Individual at Wayland

Investigation into the circumstances surrounding the
death of a man in October 2008,
after his release from HMP Wayland
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
This is the report of an investigation into the death of a man. He was released from
HMP Wayland on 6 October 2008 and was found dead, in his home, at about
12.15am the next day after taking drugs. He was 32 years old when he died.
This investigation has been undertaken under the Ombudsman’s discretionary
powers to investigate deaths which follow release from prison. It was decided to
investigate in this case to ensure that the man was given proper care whilst in
custody and was fully prepared for his release. I apologise for the delay in issuing
the report. This was caused by a delay in the police investigation and in the writing
of this report.
I would like to add my personal condolences to the man’s family, friends and
everyone affected by his death.
This investigation was undertaken by an investigator. I would like to thank the
prison’s Governor and his staff for their participation in the investigation process. A
clinical reviewer was identified by the NHS to undertake a review of the man’s
clinical care and I am grateful for her contribution to the investigation.
In the main, I believe that the man received a good level of care and understanding
from staff. Nevertheless, his death is an important reminder that however well
prepared prisoners are for release, for many it remains a difficult and dangerous
transition.
I make eight recommendations in this report.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman September 2010
2
CONTENTS
Summary
The Investigation process
HMP Wayland
Key Findings
Issues
Recommendations
3
SUMMARY
On 16 July 2007, the man was remanded into the custody of HMP Peterborough,
charged with burglary. Reception staff noted that he was using heroin,
benzodiazepines and crack cocaine, drinking 12-13 cans of lager daily and had
tested positive for cannabis. There was no history reported of him being at risk of
self harm or having any mental health difficulties. He had completed a previous
prison sentence some years before.
The man was sentenced to two years and six months for burglary on 21 August. He
was identified as a Prolific and Priority Offender because of the level of his offending
behaviour. He moved to HMP Highpoint on 13 September. It was noted that he
suffered from epilepsy, which was treated with clonazepam, and depression, treated
with mirtazapine.
He was transferred to HMP Wayland at the end of December 2007. Medical staff at
Highpoint contacted Wayland beforehand to provide a telephone summary of his
medical problems.
The man was released from Wayland on 6 October 2008, and met by a police officer
who was on secondment from the police to the Prolific and Priority Offender
Scheme, and a drug worker from a Drug Intervention Programme (DIP). He was
taken to his home by the police officer, after being allowed to go shopping alone in
Peterborough. While shopping, he had bought a can of lager, which he continued to
drink on the journey home.
Sometime in the afternoon of 6 October, it seems that he obtained an amount of
crack cocaine. He was found dead by his mother at approximately 12.15am.
My report includes eight recommendations, one of which is a repeat of an earlier
recommendation from the Ombudsman to the PCT and concerns how prisoners’
ability to take responsibility for their medication is assessed.
4
THE INVESTIGATION PROCESS
1. The investigation was opened at HMP Wayland on 15 October 2008, by one of
the Ombudsman’s investigators. He visited the prison and K Wing, where the
man lived. All documents relating to him were examined, including his medical
records. Notices were later issued informing staff and prisoners of the
investigation and inviting anyone with information to come forward. There were
no responses to these notices.
2. During the initial visit, the investigator met a number of staff including
managers, local branch representatives of the Prison Officers’ Association
(POA), and the Independent Monitoring Board (IMB). He subsequently visited
Wayland on 22 December to speak to the Governor and staff. Four staff were
interviewed. These included two officers, the clinical lead and a Counselling
Assessment Referral Advice Throughcare (CARATS) worker.
3. The investigator also interviewed several members of the Prolific and Priority
Offender Scheme. These included the police officer and the drug worker, who
met him on his release from Wayland.
4. Cambridgeshire Constabulary also conducted an investigation into the
involvement of some of their officers. This report has been made available to
the man’s family.
5. A clinical review of the man’s health needs and the care he received at
Wayland was commissioned from the NHS (formerly the Primary Care Trust).
The review was conducted by a clinical reviewer.
6. The investigator and one of the Ombudsman’s Family Liaison Officers met the
man’s family during the investigation. This gave them the opportunity to
discuss the purpose of the investigation and to raise any questions or concerns
they would like explored and addressed. The family raised a number of
concerns regarding his care in and after his release from prison. In particular,
they raised the following issues, which I hope this investigation goes some way
to address.
• Whether his medical and prescription history had been transferred to each
prison he moved to.
• He was released from prison with a high volume of prescribed medication.
The family asked whether he should have been, particularly as they believed
he had been on “suicide watch” at this time. They asked why they were not
been informed of the amount of medication he had in his possession.
• His family questioned whether the decision to allow him to drink alcohol on
his way home, at a time when he was accompanied by probation and police
staff, was appropriate.
5
• When he arrived home, his mother saw that he had an injury on his finger, a
cut to his wrist and scarring on his face. She wanted to know how they had
occurred.
• Why the Probation Service had not intervened (given their belief that he was
not fit to be interviewed) when he attended their offices on the day of his
release
• The lack of contact with the family from the Probation Service after his
death.
