Individual at Lewes

Investigation into the circumstances surrounding the
death of a man at HMP Lewes
in November 2008
Report by the Prisons and Probation Ombudsman for
England and Wales
June 2009
This is a report into the circumstances surrounding the death of a man, a prisoner at
HMP Lewes, in November 2008.
The man was found unconscious when his cell was opened that morning. The
officer who discovered him called for healthcare assistance, and staff and
paramedics attempted resuscitation. The man was then taken to hospital where he
was stabilised but assessed as brain dead. He had suffered multi-organ failure.
The man’s life support machine was turned off that evening with his family at his
side. He was 38 years old. I offer my sincere sympathy and condolences to the
man’s family and friends for their loss.
The investigation was carried out on my behalf by my colleagues. A clinical review
of the man’s healthcare at Lewes was undertaken by a clinical reviewer on behalf of
the local Primary Care Trust. I am grateful for his timely review. I would also like to
thank the Governor of Lewes and his staff for their co-operation and assistance.
Particular thanks go to the Governor’s secretaries for their help throughout the
investigation process.
The man had been in prison several times and was a heavy drug user. He had
served seven years of a life sentence and had only recently been transferred to HMP
Lewes. I understand he was frustrated by his sentence and on several occasions
had harmed himself. However, while the man reported various minor ailments, there
were no serious concerns about his well-being. He had begun re-using heroin in
custody but, to his credit, had sought help and had started a methadone treatment
programme shortly before his death.
I believe the man was well looked after while he was at Lewes. Like many prisoners,
he had harmed himself and had used drugs whilst in custody. However, it is clear
that neither played a direct part in his death which was due to natural causes. He
died from a rare condition, thrombotic microangiopathy (TM), that did not present any
symptoms indicating that he could collapse at short notice.
I have made two recommendations.
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.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2009
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CONTENTS
Summary
The investigation process
HMP Lewes
Key findings
Issues
Recommendations
SUMMARY
The man was born in August 1970. He was arrested in January 2001 and sentenced
to life imprisonment on 3 September that year.
After moving between a number of prisons, the man arrived at HMP Lewes in June
2008. He had apparently coped poorly in his previous prisons and was transferred
to Lewes because of the healthcare services that they could offer.
At the end of October 2008, the man told staff that he had been using heroin on the
wing for the previous five weeks. He was put on a methadone prescription. Beyond
that, the man did not appear unwell to the prison staff who knew him.
At some point between the evening of 2 November and 8.00am on 3 November
when he was found, the man collapsed in his cell. The officer who opened his cell
realised that the man was unconscious and called for healthcare assistance. Cardio
pulmonary resuscitation (CPR) was started quickly and continued until the
paramedics arrived and took over. The man was taken to the local hospital in
Brighton where he was declared brain dead. Prison staff contacted the man’s family
and alerted them to the seriousness of his condition. The family attended his
bedside and made the decision to end his life support that evening.
The initial information given to my investigator suggested that the man’s death might
have been caused by suicide or a drugs overdose. He had collapsed unexpectedly
and his substance misuse was, at the time, thought to have played a role in his
death. However, the post-mortem report stated unambiguously that the man died of
natural causes. Methadone was identified as a contributory factor, although what
role it may have played is not explained.
I make two recommendations in this report.
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THE INVESTIGATION PROCESS
1. The man died on 3 November 2008, following which my standard notices
were sent to staff and prisoners alerting them to my investigation. Several
prisoners wrote to my investigator. However, once it was established that the
man’s death was due to natural causes, their letters were no longer of
relevance to the investigation.
2. My investigator contacted the prison and asked for the man’s prison records.
My investigator and a colleague went to Lewes on 7 December to open the
investigation and meet senior staff, and to collect the relevant documentation.
3. The police and Coroner’s office were contacted to ensure that any relevant
information was shared, and to confirm that my investigation could continue.
4. My investigator wrote to the local Primary Care Trust to ask for the
appointment of a clinical reviewer to examine the healthcare the man received
while in prison. The clinical reviewer was unable to undertake joint interviews
with my investigator, but used the transcripts of the interviews to inform his
own report. My investigator and colleague travelled to Lewes in early
December to interview wing and healthcare staff. Further interviews were
carried out in January 2009.
5. One of my Family Liaison Officers contacted the man’s family and arranged a
visit. His mother, father and sister were present at the visit, which took place
in November 2008. Several issues were raised concerning the man’s clinical
care at Lewes, and his sister wanted to know why he had been receiving
methadone at the time of his death. The family wanted clarity about the
reason for his death and information about why he was at Lewes. The man’s
mother also raised concerns relating to contact they had had with prison staff.
