Individual at Acklington

Circumstances surrounding the death of a man at
Wansbeck Hospital, Northumberland, in October 2006,
whilst a prisoner at HMP Acklington
Report by the Prisons and Probation Ombudsman for
England and Wales
June 2007
This is the report into the death of a man at Wansbeck General Hospital on in
October 2006. The man, who was a prisoner at HMP Acklington, died after
being admitted to hospital following concerns about reduced oxygen levels in
his blood and his persistent problems with chest pain. He was 76 years old.
The man was at Acklington having been recalled to prison in July 2006. Prior
to his recall, he had been residing in an Approved Premises in Middlesbrough.
The placement had broken down due to his behaviour towards hostel staff
and his refusal to cooperate with police and probation services.
One of my Family Liaison Officers contacted the man’s daughter and son-in-
law to inform them of my investigation and to offer the opportunity to raise any
concerns. I know that they are worried about the circumstances surrounding
the man’s recall to prison and the care he received whilst in custody. They
are also unhappy about not being told that he had been moved to hospital. I
hope this report goes some way towards addressing their concerns, and I
offer them my sincere condolences for their loss.
This investigation has been undertaken by a member of my team. I would like
to thank the Governor of Acklington and his staff for their co-operation and
active participation. Special thanks go to the Ombudsman’s liaison officer for
making the arrangements for my investigator’s visit, and for finding the
answers to numerous supplementary questions my investigator directed his
way.
Northumberland Care Trust conducted a review of the care the man whilst in
prison and I appreciate its invaluable contribution to the investigation.
This report deals not only with the care the man received whilst in prison, but
also with the circumstances that surrounded his recall. I was pleased to learn
that the revocation of his licence was a last resort. It came after he had been
properly warned on more than one occasion about his behaviour and the
consequences of failing to comply with his supervision.
I make one recommendation. This concerns the unsatisfactory manner in
which the news of the man’s death was broken to his family.
This version of the report has been anonymised in preparation for publication
on the PPO website. This has required some amendment to the text of the
final report.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2007
CONTENTS
Summary 4
The Investigation Process 6
HMP Acklington 7
Key Findings 9
Issues 17
Recommendations 23
SUMMARY
On 5 July 2004, the man appeared at Teesside Magistrates’ Court and was
remanded into the custody of HMP Holme House. Upon his reception, he
was assessed by healthcare and a family history of heart disease and mobility
problems were identified. He was initially held on the healthcare unit so that
his mobility could be assessed. This and subsequent assessments showed
that he was able to move adequately with the aid of two elbow crutches.
In September and October, the man claimed that he had been assaulted. He
was seen by healthcare staff who noted minor injuries. On 25 October, he
said that he had suffered a “stroke”. When he was examined by a nurse, he
said he was fine and had no health problems other than earache.
On 24 January 2005, the man appeared at Teesside Crown Court and was
sentenced to three years’ imprisonment with three years’ extended
supervision. On 18 February, he was transferred from Holme House to
Acklington where he would remain until he was released.
A month later, he again claimed that he had been assaulted. He was
assessed by a doctor who could find no obvious signs of injury. He was seen
by another doctor the following day. This doctor too could detect no injuries.
In May 2005, the man who later died was referred for an x-ray of his pelvis,
hips and knees. The results were received on 8 June. Osteoarthritis in both
knees and mild degeneration of the left hip were noted.
The man was released from Acklington on 3 January 2006 on licence. He
was supervised by Teesside Probation and, as a condition of his release, he
had to reside at an Approved Premises in Middlesbrough. Prior to moving
there he signed the Approved Premises ‘Core Rules’. By doing so, he agreed
to refrain from abusive, aggressive and violent behaviour whilst resident in the
hostel.
In late January, he was formally warned by his probation officer for being
aggressive towards his keyworker at the hostel. In June, he made threats of
violence in writing and was issued with a further warning.
Whilst in the community, the man made concerted efforts to find independent
accommodation. Unfortunately, he failed to keep the police and probation
services informed of his plans which he was required to do as a condition of
his release.
On 28 July 2006, his licence was revoked and he was recalled to prison by
the Home Office because of his threatening behaviour towards hostel staff
and his refusal to cooperate with police and probation. He was returned to
Holme House on 31 July and was transferred to Acklington on 10 August.
During the morning of 22 September 2006, the man complained of pains in
his chest. An ambulance was called but he refused to be examined by the
paramedics. He was seen later in the morning by a nurse who conducted
basic observations and found him to be satisfactory. He was given some
painkillers to combat what he described as a sharp pain.
On 25 September, he again suffered from an episode of severe pain in his
chest. He was transferred to the healthcare centre where an
electrocardiogram (ECG) was conducted. He was seen by a doctor who
diagnosed the problem as having a gastric origin. The man was prescribed
an antacid which apparently alleviated the pain temporarily.
Later in the day, the pain returned and he was seen by a nurse. She also
found that the pain originated in the man’s abdomen, and therefore chose not
to transfer him to outside hospital. The following morning, he did not report
any pain.
