Individual at Lincoln

Investigation into the circumstances surrounding the
death of a man
at HMP Lincoln in August 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2010
This is a report into the death of a man at HMP Lincoln on 16 August 2009. He died
of natural causes.
I offer my sincere condolences to the man’s family and friends.
The investigation was conducted on my behalf by my colleague. In addition, a
clinical review into the care of the man received whilst he was in prison was
undertaken by the local PCT. I am most grateful to the clinical reviewer for her
contribution. I am also grateful to the Governor and staff of Lincoln for their
assistance during the investigation.
The man had been arrested for a breach of his licence conditions and was returned
to custody on 18 April. Not being his first time in prison, he quickly settled into prison
life and staff had no concerns about him. He had very little contact with healthcare
until the day of his death four months later.
Despite taking unprescribed drugs hours before his death, the post mortem and the
clinical reviewer confirm that coronary artery disease was the cause of his death.
Overall the man’s stay in Lincoln was uneventful and I have identified no particular
issues until the day before his death. Regrettably nearly two hours elapsed between
the first call to help the man and healthcare staff responding. The clinical reviewer
believes that earlier treatment might have detected his heart condition so that
appropriate care could have been given.
As a result I make six recommendations regarding events on the day of his death.
Since the draft report was issued, I have become Acting Prisons and Probation
Ombudsman. I endorse these recommendations. They relate to recording and
passing on medical information, staff response in emergency situations and breaking
news to families.
Jane Webb
Acting Prisons and Probation Ombudsman July 2010
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CONTENTS
Summary 4
The Investigation Process 5
HMP Lincoln 7
Key Findings 10
Issues 19
Conclusion 22
Recommendations 23
3
SUMMARY
The man was received into custody at HMP Lincoln on 18 April 2009 following a
revocation of his licence. He was screened at the prison reception and said that he
did not have any history of physical or mental health problems. He was not taking
any medication and denied any drug misuse. He quickly settled into the prison
regime and staff did not report any concerns about his health. Further to this, he
only consulted healthcare once during his four month period in custody, when he
complained of a headache.
During the evening of 16 August, the man’s cell mate witnessed him taking some
Subutex (a semi-synthetic opiate, often used recreationally) and cannabis. He
allegedly obtained the drugs from another prisoner. After taking the drugs, he
watched television with his cellmate and started to feel unwell. Believing the drugs
had started to have an effect on him, the man remained lying on his bed in his cell.
As his breathing became louder, his cell mate became concerned and pressed the
cell bell alarm at 7.59pm to alert staff.
The Operation Support Grade (OSG) immediately responded to the cell alarm. He
was told by the cell mate that the man felt unwell. At this time, he was standing up
against his bed. The OSG advised him to open the window and to remain on his
bed. He then rang the healthcare centre and spoke to a healthcare support worker
(HSW), who was about to conclude her duties for the evening. The OSG told the
HSW that a prisoner on C wing had taken Subutex and felt unwell.
The information was passed on to the registered general nurse (RGN) who was
receiving a handover from the day staff before starting his night shift. There was no
log of this call and the HSW did not identify any additional information from the OSG
about the nature of the man’s complaint. Shortly afterwards, the RGN attended an
emergency call on another wing.
Nearly two hours after the OSG went to the man’s cell, he again answered the cell
bell alarm. When he arrived at the cell, his cell mate said that the man was dead.
Despite the OSG shouting his name, he failed to respond. The OSG immediately
used his radio and requested healthcare and the orderly officer (in charge of the
prison at night) to attend C wing. Another OSG who was on the wing at the time
quickly ran to assist.
The staff entered the cell and examined the man but no signs of life were found. A
Code 1 emergency call (indicates a life threatening emergency) was radioed through
whilst the OSG began cardio pulmonary resuscitation (CPR). The healthcare staff
and paramedics arrived quickly and continued with CPR. Despite their attempts, he
was pronounced dead at 10.32pm.
I make six recommendations in my report. They relate to recording and passing on
medical information, staff response in emergencies and breaking bad news to
families.
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THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened by one of the
Ombudsman’s investigators on 20 August 2009 when he met the Governor
and some of his staff. Notices of the investigation and terms of reference had
already been sent inviting anyone with any information to contact the
investigator. The investigator encountered a number of delays due to staff
unavailability for interview, which has been acknowledged by the Governor.
2. The investigator also met the Head of Healthcare, representatives of the
Prison Officers’ Association and a representative of the Independent
Monitoring Board. He visited all parts of the prison including the wing where
the man lived, and met the prison’s liaison officer (the Head of Performance).
3. The man’s prison records, including his medical record, were made available
to the investigator during his initial visit to the prison. Additional documents
were made available when he returned to conduct interviews. The
investigator also met a Detective Sergeant (DS) of the local police. The DS
shared a number of police statements that he obtained during the police
investigation with the investigator. I am grateful to the DS for his help and
assistance.
4. A clinical review of the man’s medical care was commissioned from the local
NHS. I am grateful to the clinical reviewer for her review. As part of her
review, she conducted some interviews jointly with the investigator. She also
had sight of some of the interview transcripts and the man’s medical records.