This included a confirmation of a prison visit emailed to her on the day of her
son’s death, the return of the man’s property, and staff behaviour at the
hospital. A copy of my report will be sent to the man’s family and I hope that it
answers all their concerns.
6. The family raised a number of separate issues regarding the booking of prison
visits at Lewes. My investigator has looked into these matters and, as they
are not directly relevant to the circumstances of his death, has addressed
them in a letter to the man’s family. The man’s family also raised a number of
further issues at the draft report stage. My investigator considered these
carefully and, with regard to one of them, went back to the clinical reviewer to
request a further opinion.
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HMP LEWES
11. HMP Lewes is a category B local prison serving the courts of East and West
Sussex. It accepts both adult men and young adults, and has an operational
capacity of 723.
12. The prison has a 19 bed healthcare unit under the responsibility of the local
Primary Care Trust. Drug treatment began in 2001 and a new drug treatment
wing (B Wing) was created in 2004 with room for 29 prisoners. Lewes
operates the Integrated Drug Treatment System so maintenance prescriptions
are available as well as detoxification.
13. In her most recent inspection report in August 2007, HM Chief Inspector of
Prisons described Lewes as “reasonably safe”, but with weaknesses in anti-
bullying and suicide prevention measures. Drug and alcohol work was
described as effective and as having good links with the local community. HM
Chief Inspector’s report particularly commended the extremely good
relationships between staff and prisoners.
14. Each prison has an Independent Monitoring Board (IMB) made up of
members of the community. The Board’s role is to ensure that the prison is
properly run and that prisoners are treated decently. The Board produces an
annual report for the Secretary of State. The most recent report from the
Lewes IMB commented on how population pressures across the prison estate
had resulted in the retention of life sentenced prisoners due to the lack of
capacity at lifer centres. The Board said that lifers were waiting a long time at
Lewes before moving to an appropriate lifer unit. The Board praised the
healthcare unit and detoxification regime.
15. The man’s death was only death at Lewes in 2008. Lewes experienced three
deaths in 2007, none of them due to natural causes.
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KEY FINDINGS
Between 15 January 2001 and 9 June 2008
16. The man was arrested in January 2001 and remanded to HMP High Down.
He was subsequently transferred to a number of prisons before his trial in
September 2001. Following conviction for murder, he was sentenced to life
imprisonment on 3 September 2001 and sent to HMP Whitemoor.
17. He stayed in Whitemoor for three years before being transferred to HMP
Wakefield. The man then moved to a number of prisons before arriving at
HMP Kingston in May 2008. The man complained about pain in his back on 5
May and requested pain relief medication (his back problems apparently
started in 2006 following an incident in the gym). He was given Cocodamol
and Ibuprofen (pain relief and anti-inflammatory medicines) over the next
month, but was unhappy with this medication.
18. An Assessment, Care in Custody and Teamwork (ACCT) document was
opened on 5 June 2008 due to the man’s low mood and frustration over the
treatment of his back pain. (An ACCT document is the form used by the
Prison Service to monitor and support prisoners deemed at risk of suicide or
self-harm.) He had also refused food and began a protest in the form of non-
compliance with prison rules. The man was segregated for his own safety the
following day after threatening to set fire to his cell. The decision to segregate
was made in anticipation of his being transferred to Lewes. Staff at Lewes
would be better able to manage his healthcare needs due to the greater
healthcare provision.
19. Although they are not relevant to the circumstances of his death, I have
looked into the man’s ACCTs since they are important in telling the story of
his life in prison.
Between 10 June and 2 November 2008
20. The man arrived at Lewes on 10 June. It was unusual for Lewes to accept
someone as far into their life sentence as the man. The Lifer Manager at
Lewes told my investigator that the man “ … is quite unique to us at Lewes in
that he was somebody that came out of the lifer system into a non-lifer local
prison.” (Prisoners serving life sentences would normally only be in local
prisons from the time of their arrest to shortly after sentencing. Following an
assessment they would be moved to a first stage lifer prison to undertake
offending behaviour work.) Lewes had very few offending behaviour courses
for the man to do.
21. On his arrival, the man was received into the healthcare centre. Following his
reception meetings he was placed in a safer cell. (Safer cells have specially
designed furniture and fittings to reduce the number of ligature points.) At
2.30am on 11 June, staff noticed that he had covered his door with his
mattress and they could not see through the observation panel. When staff
went inside, the man was standing at the back of the cell holding a razor to his
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neck. He handed the razor to the staff and was escorted to the segregation
unit. He returned to the healthcare unit the following morning.