7. An Assistant Ombudsman and the Family Liaison Officer visited the man’s
family on 22 March 2010 to discuss the findings of the draft report. The family
remained concerned that he did not receive medication while in the segregation
unit. They were also concerned that a wound he sustained was not treated
appropriately and that the incidents that led to this and other injuries were not
adequately recorded. I have examined the prescription charts for the period he
was in the segregation unit and I am content that he was given the appropriate
medication while there. Paragraph 73 of my report details the treatment he
received for the wound on his wrist which was reopened following a fall during
exercise. A nurse explained that the wound was treated and dressed, but it
was not appropriate to re-stitch the wound because of the risk of infection and
possible scarring. I can also confirm from the records I have seen, the interview
transcripts and, above all, the clinical review, it is my opinion that the injuries he
sustained were logged and explained appropriately.
8. The man’s family were also concerned that he was released with various types
of prescribed medication, given his history of drug misuse, and that the police
officer was not made aware of this. The family also questioned why he was
issued with his discharge medication on 9 September, nine days prior to his
release. In her interview with my investigator, Nurse A explained she would
never speak to anyone, other than the patient, about medication for reasons of
medical confidentiality. She also explained that she notified the GP when it
transpired he had received his discharge medication over a week prior to his
release although it is not clear what was done about this.
9. The man’s family remained concerned that the Probation Service failed in its
duty of care towards him in ensuring his safe return home following his release
from prison. The family further reiterated the distress caused by the way they
feel they were treated by probation staff following his death and welcomed the
recommendation made to improve practices as a result.
10. In response to the issuing of the draft report, I have received comments from
the NHS on the recommendations which relate to HMP Highpoint, at which they
commission healthcare services. I also received feedback from the Director of
HMP Peterborough. NOMS identified no factual accuracies on the report, and
have not commented on the recommendations.
6
HMP WAYLAND
11. HMP Wayland is a category C closed training prison for adult males, situated
near Thetford in Norfolk. It holds a maximum of 1,017 prisoners. The prison
was built in 1985, and has been extended three times since. The prison now
has 13 living units (known as wings).
12. Since the Ombudsman took responsibility for investigating all deaths in custody
in 2004, there have been three previous deaths. In two of these investigations,
there have been issues concerning the standard of medical records, and in one
of the investigations, a recommendation was made. In the second
investigation, another recommendation was made that there should be a formal
process established for assessing the suitability for the prisoner to hold “in
possession” medication. These issues have been raised again during the
course of this investigation.
13. HM Chief Inspector of Prisons carried out an announced inspection of Wayland
in June 2006. Provision of healthcare services was praised as being of “high
level”. A selection of medical records were seen and found to be
comprehensive and appropriate. There was, however, a recommendation that
the secondary dispensing of medication should cease.
14. Each prison has an Independent Monitoring Board (IMB). The role of the IMB is
to ensure that prisoners are treated humanely and that there are appropriate
and adequate programmes available to prepare them for their release. They
also report any concerns to the Secretary of State, and produce an annual
report about the establishment.
15. The most recent IMB report for Wayland, for 2007/8, is critical of the NHS for
failing to meet the mental health needs of prisoners. The IMB reported that the
healthcare provision did not meet their expectations, particularly in the light of
an expanding prison population. They also noted that inadequate funding for
the integrated drug treatment system had “condemned prisoners to a
dependency on methadone”.
Personal Officers
16. The role of the personal officer is to build up and maintain a positive relationship
with prisoners. They are first port of call for questions, complaints or advice.
Assessment, Care in Custody and Teamwork (ACCT)
17. ACCT has been introduced at all prisons as a documented process 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.
18. Each prisoner is assessed within 24 hours and then reviewed further at
intervals decided on an individual basis. The ACCT guidance says that, to be
7
effective, the review should involve the people who know the person at risk or
are involved in their care.
Counselling Assessment Referral Advice Throughcare (CARATS)
19. Prisoners with a history of drug or alcohol abuse can be referred to CARATS
workers. Following a full assessment, the worker has a range of options to help
meet the individual’s needs. These include arranging for drug treatment, and
counselling work to take place to help them reduce their drug intake or prevent
them starting to take drugs in the future. The 2006 HMCIP inspection report
described the CARATS team as being well integrated, with input into sentence
and release plans.
End of Custody Licence (ECL)
20. In June 2007, the Secretary of State for Justice introduced a new early release
scheme, to ease the population pressures on prisons. Prisoners eligible for
ECL are released up to 18 days earlier than they would normally have been
released. Prisoners released on ECL are required to observe the same licence
conditions as would have been applied had they been released normally.
(Prisoners released early on licence have to comply with the conditions or they
will be returned to prison to complete their sentence)
Distribution of medication
21. Medication is issued to prisoners in two ways. “In possession” medication is
held by the prisoner in their cell, and they are encouraged to take responsibility
for it. “In sight” medication is distributed on a dose by dose basis and must be
consumed immediately in the presence of healthcare staff.
Prison Addressing Substance Related Offending (PASRO)
22. This is an accredited cognitive behavioural group work programme designed to
address drug and alcohol dependence and related offending.
Prolific and Priority Offender Scheme (PPO)
23. This is a Government-led initiative which was launched in September 2004 to
target the most prolific and persistent offenders in local communities. The
scheme is managed by multi-agency partnerships, including the police and
probation services. The PPO scheme has three strands – to prevent and deter
potential offenders from committing crime, to tackle the offending behaviour
of those individuals locally identified as committing most crime and causing
most harm to their communities, and to help rehabilitate and resettle offenders.
