Individual at Full Sutton

Investigation into the circumstances surrounding the
death of a man
whilst in the custody of
HMP Full Sutton on in 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2010
This is a report into the death of a man at HMP Full Sutton on in January 2010. The
man died from natural causes and was 76 years old. A post mortem showed that he
died from acute left ventricular failure (failure of the left side of the heart) caused by
hypertensive heart disease.
I offer my sincere condolences to his family and friends for their loss. The Senior
Family Liaison Officer, contacted the man’s family at the start of the investigation.
The investigation was carried out on my behalf by my colleague,. Both he and I
would like to thank the Governor and his staff particularly one of his governors for
their co-operation during the course of our enquiries.
I also thank East Riding of Yorkshire Primary Care Trust for appointing a doctor to
review the man’s clinical care.
As the man died from natural causes, the findings of the clinical review play an
essential part in my report. The review shows that he received good care whilst in
custody that was equitable to that which he could have expected in the community.
I make no recommendations and recognise the efforts made in the family liaison.
Jane Webb
Acting Prisons and Probation Ombudsman June 2010
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CONTENTS
Summary
The investigation process
HMP Full Sutton
Key findings
Issues
Conclusion
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SUMMARY
On 19 September 2003 the man was convicted of sexual offences and sentenced to
12 years in custody. He was sent to HMP Liverpool where he had a health screen
assessment with a nurse. The man had a significant past medical history which
included previous heart attacks, (the last in 2002), ischaemic disease and angina.
The man was transferred to HMP Full Sutton on 9 January 2004. He stayed in a
single cell on the ground floor in the vulnerable person’s wing. He had regular
contact with healthcare staff for monitoring his medication and routine blood tests.
On 9 February 2005 the man was diagnosed with diabetes. He refused to take this
medication despite the implications of his decision being explained to him. In the
years that followed he continued to have regular contact with both nurses and prison
doctors at Full Sutton. However he often refused to have blood samples taken,
failed to attend appointments with healthcare staff and refused to take his
medication, despite encouragement and advice.
On 26 January 2010, at approximately 10.20am, the man used his cell bell and told
uniformed staff that he had chest pains and was having difficulty breathing.
Healthcare staff responded, and following a quick assessment, moved him the short
distance to healthcare using a wheelchair.
Once in healthcare he was assessed by the prison doctor and an emergency
ambulance was called. The ambulance arrived and the paramedics took over his
care and stabilised his condition before transferring him to York District Hospital.
The man received treatment from hospital staff, but went into cardiac arrest. The
hospital staff attempted resuscitation but the man was pronounced dead at 12.38pm.
The man’s next of kin was recorded as his sister who lived some considerable
distance away. Due to the distance involved, the decision was taken to contact the
nearest establishment to the family, HMP Liverpool, to break the news of his death
that same afternoon.
I am satisfied that the care and attention he received at Full Sutton was equitable to
that he could have expected to receive in the community. The man did on several
occasions exercise his right to refuse treatment. I make no recommendations but
recognise the good practice adopted by Full Sutton in family liaison.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 27 January 2010 when the investigator
issued notices announcing the investigation to staff and prisoners. No
prisoners came forward as a result.
2. The investigator visited HMP Full Sutton on 1 February. During his visit he
was also given copies of all documentation relating to the man. My
investigator returned on 23 February and interviewed eight members of staff.
3. East Riding of Yorkshire Primary Care Trust asked a doctor to review the
man’s clinical care. The investigator and the clinical reviewer jointly
discussed aspects of the man’s treatment with healthcare staff at Full Sutton.
4. The investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of the investigation and request a copy of the post mortem report.
Upon completion, the report will be sent to the Coroner to assist his enquiries
into the man’s death.
5. The Senior Family Liaison Officer contacted his next of kin about the
investigation and invite them to ask any questions about his case. A copy of
my report will be sent to them.
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HMP FULL SUTTON
KEY FINDINGS
6. The man was born on June 1933 in Birkenhead, and lived in the Manchester
area prior to his conviction. He had been married but divorced some years
previously.