On 5 October, the man reported that he was short of breath. The nurse who
attended to him noticed that he was talking a lot, and this led her to suspect
that his claims about being short of breath were exaggerated. The next day,
he again claimed to be experiencing shortness of breath. Basic observations
were carried out and his vital signs were found to be within the normal range.
During the morning of 9 October, the man reported pain and feeling short of
breath. His basic signs were tested and were found to be within the normal
range. However, as a precautionary measure, the nurse decided to examine
him again later that day. She visited at lunchtime when he did not report any
particular problems. However, the nurse found out that the oxygen levels in
his blood were lower than they should have been, and she admitted him to the
healthcare centre for further tests. In the afternoon, he was moved to the
healthcare centre in a wheelchair. By this time, his physical appearance had
changed significantly and he looked unwell. The nurse decided to transfer
him to Wansbeck General Hospital and he was admitted later that day. A
number of tests were carried out over the next two days which established
that he had suffered a heart attack at some point in the recent past.
Just after 4.00pm on 11 October, the man’s condition suddenly deteriorated.
A crash team of medical staff was called but was unable to revive him. He
was pronounced dead at 4.22pm. His next of kin was informed of his death
shortly after 9.00pm.
THE INVESTIGATION PROCESS
1. My investigator considered the man’s prison documentation, including
his clinical records, before formally opening the investigation on 9
January 2007.
2. Prior to my investigator arriving at Acklington, notices were issued to
staff and prisoners announcing the investigation and inviting anyone who
had information relevant to the death to make themself known to the
investigator. One prisoner came forward and six members of prison staff
were interviewed by prior arrangement. The man’s supervising
probation officer was interviewed, and his solicitor was also spoken to on
the telephone.
3. One of my Family Liaison Officers contacted the man’s daughter and
son-in-law to offer them the opportunity to participate in the investigation
process. They raised concerns about the circumstances of the man’s
recall to prison and the way he was cared for after returning to custody.
They said they believed prison healthcare ignored his family history of
heart problems and the low levels of oxygen in his blood, and that the
professionalism of the healthcare staff left a lot to be desired. Finally,
they were unhappy that the prison failed to tell them that the man had
been transferred to hospital and about the way in which the news of his
death was broken to them. I hope this report goes some way towards
addressing their concerns.
4. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of the investigation and to request a copy of the post
mortem report. Upon completion, this report will be sent to the Coroner
to assist him with his enquiries.
5. Northumberland Care Trust conducted a review of the clinical care the
man received whilst in custody.
HMP ACKLINGTON
6. HMP Acklington opened in 1972 as a category C prison. The jail is
situated on a former Royal Air Force base near Amble in
Northumberland. It has the capacity to hold 882 prisoners.
7. One of the wings is H Wing which accommodates 120 prisoners. Cells
on H Wing are single occupancy and include full in-cell sanitation. Cells
on the ground floor are allocated to prisoners with mobility problems.
8. Northumberland Care Trust provides healthcare to the prison. Nurses
are employed to deliver primary healthcare during the daytime, seven
days a week. Prisoners who require 24 hour nursing care are
transferred to an outside hospital or another prison as there is no
inpatient unit.
9. Her Majesty’s Chief Inspector of Prisons carried out an unannounced
inspection of Acklington in April 2003. The Chief Inspector, Ms Anne
Owers, found Acklington to be a safe prison and commented that “low
levels of self-harm and the absence of self-inflicted deaths reflect well on
the proactive approach taken by staff”. However, the inspectorate
highlighted concerns about the needs of older prisoners, and those with
health conditions requiring a level of care that could not be provided at
Acklington.
10. Prior to the man’s death, seven prisoners had died at Acklington since I
assumed responsibility for investigating all deaths in custody in April
2004. Since then, three more prisoners have died. Seven of these
deaths have been through natural causes. The other four have been
self-inflicted.
Release on Licence
14. All prisoners sentenced to more than 12 months’ imprisonment are
released on licence, which means they are supervised by the Probation
Service until the licence expiry date. In general terms, the expiry date
falls three quarters of the way through a released prisoner’s sentence.
There are standard conditions for all licences, which include:
(cid:127) keep in touch with the probation officer in accordance with any
instructions that may be given
(cid:127) receive visits from the probation officer at their place of
residence
(cid:127) only undertake approved work
(cid:127) not travel outside the United Kingdom
(cid:127) be well behaved, not commit any offence and not do anything
which could undermine the purposes of supervision, which are
to protect the public, prevent re-offending and help successful
resettlement into the community.
Further conditions can be added by the Secretary of State if they are
deemed necessary to manage a person’s risk.
15. If a licencee breaks any of their conditions, they are deemed to have
breached their licence and the probation officer submits a report to the
Secretary of State (in practice, the Home Office acts as the Secretary of
State’s agent), who has the authority to revoke it. When the licence is
revoked, the person is subject to arrest by the police and return to the
nearest prison.
16. Since the Powers of Criminal Courts (Sentencing) Act 2000 was
implemented, courts in England and Wales have had the power to
extend the period a released prisoner is subject to probation supervision.