8
KEY FINDINGS
The man’s arrival at HMP Peterborough
24. On 16 July 2007, the man was received on remand at HMP Peterborough,
charged with burglary. He went through the normal reception procedure where
it was noted that he had been using heroin, benzodiazepines (tranquilisers) and
crack cocaine, and was drinking 12-13 cans of lager daily. A urine test
confirmed this. No medication was prescribed for his withdrawal from opiates
or alcohol and no clinical observations were recorded. There is no record that
he reported any history of harming himself or of having any mental health
issues. He completed a local Peterborough form, ‘Contacting Your GP’, and
registered himself as being of no fixed abode.
25. The next day, the man told the prison doctor (who is not named in the clinical
records), that he was taking clonazepam (a drug used to treat seizures), and
admitted to being dependent on alcohol. Again, no treatment for the withdrawal
of alcohol was documented and there was no record of why he was taking
clonazepam.
26. The man claimed to have had a seizure on the evening of 21 July, although this
was not reported to healthcare staff. Later that night, he was seen by a Nursing
Sister as he was suffering from a headache. He informed her of the seizure
and that he should be taking 2mg of clonazepam per day, and not 1mg (as he
had done since arriving at Peterborough). She told him that she would ensure
that the day staff were aware of his concerns.
27. The man’s father had died on 5 July, and he was not allowed to attend his
funeral. He was distressed about this, and saw a doctor on 23 July. He was
prescribed 30mg of mirtazapine (used to treat major depressive disorders) and
7.5mg of zopiclone (used for short term treatment of insomnia) daily.
28. On 25 July, the man complained of earache and was prescribed an antibiotic,
azithromycin (this was later changed to amoxicillin).
29. A night nurse reported that the man had a seizure on 2 August. It is not clear if
the nurse took any action, aside from telling the day staff. The following
morning (3 August), Nurse B saw him in his cell. He was awake but feeling
weak. She advised him to see the doctor, which he did later that afternoon.
Although 6mg of clonazepam was prescribed to be taken daily, the doctor noted
that “it is still to be confirmed of the reality of fits”.
30. The man cut his left forearm with a razor blade on 22 August. An ACCT
document was opened as he was still feeling upset about his father’s death.
The ACCT was closed on 29 August as he felt better and had no more thoughts
of harming himself.
31. On 12 September, a prison doctor made an entry in the man’s medical record
that he had been discovered hiding the clonazepam and amitriptillin in his cell.
9
It had still not been confirmed that he was suffering from fits and so it was
decided to stop prescribing clonazepam from the end of that week.
The man’s transfer to HMP Highpoint
32. The man was transferred to Highpoint on 13 September. The reception
screening noted that he had epilepsy (treated with clonazepam) and depression
(treated with mirtazapine). From the Prescription and Administration Record
Card, it would appear that he continued to receive medication. It was also
noted that he had made attempts to harm himself at HMP Bedford in 2003 and
HMP Peterborough in 2007. He did not report having any current thoughts of
harming himself.
33. The man’s ongoing ear problems were also noted. However, he did not attend
any appointments until 5 December. A week later, he was prescribed antibiotic
ear drops.
34. On 10 December, a prison drug dog (trained to detect the presence of drugs)
indicated that a parcel sent to the man might contain drugs. The parcel was
searched and found to contain herbal cannabis. There is no suggestion on his
adjudication record that any action was taken following the incident.
35. Five days later, during an altercation with another prisoner, the man injured the
little finger on his right hand. However, he told staff that the injury was caused
when his finger was “trapped in a door”. In contrast, an entry in the Continuous
Clinical Record says that he injured his finger after a seizure. It is not clear
whether there is any connection between the incidents, and there is no entry on
his medical records that he had had a seizure.
36. On the morning of 21 December, the man suffered another suspected epileptic
fit, which was reported to healthcare staff by other prisoners. It was noted in
the Continuous Medical Record that he was already receiving clonazepam for
the condition. No further action was taken.
37. At approximately 11.05am that day (and after the seizure), the man and another
prisoner climbed on to the roof of one of the prison buildings and demanded an
immediate transfer. They climbed down at about 5.20pm. As a result of their
behaviour they were taken to the segregation unit.
38. The following day, the man commenced a “dirty protest” at 6.00pm, after
demanding to have hot water every two hours. The protest ended at 7.00am
the following morning (23 December). It was noted on the Prison Incident
Report that he may have been under the influence of drugs as his speech was
slurred. He was seen by healthcare staff on 22 and 23 December who did not
report any concerns.
39. On 24 December, and while still in the segregation unit, the man harmed
himself by making five superficial cuts to his left wrist, which did not require
stitches As a result, an ACCT form was opened. The ACCT form was
reviewed three days later, when he said he was in debt and wanted to be
10
transferred to another jail. It was also noted that the injury to his finger was
getting worse.
40. The man threatened to kill himself four days later, after his request for tobacco
was refused. He said that he was concerned about his mother who, he said,
had cancer. An ACCT review later that day concluded that his behaviour was
manipulative. He threatened to hang himself “before 6.00am” and said that he
had attempted to hang himself before. He also threatened to stop taking his
medication. He told the healthcare staff that in the past year, both his father
and 13 year old brother had died.
41. A further episode of self harm occurred on 29 December at 3.50pm when he cut
his left forearm. Initially, the man did not cooperate with the healthcare staff
who wanted to treat him saying that “he was going to a better place in the near
future” and had twice attempted suicide. He finally allowed healthcare staff to
attend to his injury at 5.35pm.