5. One of the Ombudsman’s Family Liaison Officers contacted the man’s family
to inform them of the investigation and give them the opportunity to raise any
questions about the care he received. The man’s next of kin wished to share
the following information about the care he received. I hope this reports
provides his family with a better understanding of the events leading to his
death.
• They had heard rumours that another prisoner had been “dishing out
tablets”.
• The man’s daughter had visited the prison and seen her father’s cell. She
asked to meet his cell mate, however this was not possible at the time due
to his ill health. The man’s cell mate was subsequently released earlier
from prison than expected and before the investigator was able to speak
with him. The investigator attempted to contact his cell mate by letter and
telephone, but did not receive a response.
• When the man’s daughter visited the prison, she was surprised to see a
carpet runner and vase of flowers in her father’s cell. She believed the
prison may have been trying to hide something. The prison explained to
the investigator that the carpet was placed on the floor so that his family
did not see marks left as a result of the resuscitation attempt.
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• His brother said the man was rarely ill and never went to the doctor. He
therefore felt something must have been very wrong for healthcare staff to
have become involved. His brother was also concerned about the time it
took for staff to respond to his brother and questioned why this was.
6. Having received a copy of the draft report, the man’s brother commented
upon the time lapse that had occurred between his ill health being reported
and the staff responding to this and his feeling that this could have been
quicker. The man’s daughter, who also was provided with a copy of the draft
report, had made no further comments on its content at the time of issuing this
final version of the report.
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HMP LINCOLN
7. HMP Lincoln is a category B local adult male prison. Built in 1872, it receives
prisoners remanded from courts across the East Midlands. It also receives
serving prisoners transferred from other establishments, and has the capacity
to hold a maximum of 738.
8. There are four main residential units. A wing incorporates the First Night
Centre (FNC) and holds prisoners on induction and those participating in
detoxification programmes. Prisoners new to Lincoln are usually allocated to
A wing/First Night Centre. B wing holds sentenced and convicted prisoners,
and C wing holds remand and convicted prisoners. D wing is the segregation
unit, E wing is designated for vulnerable prisoners and J wing has
accommodation for prisoners participating in short duration drug treatment
programmes. The healthcare centre has in-patient accommodation.
Her Majesty’s Chief Inspector of Prisons’ report
9. HM Chief Inspector of Prisons carried out an announced inspection of HMP
Lincoln from 3 to 7 December 2007. With regard to new prisoners, the Chief
Inspector commented as follows:
“Fortunately caring staff – well supported by prison Insiders [prisoners
trained to provide information for newly-arrived prisoners] – made good
efforts to help prisoners through their difficult early days and a new first
night centre had just opened. Suicide and self-harm arrangements were
sound, as was clinical support for detoxification.”
10. The Chief Inspector noted that not all staff had been given training in
resuscitation in the previous 12 months and recommended that annual
training be implemented. She also found no evidence that resuscitation
equipment was checked regularly.
Independent Monitoring Board (IMB)
11. An IMB is appointed to each prison by the Secretary of State for Justice. Its
members are independent of the Prison Service and the prison’s
management team. Each IMB is required to produce an annual report to the
Secretary of State about the prison, highlighting good practice and any areas
of concern.
12. The IMB’s latest report covers the period 1 February 2008 to 31 January
2009. The Board noted that “Drugs and mobile phones continue to enter the
prison but the proactive regime has resulted in a significant number of finds”.
When referring to safer custody, the Board noted that there were two deaths
during the reporting year and 195 reported incidents of self harm. The IMB
said that the Listeners scheme was well used and there was a well regulated
violence reduction policy.
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Assessment, Care in Custody and Teamwork (ACCT)
13. ACCT has been introduced at all prisons to monitor and support prisoners
assessed as at risk of suicide or self harm. Once placed on ACCT, the
prisoner is observed at intervals determined by their perceived level of risk.
The observations continue during the day and the night.
14. Amongst other things, the ACCT guidance states that prisoners should be
cared for in a safe environment. It is for the case review team to decide the
most appropriate place to locate an individual prisoner within a prison.
Emergency code and medical bags
15. Lincoln operates a two code emergency system to help staff alert their
colleagues through the radio network. Code 1 indicates a life threatening
emergency (for example, heart attack or hanging). Code 2 indicates a non life
threatening act of self-harm.
16. When a Code 1 is used, it is broadcasted to healthcare as “Hotel 1” and
healthcare staff must attend with their blue and orange emergency bags.
Amongst other equipment, the bags contains observation equipment, a blood
pressure machine, pulse meter, minor dressings, oxygen masks, ambi-bag (to
assist with breathing), and some emergency medication such as adrenaline.
Other equipment brought to a Code 1 emergency includes an oxygen cylinder
and a defibrillator (which monitors a heart’s activity).
Incentives and Earned Privileges (IEP)
17. The IEP scheme was introduced in 1996 to encourage and reward good
behaviour by prisoners. There are three levels: Basic, Standard and
Enhanced. Incentives include access to in-cell television, more private cash
to spend, being able to wear their own clothes, more time out of cell and
access to extra and enhanced visits. Each prison sets its own criteria to
obtain each level.