Multi-Agency Public Protection Arrangements (MAPPA)
17. The MAPPA is a formal partnership between police, probation, prisons
and other statutory and non-statutory agencies which assesses and
manages offenders in order to minimise the risk of serious harm they
may pose to the public. There are four core functions:
(cid:127) Identification of offenders with the potential to commit serious
violent and sexual offences
(cid:127) sharing relevant information between agencies
(cid:127) assessing the risk of serious harm
(cid:127) managing that risk.
18. Offenders who come within the MAPPA remit are classified according to
the nature of the risk and its management. The higher the risk, the
higher the level at which they are managed. Level one offenders are
managed by one agency, usually the police or probation service. Level
two offenders are managed jointly by all the MAPPA agencies and level
three offenders are managed by the Multi-Agency Public Protection
Panel (MAPPP) which is made up of senior managers from the MAPPA
agencies.
KEY FINDINGS
19. On 5 July 2004, the man appeared at Teesside Magistrates’ Court and
was remanded into the custody of HMP Holme House. Upon reception,
he was assessed by a member of healthcare staff. He disclosed a
family history of heart disease and complained of back pain, poor
mobility and hay fever. It was noted that he took prescribed medication
for his health problems, including painkillers, sedatives and an
antihistamine.
20. Later that day, the man was admitted to the healthcare unit so that his
mobility could be assessed. It was noticed that he was significantly
more mobile when he thought he was not being observed by staff, and
could carry a cup without walking aids and make his bed. This
contrasted with his presentation when he arrived on the healthcare unit,
when he only managed to get round by using two elbow crutches. He
was discharged from healthcare on 6 July, and was located with the
general prisoner population.
21. A further assessment of his mobility was made by a physiotherapist on
11 August. The physiotherapist also noted that his ability to move about
deteriorated when he became aware the staff were observing him, and
also concluded that he did not require additional walking aids. He was
not deemed to require relocation to another wing or prison with disabled
access as his mobility was assessed as being satisfactory.
22. On 12 September, the man alleged that he had been assaulted by
another prisoner. He was seen by healthcare staff who noted minor
lacerations to his mouth and the top of his head. No serious injuries
were observed and he was prescribed a painkiller for the soreness.
23. The following month, on 16 October, the man alleged that he had been
struck in the face with a glass jar. He was taken to the healthcare centre
and assessed, but no signs of trauma were identified.
24. On 25 October, the man was examined in his cell by a nurse in response
to a letter he had submitted to the prison claiming he had suffered a
stroke. When questioned, he said that he was fine and had no
complaints apart from earache in his right ear. He then proceeded to
walk across his cell from his bed to a chair. The nurse checked his
pulse and blood pressure and concluded that he displayed no signs of
weakness. He was advised to report sick because of his earache. The
following day, the man fell over when his knee gave way. He was again
seen by a member of the healthcare staff who could not find any signs of
injury.
25. Six weeks later, on 11 December 2004, a physiotherapist attempted to
assess the man’s mobility needs. However, he refused to be seen and
the assessment did not take place.
26. On 24 January 2005, the man appeared at Teesside Crown Court and
was sentenced to three years’ imprisonment with three years’ extended
supervision for a total of nine offences. He was returned to Holme
House to commence his sentence. Three weeks later, on 18 February,
his suitability for transfer to another prison was assessed by a doctor.
The doctor noted that his mobility had been assessed on numerous
occasions, and it was thought that he was more physically capable than
he claimed. He was therefore deemed fit for transfer, and moved to
HMP Acklington later that day.
27. The following month, on 18 March, the man was seen by a doctor at
Acklington and claimed that he had been punched by a prison officer.
The doctor noted that no bruising was evident. Later in the day, the man
was seen by a specialist nurse who has specific responsibilities for
Acklington’s elderly and disabled prisoners. Again he claimed that he
had been the victim of an assault. She too noted that he had no obvious
injuries.
28. The next day, on 19 March, the man was assessed by another doctor
who conducted a full assessment of his basic functions in light of his
claims that he had been assaulted. The doctor could find no injuries and
the man denied that he was suffering from double vision or any other
sign indicative of concussion.
29. The same day, the man was seen by the specialist older persons nurse
in order to assess whether he needed a wheelchair to move about. She
concluded that he was able to walk with the use of one walking stick,
and therefore did not need a wheelchair.
30. Two months later, on 17 May 2005, the man was referred for a chest x-
ray as he was found to have had close contact with a tuberculosis
sufferer whilst detained in Holme House. The results came back on 19
May. He was given the all clear.
31. Four days later, on 23 May, he was referred for another x-ray, this time
of his pelvis, hips and knees. The results were received on 8 June.
Osteoarthritis in both knees and mild degeneration of the left hip were
noted.
32. In December, the man’s supervising probation officer visited him at
Acklington on two occasions. The purpose of the meetings was to start
advance arrangements for his release from prison, which would take
place on 3 January 2006. During her first visit, the supervising officer
told the man what would be expected of him upon his release. She also
told him that Teesside Probation would be seeking additional licence
conditions in order to manage the risk he posed to the public. The man
was reportedly unhappy with many of these conditions, but he agreed to
abide by them when he was released. He also signed the Approved
Premises ‘Core Rules’. By doing so, he agreed to refrain from using
abusive language or aggressive behaviour in the hostel.
