of an investigation into the death of a man. The man died,
at the age of 52, in November 2005 at HMP/YOI Forest Bank. This is a tragic
case, as the clinical review concludes that the man’s death was potentially
avoidable if he had been given appropriate medical treatment at an early
stage.
The man said that he had no next of kin and the prison has been unable to
trace any members of the man’s family.
An investigator from my office conducted the investigation. I regret the time it
has taken to produce this report.
I am grateful for the assistance my investigator received from the staff and
management of Forest Bank. I wish to acknowledge too the help of the
Greater Manchester Police who carried out their own enquiry into the man’s
death and shared information. My thanks also go to the Head of Operations
from Salford Primary Care Trust, who provided a clinical review.
I make no recommendations of my own in this report, but fully endorse those
in the clinical review. These reflect the reviewer’s concerns about the quality
of medical care, recording of information, staff response to emergency call
bells and communication with the local hospital.
Stephen Shaw CBE
Prisons and Probation Ombudsman
September 2006
CONTENTS
SUMMARY ......................................................................................................4
INVESTIGATION OUTLINE.............................................................................5
BACKGROUND...............................................................................................6
HMP/YOI Forest Bank...........................................................................6
Healthcare Centre.................................................................................7
Progress in Healthcare since the man’s death......................................7
KEY EVENTS..................................................................................................9
15 September to 3 November 2005......................................................9
4 November 2005................................................................................10
FINDINGS AND CONCLUSIONS..................................................................12
Clinical Review....................................................................................12
Clinical Care........................................................................................13
The timeliness of referral to the National Health Service ....................13
Attempts to gather information from the man’s doctor.........................14
Emergency Call Bell............................................................................14
Medical History....................................................................................14
Analysis of the Post Mortem Report....................................................14
RECOMMENDATIONS..................................................................................16
SUMMARY
This is the report of an investigation into the death of a man. The man was
aged 52 when he was found dead, at 7.50am on 4 November 2005, in the
Healthcare Centre of HMP/YOI Forest Bank.
The investigator reviewed the man’s prison records and spoke informally to
both prison staff and prisoners. A review prepared by Salford Primary Care
Trust on clinical matters.
The man had been at Forest Bank since 15 September 2005. During that
time he underwent investigations into his weight loss and abdominal pain.
The first blood tests results taken on 19 September provided sufficient
evidence for the doctor to make an urgent referral to hospital. However, his
subsequent treatment was subject to a series of unexplained delays.
As his condition was getting worse, the man was moved to the Healthcare
Centre on 31 October and located in a four bedded ward, albeit on his own.
At 6.15am on 4 November, the man pressed his emergency call bell. Staff
looked at the man through the observation window, but as he appeared to
them to be alright, they did not enter the ward. At 7.50am, he was found dead
on the floor of the bathroom.
The post mortem report gave the cause of death as gastrointestinal
haemorrhage due to a gastric ulcer. The clinical review concluded that, given
appropriate treatment, the man’s death might have been avoided.
This report focuses on the man’s time in prison custody and evaluates the
systems in place to establish whether they were (and are) fully effective.
INVESTIGATION OUTLINE
1. The investigation into the man’s death was led by one of my
investigators. He visited the prison and saw the areas where the man
had been, including the Healthcare Centre and the wing on which the
man had previously been located.
2. He issued a notice to staff and prisoners inviting anyone with
information relating to the man’s death to make themselves known to
the investigator.
3. My investigator also spoke to the Chair of the Independent Monitoring
Board (IMB), the Prison Officers’ Association (POA), one of the prison
chaplains, and various other members of staff, including the Healthcare
Manager. My investigator spoke informally to staff and prisoners who
knew the man and were involved in the events surrounding his death.
4. The prison gave my investigators full access to all the documentation
surrounding the man’s time in prison. The police also provided copies
of the documents and statements in their possession. My investigators
obtained some further information from probation and court services.
5. Salford Primary Care Trust convened a panel to facilitate a clinical
audit of the man’s care while in prison. The PCT conducted a number
of interviews with staff. In cases such as this, interviews are normally
conducted jointly. However, these interviews were conducted solely by
the PCT, as my investigator was unavailable at the time.
BACKGROUND
HMP/YOI Forest Bank
6. Built on the former Agecroft Power Station in Salford, Forest Bank was
opened in January 2000 and is managed by United Kingdom Detention
Services (UKDS)1. It has a maximum population of 1,064 male adult
and young offenders, mostly held in single cells. The population is a
mixture of convicted and unconvicted prisoners. There have been two
other deaths at Forest Bank since it opened, one of which was self-
inflicted.