42. A little later (the time was not recorded), the man again threatened to kill himself
and the ACCT observations were increased to five times per hour. He harmed
himself again by cutting his right cheek after asking for the evening meal, which
he had earlier refused. These injuries were sufficiently severe for him to be
taken to hospital where they could be stitched.
43. As a consequence of the roof climb and his request for a transfer, the man
moved to Wayland on 31 December. An entry on his Continuous Clinical
Record said “Fit for transfer, has issues with his medication, states not strong
enough”. Staff at Highpoint telephoned their counterparts at Wayland and
updated them on his medical history.
The man’s transfer to Wayland
44. The man arrived at Wayland and went through the normal prison reception
process. During the reception interview with the nurse, he asked for co-
codamol (a pain killer) and said he was allergic to paracetamol. The reason for
the request was not recorded and it does not appear that he was given either
medication. It was noted that he suffered from epilepsy and had a fractured
right little finger. His current prescriptions of 2mg clonazepam and 30mg of
mirtazepine daily were noted. The ACCT document remained open.
45. The man’s ACCT document was closed on 3 January 2008. He was
considered to be “now settled at Wayland”.
46. On 24 January, the man was assessed by a CARATS worker. He told her that
(and in contrast to his reception interview at Peterborough) he never drank
alcohol because of his epilepsy, was employed as a delivery driver and had
been drug free for two and a half to three years. She also recorded on the
Comprehensive Substance Misuse Statement that he last used drugs almost
three years earlier when he smoked heroin, was now substance free and that
he “had never deliberately hurt himself”. He also said that he had a lot of
contact with his children.
11
47. The CARATS worker noted in her assessment that the man was currently
suffering from epilepsy and taking clonazepam. At interview with my
investigator, she said however that she was unaware that he was taking
prescribed medication. She said that, generally speaking, there would be a
heightened risk of overdose if he mixed alcohol and/or prescribed medication
with an illegal drug. A careplan was subsequently drawn up for him to address
the links between his substance use and offending.
48. Over the next few months, the man came into contact with medical staff on
several occasions. On 4 February, his ongoing problem with an ear infection
was noted. His injured finger was reviewed on 17 March, and he was
prescribed 500mg of naproxen (an anti inflammatory drug). On 23 April, a
discussion took place with him concerning the possibility of amputating the tip of
his right little finger.
49. On 26 April, the man was taken to outside hospital after telling prison staff that
he had taken 50 paracetamol tablets. He refused to wait for the Accident and
Emergency clinician and was returned to Wayland without treatment. There is
no record of how he, who had said that he was allergic to paracetamol,
obtained these tablets. An ACCT document was opened on 27 April but was
closed the same day, after he admitted lying about the incident in order to
obtain other medication. An ACCT post closure review took place on 4 May
with no further issues or concerns noted.
50. Despite being taken to outside hospital and the incident being reported to
healthcare, there is no evidence that a Security Information Report (SIR) was
raised or his medication reviewed. The man refused to be examined or
screened by healthcare staff on his return to prison.
51. Surgery on the man’s finger was carried out without any complications on 2
May. The dressing was reviewed the following day, and there was no sign of
infection and he could move it easily. Another appointment was made for 15
May for sutures to be removed, but he did not attend.
52. The man did go to a healthcare appointment on 17 May. He had removed the
stitches from his finger by himself. The wound did not require a dressing and
he was asked to report any deterioration to staff.
53. On 3 July, the man went to an appointment with an Ear, Nose and Throat (ENT)
consultant for treatment of his ear infection. Cotton wool was removed from
one ear and microsuction was performed on the other and ointment applied.
Another appointment was to be arranged for a review.
54. The man started the PASRO course five days later, as arranged by the
CARATS worker. This course attempts to address the links between substance
use and offending, and he was also keen to obtain support whilst in custody
and after release to help him stop using drugs.
12
55. The man reported having a grand mal seizure at 10.30pm on 14 July, which he
said was the second in six months. (Grand mal seizures feature loss of
consciousness and violent muscle contractions and, while they can be caused
by low blood sugars or a stroke, most are caused by epilepsy.) It was not
witnessed by anyone else. He reported to healthcare feeling well, except for a
small cut to the bridge of his nose. Although he was told to make an application
to see the doctor, there is no record that he did.
56. On 17 July, the man again reported having a seizure. He was seen by a prison
doctor, who noted that he had been seen in the past by a neurologist and
treated with tegretol and epilim but that they had not stopped the seizures. His
misuse of medication was noted and the clonazepam was increased to 2mg
three times per day. The doctor suggested that he should see his community
doctor on release from prison, which was expected on 18 September.
57. Nurse A noted in the Patient Record on 26 July, that the man appeared to be
drowsy with slurred speech when he went to collect his medication that
afternoon. The information was passed to the Security Department using an
SIR. The Security Manager recommended that staff on his unit monitor and
search him. The Security Governor also recommended that a Mandatory Drug
Test should be carried out but there is nothing on his records to suggest that
any of these actions were carried out.
58. Also on 26 July, the man visited healthcare suffering from further pain in his left
ear. He was found to be suffering from a chronic inflammation with a creamy
discharge and was given co-codamol to relieve the pain.
59. On 29 July, Nurse A informed Security that the man had not swallowed his
medication and was being bullied to bring it back to the wing for other prisoners.
Another SIR was raised and brought to the attention of wing staff but again, no
action appears to have been taken.