7. On 19 September 2003 a man was convicted of sexual offences and
sentenced to 12 years in custody. He was sent to HMP Liverpool where he
underwent a health screen assessment with a nurse. The man told the nurse
that he had previously suffered heart attacks, the last in 2002, and had been
in hospital a few months before entering prison. He also said that he suffered
from asthma and deep vein thrombosis (DVT) (formation and migration of
blood clots). He said that he had been a smoker for 60 years and had no
intention of giving up.
8. Healthcare staff at Liverpool contacted the man’s community doctor to confirm
his medication and the details of a recent hospital admission. The doctor
confirmed that the man had been in hospital from 24 January to 4 February
2003 under the care of a consultant physician at the Manchester Royal
Infirmary. The man had a history of hypertension (high blood pressure), left
ventricular failure (failure of the left side of the heart) and angina (chest pain
caused by lack of blood supply to the heart). Whilst at hospital the diagnosis
was also made that he also had mild chronic obstructive pulmonary disease
(COPD - narrowing of the airways in the lungs) and arterial fibrillation
(abnormal heart rhythm).
9. As a result of his medical conditions the man was prescribed Frusemide (for
the treatment of heart failure), Pravastatin (for the treatment of high
cholesterol), Ramipril (for the treatment of high blood pressure and heart
failure), Isosorbide Mononitrate (for the treatment of angina), Digoxin (for the
treatment of artrial fibrillation), Spironalactone (for the treatment of heart
failure) Warfarin (for the treatment of DVT) and aspirin.
10. The man transferred to HMP Full Sutton on 9 January 2004. A health screen
check confirmed his medical history and medications. He was allocated a
single cell on the ground floor. He had regular contact with healthcare staff to
monitor his medication and have routine blood tests.
11. On 9 February 2005 the man was diagnosed with type two diabetes (non
insulin dependant diabetes) and the prison doctor prescribed Metformin. He
refused to take this medication due his interpretation of the effects of the
medication upon the heart, even though the implications were explained to
him.
12. Over the following two years the man continued to have regular contact with
nurses and prison doctors at Full Sutton. However it was not uncommon for
him to refuse to have blood samples taken and decline to take his medication,
despite encouragement and advice from the healthcare staff. By March
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2007,the doctor had added Salbutamol (for the treatment of COPD) and
Beclomethasone (for the treatment of asthma) to his prescribed medications.
13. The prison doctor prison doctor, wrote to a consultant haematologist, at the
York District Hospital on 12 March requesting an outpatient appointment for
the man to review his level of Warfarin. An appointment was arranged for 28
June but, on the day the man refused to go to hospital. This was against the
advice of the healthcare staff, and he signed a disclaimer to that effect.
14. On 17 October a nurse saw the man to review his asthma. He told the nurse
that he had not been taking his medication as his asthma did not cause him
any difficulties. The nurse advised him about the reasons and benefits of
taking the medication and he agreed to resume taking it. The nurse also
advised him about the effects of smoking on his health.
15. The man saw a nurse for a coronary heart disease review on 18 February
2008, to check his cholesterol levels. However he refused to have blood
samples taken and told the nurse that he felt well. He also refused to have
blood samples taken on 16 May and 9 June.
16. Between 19 June and 19 January 2009 the man failed to attend five
appointments with healthcare staff. On 26 January, he saw another nurse for
a coronary heart disease review. Yet again he refused to give his consent for
blood samples to be taken. The nurse explained that blood samples were
part of the process to manage his long term, potentially life threatening,
conditions. They were needed to enable doctors to identify problems and
make any necessary changes to his medication. He told the nurse that he felt
fine and did not need blood tests, but he did agree to his weight and blood
pressure being checked. His weight was recorded as 90kg and his blood
pressure was 161/81. (The normal range for blood pressure is 100/70 to
140/90, although the pressure does vary throughout the day depending on the
individual’s activities. A blood pressure reading of greater than 140/90 is
classed as high and a reading of 90/60 or below is classed as low.)