7. The prison serves the Magistrates’ and Crown Courts in the Greater
Manchester area. The establishment comprises six house blocks each
with identical two-storey wings radiating from a central hub. Each wing
is designed to hold up to 65 prisoners (rising to 85 if the jail is
overcrowded). Purposeful Activity is provided for approximately 800
prisoners in a variety of industrial workshops, courses, education
classes, catering, and other types of employment such as cleaning,
gardening and orderlies.
8. In June 2002, Forest Bank underwent a full inspection visit by Her
Majesty’s Chief Inspector of Prisons. The relevant recommendations
(which have subsequently been implemented) of the report of that
inspection were that:
(cid:1) there should be an overall safer custody strategy, linking reception
and induction, detoxification, anti-bullying and health issues in order
to deal with all elements of potential vulnerability,
(cid:1) detoxification procedures should be in accordance with the relevant
Prison Service Order,
(cid:1) all prisoners held in the healthcare unit should have care plans.
1On 12 October 2006, UKDS changed its company name to Kalyk.
Healthcare Centre
9. The Healthcare Centre provides 24-hour medical and nursing cover
and inpatient facilities for up to 25 prisoners. The healthcare team offer
a wide range of primary care services.
10. The Primary Healthcare Team are all employees of UKDS and there is
a 60/30 split between General and Psychiatric Nurses. There is a full
time Locum Medical Officer cover. The doctors at Forest Bank provide
a 24 hour medical call service to respond to emergencies.
11. For emergencies, the prison operates a local call system. If
emergency medical assistance is required, the member of the
healthcare team designated as the emergency response (Hotel 2)
attends the emergency, assesses the situation and commences any
treatment, before deciding on the next course of action. Hotel Two is
available 24 hours a day and is contactable from the communications
room, via the UHF radio.
12. Staff detailed to work in the Healthcare Centre at night are not issued
with prison security keys. Night staff all carry a sealed pouch, with a
cell key in, so access to cells can be made quickly in the event of an
emergency. If a door needs to be unlocked for a routine purpose, the
Duty Manager is contacted.
13. There is a detoxification facility that provides accommodation for up to
86 prisoners. Of the total accommodation available in the unit, 16 beds
are retained for those who require the closest supervision. Healthcare
staff work alongside three key workers who are assigned to the unit. A
Counselling, Assessment, Referral, Advice and Throughcare service
(CARAT’s) is also provided for prisoners with substance misuse
problems.
14. Links have been established with Salford University to allow
postgraduate students to work on the healthcare unit as a placement
within their training syllabus. As part of this link, a reciprocal
arrangement with regard to training has been implemented.
Progress in Healthcare since the man’s death
15. The Healthcare service at HMP Forest Bank has been and continues to
be a developing service which is making significant changes and
positive contribution to the health and well being of prisoners. The
Prison Senior Management Team is fully supportive in driving forward
the changes to modernise prison health. There is recognition and
renewed philosophy that healthcare is an integral part of prison life and
that good healthcare and health promotion can enable individuals to
function to their maximum potential on release.
16. An effective and mutually supportive partnership between HMP Forest
Bank and Salford PCT is well developed. This collaborative approach
encourages the sharing of information and professional expertise. The
PCT were invited to participate in the process for recruitment of
clinicians to secure an appropriate contract for the provision of Primary
Medical Care service to HMP Forest Bank. This process was
successful and the service is now provided by a local GP practice that
welcomes the challenge and is committed to working with the
healthcare team to provide consistent quality care with effective
treatment outcomes.
17. An experienced Head of Healthcare has been appointed since the
mans death, and has provided the healthcare service with a clinical
focus and development plan, which has already provided as
improvement in patient care and professional nurse development.
18. A review of the nursing skill mix and work profile has identified training
needs and opportunities for development. The revised structure
facilitates the management of nurse led clinics where early detection
and treatment of ill health will improve patient experience and
treatment outcomes. There is a focus on using the opportunity to offer
health promotion advice to enable individuals to make informed health
choices. Part of the review includes the clinical management and care
for those prisoners with substance misuse from the point of reception
and throughout custody and release.
19. There is a dedicated inpatient team who are developing structured
intervention programmes for the management of patients in the unit.
Every inpatient has a nursing care plan and there is a regime for
medical ward rounds when every patient is assessed and reviewed by
the lead nurse and doctor. There is provision of a Clinical IT System
at HMP and an implementation plan has been agreed between HMP
Forest Bank and Salford PCT to ‘go live’ in early 2007. This forms part
of the Npfit programme which will ensure that prisons have access to
appropriate NHS links.