33. The man was managed at level two of the Multi-Agency Public
Protection Arrangements (MAPPA) as a result of the offences of which
he had been convicted. This meant that numerous agencies were
involved in his case. An example of how this worked in practice was
illustrated later in December when he was interviewed jointly by his
supervising officer and a detective from Cleveland Police.
34. On 2 January 2006, he was examined by a nurse, who assessed him as
being fit for discharge. During the course of the assessment, the man
claimed he was suffering from dysentery, although nothing about his
presentation indicated that this was the case.
35. The following day (3 January), the man was released. The extended
supervision imposed by Teesside Crown Court meant he would be
managed by the probation service until 4 October 2009. His supervising
officer collected him from prison and transported him to a police station
in Middlesbrough. After he signed some necessary forms, his
supervising officer took him to the Approved Premises where he was
formally inducted by hostel staff.
36. On 19 January, the man refused to sign his Approved Premises
supervision contract or his licence supervision plan, saying he refused to
address his offending behaviour because he had not committed any
offences. He was subsequently formally warned by his supervising
officer for a separate incident of being aggressive towards his keyworker
at the hostel and using abusive language. This was in contravention of
both the Core Rules of the Approved Premises and condition 5 (vi) of his
prison licence, both of which he signed prior to his release. Condition 5
(vi) specifies that those released from prison on licence must ‘be well
behaved, not commit any offence and not do anything which would
undermine the objectives of [their] supervision …’
37. In March, the man started to complain that living in the hostel was having
a negative effect on his mental health. His supervising officer and the
hostel arranged for him to be assessed by mental health professionals
from the Custody Diversion Team. However, he refused to be
interviewed and the assessment did not take place.
38. By this time it was evident to both hostel staff and his supervising officer
that the man was unhappy about living at the hostel. He repeatedly
expressed a wish to leave and live independently. However, he was
prohibited from doing so without first obtaining the permission of his
supervising officer who had the authority to veto any accommodation
that she deemed unsuitable. On 10 April, the man arranged to travel to
Scarborough to view properties. He failed to provide his supervising
officer with the addresses of the properties, and did not supply the
contact details of the landlords. He was therefore asked to provide the
details of the vehicle in which he was going to be travelling to
Scarborough so that North Yorkshire Police could be informed. The
details he supplied were of a vehicle that was neither registered nor
licensed, and as a result permission to travel to Scarborough was
denied. When the man attempted to make the journey, he was actively
prevented from doing so by Cleveland Police and returned to the
Approved Premises.
39. In June, the man once again told probation staff that living at the hostel
was damaging his mental health. He said that he felt as though he might
attack someone and expressed a view that he would not be responsible
for his actions. On 23 June, he was interviewed by a community
psychiatric nurse, and was not assessed to be suffering from any
significant mental health problems. When the nurse suggested to the
man that he was more aggrieved or frustrated than mentally ill, he
threatened to physically harm the female staff working at the hostel. He
also handed the nurse some handwritten notes in which he made explicit
his threats of violence to the female staff. He was issued with a further
(and final) warning by his supervising officer for his behaviour.
40. According to the supervising officer, the man persisted in his attempts to
move to the coast, despite being told that the MAPPA would not allow it.
He responded by saying that he would rather go back to prison than live
where the police and probation told him.
41. On 28 July, the man’s case was discussed at a level two MAPPA
meeting. The meeting was told that his behaviour in the hostel,
particularly towards female members of staff, was becoming increasingly
difficult to manage, and that his failure to co-operate with police and
probation over his housing was undermining the objectives of his
supervision. Those present, including representatives from housing,
health, police and probation, unanimously agreed that he could no
longer be safely managed in the community. The meeting directed that
the man’s licence be revoked immediately, and the supervising officer
completed the necessary paperwork. The Home Office authorised the
recall to custody later that day and he was arrested and taken to Holme
House on 31 July.
42. Upon his arrival at Holme House, the man was assessed by a member
of healthcare staff in accordance with reception procedures. He told the
nurse that he had an appointment scheduled with the James Cook
University Hospital for a hernia operation. Otherwise, no changes in his
health from his previous period in custody were noted.
43. On 3 August, he collapsed with severe abdominal pain. He was seen by
a doctor, and an ECG was carried out which revealed that he was
suffering from a heart block and extra heartbeats. The doctor noted an
irregular pulse and the right-sided hernia. The man was made
comfortable by healthcare staff and advised to rest. Subsequent tests
failed to add anything to the initial findings of the doctor and ECG.
44. The next week (10 August), the man was transferred back to Acklington.
He underwent reception procedures which again identified the presence
of a hernia. He was referred to the chronic disease management clinic
which it was hoped would help him to manage his symptoms.
45. On 21 August, the man had a General Practitioner appointment. He did
not attend, although it was subsequently discovered that the reason he
failed to turn up was because there were no wheelchairs available to
take him from his wing to the healthcare centre. He was seen the
following day by a nurse and again on 23 August by a doctor. After
examining the man, the doctor wrote in the clinical notes that the man
was experiencing ‘nil of a serious nature’.