Personal officer scheme
18. A personal officer is a prisoner’s first port of call if they have any questions,
complaints or need any advice. On C wing, prisoners are assigned a primary
and secondary personal officer. The secondary personal officer covers when
the primary personal officer is absent.
Reception and induction
19. A Cell Sharing Risk Assessment (CSRA) is opened by a reception officer who
completes the basic details. Reception staff do not have access to a
prisoner’s past records and so the prisoner is the main source of information.
The form is handed to the First Night Centre staff where a confidential
interview is conducted. The document is then passed to healthcare staff. The
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CSRA is intended to provide consistent and continuing risk assessment
regarding sharing cells.
20. The initial healthcare screen concentrates on the prisoner’s immediate well-
being, their mental health, risk of self harm or suicide and any drug or alcohol
withdrawal or detoxification issues.
21. All new prisoners are located on the induction wing. Prisoners are asked
about any immediate concerns, such as disability, their offence and general
well being. The induction includes a further assessment, medical screening,
and input from the education and offender management units. Prisoners are
given a new reception pack, telephone pin numbers and visiting arrangements
are explained.
Sealed key pouch
22. Sealed key pouches containing a cell key are distributed to all night staff
patrolling units holding prisoners. They are to be used to gain entry into cells
in an emergency (at night) to attend to a prisoner whose life is in danger. On
discovering a life threatening incident, staff must raise the alarm by contacting
the Control Room. The night patrol officer must decide whether aid is
required immediately, or whether any delay may result in a very serious harm
or death. If the latter is the case, the officer should break open the sealed
pouch and use the key to open and enter the cell.
Police investigations of deaths in custody
23. With all deaths in prison custody, the police are notified by the prison as soon
as the death has been discovered. In the first instance, the police treat the
area where the person is found as a crime scene and, as part of their
investigation, note the names of everyone involved and those who have been
in contact with the body. Additionally, they note the identity of all those
entering and leaving the cordoned area. It is only when the police are
satisfied that the death is not suspicious that the Ombudsman’s investigators
begin their own investigation.
Previous deaths in HMP Lincoln
24. Since the Ombudsman assumed responsibility for investigating all deaths in
prisons in 2004, 13 deaths have been investigated at Lincoln. Of these, 11
were self-inflicted and two were the result of natural causes. Of particular
relevance to the current investigation are the deaths of two prisoners in
December 2007 and February 2008. As a result of both investigations, the
Ombudsman made recommendations relating to first aid training at Lincoln.
This is a concern that I return to in this report and which the Inspectorate has
also highlighted previously.
9
KEY FINDINGS
25. The man was arrested for a serious offence committed in March 2008. On 18
August, Nottingham Crown Court sentenced him to 15 months imprisonment.
He commenced his sentence at HMP Lincoln.
26. On 9 October, the man transferred to HMP Ranby where he spent five months
before being released in February 2009. Two months later (on 18 April), the
man was recalled to prison because he had breached conditions on his
licence. He was arrested by the police and returned to Lincoln arriving at
around 1.10pm.
27. He went through the normal prison reception process. The Prisoner Escort
Record (PER), which accompanied him from the police, noted that he had no
known risks. Reception staff completed the cell sharing risk assessment
(which decides whether a prisoner is a risk to others he may share a cell with)
and noted that he was a “Low” risk. The cell sharing risk assessment (CSRA)
noted that he had no alcohol or drug problems and was a smoker. Staff noted
on the front of his wing history sheet “staff be aware licence revoke increased
risk of self harm”.
28. As part of his assessment, the man was interviewed by a member of the
healthcare team. No concerns, including any relating to harming himself or
suicide, were noted.
29. He was duly located onto A wing (cell A1 -13) to commence his prison
induction, which he received over the next few days. No concerns were
raised by staff as he settled into the prison regime.
30. Having completed his induction, the man was moved onto C wing on 21 April.
He was placed in a double cell with another prisoner. His CSRA remained
“Low” and no concerns were noted by staff. On 23 May his personal officer
met with him. His personal officer told the investigator that he noted the
man’s wing history sheet to the effect of “He remains quiet and polite works in
textiles no concerns”.
31. On 26 May, the man was seen by the healthcare nurse as a result of a
complaint of headaches. He was examined and said that he had drunk ten
pints of beer a day for 30 years. His blood pressure was considered normal
and he was prescribed paracetamol, ibuprofen and thiamine.
32. The man had also been appointed a second personal officer who knew him
from his previous sentence. His second personal officer told the investigator
that he met the man on 1, 14 and 28 June and noted in his wing history sheet
that he had no concerns about him.
33. The officer described him as someone who had a good rapport with staff and
prisoners. He had settled well on the wing and was not afraid to ask for
anything he needed or to raise concerns he might have.
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34. During their last meeting on 28 June, the man asked his second personal
officer if it would be possible for him to speak to his daughter, who was in
custody in another prison. This was subsequently arranged and staff
facilitated an inter-prison telephone call to his daughter on 2 July.