60. The man was visited on 12 August by two Offender Managers with the
Probation Service. The purpose of their visit was to prepare him for his release
from prison. As he was registered as a priority and prolific offender, it was
necessary to ensure that a coordinated approach to his release was taken by all
agencies. He was notified subsequently in a letter dated 15 August, that he
would be released under ECL terms on 18 September.
61. On 28 August, the man received his PASRO report. He had missed four of the
20 sessions, one due to illness and three whilst in the Segregation Unit. The
report was otherwise positive. He took an active role in group discussions, his
assignments were completed to a high standard and he appeared to work well
in a group environment.
62. The next day, as part of his ongoing contact with the CARATs worker, the man
completed his release plan and discussed overdose and tolerance issues with
her. He signed the ‘Overdose & Tolerance Information Form’ to confirm this.
The CARATs worker later confirmed to my investigator that he had been given
13
verbal information that tolerance to drugs diminishes the longer the period when
they are not used.
63. Following SIRs that the man “was selling his sleepers [sleeping pills]” to another
prisoner, the Security Department recommended that his medication was
reviewed and that wing staff should be notified how may tablets he had, so that
they could check him regularly. There is no record of whether this was carried
out.
64. The man was issued with his discharge medication, clonazepam, on 9
September. However, at 4.30pm, he asked for a repeat prescription as he said
he had lost the original allocation. His request was refused. There is no record
to explain why the medication was given on 9 September, nine days before his
expected release date. There is also no record of whether he was given any
other medication, or whether Security had been informed or a cell search
carried out.
65. Eight days later, on 17 September, the man was notified that he had been
refused ECL. This was because he had escaped from lawful custody in 2004
and run away from police officers while handcuffed. The incident automatically
precluded him from ECL, and had only been identified on the statutory check
made two days before release.
66. In response to being refused early release, the man harmed himself at about
8.10pm by cutting his left wrist. Paramedics were called, arriving at 9.00pm,
and he was taken to hospital. He returned to Wayland at 1.00am and an ACCT
form was immediately opened.
67. A prison doctor reviewed the man’s medication on 19 September. He
recommended that the co-codamol (which was not working) be changed to
dihydrocodeine. Paracetemol was also issued, despite him previously saying
that he was allergic to it. He was also prescribed enough mirtazapine to last
until his new release date of 6 October.
68. On 21 September, the man was seen again by nursing staff trying to secrete his
clonazepam as it was being administered. There is no record, either within the
ACCT or his security documentation, that the information was communicated to
other departments. The ACCT form was closed the next day after he said that
he was looking forward to going home and caring for his mother. The closure
meeting was attended by three staff, including healthcare, and the man. An
ACCT post closure review took place on 29 September and no issues were
raised.
69. Healthcare staff reported that, on 25 September, the man had passed the
clonazepam to another prisoner and, so, the doctor had stopped his
prescription.
70. The next day, the man fell during the exercise period. He re-opened the wound
on his left wrist, which was later dressed by a nurse. Nurse A explained to the
investigator that his wound was dressed with an inadine dressing (which
14
contains the antibacterial agent iodine). It was not appropriate to re-stitch the
wound because of the risks of infection and possible scarring. The Accident
Form records that “there does not appear to have been any reason or cause for
him to fall and he has not stated that he slipped or tripped over anything”. It
was also noted that his medication should be reviewed because he had passed
it to another prisoner, but there is no record of what action was taken or
whether he saw a doctor.
71. The man reported that he had had a seizure on 28 September. Wing staff did
not consider it to be ‘real’, and there were no witnesses who could describe the
length and type of episode. The next day, 29 September, Nurse A recorded in
the Patient Record that he was threatening to sue because his clonazepam had
been stopped.
Events of 6 - 7 October
72. A Principal Officer (PO), who was the discharging officer, told the investigator
that the man’s discharge through reception on the morning of 6 October took
place as normal. He was identified as the correct prisoner for discharge, his
discharge licence was checked and the conditions were explained. He signed
the licence and was given a copy. He was given his property, his personal
money and discharge grant. He signed Section 21 of the Firearms Certificate
which prohibited him from possession of a firearm for five years. Staff checked
whether he had any complaints or there were any outstanding issues before
giving him his discharge medication in a sealed bag.
73. A doctor at Wayland was asked by the Coroner’s Officer to confirm what
medication the man was prescribed before his release. In a letter, dated 29
October 2008, he confirmed that he was prescribed: mirtazapine (30 mg once a
day), dihydrocodeine modified release tablets (120 mg twice a day),
paracetamol tablets (500 mg one or two four times a day) and clonazepam (two
mg tablets one in the morning and two in the evening). His medication was
given to him by prison staff, which is not normal practice.
74. Nurse A told my investigator that the doctor had prescribed a month’s supply of
medication. This is normal practice at Wayland, as there is no guarantee when
a prisoner will contact his doctor. However, because of the man’s history of
misuse and the nature of the medication he was prescribed, Nurse A decided to
discharge him with just one week’s supply.
75. On leaving the prison, the man was met by a police officer seconded to work
with the PPO scheme and a Case Manager with the Drug Intervention
Programme (DIP) Team. He was taken to the DIP team office to begin his
induction and take a urine test. He was unable to produce a urine sample.