46. During the morning of 22 September, the man complained of chest pain.
As there are no healthcare staff in the establishment between the hours
of 7.45pm and 7.30am on a weeknight, wing staff immediately called for
an ambulance. North East Ambulance Service has confirmed that it
received a call-out at 6.46am and that the ambulance arrived at the
prison at 6.55am. The paramedics then went to H Wing, but the man
refused to be seen by them. It is reported that he was verbally abusive
towards them, and they left the prison without examining him.
47. At around 7.20am, the specialist older persons nurse arrived at
Acklington to start her shift. As she was passing through the front gate,
a prison officer who had worked the night shift told her that an
ambulance had been called out to see the man but he had refused to be
examined. She went to his cell where she found him lying on his bed.
She examined him and observed that his colour was good, he did not
look distressed, and no signs of sweating were evident. The man also
denied that he was feeling nauseous. When the nurse asked him to
describe the pain, he replied by saying it felt sharp. The nurse told my
investigator that pain associated with cardiac arrest is usually described
as crushing, and she therefore concluded that his complaint was more
likely to be respiratory rather than cardiac. When she asked him why he
had not spoken to the ambulance crew, he swore at her and became
verbally abusive. The specialist nurse therefore left the cell and could
not conduct any further examinations to check whether the man was
experiencing respiratory problems.
48. Later that morning, the specialist older persons nurse went to see the
man again. On this occasion, he was not abusive and merely requested
more painkillers. As he was scheduled to receive his prescribed
painkillers at that time anyway, he was given the medication. The nurse
told my investigator that he looked fine at this point and she had no
concerns about his presentation.
49. Just before 7.45am on 25 September, the man complained to the staff
on H Wing that he was suffering from chest pain. A nurse attended to
him and found him to be sweating and writhing in pain. She arranged for
him to be transferred to the healthcare centre where an
electrocardiogram (ECG) was carried out. The ECG showed that the
electrical activity in his heart was abnormal and suggestive of ischaemic
heart disease (meaning the blood supply to heart was reduced).
However, having read the ECG print-outs, the prison doctor concluded
that the ischaemia was of historical origin. In the man’s clinical notes,
the doctor has identified that an ECG carried out in August 2005 found
the same problem. He therefore suspected the man’s pain on 25
September to be of gastric origin. The man was prescribed Omeprazole,
which suppresses the secretion of acid in the stomach, and this
apparently had the effect of alleviating his pain. The doctor made a
referral to the consultant cardiologist at Wansbeck Hospital to deal with
the bigger problem of insufficient blood being supplied to the heart.
Meanwhile, the man returned to H Wing.
50. Later in the day, the specialist older persons nurse was called to H Wing
where the man was once again complaining of chest pain. After
conducting observations of his blood pressure, pulse and respiration,
which were all found to be normal, the nurse determined that the origin
of his pain was in his abdomen. As he had a longstanding problem with
a hernia, this did not unduly concern the nurse and she refused the
man’s demands that he be taken to hospital. Early the following
morning, the nurse saw the man at the medication dispensary on H
Wing. He did not report any pain.
51. On 5 October, the man reported to wing staff that he was short of breath.
A nurse was called from healthcare, and he told her that he had been
short of breath for three nights in a row and had not slept as a result.
However, the nurse observed that he was talking a lot, apparently
without great exertion, and this led her to suspect that his claims about
being short of breath were exaggerated. She continued her
examinations and found that he had a good colour, and blood pressure,
pulse and respiration were normal. At one point during the examination,
the man became verbally aggressive towards the nurse, but she
managed to calm him down and reassure him that he was alright.
52. The following day, the man again complained of shortness of breath. On
this occasion, he was seen by the specialist older persons nurse who
found his basic observations to be within the normal range. The man
told the nurse that he had been vomiting and not eating for the previous
eight or nine days, although the nurse could find no obvious signs of
weight loss or dehydration to substantiate his claims. However, she did
make a non-urgent appointment for him to see the prison doctor.
53. During the morning of 9 October, wing staff asked the Deputy Clinical
Team Leader, a qualified nurse, to see the man as he had rung his cell
bell on numerous occasions through the previous night. He told the
Deputy Clinical Team Leader that he had been suffering from pain and
shortness of breath throughout the night. He demanded to go to
hospital, but the Deputy Clinical Team Leader could find no reason to
transfer him out; his colour was good and no shortness of breath was
observed. Indeed, when asked by the Deputy Clinical Team Leader to
describe the pain, he said it was coming from his stomach rather than
from his chest. As the man already had a non-urgent appointment to
see the doctor, the Deputy Clinical Team Leader took no further action
although she did ask him whether he would like to come to healthcare.
He replied in the negative and said he was fine. The Deputy Clinical
Team Leader told the man that she would come and see him again at
lunchtime to see how he was doing.
54. At lunchtime, the Deputy Clinical Team Leader returned to H Wing and
carried out a series of basic checks on the man. His blood was fine, but
the Deputy Clinical Team Leader found that he seemed to be struggling
to catch his breath. She told my investigator that he appeared a little bit
panicky and, when she tested the amount of oxygen in the blood, she
found his reading to be 10per cent less than it should have been.