35. His first personal officer described him as “always polite and whose mood was
generally jovial”. The man had submitted an application for enhanced status
under the Incentives and Earned Privileges (IEP) scheme on 8 July, which
was fully supported by his first personal officer. (At the time of the man’s
death, his enhanced IEP had not been approved.)
36. The man was aware that he would have to undertake a drugs test before
enhanced status could be approved. He told his first personal officer that he
did not take drugs, although he had been a drinker in the past. The officer
said that he came into contact with him fairly often and had seen no reason to
believe he was taking any drugs. It was also around this time that he asked to
share a cell with another prisoner. This was later risk assessed and
approved.
37. The man’s first personal officer last saw the man around the beginning of
August after which he took annual leave and changed his duties. He had no
concerns about him.
38. Around 3 August a seconded probation officer interviewed the man in
response to his application to see someone from the probation unit.
39. At interview with the investigator the seconded probation officer said that the
man was working in the textiles workshop when he went to see him. During
their discussions the seconded probation officer said that he there was
nothing in the man’s demeanour which alerted him to any concerns. Their
meeting lasted about an hour and concerned the man’s uncertainty about how
the licence recall process worked. He had never been recalled to prison
before and explained the circumstances of his recall to the probation officer.
40. The man was aggrieved at what he perceived to be a poor level of service
that he received from the Probation Service in the community. He said he
had reported to the Probation Office around five times and was seen by a
different probation officer on each occasion. In all, he said his five visits
amounted to about 15 minutes at the office. The probation staff told him that
as he had no drug or alcohol related problems and was not required to attend
any rehabilitation programmes to address his offending behaviour, there was
little that could be done with him. He said that he subsequently obtained
employment and accommodation but did not notify the probation office. He
then failed to attend the Probation Office on a number of occasions which led
to his recall to prison.
11
Events on Sunday 16 August
41. Until this time, no concerns had been raised about the man who died. He had
shared a cell (number C2 – 17) with another prisoner that he had requested
for around five weeks. During this time, his cell mate said (in his police
statement) that the man had taken Subutex (by snorting it) around once a
week and occasionally smoked cannabis.
42. The man’s cell mate said that he and the man woke up around 8.30am on 16
August. They had some coffee and talked until about 9.30am, when their cell
was unlocked. They proceeded to obtain their canteen, which included
buying tobacco. Having returned to their cell, the man later went out on
exercise before returning for the lunch time break. Sometime during the
morning, the man’s cell mate said that another prisoner had come to their cell
and offered the man some cannabis. Both prisoners collected their lunch,
returned to their cell and watched television for the afternoon.
43. At sometime between 2.15pm and 3.15pm, the cells were unlocked and
prisoners were allowed a period of association (time out of cell). The man’s
cell mate said that during this time, another prisoner came to their cell and
offered the man some Subutex, which he accepted in exchange for tobacco.
44. Following the period of association and the evening meal, all cells were
locked again around 5.00pm. Both prisoners resumed watching the
television. The man’s cell mate said that it was very soon after this that the
man snorted some Subutex and rolled a cannabis cigarette. He offered some
to his cell mate but he refused.
45. An hour later, the man said that the drugs had started to have an effect on
him. As he got up from sitting on the bottom bunk, he became unsteady on
his feet and eventually fell over. His cell mate said he repeatedly asked if he
was okay. The man responded and said he “would be alright” and that his cell
mate should leave him alone.
46. Having returned to his bed to lie down, his cell mate said he could hear the
man’s breathing becoming louder. Shortly afterwards, the man got up and
tried to walk around the cell. His cell mate repeated to the man that he
thought something was wrong with him and decided to alert staff by pressing
the cell alarm bell.
47. An Operation Support Grade (OSG) arrived for his night duty shift at around
7.05pm and received a briefing from the officer in charge. At interview he told
the investigator that there were 186 prisoners on C wing. He carried out a roll
check, and checked all locks and bolts on the wing, which included checking J
wing’s 15 prisoners. He had no concerns as a result of these checks. The
OSG then began his normal duties which include pegging on the landing
(walking the wing from one end to the other, using an electronic pegging
device to record his movements), every 30 minutes, answering cell bells and
checking ACCT and escape list prisoners.
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48. At approximately 7.55pm, The OSG said he responded to a cell bell alarm
from C2-17, the man’s cell. (It is recorded on the prison electronic cell bell
recording system as being pressed at 7.59pm and responded to 53 seconds
later). He opened the cell observation flap to see the man’s cell mate at the
door and the man standing by his bed. The man turned around and looked to
be standing casually with his arm on the top bunk. Although he appeared to
look fine, he said he “could do with some air”. The man’s cell mate said in his
police statement that the man could not breathe properly. He repeated the
words on his behalf and added that a doctor was needed.
49. The OSG described the evening as hot and advised the cell mate to fully open
the cell window. The cell mate told the OSG that the man had taken Subutex.