22. An ACCT review meeting was held on 12 June at which the man said that he
did not have suicidal feelings but that his self harm feelings fluctuated. He
faced a disciplinary hearing for covering his door and was punished with
seven days loss of canteen and association, suspended for three months. On
14 June, the man was returned to a standard prison wing. A further ACCT
review meeting took place on 17 June and he was said to be settled, with low
risk of self-harm. Further reviews were held on 25 and 28 June where the
man was described as settling into wing life well, with no current concerns.
The ACCT document was closed on 21 July. The post-closure review held on
28 July reported no problems and confirmed the closure of the ACCT.
23. On 7 July, the man was moved up to the fourth landing on his wing. His
personal officer wrote in his documents:
"Since his move to the 4's landing things have improved for the man he
has really got his act together. His attitude and mental wellbeing has
improved greatly so much so that he has been given a chance as a
wing cleaner which he has taken with great enthusiasm."
24. The role of wing cleaner gave added responsibility and extra time out of his
cell which noticeably improved the man’s mood. However, on 15 September,
the man failed a mandatory drugs test. This resulted in his immediate sacking
from the position. The personal officer recalled that the man took the news
well and accepted responsibility for the consequences of the failed drug test.
25. On 29 September, the man became distressed due to concerns about his
sentence. He showed staff a noose he had made but said that he could not
find anywhere to attach it. Another ACCT document was opened. Staff
carried out a risk assessment and the man expressed suicidal ideas as he felt
hopeless due to his sentence. He said that he felt as though he had limited
prospects for release, and was frustrated since his failed drug test meant that
he was unable to transfer to the therapeutic community at HMP Dovegate. It
was decided to move the man to a safer cell and that he should be observed
constantly (when a member of staff sits outside the cell all the time). The
following day, the man told the Registered Mental Health Nurse (RMN) that he
was not suicidal and had merely become depressed the previous day thinking
about his sentence and his family. In interview, the RMN recalled that the
man had calmed down a lot and realised that his actions the previous evening
were not a reflection of his general feelings. He returned to the wing the
same day.
26. The man asked for the ACCT to be closed at the case review meeting on 7
October and said that he had no further thoughts of self-harm. At the post-
closure review meeting held on 14 October, the man reported feeling very
happy with the progress he had made over the previous week.
7
27. On Friday 24 October, the Senior Officer (SO) called the CARATs department
to tell them the man had said that he would like to see a CARATs worker.
CARATs (Counselling, Assessment, Referral, Advice and Throughcare) works
with prisoners with drug problems. The man’s CARATs worker described the
service as follows:
“… when the prisoner comes into the prison they are referred to the
CARATs team and then all the way through their custody. We look at
what we need to do with them and we work with them, doing the cell
packs, doing group work. We support them all the way through their
sentence.”
The CARATs worker described the cell packs to my investigator by saying, “It
teaches them about the effects of heroin, what it does to their body, the
learning that they get from it. It’s a bit like a little homework pack really”.
28. On that Friday, the CARATs worker was on leave so it was her colleague who
went to see the man. During their conversation the man told her that he had
been using heroin on the wing. He expressed a desire to stop using the drug,
and the second CARATs worker told the man she would contact the drug
treatment team to help arrange this. The second CARATs worker also gave
him some CARATs documents and material. The second CARATs worker
then rang the Lead Drug Treatment nurse and told him that the man was
withdrawing and feeling unwell.
29. The Lead Drug Treatment nurse was going off duty at this point and so was
unable to see the man. He advised the second CARATs worker to arrange an
appointment with a doctor so that the man could receive medication to relieve
his symptoms if necessary. Before going off duty, the Lead Drug Treatment
nurse advised his colleague that she might get a call regarding the man over
the weekend.
30. No doctors were available over the weekend and so on Monday 27 October
the drug treatment nurse went to see the man in response to the requests
from the CARATs worker and wing staff. When the drug treatment nurse saw
the man he did not show any obvious signs of withdrawal from heroin. He
admitted to the drug treatment nurse that this was because he had been using
heroin for about five weeks and had just used again. The drug treatment
nurse took a urine sample which tested positive for opiates, and told the man
that she would need to see him in a state of withdrawal before she could
progress with any treatment. The drug treatment nurse visited the man the
next day when he was showing signs of heroin withdrawal. In interview, the
drug treatment nurse said:
“He was sweating, his skin was clammy, his pupils were dilated
whereas the day before they were really quite small indicating that he
had just used but they were dilated and he was sweaty and clammy.”