76. After leaving the DIP office, the man asked the police officer to take him into
town as he wanted to buy a new pair of trainers. He was taken to the town
centre and allowed to shop on his own. About 15 minutes later, he returned to
the police officer with some shoes and a hooded top. He was drinking from a
can of lager. (His mother later told police officers that, during the visit to the
15
shops, her son committed a shoplifting offence and stole the hooded top.) The
police officer left him at his home at approximately 12.45pm, where he was met
by his mother and sister. The police officer left almost immediately. The man’s
mother thought that he was a probation officer.
77. The man’s mother said that her son’s appearance and actions suggested that
he had used drugs. She described him as very pale. Both his mother and
sister said he was very high spirited, excitable, giddy and slurring his words. He
assured them both that he was fine, but was very tired as he had not slept for
three days because of the excitement of coming home.
78. According to his mother, the man was due to go to an appointment with the
Probation Service at 4.00pm later that day (6 October). He left the house,
accompanied by her youngest daughter’s boyfriend, and returned at about
4.50pm, which was earlier than expected. His mother said that this was
because “they (probation staff) had refused to interview him in his current
state”. His sister had left the house and telephoned him after he had returned
home. She confirmed that, from the way he was speaking, “he was not with it”
and she said “he was behaving as if he had taken something”.
79. The man said he wanted to get some sleep and, after eating a small portion of a
sandwich, he appeared to fall asleep at about 7.30pm. His mother told my
investigator that it was not until about 12.00am -12.15am that she realised that
something was wrong and discovered that he had died. She told the police that
it was around 1.00am that she discovered him. Information provided to the
investigator indicates that an ambulance was called at 1.49am and arrived at
1.55am. The paramedics attempted cardio pulmonary resuscitation (CPR)
without success. He was pronounced dead at 2.16am. The police were called
at 2.26am and his mother told them that he had bought some crack cocaine
and had smoked it in the kitchen.
Events after the man’s death
80. The man’s mother said she tried to contact the probation officer to speak with
someone about what had happened. Despite telephoning and leaving
messages, she said she heard nothing further from the Probation Service.
81. The Probation Integrated Case Record shows that the man’s mother contacted
the Probation Office asking someone to contact her to discuss her son’s death.
The Offender Manager told my investigator that she telephoned the man’s
mother and that, although it was a difficult conversation, she believed that she
dealt with it sensitively. She was told by her senior managers that she should
take no further action and that the death would be dealt with by more senior
staff. The man’s Offender Supervisor told my investigator that she telephoned
his mother on 16 or 17 October.
Post mortem and toxicology examination
82. The post mortem and toxicology examination concluded that the cause of the
man’s death was an overdose of dihydrocodeine (an opiate based drug) and
16
ischaemic heart disease (a disease which reduces blood supply to the heart).
Urine samples detected levamisole, diltiazem and phenacetin, which are
markers of illicit cocaine use. Traces of cocaine were also found.
17
ISSUES RAISED IN THE INVESTIGATION
Clinical Care
83. A clinical review was commissioned from the NHS. A Prison Healthcare
Commissioner undertook the review. She reviewed the medical records and
interviewed one member of staff, Nurse A, the Clinical Team Leader at
Wayland. She makes ten recommendations in her report which are applicable
to all the prisons that cared for the man. I draw attention here to eight.
84. Throughout his period in custody, the man stated he was taking clonazepam.
However, no efforts were made at Peterborough, Highpoint or Wayland to
confirm that he actually suffered from epilepsy. The clinical reviewer points out
that clonazepam is not only an inappropriate long term medication for the
treatment of epilepsy, but its use is cautioned with patients with a history of drug
or alcohol abuse or depression. The man’s dosage of clonazepam was
increased on 3 August 2007. However, notes made in his medical record at
Peterborough indicated that healthcare staff were still not certain that he did
indeed suffer with epilepsy. The clinical reviewer makes the following
recommendation
Healthcare staff should evidence that they have attempted to contact
doctors and other service providers to ensure continuity of clinical care
between prison and the community. Contact should be made with the
home doctors for a medical history if it has not already been done by
previous prison.
85. During his reception screening at Peterborough, the man was noted as using
heroin, benzodiazepines, crack cocaine and drinking 12 – 13 cans of lager per
day. There is no evidence that he was prescribed any treatment to manage the
symptoms of either opiate or alcohol withdrawal he might experience. The
clinical reviewer has made the following recommendation to HMP
Peterborough, which I bring to the attention of the Head of Healthcare:
The Head of Healthcare at Peterborough should undertake a review of
policy and procedures for the management of substance misuse and
alcohol detoxification.
86. The provision of pain relief medication appears to have been an issue
throughout the man’s stay in custody and, other than his ongoing ear infection
and the injury to his little finger, no other source of pain was noted. Codeine-
based analgesia prescriptions were repeated without a review and no attempt
was made to seek advice about his pain management.
The Heads of Healthcare (at Peterborough, Highpoint and Wayland)
should review their medicines management processes including the
triggers for the management of inappropriate prescribing and agreement
what constitutes a “medication review”.
18
87. There are concerns about record keeping in Peterborough, Highpoint and
Wayland. At Peterborough, a comprehensive clinical history was not taken
when the man arrived in reception. At Highpoint, an unsigned entry in the
Continuous Clinical Record suggested that he had returned from hospital
although there was no reason recorded as to why he had gone. At Wayland, on
25 September, it was noted that his medication needed to be reviewed but
there is no record of what action was taken. On 3 October, a doctor restarted
his clonazepam, although no reason is recorded.