On learning this information, the OSG said he told the man to lie down if he
needed to and he would contact the healthcare centre. The OSG did not
suggest that the cell mate referred to the man having breathing difficulties or
needing a doctor in either his police statement or in his interview with the
investigator.
50. The OSG went to the wing office and telephoned the healthcare centre. The
telephone was answered by a healthcare support worker (HSW). He told the
HSW that the man was in his cell, said he needed some air and had
apparently taken Subutex. The HSW did not ask for any further details about
the man’s condition. The OSG continued his duties of patrolling the landing
and answering any cell bells that went off on C and J wings, expecting that
someone from healthcare would deal with the man soon.
51. At interview with the investigator, one of the Registered General Nurse’s
(RGN) said that he normally worked nights in the prison. He was assisted by
an HSW who was not medically qualified. Although he was not rostered to be
on duty this night, he was asked to work the shift so that another RGN who
was rostered to work could shadow him because it was her first night duty
shift.
52. The RGN arrived at the prison that evening around 7.45pm. (His official hours
of work were 8.45pm until 7.45am.) As routine, the night duty staff received a
handover from the evening duty (ED) staff whose shifts normally end at
8.45pm. The handover comprises of information on all the individual
prisoners that were in healthcare, an update on any particular events that had
occurred during the day, and a general discussion about other issues such as
the distribution of medication that might be required during the evening and
night. Once the handover is completed, it is normal for the ED staff to finish
their shift.
53. The ED staff on duty were the HSW who answered the telephone in
healthcare and a RGN. During their handover talk to the night shift RGN, a
telephone call was received in the healthcare centre which was answered by
the HSW. The RGN told the investigator that the telephone was located
across the room so he did not hear any of the conversation between the caller
and the HSW. The HSW however returned and said that she had been
13
informed that a prisoner on C wing had taken Subutex and was not feeling
very well. The RGN said he told her “don’t worry about it I’ll sort it”. He told
the investigator that there was no indication that this was an emergency.
Their handover meeting concluded soon afterwards and the HSW and the
evening duty RGN left the prison.
54. Within minutes of the ED staff leaving the healthcare centre, the RGN said he
responded to a Hotel 1 emergency call to attend an incident on E wing. Over
on C wing, the OSG confirmed that he was aware of the emergency call
broadcast over the radio.
55. The RGN immediately went downstairs into the treatment room and collected
the grab bag (a medical bag containing dressings, suturing and other
equipment). He proceeded to the gate of A wing which was locked.
Healthcare staff do not carry keys at night and so he returned to the office to
ring for an officer to open the gates. However, as he was doing this, the HSW
arrived in the healthcare centre to start her night duty. As she had been
escorted to the unit by an officer, the same officer then led the RGN and HSW
to E wing.
56. The RGN said the prisoner had had an epileptic fit and fallen out of his bed.
The prisoner was conscious but appeared to have incurred a serious head
injury with blood over his bed. Having cleaned and attended to the prisoner’s
wound, the RGN said he spent a further ten to 15 minutes with the prisoner
talking about his medical health and how frequently he had fits.
57. The Night Orderly Officer (the officer in charge of the prison) told the
investigator that he began his duty at around 8.00pm. He also had attended
E wing as a result of the emergency. On leaving the cell, the RGN told the
night orderly officer that the prisoner was okay and, if any further problems
arose, he should be contacted. The RGN then made his way to the E wing
office to update the prisoner’s medical record before returning to the
healthcare centre.
58. At interview with the investigator, another OSG said that he had telephoned
the OSG that responded to the man’s cell bell on C wing about 8.15pm. The
OSG that responded to the cell bell told him that at about 8.00pm he had
contacted healthcare and reported the man’s condition. No one from
healthcare had yet come to the wing. The OSG that responded to the cell bell
was aware that healthcare had responded to an incident on E wing, and
expected the nurses to come straight from there to C wing, which was next
door.
59. The RGN that was shadowing arrived to start her shift on night duty around
8.30pm. The other RGN and HSW informed her that she had just missed an
incident where a prisoner had had an epileptic fit. After updating her on this
and other issues for the night, the RGN and HSW proceeded to carry out their
normal duties. The RGN that had just arrived shadowed the other RGN which
involved doing the medication round in the healthcare centre, followed by a
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visit to E wing, and then a visit to B wing to administer a controlled drug to a
prisoner. All the healthcare team on the night duty shift carry a radio.
60. In the cell mates police statement, he said that at about 9.00pm he got out of
bed to use the toilet. He realised that the man was in the same position as
when he had last checked him. He touched the man and discovered he was
cold. The cell mate also checked for a pulse but could not find one. He
immediately pressed the cell alarm bell and said the OSG responded a short
time afterwards.
61. At 9.50pm, the OSG said he again responded to a cell bell alarm from the
man’s cell. (It is recorded on the electronic cell bell record as being pressed
at 9.52pm and responded to 41 seconds later.) On this occasion, the cell
mate said he thought that the man was dead. The OSG said he immediately
tried to get a response from him (who he could see lying on his bed and
appeared to be asleep) by calling his name. He failed to respond. The cell
mate become very distressed. He was crying and then collapsed on the floor
behind the cell door.