However, he looked satisfactory and he said he was alright so the
Deputy Clinical Team Leader said she would move him to healthcare for
observation when prisoner movements started after 1.30pm.
55. When the prisoners were unlocked at 1.30pm, the man was transferred
to the healthcare centre in a wheelchair. The Deputy Clinical Team
Leader again tested his blood pressure and conducted basic
observations which showed that his condition was deteriorating. His
pulse was in the region of 126-140 beats per minute, which is too fast
and meant his heart was not functioning properly. After testing his blood
again, the Deputy Clinical Team Leader decided to transfer the man to
Wansbeck General Hospital. An ambulance was called and he left
Acklington accompanied by two prison officers. He arrived at the
hospital shortly afterwards, and was admitted as an in-patient later in the
day. In accordance with the bedwatch guidance, the man would
continue to be guarded by two members of prison staff until he died on
11 October.
56. At 7.30am on 11 October, two prison officers commenced the bedwatch
duty. One of them told my investigator that the man was asleep when
she arrived, but over the course of the day he readily engaged in
conversation with both herself and her colleague. At 8.55am, the man
was seen by a doctor, and later in the morning healthcare staff at the
prison telephoned the hospital to check on his progress. The nurse who
made the call was told that the hospital had confirmed that the man had
had a heart attack and that there were no plans to discharge him.
57. Just after 4.00pm, the man’s condition suddenly deteriorated. One of
the bedwatch officer’s told my investigator that he was lying on his back
when he abruptly turned on to his side and the colour in his face rapidly
drained away. She alerted nursing staff by calling out to them, and they
arrived at the bedside within a matter of seconds. Moments later a crash
team arrived, and the two prison officers were moved out of the way.
The curtains were closed and the medical staff worked on the man.
Sadly, the crash team was unable to revive him and he was pronounced
dead at 4.22pm.
58. One of the bedwatch officers subsequently telephoned the prison to
report the man’s death. Acklington activated its contingency plans for
responding to a death in custody, and at 5.16pm the Deputy Governor
telephoned the man’s daughter to tell her the sad news. Unfortunately,
the call went unanswered so the Deputy Governor left a message on the
answering machine asking her to call him at the prison as a matter of
urgency. At 6.00pm, the man’s daughter telephoned Acklington but was
told that the Deputy Governor had left for the day. Nobody else at the
prison was able to help or provide her with any information, and she
therefore had no choice other than to wait for the Deputy Governor to
call back, which he did at 9.00pm.
59. Staff at Acklington subsequently contacted the man’s daughter to offer
her and her husband the opportunity to visit the man’s cell. They also
discussed the arrangements for the funeral, the costs of which were met
by the prison.
ISSUES
Circumstances surrounding the man’s recall to prison
60. One question my investigator has sought to answer is whether the man’s
recall to custody was justified. It is documented in his prison and
probation records that he believed he had been recalled unjustly, and his
family has expressed concerns about the way he was treated whilst in
the community. Indeed, they told my Family Liaison Officer and the
investigator that they thought the criminal justice agencies treated the
man in a discriminatory manner because of the nature of his offences.
61. As detailed above, the man was released on licence from Acklington on
3 January 2006. Due to the nature of his offences, the fact he denied
committing them, and his failure to engage in any offending behaviour
work whilst in prison, he was assessed as posing a high risk of
reoffending. Consequently, a number of additional conditions were
attached to the standard licence so that his risk could be managed and
his behaviour monitored. One of these was a requirement that he live at
an Approved Premises. He was not allowed to live elsewhere without
obtaining the permission of his supervising officer.
62. The supervising officer told my investigator that, throughout his licence
period, the man made concerted efforts to secure accommodation
independently. Whilst the probation service and the other MAPPA
agencies did not oppose this in principle, the man’s refusal to provide the
addresses of the properties or the contact details of the landlords meant
that probation could not grant him permission to move. In addition, the
supervising officer reported that she became aware that the man was
providing false information to housing providers: in one housing
application, he failed to disclose any of his convictions. In another, he
stated that he was currently living in a homeless hostel, whereas he was
actually living in a hostel approved by the Home Office to house
offenders. It is for these reasons that the supervising officer wrote on
the revocation paperwork she sent to the Home Office that the man had
been uncooperative with regard to his housing, and that this was serving
to undermine the purposes of his supervision.
63. Prior to moving in to the hostel, the man signed the Approved Premises
‘Core Rules’. By doing so, he agreed to refrain from using abusive
language or aggressive behaviour in the hostel. Over the course of his
tenancy he was formally warned on two occasions by his supervising
officer, once for being verbally abusive and aggressive towards a female
member of staff, and once for threatening violence against female staff
in writing.
64. In my view, the formal warnings the man received were entirely
proportionate to the seriousness of his behaviour. It was made explicit
to him before he arrived at the Approved Premises that aggressive or
abusive behaviour would not be tolerated, and this was reinforced in the
warning letters. Approved Premises staff have the right to go about their
duties without fear or intimidation.