KEY EVENTS
15 September to 3 November 2005
20. On arrival at Forest Bank on 15 September 2005, the man told staff
that he had no next of kin. During the reception health screening, the
man said that he had abused alcohol for a number of years, but
stopped when he began suffering from vomiting and severe stomach
pain. Consequently, he had not had an alcoholic drink for four months.
Question 11 of the assessment asks the assessor to record their
impression of the prisoner’s behaviour and mental state. This section
of the form was not completed.
21. The man then completed the first night induction, where his immediate
needs were discussed, including an explanation of how to access the
Listeners (prisoners trained to offer support to others) and Samaritans.
There is and was no personal officer scheme in operation at Forest
Bank, so the man was told to contact the nearest member of staff
should he have a problem. He was then located in E-wing.
22. On 16 September, the man was seen during morning surgery by a
doctor, a locum medical officer. The doctor noted that the man had a
history of abdominal pain, was vomiting blood once or twice a day and
lost weight, but had a regular bowel habit. The physical examination at
this time revealed an enlarged liver. The man weighed 56 kilograms.
The doctor ordered blood tests, and said that the man would require an
upper gastrointestinal tract endoscopy. The doctor said that he would
review the man the following week. The blood tests were taken on 19
September and returned to the prison the following day.
23. Another locum medical officer, reviewed the bloods results on 1
October. They showed that the man was anaemic. This was eleven
days after the receipt of the results and I have been unable to establish
a reason for the delay.
24. The man eventually saw the locum medical officer on 10 October. This
was nine days after the results had been assessed by him. Again, I
have been unable to establish a reason for this delay. The doctor
described the man as being very thin, and with an enlarged liver. The
doctor prescribed Ferrous Sulphate and referred the man to the
Gastroenterology Department at Hope Hospital.
25. On 31 October, a Prison Custody Officer (PCO) referred the man to the
community mental health in-reach team. The PCO’s referral said that
the man had lost a significant amount of weight, which was thought to
be due to his physical problems. The PCO said that the man appeared
to be responding to hallucinations, grinning and his behaviour was
described as bizarre.
26. The deputy team leader of the community mental health in-reach team
assessed the man’s mental health on 1 November. Her impression
was that the man was paranoid, that he was suffering from a psychotic
illness and lacked insight. The man was admitted to the Healthcare
Centre and located in a four-bed ward, although he was the only
patient there.
27. On 3 November, an RMN noted that the man’s weight had fallen to 54
kilograms. She wrote in the clinical record that she would discuss with
the doctor whether fortified drinks should be prescribed to the man.
28. At about 7.45pm, a prisoner orderly served hot water to prisoners in the
Healthcare Centre. He said that the man was acting as normal, going
about his regular routine and appearing to be fine.
29. At about 8.00pm on 3 November, a nurse and PCO commenced night
duty. They received a verbal handover from the day staff, counted the
prisoners and relieved the day staff. No specific information about the
man was passed on to the night staff.
30. This was the first night that the PCO had worked in the Healthcare
Centre. The Nurse was the Hotel 2, emergency response. Both staff
said that the man was alone in Ward One, sitting in a bedside chair
watching television. At 10.00pm, the PCO conducted a further roll
count and the man was still watching television in the chair. At
midnight, the PCO noticed that the man was by then in bed, apparently
asleep.
4 November 2005
31. At 5.00am, the PCO conducted another roll count and the man was still
in bed. At 6.00am, the PCO noticed that the man had sat up in bed.
32. At 6.15am, a nurse reported for day duty and began to receive a
handover from the night nurse, including the role of Hotel 2. At this
time, the man pressed the emergency call button, which was on the
wall next to his bed. The PCO was not sure how to identify the correct
ward on the activation system, so called for the nurses to assist him.
33. They went to the ward and could clearly see the man. He was lying on
his side and raised his head and made eye contact with the day nurse,
but did not give her the impression that he wanted to attract her
attention. The staff did not consider that there was anything to be
concerned about, and went about their duties.
34. The night nurse went home shortly afterwards, as she had been
replaced by the day nurse. A day PCO arrived for duty in the
Healthcare Centre, at 6.30am and, after a handover, the night PCO
went home. The man’s health was not discussed at the handover
meeting.
35. The prisoner orderly was unlocked at 6.30am to help serve breakfast to
prisoners. Shortly after 7.00am, he placed a tray of breakfast on the
flap of the inspection hatch of Ward One. He placed the meal on the
flap, as he could not see the man in the ward, and assumed he was in
the toilet.