62. The OSG failed to gain a response from the man. He was satisfied that the
situation was a genuine emergency and carried out a risk assessment to
consider entering the cell. The OSG immediately called for support from
another OSG, who had recently arrived on C wing. He then radioed through
to the Control Room to request the healthcare team and the orderly officer to
attend C wing.
63. The other OSG said that he was in the C wing tea room on the first landing.
He was aware that his colleague had gone to respond to a cell bell on the
second landing and within seconds heard him shouting “Are you alright mate,
move”. The OSG responded to shouts of assistance from his colleague and
ran to the man’s cell, arriving within five seconds. As he got there, his
colleague was in the process of the breaking the seal on his emergency key
pouch and alerting the Control Room to request healthcare and the orderly
officer.
64. As the two staff members pushed open the cell door it initially jammed as the
cell mate was behind it. They managed to push it wide enough to go inside
and found his cell mate still crying and in a hysterical state.
65. The OSG who responded to the cell bell went to attend to the man and
checked for any signs of life. No pulse could be found. On seeing this, the
other OSG also checked the man for signs of life but could not find any. The
OSG who responded to the cell bell immediately radioed through a Code 1
emergency, whilst the other OSG removed the cell mate from the cell.
66. The OSG who responded to the cell bell begun cardio pulmonary
resuscitation (CPR) on the man. Although he told the investigator that he had
not had any recent first aid training, he felt confident about carrying it out.
15
67. The night orderly officer said that at around 9.50pm, he received a message
via the Control Room to attend C wing with healthcare. Around 20 to 30
seconds later this message was changed to a “Code 1, Level 2, Charlie wing”.
Along with an officer, the night orderly officer quickly made his way to C wing,
arriving in about 30 seconds. When they arrived, the OSG who had recently
started his shift on C wing was on the landing trying to console the man’s cell
mate.
68. The night orderly officer looked into the man’s cell, and saw the OSG who
responded to the cell bell carrying out CPR on the man, who was lying on his
bed. Despite not having received any recent first aid training, he offered to
assist the OSG try to resuscitate the man. However the healthcare team
arrived at this point.
69. Like the night orderly officer, the two RGN’s had heard the initial request for
healthcare and the Orderly Officer to attend C wing. As the incident was not
initially broadcasted as an emergency, they intended to finish giving out a
controlled drug, before making their way to the incident on C wing. However,
within 30 seconds, an emergency Code 1, Hotel 1 was broadcast over the
radio net. The RGN who was first on duty immediately made his way to the C
wing whilst the RGN that was shadowing him locked away the controlled
drugs that they were dispensing. She then made her way to C wing.
70. The RGN who was first on duty arrived at the man’s cell seconds after the
night orderly officer. The night orderly officer contacted the Control Room and
requested an ambulance, recorded on the prison incident log as occurring at
9.54pm. When the RGN arrived in the man’s cell, along with the OSG who
responded to the cell bell and the night orderly officer, he placed the man on
the floor.
71. The RGN examined the man for any signs of life. He could find no pulse and
his eyes were dilated. He continued with CPR, doing chest compressions.
The HSW, who had also responded to the emergency call, arrived at the
man’s cell seconds after the RGN. She described the man as “cold to touch,
very cold”.
72. The HSW said that as the RGN had asked whether the RGN that was
shadowing him was coming with any of the emergency bags, she left the cell
to look out for her. As the RGN that was shadowing approached the cell, it
was obvious that she did not have the emergency bags in her possession.
The HSW asked where they were. The RGN that was shadowing said she
thought that as she had been locking up the medication room, the HSW would
have collected the emergency bag.
73. The HSW quickly ran to collect the emergency equipment from the E wing
treatment room, which is on the same landing as the C wing landing. She
returned back to the cell less than two minutes later with the orange
emergency bag. The officer that attended with the night orderly officer, who
was on the landing when the RGN who was shadowing arrived, assisted the
HSW by carrying the blue emergency bag, defibrillator and the oxygen.
16
74. The two RGN’s continued with CPR whilst they waited for the emergency
equipment. When it arrived, oxygen and the defibrillator were used to assess
and try to revive the man. Despite this, he still failed to show any signs of life.
The defibrillator advised not to shock, which indicated that the man’s heart
showed no electrical activity at that time.
75. The paramedics arrived at the prison at 9.56pm and were escorted through to
C wing cell by the officer that had attended with the night orderly officer. He
remained outside the cell and offered support to the cell mate, who was still in
a distressed state. The paramedics used their equipment and continued to try
and resuscitate the man but he remained unresponsive despite their efforts.
his death was subsequently declared at 10.32pm.
Events after the man’s death
76. On confirmation of the man’s death, the night orderly officer immediately
informed the duty Governor. The death in custody contingency plans were
instigated and the relevant agencies were informed of the man’s death. They
included contacting the prison care team and the IMB. The cell was sealed to
await the arrival of the police and the undertakers. The man’s cell mate was
placed on ACCT, taken to the healthcare centre and offered further support.