31. Following confirmation of withdrawal and discussion with the prison doctor,
the man was placed on a 14 day methadone detoxification programme. He
8
remained in his usual cell having refused to move to the detoxification wing (B
Wing). His friend said that the man did not want to leave his friends behind
and have to familiarise himself with the different regime on B Wing.
32. When a prisoner asks for detoxification, provides a positive urine sample, and
exhibits withdrawal symptoms, the nurse must also check the medical record.
A discussion is held with the doctor to ensure they are satisfied that
methadone should be prescribed. The standard 14 day prescription begins
on 20 mgs (a slightly lower dose to avoid potential overdose), before rising to
25mgs and then stabilising on 30mgs for two days before reducing again.
The methadone is in liquid form and must be drunk in front of the nurse at the
treatment hatch. The nurses observe the prisoner while the methadone is
drunk, looking out for drowsiness or slurred speech that could indicate
problems. This also presents an opportunity for the prisoner to report any
problems with their detoxification. Engagement with the CARATs service is
also offered throughout the detoxification programme. The man did not report
any concerns about his prescription to the drug treatment nurse or to the
CARATs staff.
33. The CARATs worker saw the man on Monday 27 October and recalled in
interview that he seemed focussed and keen to continue his detoxification
regime. The CARATs worker told my investigator that she had no concerns
about him.
34. On the evening of Sunday 2 November, the personal officer answered the
man’s cell bell. The man asked if he could get him some paper to write
letters. The personal officer returned to the man’s cell at approximately
6.15pm with the paper, and discussed the climax of the Formula One season
with him. In interview, the personal officer said, “… the night before he was
absolutely fine, and he was just chatting to me … he seemed very upbeat.”
35. The personal officer told my investigator that the evening role check was
carried out at approximately 8.30pm and normal practice was to do another at
around 5.30am.
3 November
36. At approximately 8.00am, the personal officer began opening the cells on the
fourth floor of the wing. When he reached the man’s cell he opened the door
and saw him lying on his mattress on the floor apparently asleep. The
personal officer called to the man and then moved on to the next cell. (My
investigator was told that finding a prisoner on the floor was not in itself
unusual as some prisoners choose to sleep on the floor.) However, before
the personal officer reached the next cell he became concerned as to his
knowledge the man had never before chosen to sleep on the floor. The
personal officer returned to the man’s cell and called to him again. Having got
no response, the personal officer went into the cell and called out again. The
personal officer crouched in order to try to shake the man and noticed a filmy
liquid surrounding his head and what appeared to be vomit in his mouth and
nostrils. The personal officer immediately called out to his colleagues on the
9
landing for urgent medical assistance. He checked the man’s pulse and
believed that he felt a faint pulse.
37. One of the officers on the wing radioed for healthcare assistance and the duty
governor was also informed. Wing Officers went to the cell in response to the
personal officer’s calls for assistance and also checked the man’s pulse.
They too believed that they might have felt a faint pulse. Soon after they
checked the man’s pulse, the healthcare staff arrived at the cell.
38. The prison nurse and Healthcare Assistant (HCA) had run to the cell from the
first floor landing on the in-patients healthcare centre and arrived at the man’s
cell at approximately 8.04am. They carried the resuscitation bag which they
had collected from the treatment room on the landing. The resuscitation bag
contains a variety of medical equipment including oxygen. The officers
vacated the cell to allow more room for the resuscitation attempt, and began
to lock other prisoners back in their cells.
39. The prison nurse checked the man and described this process to my
investigator as follows:
“I checked his vital signs first, checked for breathing, pulse and
checked his pupils for reactivity and when there was none of those and
his GCS [Glasgow Coma Scale which rates the level of consciousness
of an individual] was nil then I started CPR [cardio-pulmonary
resuscitation]”.
40. Having done this, the prison nurse shouted out that she needed an
ambulance. There were many staff standing around the cell entrance and the
request for an ambulance was immediately radioed through. A facemask and
ambu bag (a manual ventilation bag) was applied to the man to establish
regular oxygen supply, and CPR was undertaken with a ratio of 30
compressions to two breaths (this is the correct ratio). The prison nurse
asked for a defibrillator and it was passed to her by one of the officers outside
the cell. The defibrillator was attached to the man but it did not advise that he
should be shocked. (A defibrillator provides an electric shock to the heart to
try to get it started again. The machine itself advises the operator whether to
deliver a shock. It does not do so when the heart does not have sufficient
rhythm as it would not have any effect.)