The Heads of Healthcare (at Peterborough, Highpoint and Wayland) and
Primary Care Trust providers should ensure there are systems in place to
undertake regular audits of clinical records to ensure that minimum
standards are met.
88. The clinical reviewer has commented that when the man was transferred from
Highpoint to Wayland, Highpoint staff provided Wayland staff with a verbal
handover of his medical history. This should be commended as good practice.
The Governor of Highpoint should commend its healthcare staff for
providing verbal assessments on the healthcare needs on transfer of
prisoners to other establishments.
89. There was some evidence to suggest that the man was trading and misusing
his own medication. He had allegedly taken 50 paracetamol tablets, for which
he was taken to outside hospital. There is, however, no evidence to suggest
the “in possession” risk assessment was ever reviewed. He claimed to be
allergic to paracetamol, but was, on several occasions, prescribed this
medication in combination with other medication. There is no evidence to
suggest that any allergies to paracetamol were investigated by healthcare staff.
The Heads of Healthcare (at Peterborough, Highpoint and Wayland)
should review “in possession” risk assessments whenever there is
evidence to suggest misuse.
90. In addition, on discharge, the man was given his medication at reception by a
prison officer. Officers do not have health care qualifications and so it is
reasonable to assume that they are unable to offer any advice to the prisoner
about the medication. (This is termed as secondary dispensing of medication.)
The Head of Healthcare in Wayland should undertake an urgent review of
prescribing practices and secondary dispensing of this nature should
cease immediately.
Treatment of physical injuries
91. The man’s mother asked why his face was scarred, and the tip of his finger
missing. The scar to his face is likely to have been as a result of the alleged fit
he suffered on 14 July. The tip of his finger was amputated in hospital after he
said it had been trapped in a door during a fight with another prisoner.
19
According to medical records, his finger healed well with no complications.
There are no entries on his medical record to indicate that he received any
injuries as a result of the fighting incidents that he was involved in.
Preparation for release
92. The CARATs worker told my investigator that the man was frequently warned
about the danger of using drugs in the community. He was told that any period
of abstinence would have substantially reduced his tolerance to illegal drugs.
He was advised that, to avoid the risk of overdose, he should not return to the
same level of drugs he had used before coming into custody. She also said
that prisoners were warned that drugs available in the community were likely to
be of a higher strength than those available in prison.
93. I am satisfied that the man knew the risks he would be taking should he return
to drug use on release.
94. The man’s mother was concerned that she did not know that he was being
released with a quantity of prescribed medication. At interview with my
investigator, the DIP Senior Practitioner said that the DIP team work is under
strict rules of confidentiality and do not contact the family as it would present as
a conflict of interest.
95. The DIP worker who met the man on his release said that she was aware that
he had medication in his possession as he showed it to her. He explained that
he had medication for epilepsy and opiate based pain killers (which is why he
was asked to provide a urine sample on his arrival at the DIP office in
Peterborough).
96. The man’s mother thought that the prison should have done more to consider
his individual circumstances before prescribing a week’s supply of medication,
particularly as he was coming home and would return to the care of the family
doctor. She believed that he was still on “suicide watch” at the time of his
release, which should have meant that he was given less medication.
97. Nurse A explained that, as there had been suspicions that the man was abusing
his medication, he had been discharged with one weeks, rather than a four
week, supply. She told my investigator that the approach taken by the prison is
the same as in the community. Patients are deemed to be responsible for any
medication prescribed by their community doctor.
98. Nurse A also said that it was not normal practice for prison or healthcare staff to
contact a prisoner’s family about the medication they were being discharged
with. Again, she explained that without the man’s consent, it would have been
a breach of medical confidentiality.
20
Transfer of medical records between prisons
99. The man’s mother was concerned whether each prison had the correct
information about his health. Nurse A told the investigator that records transfer
from prison to prison. Systemone (a NHS computer system used by PCTs)
allows for electronic transfer of records. However, not all establishments are
connected to it. If they have their own computer system, they print out their
records and transfer them with the prisoner. Records are transferred from
prison to prison electronically or by hard copy. From the evidence available,
staff at each of the receiving prisons had access to the man’s previous medical
records.
The decision to allow the man alcohol
100. My investigator raised this issue with senior police officers and it has been
subject to a police investigation. The police investigation considered that the
man asked the police officer to take him shopping to buy a pair of trainers but
when he returned to the car he was drinking a can of lager. The police officer
was not aware that the man intended buying alcohol and, as there is a drinking
ban in force in the city centre, he had to decide whether to enforce the ban or
remove him from the city centre and allow him to keep the alcohol. As he was
not in custody, the police officer elected to remove him from the centre of town
and allow him to keep the alcohol.
The man’s contact with the Probation Service
101. The man was required to attend an appointment with the Probation Service at
4.00pm on the day of his release. However, he was turned away because of
his behaviour and the appointment rescheduled for the following day. She
asked why, given his appearance, probation staff did not do anything to
intervene at this point.
102. One of the offender managers was supposed to see the man at 4.00pm. She
told the investigator that it was actually a receptionist at the office who had
telephoned her whilst she was travelling back from a meeting. Office staff were
concerned about his condition. They described him as being “in a state” and
using the toilet, in a communal area, with the door open. She explained that the
reception staff are not trained to deal with these situations. She thought that
they wanted reassurance that she was on her way back to the office for the
appointment and that they were doing the right thing.
