Individual at Bristol

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING
THE DEATH OF A MAN AT HMP BRISTOL
ON 15 NOVEMBER 2004
Report by the Prisons and Probation Ombudsman for England and
Wales
February 2006
This is the report of an investigation into the circumstances of the death of a
man at HMP Bristol on 15 November 2004. The man died from natural causes
at the age of 49. He had been in custody continuously since the age of 17.
I would like to extend my condolences to his family and to those touched by
his death. I am grateful to the family, and to the management and staff at
HMP Bristol, for their assistance and co-operation during the course of this
investigation. I very much regret the severe delay in completing this report.
I judge that the man’s death could not have been predicted. Indeed, it could
be said that his life raises far more questions than his death. However, there
are lessons that can be learned, particularly in the healthcare management of
those suffering from hypertension. I am also concerned by the way that the
news of his death was communicated to his family, and the initial contact they
had with the prison.
I make four recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2006
Contents
Summary
Investigation Process
Events of 15 November 2004
The prison’s response following the death
Contacting the man’s family
Findings and Conclusions
List of recommendations
Summary
The man was just 17 years old when he was sentenced for murder in 1972.
He was 49 at the time of his death in HMP Bristol and had spent all of the
intervening 32 years of his life in prison.
He suffered from hepatitis, hypertension and osteoarthritis. He was also a
long-term heavy smoker. Over the years, he had been a prolific self harmer
and had taken many drugs, both prescription and non prescription. All
together, these had taken their toll on his body.
On 15 November 2004, at about 7.15pm, he was found lying in his cell during
routine checks. Despite resuscitation attempts, he was pronounced dead at
7.35pm. The post mortem report states the cause of death as:
1a Acute Myocardial insufficiency
1b Coronary artery atheroma
His tariff had been set at 14 years. Much of his time in prison was
characterised by self harming, drug taking and disruptive behaviour. To some
degree this may have been due to his youth and immaturity at the time of his
sentence, coupled with the intense guilt he clearly felt about his offence. He
also did not appear to cope well in prisons with a lower security status,
although ‘progressive’ moves to lower category prisons were attempted on
several occasions.
In the main, his medical care was appropriate to his needs. However, there
did not appear to be systematic monitoring of his hypertension.
The initial contact with his family, and that in the day following his death was
unacceptable. The family were contacted by the police but not left details of
who to speak to in the prison. After they then contacted the police again, the
family were given the name and number of someone in the prison but were
told they would not be available until 8am, some 6 hours away. When they
phoned the prison at 8am, they were informed that the identified person was
not on duty.
The man died as a result of diseased arteries to the heart. His death could
not have been predicted. However, there are lessons that can be learned
regarding how prisons liaise with bereaved families and the monitoring of
health conditions.
Investigation process
I appointed one of my colleagues to investigate on my behalf. The investigator
and her manager visited HMP Bristol and met with the Deputy Governor.
They were given a full briefing about the circumstances surrounding the man’s
death. They visited the wing where the man had died and spoke to staff and
prisoners.
They then met with representatives of the Prison Officers’ Association and of
the prison’s Independent Monitoring Board. A notice to staff and a notice to
prisoners were issued, inviting anyone who might have information relating to
the man’s death to make themselves known to the inquiry team. No-one
came forward as a result of these notices.
The investigator took away with her all of the files and records relating to the
man and commissioned a clinical review from the Clinical Governance Lead
for Bristol North Primary Care Trust.
One of my family liaison officers contacted the man’s sister. The investigator
and the family liaison officer visited his mother and one of his sisters. They
raised a number of questions. These largely related to the healthcare that the
man had received. Some of these questions are answered in the main body
of this report and others have been addressed separately in a letter direct to
the family. I repeat here my indebtedness to the family for their assistance
and patience.
Events of 15 November 2004
On 15 November 2004, staff and prisoners did not notice anything unusual in
the man’s behaviour or mood during the day. He took his meals and
medication as usual and spent time playing on his PlayStation.
At about 5.30pm, after the man had got a drink, the wing officer locked the
door to his cell. The man did not press his cell bell to call for staff after this
time. Some other prisoners were out on association that evening, but the
man was not.
At 7.10pm, the wing officer was conducting a roll check. This is where the
officer counts and checks that all prisoners are in their cells. When he came
to the man’s cell at about 7.15pm, he looked through the observation panel
and saw the man lying on the floor with his head resting on the bed. He
knocked on the door and shouted the man’s name. As there was no answer,
the wing officer entered the cell, touched the man’s shoulder, and asked him if
he was okay. Again, there was no response. The wing officer reported that
the man looked pale, and was cold to touch. The wing officer felt
unsuccessfully for a pulse.