41. The ambulance arrived at 8.15am and paramedics and prison healthcare staff
continued CPR. The paramedics administered Naxolone, an opiate blocker,
in case the cause of the man’s collapse was due to a drug overdose.
Adrenaline and Atropine were also administered which resulted in a slight
pulse. A second ambulance was requested by the paramedic crew in order to
bring further equipment. The paramedics’ defibrillator was put onto the man
but it too advised that a shock should not be given. At 9.20am, the decision
was made to take the man to hospital.
42. When the paramedics reached the ambulance with the man, he suffered
another arrest and paramedics had to resuscitate him again before they could
10
leave for the hospital. Two officers accompanied the man as escort staff
when the ambulance left the prison at approximately 9.30am. The man was
moved to the Intensive Care Unit (ICU) following an initial assessment in a
resuscitation room in the Accident and Emergency (A&E) department. The
risk assessment judged it unnecessary to apply restraints to the man since, in
the words of the first escort officer:
“… it wasn’t necessary because the inmate was obviously
incapacitated in more ways than one … we were sat near a door …
about twenty-five, thirty foot away but we could see the man and we
could see the family.”
Contact with the man’s family
43. The duty governor told my investigator that, once the man left for hospital, he
ensured the care team was fully apprised of his condition. The duty governor
then went through the man’s records for contact details. I understand that
next of kin details for the man were incomplete and that this prevented
immediate contact with his family. The only Family Liaison Officer (FLO) at
Lewes at that time was absent from the prison and so the duty governor
asked the prison chaplain to help contact the family. This was at
approximately 10.30am.
44. The prison chaplain looked at the man’s next of kin records and discovered
that he had a son at HMP Deerbolt. The chaplain told my investigator that he
called his counterpart at Deerbolt and attained the telephone number for the
man’s mother. The prison chaplain called the family but there was no
response to his first two calls. Between 12.00noon and 12.30pm, the prison
chaplain telephoned for a third time and managed to speak to the man’s
stepfather. He advised him of the seriousness of the man’s condition and
suggested that he and the man’s mother should go to the local hospital as
soon as possible. The prison chaplain also called the man’s former partner
and told her that the man was in hospital.
45. The man’s family arrived at the hospital and asked questions of the escort
staff, many of which they were unable to answer as they did not know him.
The Principal Officer (PO) contacted the prison FLO at 5.00pm to ask her to
go to the hospital to support the escort staff. It appears that the escort staff
felt uncomfortable trying to deal with the questions that the family were asking
them. The second escort officer told my investigator:
“If you haven’t got the information to give someone you just keep
saying the same thing over and over again … Whether they thought we
were keeping something back from them I don’t know but that just
wasn’t the case, we just didn’t have the information.”
46. The prison FLO arrived at the hospital at 6.00pm and went to see the escort
staff. The man’s family were at his bedside. At 6.30pm the man’s stepfather
approached the prison FLO and told her that they were waiting for other family
members to arrive and were planning to turn off life support at 8.00pm. The
11
man’s stepfather asked if all contact with the family could go through him and
the prison FLO agreed. Family members arrived at approximately 7.00pm
and gathered around the man’s bed. The hospital staff began to turn off his
life support at 8.00pm and the hospital doctor declared the man dead at
8.15pm.
47. After some time at the man’s bedside the family went into another room. The
prison FLO waited for a short time and joined the family at 9.00pm to pass on
condolences on behalf of the prison. At 9.15pm, the man’s son arrived with
his girlfriend. At 9.20pm, the prison FLO left the family. She promised to
contact them in the next few days if they did not contact her first.
48. The prison FLO telephoned the man’s former partner, the mother of the man’s
children, at 9.10am on 4 November. The former partner told the prison FLO
that the man’s mother had already informed her of his death. The prison FLO
left her contact details with the former partner.
49. At 12.50pm on 4 November, the prison FLO spoke to the man’s sister, to
respond to questions that she had rung with earlier that morning. The man’s
sister expressed dissatisfaction that a governor from the prison had not
contacted the family. The prison FLO raised this with the Deputy Governor
who called the man’s mother at 3.00pm. During their conversation, the man’s
mother asked the prison to contact the man’s pen-friend in HMP Downview
and his former brother-in-law in HMP Wormwood Scrubs to inform them of his
death. The family also wished the family of the man’s victim to be told. The
Deputy Governor agreed to these requests.