77. A hot de-brief meeting (held immediately after a serious incident) was
conducted by the Governor. Staff were given the opportunity to discuss the
events of the night and further support was given. The care team offered
support to staff. Throughout the remainder of the night, the night orderly
officer said he made frequent visits to all the staff involved in the attempt to
resuscitate the man who died, to ensure they were okay.
78. A family liaison officer was appointed and she immediately attended the
prison arriving around 11.30pm. She checked the man’s prison records and
confirmed his next of kin details and that they were located in
Nottinghamshire. Following discussions with the duty governor and the
police, the decision was made that it would be more appropriate for
Nottinghamshire Police to notify his next of kin of his death. This was
subsequently done around 8.00am the next day.
79. The prison’s family liaison officer spoke with members of the man’s family
throughout the morning and provided further information about his death. The
family were invited to visit the prison and provided with all the necessary
contact numbers, including that of the coroner. In line with prison procedures,
they were also offered financial assistance towards the funeral.
80. During the day on 17 August, all prisoners on an open ACCT were reviewed
including the man’s cell mate. From prison security intelligence and
subsequent police investigations, two other prisoners were later arrested and
charged with supplying drugs to the man who died.
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Post mortem
81. The post mortem report confirmed that the cause of the man’s death was
coronary artery disease. The report comments that coronary artery disease is
a known cause of sudden death and its presence was consistent with the
symptoms suffered by him prior to his death. Rapid medical intervention is
crucial to improve the outcome in cases of coronary thrombosis. In this case
no fresh thrombus was identified and death may have resulted from a fatal
cardiac arrhythmia. As such, the pathologist has reported that it is not
possible to say whether earlier medical intervention would have made a
difference to the outcome.
82. The toxicological analysis confirmed the presence of traces of buprenorphine,
which is consistent with the information provided that the man had taken
Subutex prior to his death. (Subutex contains buprenorphine.) The post
mortem report concludes that whilst Subutex has been known to produce side
effects such as changes in blood pressure and heart rate which may have the
potential to precipitate a cardiac event, it is not possible to say whether this
was a contributory factor to his death.
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ISSUES
83. The clinical review makes seven recommendations. I refer in my report to
those which I believe are the most pertinent to my investigation, and have
made the Primary Care Trust aware of the remainder.
Assessing the man’s condition
84. The OSG who responded to the cell bell contacted healthcare by telephone
and reported that the man had taken Subutex and was unwell. This
information was received by the HSW and passed on verbally to the nurse
who was on duty for the night and who was receiving a “handover” at the time
of the call. Very soon after this limited piece of information was passed over
the nurse was called away to an emergency on another wing. The
information about the man appears to have been forgotten.
85. At the time, the man’s illness was thought to be because he had taken
Subutex. His symptoms and condition had not been medically assessed at
this stage. The OSG who responded to the cell bell was not medically trained
and there appeared to be no sense of urgency for the man to be seen by
healthcare staff. There was also no record of this telephone call. The HSW
did not recall being given, nor did she request, any details of the nature or
severity of his symptoms.
86. The clinical reviewer notes that if the man had received medical attention
when he complained of breathing difficulties, it is possible that his acute heart
problem and any rhythm abnormality would have been detected and
appropriate emergency care provided.
87. It is the usual practice within the Prison Service that prisoners with an acute
health problem at night are assessed by officers who pass this information to
healthcare staff. There is no formal system to gather information about the
healthcare needs of a prisoner with an acute medical problem. Responsibility
for assessing the urgency of a prisoners symptoms lies with healthcare and
not discipline staff.
88. At the time of this incident, there was no system in place to document the
handover of prisoners with health problems between staff shifts. I am pleased
to note that since the man’s death, the Primary Care Trust have introduced a
system whereby reports to healthcare are recorded for handover between
officers. The clinical reviewer, however, makes the following
recommendations to the Head of Healthcare, about reporting prisoner’s health
issues.
The process for assessing and communicating the details of prisoners
who develop acute health care problems should be completely reviewed.
There should be a system which allows assessment and documentation
of the nature of any acute medical complaint, including time of call,
19
presenting complaint, the effect that this complaint is having in terms of
breathing, circulation, conscious level and general condition.
There should be a triage or assessment system in place to enable
prisoners who develop acute, potentially life threatening problems to
receive prompt, skilled assistance within an equivalent time frame to the
999 emergency response provided by the Ambulance Service within the
community. Less urgent problems should be reviewed by the most
senior member of health care staff available to decide on the type and
speed of response.
First aid training
89. Three of the officers who responded to the emergency had not had recent first
aid training. I have previously recommended in investigations that first aid
training is provided for all staff in contact with prisoners. I suggest that basic
life support or first aid training should be reviewed for frontline staff to ensure
that their knowledge of resuscitation procedures is up to date. I acknowledge
however that it is doubtful that it would have made a difference in this case, as
healthcare staff arrived promptly.
The Governor should review the need for first aid or basic life support
training for staff on frontline duties.