17. On 20 April the man saw the the same nurse, as he complained of a dry
cough which was worse when he lay down. He told the nurse that he had not
been using his inhaler medication. The nurse referred him to the prison
doctor who prescribed Co-amoxiclav (antibiotic for treatment of respiratory
tract infections) and advised the man to continue taking Salbutamol and
Beclometasone.
18. Three days later he saw a different prison doctor, because he experienced
heartburn at night. He also told the doctor that he had not taken the
Metformin. The doctor prescribed Omeprazole (for treatment of heartburn)
and encouraged him to have blood samples taken, to which he agreed. The
doctor recorded his blood pressure as 160/80.
19. Three days later he saw another nurse for the blood samples to be taken.
The man again refused to have any samples taken and said that he felt better
without having them done. The nurse again explained the reasons for the
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blood tests and the risks to his health. He also refused to have the flu
vaccination, and declined the services of the chiropodist. The man asked to
sign a disclaimer form to refuse all future blood tests and this was signed on
28 April.
20. On 24 July the man saw a nurse because he needed to urinate frequently
during the night which concerned him. He also told the nurse that he had
passed blood in his urine some five months previously but had not told
anyone. He said he still had not taken the Metformin. The nurse advised him
to take his medication as prescribed and see if his condition improved. He
should contact healthcare straight away if he passed blood in his urine.
21. The man saw a nurse on Saturday 10 October because he passed blood with
his urine. He told the nurse that this had been happening for about two weeks
and he had hoped that it would have sorted itself out. He said that he had
passed a clot of blood before he passed any urine that morning. The nurse
referred him to see the doctor the following Monday, and told him to contact
healthcare straight away if he felt unwell or was unable to pass urine. The
nurse tested his urine which showed that blood was present and his glucose
and protein levels were raised.
22. Two days later the man saw a prison doctor.. He had no fever or pain and he
looked his usual self. He told the doctor that he had not passed as much
blood in his urine that morning. The doctor wanted to refer him to the hospital
but he refused any further intervention. The man said that he had a bad
cough which produced green sputum for which the doctor prescribed a course
of Amoxicillin (antibiotic for respiratory tract infections).
23. On 10 November the man saw the prison doctor to review his diabetes. He
told the doctor that he was now taking his medication and also watching his
diet. The doctor discussed the need for further investigation of the blood in
his urine and the risks of not doing anything. He agreed. The prison doctor
wrote a referral letter that same day to a consultant urologist, at York District
Hospital, and asked for an urgent appointment in his clinic.
24. The man had an appointment with the consultant arranged for 7 December.
On the day of the appointment the man refused to go to the hospital despite
encouragement from healthcare and wing staff. The consultant wrote to the
prison on 9 December to say that a future appointment would be made for the
man.
Events of 26 January 2010
25. A staff training day took place on 26 January 2010. This meant that the
prison was on “patrol state” and prisoners were in their cells rather than being
involved in other activities. At approximately 10.20am an officer responded to
the cell bell from the man’s cell. Through the observation hatch the officer
could see the man sitting on his bed. He told the officer that he had chest
pains and was having difficulty breathing. The officer ran to use the telephone
in the cleaner’s office and contacted the control room to make a Code Blue
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call (the code for a medical emergency when someone is experiencing
difficulty breathing).
26. An officer returned to the man’s cell and was joined by a Principal Officer (PO)
and Senior Officer (SO).. The officers went inside and reassured the man that
healthcare staff were on the way. Within one minute two nurses arrived and,
following a quick assessment, used a wheelchair to take him the short
distance to the healthcare centre.
27. Once in healthcare he was assessed by a prison doctor and an emergency
ambulance was called at 10.56am. Whilst waiting for the ambulance the man
talked to the doctor and the nurses. The ambulance arrived at 11.16am and
the paramedics took over the man’s care. They stabilised his condition before
transferring him to York District Hospital at 11.42am.