65. In my opinion, the probation service and other MAPPA agencies were
right to look at these incidents as part of a pattern of deteriorating
behaviour, rather than in isolation. Given this, the man’s on-going
refusal to cooperate with the police and probation services about his
housing, and the assessment that he posed a high risk of harm to the
public, I do not question the decision of the MAPPA to recall him to
prison. Clearly his behaviour was worrying, and the agencies that make
up the MAPPA could not be sure that he could be managed safely in the
community.
The man’s access to services and entitlements
66. One of the main concerns of the man’s family concerned his inability to
access services whilst in custody. His daughter told my investigator and
Family Liaison Officer that, whilst in the community, the man was
classified as disabled and entitled to relevant benefits. When in prison,
he was not given the same status, and his daughter felt that this was
tantamount to discrimination.
67. There is no documentation in the man’s clinical records to show that he
was classified as disabled when living in the community. Indeed, prior to
being remanded into custody, he was observed by police officers riding a
bicycle. Upon his reception into custody, he was seen to require the use
of two elbow crutches. A number of assessments completed by nurses,
doctors and physiotherapists, carried out independently of each other,
found that these walking aids were adequate for his needs. The clinical
review has found that ‘when [the man was] not aware that he was being
observed, [he] was noted to be reasonably mobile’.
68. After his recall to custody in July 2006, the man who later died was
observed to be less mobile. However, my investigator was told that this
only affected him when he had to move relatively long distances in the
prison, such as from the wing to the healthcare centre. On these
occasions, he would be pushed in a wheelchair. I note that, on 21
August, he was unable to attend an appointment with the prison doctor
because there were no wheelchairs available. This is clearly
unacceptable, and my investigator spoke to the Head of Healthcare to
raise his concerns. The Head of Healthcare confirmed that there had
been a problem with wheelchairs that had been specifically acquired to
transfer prisoners to healthcare being misused to take them to education
classes. He assured my investigator that the problem of
misappropriation of wheelchairs has been resolved, and I therefore
refrain from making a formal recommendation.
69. The man’s daughter told my Family Liaison Officer and investigator that
the man had sent her numerous letters from prison in which he said he
was missing out on meals because he could not collect them from the
hatch on the wing. My investigator looked into this matter and spoke to
the Principal Officer who is in charge of day-to-day operations on H
Wing, and a prisoner on H Wing. The Principal Officer confirmed that,
after the man was recalled to prison in July 2006, his ability to get round
was noticeably worse than when he had been in prison previously. To
overcome this, wing staff commissioned a prisoner on H Wing to collect
the man’s meals from the hatch every day and take them to his cell. The
prisoner told my investigator that he has carried out tasks of this kind for
some time. At the time he was interviewed, he was collecting meals for
two other prisoners with mobility problems. By way of reward for helping
his fellow prisoners in this way, the prisoner receives the television in his
cell for free – equivalent to £1 a week.
70. Over the course of his sentence, the man submitted a series of
complaints to Acklington about the fact that, one evening every week, he
had to make a choice between queuing for his canteen (cigarettes,
sweets, soft drinks and so forth) and going outside for fresh air. The
regime on H Wing is that, on the day the canteen is delivered, the hour
(6.00pm - 7.00pm) given over to exercise for the rest of the week is split
into two half-hour sessions. Prisoners have the choice of either taking
half an hour’s outside exercise first before collecting their canteen, or
vice versa. In his complaints, which have been examined by my
investigator, the man says that his mobility problems prevented him from
doing both activities and, if he wanted to collect his canteen, he
necessarily missed out on outside exercise. He said that this violated
his right to one hour’s exercise in the open air each day.
71. Prison Service Order (PSO) 4275 says that, ideally, ‘prisoners should
have the opportunity to spend at least an hour in the open air each day
and that the period allowed should not normally be less than half an
hour’. It is therefore clear that the man was wrong to believe he was
entitled to one hour’s exercise every day, as the minimum period is 30
minutes.
72. That said, my investigator sought to establish whether the man would
have been able to go out into the fresh air on the day the canteen was
delivered, given his mobility difficulties. H Wing is laid out in such a way
that there is a relatively short distance, no more than ten metres,
between the end of the ground floor landing and the gate to the exercise
compound. Given that the canteen is distributed from the end of the
landing nearest the gate, my investigator believes that the man would
have been able to go outside into the exercise compound if he had
wanted to.
73. The H Wing prisoner told my investigator that the man never mentioned
anything to him about missing out on aspects of wing life. He reported
that the man would go out on exercise every evening and sit on the
bench, and he expressed the view that he was not disadvantaged
because of his mobility problems. My investigator could find no
evidence that the man was discriminated against, and it would seem he
received all his meals and other entitlements.
The quality of the man’s care
74. The man’s family also expressed concerns about the quality of care the
man received whilst in custody. They told my Family Liaison Officer they
thought the Prison Service ignored his family history of heart problems
and the low levels of oxygen in his blood. Furthermore, they said that
the judgment of the healthcare staff was clouded by the fact that they
thought he was exaggerating his ailments and they questioned the
professionalism of the healthcare team.