Emergency response
90. The emergency response from healthcare staff was timely. The clinical
review noted that every effort was made to resuscitate the man. However,
when staff responded to the emergency Code 1 call, they did not bring a
defibrillator and the emergency bag which resulted in a minimal delay. The
clinical reviewer notes that because CPR was carried out during this time, it
was unlikely that the equipment would have made a difference to his chance
of survival. It is essential however that all necessary equipment is
immediately taken to a life threatening situation.
All emergency equipment should be brought to the scene as soon as a
Code 1 call is made.
Family concerns
91. When the man’s daughter visited the prison, she was surprised to see a
carpet runner and vase of flowers in her father’s cell. The prison explained to
the investigator that the carpet was placed on the floor to avoid the family
having to see marks left as a result of the resuscitation attempt. I am content
that this was done with the best of intentions, although I have suggested the
prison consider the impact of making such decisions without talking to the
family beforehand.
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Access to illegal drugs
92. I have come across the supply of unprescribed drugs in many investigations I
have conducted following the death of a prisoner. I am aware that the Prison
Service work hard to combat this illegal trade within their establishments and
Lincoln is no different. I am pleased therefore that Lincoln security
department and the police shared intelligence which resulted in prisoners
being charged with supplying drugs to the man who died.
Breaking the news of the man’s death to his family
93. In the supplementary guidance to chapter four of the Prison Service Order
2710 (entitled “Follow Up to Deaths in Custody”), prison governors are given
advice as to how news of a death should be broken to relatives. A
“recommended option” is given:
4.9 The family should be informed face to face as soon as possible after
the death. Wherever possible, this should be done by a dedicated Family
Liaison Officer working alongside the Chaplain, or Governor or most
senior individual available together with the Chaplain. No member of staff
should be deployed alone. The police should be told that the visit is to be
made and, if judged necessary, should be asked to escort the team or
remain nearby. If a dedicated Family Liaison Officer is available for
deployment, the duty governor can remain in charge at the scene. This
option is recommended because it is what families and agencies that work
closely with them say they prefer and expect; it shows that the death is
being taken seriously by the prison; and it may help prevent the case
running for many years at great cost. If face-to-face prison notification is
not possible, there should be swift face-to-face follow-up.”
94. Of the previous four reports I have issued concerning deaths in custody at
Lincoln, all have noted that news of the death was not broken to family
members by a member of prison staff. On three occasions, this was because
of information given by the police; the fourth was because of the distance from
the prison to the family’s home (a distance of 75 miles). While there may
have been good reasons for not visiting each family, I am concerned that
Lincoln have not followed (or thought they were in a position to follow) the
PSO’s recommended option on so many occasions. Given that, once again,
the news of a death at Lincoln was not broken by staff from the prison, I feel
that it is appropriate that the Governor examines FLO procedures at Lincoln
and assures himself that staff are confident about undertaking this crucial role.
The Governor should assure himself that the provisions of PSO 2710
are followed when breaking bad news to families, and that the
appointed staff are confident about the role.
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CONCLUSION
95. The man who died had been recalled to prison after breaching the terms of an
earlier licence. On arriving at Lincoln, he told staff that he had no health
problems. During his time in custody, he gave little concern to staff at Lincoln.
96. On the evening of 16 August 2009, he used both Subutex and cannabis.
Shortly afterwards, he told his cell mate that he felt unwell. His cell mate
alerted staff who, in turn, informed healthcare staff. Unfortunately, it seems
that, because of a staff handover, no one from healthcare visited him at this
time. The clinical reviewer believes that had assistance been provided to him
at this time, his chances of survival would have been much improved.
97. A little later, the man’s cell mate found him apparently dead. Although
resuscitation was attempted, it was unsuccessful and he was pronounced
dead at 10.32pm.
98. This investigation has found that systems in healthcare need to be reviewed
so that information is passed effectively between staff. Other
recommendations have been made concerning first aid training for frontline
staff, and about visiting families to break bad news.
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RECOMMENDATIONS
To the Head of Healthcare:
1. The process for assessing and communicating the details of prisoners who
develop acute health care problems should be completely reviewed.
The Prison Service has accepted this recommendation
2. There should be a system which allows assessment and documentation of the
nature of any acute medical complaint, including time of call, presenting
complaint, the effect that this complaint is having in terms of breathing,
circulation, conscious level and general condition.
The Prison Service has accepted this recommendation
3. There should be a triage or assessment system in place to enable prisoners
who develop acute, potentially life threatening problems to receive prompt,
skilled assistance within an equivalent time frame to the 999 emergency
response provided by the Ambulance Service within the community. Less
urgent problems should be reviewed by the most senior member of health care
staff available to decide on the type and speed of response.
The Prison Service has partially accepted this recommendation
4. All emergency equipment should be brought to the scene as soon as a Code 1
call is made.
The Prison Service has accepted this recommendation
To the Governor:
5. The Governor should review the need for first aid or basic life support training
for staff on frontline duties.
The Prison Service has accepted this recommendation
6. The Governor should assure himself that the provisions of PSO 2710 are
followed when breaking bad news to families, and that the appointed staff are
confident about the role.
The Prison Service has partially accepted this recommendation
23