50. The man’s mother called the prison at 9.50am on 7 November to ask whether
the prison would consider increasing their offer towards the funeral expenses.
Following discussion with the Deputy Governor, the prison FLO spoke to the
man’s mother the next day and told her that the prison would not increase
their contribution. The man’s mother told the prison FLO that the family did
not want anyone from the prison at the funeral, and they did not want flowers
sent either. The man’s funeral took place on 14 November.
51. At 3.30pm on 20 November, the prison FLO and the Senior Officer visited the
man’s stepfather and mother’s home to return his property. The prison FLO
agreed to provide the man’s mother with an envelope to send some of the
man’s CDs to other prisoners. The man’s mother expressed unhappiness
with the prison’s refusal to increase its offer towards the funeral costs, and the
prison FLO advised her to write to the Governor. The man’s mother chose
not to do so and did not raise the issue with the prison again. On 28
November, the prison sent a cheque for the funeral expenses to the funeral
directors.
52. The man’s mother also complained of the difficulty that the family had had in
arranging a visit with the man prior to his death. The prison FLO said that she
would bring this to the attention of the Governor.
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Care for prisoners and staff
53. The Governor issued a notice for each prisoner telling them what had
happened to the man. The prison chaplain, with his Muslim colleague,
organised a memorial service on the following Friday afternoon.
54. The officers who discovered the man were offered a hot debrief to talk
through their role in the resuscitation attempt, but they said that they did not
feel it was necessary. The care team visited as soon as the officers left the
man’s cell and offered support. The prison nurse told my investigator:
“I actually spoke to the officers myself to see if they were okay because
sometimes it is helpful to speak to somebody who was actually there
so I just offered my support to the officers who found the man.”
55. One officer said that he felt there was plenty of support available should he
have needed it.
56. The prison nurse attended a debrief with some healthcare staff and the PCT
but not with the officers involved. She felt well supported by the prison.
Unfortunately, the prison nurse learnt of the man’s death from the Governor’s
notice to prisoners.
57. All of the staff involved in the resuscitation attempt spoke highly of the care
and support offered by the prison. The care team quickly approached the
staff, and the chaplaincy was also available to any who needed it. I am
pleased to acknowledge that Lewes takes such matters seriously.
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ISSUES
Medical issues
Clinical care
58. The man was transferred to Lewes from Kingston because Lewes has 24
hour in-patient healthcare facilities. The clinical reviewer notes that the man
had fluctuating thoughts about self-harm which meant that it was difficult to
manage his needs. However, the clinical reviewer writes that, “the man
appears to have received a commendable level of support from the various
drug and psychiatric agencies whilst in custody.”
59. The clinical reviewer points out that it seems the man’s back pain was never
assessed by healthcare staff beyond the prescribing of painkillers. However, I
understand that the man’s focus was on the continued provision of painkillers,
rather than a detailed assessment of his back problem.
60. With regard to the condition that caused the man’s collapse, the clinical
reviewer writes:
“The man died suddenly and unexpectedly of a rare and serious
medical problem Thrombotic Microangiopathy (TM). [This is a
condition affecting the blood vessels that can cause organ failure. It
presents non-specific symptoms.] His lifestyle and habits may have
been contributory factors in the development of TM, but there appear
not to have been any symptoms prior to his collapse that would have
suggested to his carers that his demise was imminent.
“I find no fault with the quality of care he received within the prison or
hospital medical services.”
61. The man’s family questioned whether the staff who saw him at the time of his
request for drug withdrawal treatment should have considered the possibility
of him suffering from Thrombotic Microangiopathy. The symptoms that the
man exhibited were entirely consistent with heroin withdrawal. The clinical
reviewer found no fault with the medical care the man received and I do not
think it reasonable to expect his underlying condition to have been noticed at
that time.
62. The man’s family told my investigator that the hospital consultant had told
them that his blood contained Methadone and Gabapentin. The family were
interested in the relevance of the Gabapentin in his blood. The man had been
prescribed Gabapentin in the weeks leading up to his death. My investigator
asked the clinical reviewer to provide an opinion on the prescription of both
Methadone and Gabapentin. He wrote to my investigator with the following
comments:
“Methadone is an opioid analgesic frequently used in the detoxification
of patients with a heroin and other illicit drug use. It has a low
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incidence of side effects, and self harm with methadone is difficult.