28. An escort risk assessment was completed, and the man was accompanied to
hospital by two officers but no restraints were in place. He arrived in the
emergency department at 12.05pm. The man received treatment from
hospital staff; however he went into cardiac arrest. The hospital staff
attempted resuscitation but the doctor pronounced him dead at 12.38pm.
29. The man’s next of kin was recorded as his sister, who lived some
considerable distance away. Due to the distance involved, Full Sutton
telephoned the nearest prison to the family, HMP Liverpool, to ask for the help
of their family liaison officer. Liverpool agreed and an officer, Family Liaison
Officer, went to visit his sister that afternoon to break the news of his death.
30. A debrief was held later that day for the staff involved in the emergency
response, with appropriate support offered by the Care Team. The wing staff
completed incident reports, but none were completed by the healthcare staff.
31. In accordance with the family’s wishes, Full Sutton made the arrangements
for his funeral and disposal of his property and belongings. The funeral took
place on 8 February and was conducted by the prison chaplain.
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ISSUES
Clinical Care
32. The man had long standing medical conditions, which were correctly identified
when he entered custody. The clinical review specifically commentated:
“The man had significant past medical history which included that of
previous myocardial infarctions, angina, hypertension, poor left
ventricular function, mild chronic obstructive pulmonary disease and type
2 diabetes mellitus.”
33. The clinical care reviewer judges that the care he received at Full Sutton was
equitable to what he could have expected in the community. The clinical
review made the following comments about healthcare services at Full Sutton:
“HMP Full Sutton has got facilities for managing long term conditions
which are comparable to the care expected to be provided in the
community.”
34. There were many occasions where he declined medical treatment, missed or
refused appointments. It seems that staff made considerable attempts to
engage with him, and encourage him to take his medication. They included
occasions where nurses and doctors outlined the importance and potential
risks of declining blood tests, medical investigations, and non compliance with
medication. The clinical review said;
“It is very clear from review of medical records that his compliance with
medication was extremely poor. This was despite repeated attempts by
the medical and nursing staff to explain to him the importance of taking
medication.”
Use of restraints
35. Unfortunately there have been too many reports where the Ombudsman has
been critical of the use of restraints when prisoners are under escort in
outside hospital. It is pleasing therefore to recognise that Full Sutton ensured
that the man was treated with dignity and respect during the emergency
response and treatment in hospital.
Incident reports and hot debrief
36. There are a number of rules, regulations and guidelines by which prisons are
run. They are outlined in Prison Service Orders (PSOs) and Prison Service
Instructions (PSIs). PSO 1400 “Incident Management Manual and PSO 8150
“Prison Service Post Incident care for Staff detail the procedures to follow
after a death in custody has occurred. Uniformed staff involved in the
emergency response correctly provided individual incident reports. However
healthcare staff did not provide reports despite being asked to by the Deputy
Governor. At the time that Mr Piercy was taken to hospital the prognosis
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would have been uncertain. However, as he died so shortly after arriving at
hospital, there was an expectation that healthcare staff would provide incident
reports when asked. Full Sutton appropriately followed PSO 8150 by
ensuring a debrief took place and support was available for staff.
Family Liaison
37. I am pleased to note that Full Sutton contacted HMP Liverpool to ask their
family liaison officer to contact the man’s next of kin. As Liverpool was closer
to the family home, it meant the news was broken face to face in a timely
matter and by an appropriately trained member of Prison Service staff. It is
therefore pleasing to see that Full Sutton followed this guidance, and
Liverpool readily agreed.
38. In addition, Full Sutton also took responsibility for arranging the man’s funeral
and handling all external communications. This was compassionate and in
line with the family’s wishes.
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CONCLUSION
39. During his time at Full Sutton, the man had well documented regular
interventions with doctors and other healthcare staff. I am satisfied that the
care that he received at Full Sutton was equitable to that expected in the
community. He had a responsibility for his own health and could have
accepted medical attention but often exercised his right to refuse treatment.
40. I believe that the man was treated with dignity and respect during the time he
was at Full Sutton. Following his death Full Sutton appropriately followed the
guidance given in PSO 2710, “Follow up to death in custody”.
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