The wing officer then left the cell and shouted to another officer, the prison
officer that there was a code blue in cell D4 15. (A code blue means that
someone is not breathing.) the prison officer then used his radio to call for
urgent assistance, whilst the wing officer returned to the cell. He moved
furniture out of the way to make some room, and began to move the man so
that his body was flat on the floor. At this point, the wing officer found that the
man was cold and quite rigid. As the wing officer was trying to put the man
into the recovery position, he was joined by other officers, the unit manager -
Principal Officer (PO) - and by nursing staff.
The staff nurse checked for a pulse, but could not find one. She then
commenced cardio pulmonary resuscitation (CPR) with the help of the PO. A
second nurse arrived shortly afterwards with an automated defibrillator
machine. The second nurse placed the necessary pads on the man for the
defibrillator machine. The defibrillator instructed not to shock. The
paramedics from Avon Ambulance Service arrived quickly. They found no
signs of life and pronounced death at 7.35pm.
The prison’s response following the death
Bristol has a comprehensive ‘Death in Custody’ booklet that is completed by
the orderly officer, investigating governor and the doctor in the event of a
prisoner’s death. It provides detailed information including prisoner details,
when and how the death occurred, Coroner information and post mortem
arrangements. My investigator found that most sections of this booklet had
been completed thoroughly and that the documentation was very useful.
Following the man’s death, the prison’s contingency plans for a death in
custody were implemented. A hot debrief took place, and staff and prisoners
on the wing informed and offered support. Statements from all those staff
who had been involved were taken. My investigator found that these
contained appropriate and relevant detail.
The post mortem was conducted on 17 November. This confirmed the cause
of death to be acute myocardial insufficiency, and coronary artery atheroma.
Contacting the man’s family
HMP Bristol asked the police to break the news to the man’s family as they
live in Berkshire. For reasons I have been unable to ascertain, the police did
not attend the man’s family’s home till 2am some six and half hours after his
death.
When the police arrived at the family home, they did not have the correct
family name which caused the man’s mother some distress. Nor did the
police leave a contact name or number for someone the family could call at
the prison for more details. They had to phone the police station to obtain
one. The police gave a name but said that person would not be available till
8am. The man’s family then had to wait six long hours not knowing really
what had happened other than that the man had died.
The man’s family phoned at 8am, but were told that the named contact they
had been given was not in the prison that day. The man’s family reported that
they had to make a number of calls to try and find out the circumstances
surrounding the man’s death.
Bristol subsequently offered the man’s family the opportunity to visit the prison
which they accepted. During the visit, they met with the deputy governor who
attempted to answer the family’s questions.
Findings and Conclusions
The man died of natural causes. His death could not have been predicted.
However, there are issues that warrant further consideration and explanation.
Medical care
The man was only 49 when he died. I have little doubt that 32 years
continuously in prison had an effect on his general health. It is known that the
man had abused drugs, smoked and self harmed over the years.
In 2000, the man was diagnosed as having hepatitis C. As the tests revealed
there was no active hepatitis C infection, it did not require medication but was
regularly monitored. In December 2003, the man was diagnosed with
hypertension. Hypertension is a major but modifiable contributory factor in
coronary heart disease. The National Institute of Clinical Excellence (NICE)
states that to identify hypertension the patient must have high blood pressure
(above 140/90mmHg) on at least two occasions. The clinical reviewer found
no evidence in the medical record that these recordings had been taken.
There was also no clear evidence of systematic monitoring or management of
the man’s hypertension. This was compounded by the fact that the records
were not in date order and sometimes difficult to follow. The NICE provides a
clear flowchart for the management of hypertension in adults within a primary
care setting.
I therefore make the following recommendations:
I recommend the PCT in partnership with the prison develop a local
policy for the diagnosis, care and the management of hypertension in
accordance with the guidelines laid down by the National Institute of
Clinical Excellence.
I recommend that healthcare professionals should be reminded of their
responsibilities for appropriate standards of records and record keeping
in accordance with professional standards and a clinical audit system
introduced to ensure compliance.
The management of the man’s hypertension had greatly upset his family.
Medication
The man was on appropriate medication for his conditions. The man had
once been prescribed with Rofecoxib otherwise known as Vioxx. He started
taking this on 17 March 2004 for the pain and inflammation related to
osteoarthritis. However, on 30 September 2004, the drug was withdrawn on
the advice of the Committee on Safety of Medicines. It was withdrawn as it
was discovered that there was an increase of three thrombotic events per
400 patient years of treatment?. This difference in event rates was only
apparent after 18 months of treatment. The medication was stopped at an
appropriate time and there is no evidence that the Rofecoxib contributed to
his death as he had stopped taking the medication on 3 October 2004, and
had only been taking it for seven months.