Gabapentin is an anti-epileptic drug also licensed for the treatment of
neuropathic pain. I have looked at the literature concerning the
concomitant use of these drugs and there appears to be no interaction
between the two. Sedation can occur with both, but this can be
regarded as an additive effect rather than an interaction. In my opinion
the concomitant use of methadone and Gabapentin in this patient was
entirely appropriate.”
The attempted resuscitation
63. The man was found at approximately 8.00am on Monday 3 November by his
personal officer when he unlocked the cells in the morning. The alarm was
quickly raised and healthcare staff quickly reached his cell. CPR was
immediately carried out and continued by paramedics when they arrived at
8.15am. The clinical reviewer raises no concerns regarding the resuscitation.
I am also satisfied that staff made every effort to save the man.
Family issues
Contacting the man’s family
64. The man’s family has raised several concerns with my investigator regarding
liaison with the prison. The family was unaware of the prison’s first attempt to
call them as they were not at the family home at the time. The prison chaplain
was asked to contact the family at approximately 10.30am but was unable to
reach anyone at the man’s parents’ house until some time between noon and
12.30pm. I consider it a key responsibility for the prison to try to make contact
with the family as soon as possible. The duty to contact the family following a
death in custody is set out in Prison Service Order (PSO) 2710:
“Governors/Directors of contracted prisons must have in place a local
protocol explaining what support will be offered to a family bereaved by
a death in custody. They must also:
“Arrange notification to the next-of-kin and any other person reasonably
nominated by the prisoner as soon as possible in a suitable manner
giving an accurate factual account of what has happened.”
65. PSO 2710 refers to deaths in custody but the same principles apply to cases
when the severity of the situation requires the family to attend the hospital as
soon as possible. It is unfortunate that the contact details for the man were
not adequate for Lewes to contact his family any sooner. However, the prison
clearly made efforts to obtain these details by contacting Deerbolt. The man’s
family said that Lewes did have their contact details, and would not have been
able to get them from Deerbolt. The prison chaplain explained during
interview how he got the contact details and I have no reason to dispute his
account.
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66. The man’s family was also surprised that the initial telephone call came from
the prison chaplain and not from a governor. It is for the prison to decide who
would be the best member of staff to break such difficult news to a family. My
investigator was told that the prison chaplain was asked to make the
telephone call due to the pastoral care and experience he could bring to the
role. The FLO guidance (supplementary to PSO 2710) explains the benefits
of involving the chaplain in this role:
“Traditionally Governors have asked a Chaplain to break the news of a
death to a family. Chaplains are trained and experienced in
bereavement issues and are ideally suited to this task.”
67. Given this, I consider that the decision made by the duty governor to ask the
chaplain to contact the family was both reasonable and proper.
68. The prison chaplain relayed the necessary information to the family but did
not offer to arrange transport for them to the hospital. The family has not
raised this as a concern with my investigator, but I would suggest to the
Governor that such an offer might be considered in any similar situation.
The escort staff at the hospital
69. The man’s family has raised concerns about the behaviour of the escort staff
at the hospital. The family explained to my investigator that they felt that
escort staff were flippant and unprofessional. My investigator interviewed a
member of the escort staff who denied these allegations. He said that,
although it was a very difficult situation, he was confident staff acted
appropriately. He told my investigator that he and his colleague felt very
isolated as the family asked many questions that they were unable to answer
having had no involvement when the man collapsed. The escort officer said
that he felt that the family was blaming him for the man’s situation, and this
was not helped by the lack of information that he was able to pass on.
70. It was this tension that caused the prison FLO to attend the hospital at
approximately 6.00pm. By all accounts, her arrival helped matters as the
family had someone able to liaise with them directly and answer more of their
questions.
71. Given that the accounts of the family and the escort staff differ, I am unable to
judge whether staff did or did not act appropriately during their time at the
hospital. Small things such as body language matter hugely when people are
under stress. According to the bedwatch documentation, a management visit
was made by a Principal Officer at 5.20pm and this gives no indication that
the escort staff were behaving other than entirely appropriately. However,
without making any judgement about what happened on this occasion, it
would be good practice for the Governor to remind escort staff of the
sensitivity of escort duty and the absolute importance of maintaining a
professional attitude at all times.
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The Governor should remind all escort staff of the sensitivity of escort
duty and the absolute importance of maintaining a professional attitude
at all times.