75. As part of the investigation, three nursing staff directly involved in the
man’s care were formally interviewed. My investigator was impressed
by their knowledge of the man’s health needs and could find no evidence
that would support the view that they were unprofessional. Indeed, the
available evidence suggests that they continued to engage with him in
spite of his challenging behaviour, which included incidents of verbal
abuse.
76. The clinical review carried out by Northumberland Care Trust concludes
that “all clinical staff did their best to manage a very difficult case and I
have no criticism of the decisions that were made”. As such I cannot
endorse the family’s opinion that the man’s health needs were ignored.
The events of 22 September
77. During the morning of 22 September, the man who died complained to
wing staff that he was experiencing pains in his chest. As there is no
healthcare cover at Acklington at night, the emergency services were
called. When the paramedics arrived at the prison and attempted to
examine him, he responded with verbal abuse and refused to be treated.
The paramedics therefore left the prison without examining him.
78. The man’s family have pointed out that one of the symptoms associated
with a heart attack is agitation. They told my Family Liaison Officer that
they think the paramedics should have realised this and insisted on
examining him.
79. My terms of reference preclude me from investigating complaints about
the conduct of staff from the emergency services. However, it is the
case that patients who are not otherwise mentally incapacitated have the
right to refuse treatment. Whilst there is an expectation that all medical
personnel give patients all the information necessary to make an
informed decision, they cannot examine them against their will. As there
is no evidence to suggest that the man was unable to make an informed
decision, it would be hard for me to justify criticising the paramedics
involved or referring the matter the appropriate disciplinary body.
Informing the man’s next-of-kin of his transfer to hospital
80. The man’s daughter told my investigator and Family Liaison Officer that
she was extremely unhappy that the first she heard of her father’s
transfer to hospital was when the news of his death was being broken at
9.00pm on 11 October. She said that the prison had had ample
opportunity to inform her between the time her father went to hospital
during the afternoon of 9 October and his death two days later.
81. Acklington has said that it does not routinely contact next-of-kin when
prisoners are transferred to outside hospital. The main reason for this is
that there are security implications of doing so. I accept that there are
such implications, although Acklington is a category C prison and I would
expect security to be tempered by common sense in the case of a 76
year old man with no known contact with organised crime. Moreover, in
all instances where it looks as though a prisoner is likely to die (rather
than being sent to hospital because of a broken limb, or something of
that nature), my expectation is that the family are informed so that they
have the opportunity to see them. That said, in this case, there was little
reason to suspect that he would not be returning to the prison – the
Deputy Clinical Team Leader told my investigator that she thought the
hospital would be able to conduct some extra tests and stabilise him.
One of the bedwatch officers similarly reported that the man was happily
engaging in conversation shortly before he died, and that the
deterioration in his health was sudden.
82. In this case, I am persuaded that Acklington believed right up until the
man’s death that he would in all likelihood be returning to the
establishment. His rapid deterioration was not predicted by prison staff,
or by Wansbeck General Hospital. However, I draw my comments in
para 82 to the attention of the Governor and Area Manager.
Informing the man’s next-of-kin of his death
83. After Acklington was informed of the man’s death, the prison activated its
contingency plan for responding to a death in custody. As part of this
plan, the Deputy Governor telephoned the man’s daughter to pass on
the sad news shortly after 5.15pm. This was timely and shows that the
prison appropriately prioritised this sensitive task. Unfortunately, the call
went unanswered and he left a somewhat ambiguous message (to the
effect of “please call me urgently”) on the answering machine.
84. When the man’s daughter called the prison 45 minutes later, the Deputy
Governor had left for the day and nobody else at the prison was able to
tell her what was going on. Entirely understandably, this left her and her
family feeling extremely anxious.
85. My investigator has found out that, after leaving the message on the
answering machine, the Deputy Governor contacted the man’s
daughter’s local police force to ask them to visit her in person to break
the news. This is common practice when prisons are located some
distance from the home of the next-of-kin. However, it would appear that
the police only turned up at the house after 11.00pm. In the meantime,
the Deputy Governor had telephoned the man’s daughter again (around
9.00pm) to tell her what had happened. This was some four and a half
hours after the man had died and three hours after she had telephoned
the prison.
86. I was extremely disappointed to learn that the man’s daughter could not
find out any information when she called the prison as directed. As a
minimum, I would have expected her call to have been directed to a
senior member of staff such as another governor or a principal officer
who had been briefed on the circumstances of the man’s death. If this
was not deemed to be appropriate, the man’s daughter should have
been provided with an alternative number on which to contact the
Deputy Governor.
87. On this occasion, it would appear that a number of relatively minor
shortcomings culminated in there being an unnecessary delay in
informing the man’s next-of-kin of his death. I urge Acklington to look
into what went wrong on this occasion and to develop a more robust
system for informing next-of-kin when a prisoner dies.
Acklington should review the system currently in place for
informing next of kin of a prisoner’s death, and implement any
changes as necessary.
RECOMMENDATIONS
To the Governor
1. Acklington should review the system currently in place for
informing next of kin of a prisoner’s death, and implement any
changes as necessary.