103. The offender manager believed that the man was under the influence of either
drink or drugs. She thought that he was not in a fit state to complete the
induction process. He blamed his condition on his epilepsy medication but she
could not remember whether he said he had taken it or not. He said he had not
taken anything illegal. He was acting differently to how he had when she had
seen him in prison, but she did not think that he was a risk to himself. She said
that there was nothing in his behaviour that gave her particular cause for
concern. Another appointment was made and he left the office.
21
Probation contact with the man’s mother
104. There seems to be confusion about the contact the Probation Service had with
the man’s mother after his death. While she maintains that she had no contact,
despite leaving telephone messages, it seems that two members of the
Probation Service did call her, one on the morning of his death, and the second
some ten days later.
105. All three probation staff mentioned that client confidentiality was vital and, in
normal circumstances, they are not allowed to provide information to family
members. Additionally, they were not allowed to discuss the man whilst an
investigation into his death was ongoing, and were aware that the Coroner had
requested a report from probation staff.
106. The probation staff interviewed told the investigator that they had received no
guidance from senior managers either about how they should deal with the
man’s death or how his family would be contacted or supported. Although
circumstances such as these are uncommon, there should be procedures in
place to ensure that families are contacted as appropriate and are offered
support. Given that this is a difficult time for staff, I also expect them to be
supported during any such events, including the death of an offender. It seems
clear that guidance needs to be in place to allocate specific responsibilities
(including to senior officers) to ensure that they are handled effectively and at
the appropriate level.
There should be a policy in place for the support and guidance of
probation staff in Peterborough in the event of any untoward incident.
This policy should ensure that any family members involved are also
given appropriate support and guidance.
22
CONCLUSION
107. The man misused several substances, including heroin and alcohol, and
admitted this when arriving at Peterborough in 2008. He also said that he had
epilepsy, and was given medication. During his time in prison, he claimed that
he had several seizures and also had other medical problems. He threatened
to harm himself.
108. This investigation has identified procedures that can be improved. In particular,
prisons should ensure that they provide continuity of medical care by speaking
to a prisoner’s doctor when necessary. They also need to ensure that medical
records are properly kept. It is surprising that it was never established whether
he had epilepsy, but that medication for the condition continued to be
prescribed. There are obvious risks involved to prisoners of such practice.
109. However, once someone is released from custody, they are responsible for
their own care. He was properly warned about the possible consequences of
taking illegal substances, but it seems he chose to ignore these warnings.
23
RECOMMENDATIONS
1. Healthcare staff need to be able to evidence that they have attempted to
contact GPs and other service providers to ensure continuity of clinical care
between prison and the community. Contact should be made with home GPs
for a medical history if it has not been done by previous prison with an
accompanying audit trail.
The NHS responded: “When medical records of serving prisoners at HMP Highpoint
are requested from community GPs, there is always an audit trail to support this
within the patient’s clinical records, this includes written documentation and copies of
written correspondence and the patient’s consent. We also liaise with other relevant
providers for example Community Mental Health and Drug Intervention Programme
Teams and use the same process”
2. The Head of Healthcare at Peterborough should undertake a review of policy
and procedure for the management of substance misuse and alcohol
detoxification.
The Director of HMP Peterborough responded: “We have reviewed our protocols for
the management of substance misuse and alcohol detoxification as part of the
implementation of IDTS [Integrated Drug Treatment System] in September [2009].”
3. The Heads of Healthcare (at Peterborough, Highpoint and Wayland) should
review their medicines management processes including the triggers for the
management of inappropriate prescribing and agreement of what constitutes a
“medication review”
The NHS responded: “At HMP Highpoint there is a robust Medicines Management
process in place and a prescribing formulary, there is also a process to follow when
GP’s need to prescribe off formulary. When a medication review is undertaken the
consultation is fully documented in clinical records using System 1.”
The Director of HMP Peterborough responded: “We no longer prescribe codeine
based medication.”
4. The Heads of Healthcare (at Peterborough, Highpoint and Wayland) and
Primary Care Trust providers should ensure there are systems in place to
undertake regular audits of clinical records to ensure that minimum standards
are met.
The NHS responded: “The Community Healthcare has an annual audit plan in place
for the auditing of clinical records and the Community Healthcare Team based at
HMP Highpoint participates in this.”
The Director of HMP Peterborough responded: “We have … already put in place
procedures for … regular audits of clinical records.”
24
5. The Governor of Highpoint should commend its healthcare staff for providing
verbal assessments on the healthcare needs on transfer of prisoners to other
establishments.
The NHS responded: “The Governor of HMP Highpoint did commend the Healthcare
Manager for the actions of her team when dealing with the transfer of Mr M to HMP
Wayland, this was relayed to the Healthcare Team.”
6. The Heads of Healthcare (at Peterborough, Highpoint and Wayland) should
review “in possession” risk assessments whenever there is evidence to suggest
misuse.
The NHS responded: “At HMP Highpoint there is a robust policy and procedure in
place for the management of in-possession medication, this includes the
management of reviews and makes direct reference to when these will take place;
this includes any change in circumstances and misuse of medication.”
The Director of HMP Peterborough responded: “We have … already put in place
procedures for reviewing in-possession risk assessments.”
7. The Head of Healthcare in Wayland should undertake an urgent review of
prescribing practices and secondary dispensing of this nature should cease
immediately.
8. There should be a policy in place for the support and guidance of probation staff
in Peterborough in the event of any untoward incident. This policy should
ensure that any family members involved are also given appropriate support
and guidance.
25