72. I sympathise with the situation the escort officers were placed in and I
consider it disappointing that the Family Liaison Officer or a suitable governor-
grade was not at the hospital to meet the family on their arrival. Escort staff
are not trained in family liaison skills and often have no knowledge of the
prisoner they are escorting. When they are not provided with a point of
contact at the prison, a family may erroneously believe that the escorts are
being obstructive. One escort officer told my investigator:
“I think as soon as the family arrived I’d been more than happy to sit
there and let them ask me questions and what I could answer I would
answer. Perhaps someone from the prison getting in contact sooner to
explain to the parents what had happened and then after that point if
we were able to base ourselves away from the ward, so as not to
antagonise the situation which I felt us being there was doing.”
73. On this occasion, the family asked questions of the escort staff they were in
no position to answer. Such a situation can easily lead to tension and should
be avoided where possible. Indeed, in other investigations I have
commended prisons where a governor grade has met a family at the hospital.
Therefore, I recommend:
The Governor should ensure that, when a prisoner is likely to die, a
senior member of staff is identified to meet the family.
Funeral expenses
74. The man’s family has explained that they were initially disappointed by the
amount the prison offered with regard to payment of the funeral expenses.
However, I have discovered that the sum offered was in accordance with
Prison Service policy and properly balanced the duty to the family and to the
public purse. I consider that the prison acted appropriately in this regard.
The man’s property
75. The family was also initially confused by statements made by the prison with
regard to the man’s property. I understand that this was a misunderstanding
relating to which property was in the man’s cell and which was held in
storage. I understand that all the property has now been returned to the
family. The family also expressed some discontent with the answers provided
to them by the Family Liaison Officer. This is unfortunate, and although I am
unable to comment on it with any certainty, I would encourage the Governor
to ensure that families are kept as fully informed as possible in any future
death in custody.
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Prison visits at Lewes
76. The man’s family told my investigator that they were sent a visits booking
confirmation on the afternoon of the man’s death. Although I believe that the
visits clerk had no idea that the man was in hospital at the time the
confirmation was sent out, it was clearly most unfortunate and added to the
distress of the family. Prison Service Order 2710 requires the visitors centre
to be informed of any death in custody. Although the man was not dead by
the time the email was sent out, I suggest that, where the prognosis is
particularly poor (as with the man), consideration should be given to informing
the visits clerk as soon as possible. This could help prevent a recurrence of
this unfortunate situation.
Other issues
Use of heroin
77. It is self-evidently of concern that the man was able to acquire heroin while in
Lewes, and to have used it on a presumably regular basis for a number of
weeks. I am aware that the Governor and his staff take the matter very
seriously. I also understand that, as in all prisons, there are measures in
place to try to minimise the availability of illicit drugs. In support of the
Governor, the Area Manager will wish to assure himself that all reasonable
actions are being taken to prevent the ingress of drugs into Lewes.
Methadone treatment programme
78. It is to the man’s credit that he came forward of his own accord and expressed
a desire to detoxify from heroin. He was placed on a 14 day methadone
detoxification programme starting on 20 mgs a day. As the clinical reviewer
says in his report, there were no symptoms of any serious physical problem
during the man’s detoxification and he did not raise any concerns with staff.
79. Methadone is listed as a contributory factor on the post mortem report but no
information is provided as to why or how it contributed to the man’s death.
The report states:
“The pneumonia may therefore be related to the thrombotic
microangiopathy in this case and the therapeutic levels of methadone,
whilst unlikely to have been directly fatal, in this case may have been
contributory.”
80. Despite my investigator asking for his views, the clinical reviewer has been
unable to comment on any link between methadone and the man’s collapse. I
consider that their decision to place the man on a methadone detoxification
programme was entirely appropriate. The man himself actively wanted it to
happen, his urine tested positive for opiates, and drug treatment staff
witnessed him displaying physical signs of withdrawal. Given these factors, I
do not see how staff could reasonably have acted any differently.
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The possibility of the man taking other drugs the night before he died
81. The family and other prisoners raised the possibility of the man taking drugs
from another prisoner on the night before he was found. A wing officer
confirmed that he was told this but the prisoner in question denied the
allegation. The post mortem examination did not find any drugs in the man’s
system other than the appropriate amount of methadone.
Conclusion
82. The man’s death was entirely unexpected. I am satisfied that the clinical care
the man received was satisfactory and that staff made appropriate efforts in
an attempt to save his life. His family has raised several issues regarding
contact with the prison that my investigator has looked into and they have
resulted in my two recommendations. I hope that this report deals with all
their concerns.
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RECOMMENDATIONS
1. The Governor should remind all escort staff of the sensitivity of escort duty
and the absolute importance of maintaining a professional attitude at all times.
2. The Governor should ensure that, when a prisoner is likely to die, a senior
member of staff is identified to meet the family.
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