36. After completing the deliveries, the prisoner orderly returned to the
man’s ward to offer him some toast. He found that the breakfast had
not moved, he thought it unusual, so looked further into the ward. He
noticed that the man was lying on the floor in the toilet, not moving.
The orderly immediately shouted for the day PCO who entered the
ward.
37. The PCO saw that the man was ashen in colour, lying on his back, with
congealed blood around his mouth and on the floor. He was in a
position which looked as though he had rolled sideways on to his back,
after being hunched over the toilet bowl. It appeared as if he was
supporting himself with his arms hooked over the edge of the bowl.
The PCO used his radio to alert other staff that there was a “Code
Yellow 2” in the ward. (This told staff that there was an emergency and
that a prisoner was unconscious.) The emergency response was
immediate. However, as it was obvious to the medical professionals
who attended that the man had died, resuscitation was not attempted.
38. Despite determined efforts, including searching the records of other
agencies and advertising in local and national newspapers, the prison
has been unable to identify any of the man’s family or friends.
FINDINGS AND CONCLUSIONS
39. The man had a history of alcohol abuse. He had stopped drinking
alcohol for four months, as he was being treated by his GP for stomach
pains and vomiting. However, the pains and vomiting had not stopped
when the man was taken to Forest Bank.
40. Following a mental health assessment, the man was located in the
Healthcare Centre. It is surprising that he was not admitted to the
Healthcare Centre at an earlier stage for his physical condition, which
had caused concern from the day of his reception into prison.
Clinical Review
41. The Operations Manager of the Salford PCT, co-ordinated the clinical
review. In order to examine relevant health issues and assess the
clinical care, the Salford Primary Care Trust serious untoward incident
policy was followed. The Operations Manager and the PCT Clinical
Lead reviewed the documentation and carried out interviews with the
healthcare managers. The clinical review is based on this and
evidence gained from interviewing nursing staff, prison custody staff
and the GPs involved.
42. The clinical reviewer was asked to specifically comment on the
timeliness of the prison in referring the man and the attempts to gather
information from the man’s doctor. The reviewers were also asked to
assess the appropriateness of the staff failing to enter the ward on the
morning of the man’s death when he pressed his emergency call bell.
On initial assessment of the case, it appeared to the investigator that
staff might have been working on the assumption that the man’s
problems were related to his history of alcohol abuse, and the reviewer
was asked to establish whether this lessened the interventions that
were offered.
43. When asked, the locum medical officer was not aware of the National
“Standard ‘2 week wait’ referral for suspected cancer“. It is clearly
evident that earlier intervention could have prevented this man’s death
from this condition. It is unclear if the processes were in place for
cancer 2-week wait referrals at HMP Forest Bank. This not
withstanding locum medical officer showed a clear lack of knowledge of
a widely well-publicised system and guidelines that have been in place
for a number of years. This deficiency and other issues that became
evident during the interview raises concerns around his overall
performance as a clinician and a doctor at the PCT is of the opinion
that at this point the Primary Care Trust on whose performers list locum
medical officer appears, should be informed, for them to assess his
skills and competencies and if necessary take any further action
following this assessment.
44. The investigation team has discovered from the locum agency that
locum medical officer was working within HMP Forest Bank between 1
and 10 October and could have viewed the man’s records with the
blood results in that time.
Clinical Care
45. The clinical review concluded that the reception screening offered to
the man was insufficient and there were gaps in the documentation
especially Question 11. This is unfortunate, as it would have provided
a benchmark for future assessments.
46. The man was seen during morning surgery on 16 September, but there
was a three day delay between the ordering of the blood tests to their
drawing and submission to hospital on 19 September. The clinical
reviewer has discovered that there was enough time to have the blood
tests drawn and sent to the laboratory at the hospital on the same day
they were ordered. This time delay is unexplained.
47. The first blood test results were returned to Forest Bank within 24
hours of reporting, as is normal procedure within pathology at the
hospital. However, the man’s medical record shows no evidence of:
(cid:1) the date the results were received at Forest Bank,
(cid:1) the results being brought to the attention of the GP,
(cid:1) an appointment being made for the man to be notified of these
results.
48. There are two further unexplained time lapses. The first was for 11
days between the blood test results being received at the prison and
the doctor reviewing them. The second delay of nine days was
between the doctor reviewing the blood test results and seeing the
man. Both these delays are unexplained and are unacceptable.
49. The first blood results, combined with the patient history of weight loss,
abdominal pain, haematemesis and hepatomegaly, indicates that there
was sufficient evidence for the GP to make an urgent referral to the
hospital.
50. The referrals to hospital were made to “departments”, rather than
named consultants. There is no documented evidence of these
referrals being followed up.