On 4 October 2004, the man was assessed fit as suitable to have some in
possession medication. This was after several months of not having this
allowed due to a previous overdose. On 3 November, he was permitted to
have all his medication in possession. This was a positive forward step for
him.
His last hospital appointment had been on 28 October for investigations into a
cyst on his left scrotum.
The length of time the man had been in prison
His tariff was set at 14 years. At the time of his death he had served 32 years
and was still far from release.
The reasons for this were complex. He had been disruptive for a number of
years. He was involved in drug taking, and would often declare himself a
vulnerable prisoner due to debts he owed. He seemed to punish himself
repeatedly for his crime, either by his reckless behaviour or by self harming.
At times during his years in prison, his self harming was prolific including
several suicide attempts.
In 2003, he had eight adjudications (prison disciplinary hearings). Two of
these for were for unlawful use of controlled drug, and one was for possession
of drugs. In 2004, he had three adjudications the last of which was in August.
His life sentence plan was, in the main, regularly reviewed. Over the years,
he had completed several GCSEs, drugs awareness courses and an
enhanced thinking skills course. He also had three periods in the therapeutic
community at Grendon prison. He found it very hard to talk about his feelings
in front of others in that environment. He had to leave Grendon due to
returning to drugs. He was often assessed as being a risk to himself more
than to other people.
The man moved to four lower category prisons at various points during his
sentence. On each occasion, he found it difficult to cope and was returned to
a higher category prison.
On other occasions, he was in the process of being moved to lower security
prisons but would jeopardise the move. For example, he refused to move to
Highpoint in 2003, the day before he was due to move. He said that, if he
was made to move, he would threaten to escape thereby making the move
impossible.
At his last Parole Board review in 2002, it was felt he needed to undertake
more drug and alcohol related work before a move to open conditions could
be considered. His move to Ashwell was in order complete this work.
However, he was unable to cope well in the conditions and was returned to
Bristol.
Staff reported that he had been more settled in the last few months before his
death. He had been complying with the regime and was friendly towards
staff. Some felt that, although he wanted to be released, he was afraid of
what it might mean. Thus, when he got close, or a progressive move came
up, he did not seem able to cope with it.
Family contact
HMP Bristol asked the police to break the news to the man’s family as they
did not live locally to the prison. For some reason, the police did not attend
his family home till 2am. Breaking the news of a death in custody is both
sensitive and demanding. The way in which it is carried out may well colour a
bereaved family's whole relationship with the Prison Service. The two main
objectives should be to break the news speedily and to do so in a way that
emphasises the Prison Service's accountability, sense of shared loss, and
commitment to the family as members of the public that the Service serves. I
appreciate that speed and personal involvement of the Prison Service may
sometimes be in conflict.
If at all possible, the governor or other member of senior management in the
prison where the prisoner has died should personally break the news. Where
this is not possible, I do not think that the Prison Service should routinely rely
on the police:
Where it is not possible for the governor or a senior manager from the prison
where there has been a death to break the news personally, a governor at the
prison closest to where the deceased’s next of kin lives should normally be
asked to do so on behalf of the Prison Service as a whole.
I recommend that the Governor of Bristol reviews his contingency plans
for a death in custody in light of this report.
The man’s family were not provided with a contact point they could call
immediately. They had to phone the police to request this information. They
were further told no-one would be available to speak with them till 8am.
When they phoned at 8am, the person whose name they had been given was
not on duty that day. This was most upsetting for his family. If, as a last
resort, the police are needed to inform the family, the prison should ensure a
contact number of a suitable member of staff is provided. The prison should
seek confirmation that the police have made the visit and provided the
relevant information.
I recommend that if, as a last resort, the police are needed to inform the
family of a death in custody, the prison should provide information of an
immediately available contact point and seek confirmation that the
police have made the visit and provided the information.
Furthermore, his family encountered some difficulty in receiving his property.
To date, they still believe that they are missing some of his property.
The post mortem found that the man died of acute myocardial insufficiency
and coronary artery atheroma. In layman’s terms, there were fatty deposits in
his coronary arteries which obstructed the blood flow to his heart. His death
could not have been predicted, and every effort was made to save him when
he was found by staff.
List of Recommendations
Local
I recommend that the Governor of Bristol reviews his contingency plans for a
death in custody in light of this report.
I recommend that if, as a last resort, the police are needed to inform the family
of a death in custody, the prison should provide information of an immediately
available contact point and seek confirmation that the police have made the
visit and provided the information.
Healthcare
I recommend the PCT in partnership with the prison develop a local policy for
the diagnosis, care and the management of hypertension in accordance with
the guidelines laid down by the National Institute of Clinical Excellence.
I recommend that healthcare professionals should be reminded of their
responsibilities for appropriate standards of records and record keeping in
accordance with professional standards and a clinical audit system introduced
to ensure compliance.