The timeliness of referral to the National Health Service
51. In the opinion of Salford PCT’s Clinical Lead, the man’s symptoms and
history of vomiting blood should have resulted in an urgent and
immediate referral to the hospital. The man fitted the criteria for the
“two week wait” for suspected cancers, as detailed in national
guidance. The medical records for the man are sufficiently detailed to
suggest that doctors would have acted in a timely fashion to prevent
the man’s condition from worsening.
Attempts to gather information from the man’s doctor
52. No attempt was made by Forest Bank to gather information from the
man’s own doctor, as he denied having one. However, the Salford
PCT investigator, identified the man’s doctor using the National
Tracking database. The prison would benefit from having a link to the
database, to allow them to trace doctors, when this information is not
available from a prisoner.
Emergency Call Bell
53. On the morning of his death, the man pressed his emergency call bell.
Staff checked him through the window of the ward, but as he
responded by raising his head they did not check him more closely.
My investigator asked the clinical reviewer to comment on the
appropriateness of this.
54. The alert light accompanying the bell illuminates by every bed within
the ward. Lockers or chairs beside the beds obscure these lights in
two of the four beds in the Ward One. There was a slight delay in the
response to the emergency bell, as the PCO on duty that night had
never worked within Healthcare Centre and needed the assistance of
other staff to identify who was calling for help.
55. The emergency call bell is activated by patients needing assistance.
When staff responded to the man’s call for help, he raised his head, but
he should have been spoken to in order to ascertain the reason why he
called for assistance. The man was the only patient in that ward and
with three members of staff present, I see no reason why they did not
enter the ward and speak to him.
Medical History
56. When my investigator made an initial assessment of this case, it
appeared to him that staff might have been working on the assumption
that the man’s problems were related to his history of alcohol abuse.
During the PCT interview process, all staff denied being influenced by
this assumption. Following the investigation, I am happy that the man’s
history of alcohol abuse did not lessen the interventions that were
offered to him.
Analysis of the Post Mortem Report
57. The post mortem report concluded that the man died from
gastrointestinal haemorrhage, due to a gastric ulcer.
58. The report recommended that a doctor with post graduate experience
in primary care should comment as the pathologist expressed concerns
that, despite a clear history of vomiting blood, and confirmation of
significant anaemia, the man was not referred for urgent investigation
of his upper gastrointestinal tract. The clinical reviewer asked a doctor
from the PCT to comment on this.
59. The doctor from the PCT is of the opinion that sufficient information
was available from the initial history and examination of the man to
have initiated a referral to a gastroenterology unit urgently. The doctor
from the PCT considers that this may not have been done, because of
the restrictions of the prison environment and the difficulties the prison
system encounters when sending prisoners to hospital.
60. When the blood test results were returned, they revealed a significant
degree of anaemia that would have warranted blood transfusion to
correct and further urgent investigation. The man was prescribed iron
therapy and had further blood tests ordered as a routine. This was a
failing on the doctor’s behalf to correctly identify the appropriate
treatment to manage the patient’s clinical condition.
61. The clinical review concludes that the man’s death was avoidable, at
that time, from a condition that is easily treated, if the correct action
had been taken when he was seen by a doctor.
RECOMMENDATIONS
1. I recommend that the Forest Bank management team continues to
work with Salford PCT to develop robust, consistent services. Medical
professionals need to be assessed and developed to ensure the
highest quality of services are available to prisoners.
2. I recommend that computer systems are developed to ensure that the
prison has access to appropriate links with the local hospital and wider
National Health Service are available.
3. All medical investigations and letters of referral must be logged and
documented within the Medical Record, and must provide
comprehensive details.
4. The Healthcare Centre managers must ensure that prisoner care plans
are up-to-date, and entries in the Medical Record are made
contemporaneously. The entries must be concise and legible.
5. I recommend that all staff should be made aware of the different alerts
within the Healthcare Centre, when the emergency call bells are
activated. All lights associated with the emergency call bells should be
visible from the observation windows at all times.
6. I recommend that the Director reminds his staff that, if a prisoner
activates the emergency call bell, it is imperative to investigate the
reason for that call and not rely on eye contact.
7. I recommend that locum prison doctor is interviewed by the PCT to
complete the clinical investigation. Depending upon the outcome of
this interview, an assessment and decision needs to be taken locally as
to any further action if required regarding locum prison doctor’s
professional registration.
8. I recommend that the host PCT on whose performer’s list locum prison
doctor appears, to be informed, for them to assess his skills and
competencies and depending upon the outcome of this assessment
instigate further action.