Individual at Parc

Investigation into the circumstances surrounding the
death of a prisoner at HMP&YOI Parc
on 9 January 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2009
This is the report into the circumstances surrounding the death of a prisoner at
HMP/YOI Parc. After going through the reception process at Parc on 3 November
2008, the man was immediately located in the healthcare wing to be treated for his
existing medical conditions. He remained in the healthcare wing for most of the time.
On 9 January 2009, he was discovered collapsed in his cell by a nurse. Nursing
staff quickly responded and administered cardio pulmonary resuscitation which
continued until the arrival of paramedics. Sadly, resuscitation attempts were
unsuccessful, and the man was pronounced dead by paramedic staff at 4.21pm. He
was 58 years old.
I would like to offer my condolences to those who knew him and have been touched
by his death.
One of my investigators conducted the investigation on my behalf. I am grateful to
the Director of Parc and her staff for their assistance and co-operation. I am also
grateful to the Healthcare Inspectorate Wales who carried out a review of the man’s
medical care while in custody.
The clinical review concludes that the healthcare afforded to the man appears to
have been generally good. Medical records were in good order, and staff reacted
swiftly and correctly to resuscitate him when he collapsed. However, the report
expresses concern that the confusion that he exhibited a fortnight before his death
was not investigated more thoroughly to eliminate a medical cause. I concur with the
reviewers views and endorse two recommendations made by them.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2009
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CONTENTS
Summary 4
The investigation process 5
HMP & YOI Parc 7
Key findings 8
Issues 13
Recommendations 15
3
SUMMARY
The man was sentenced to 50 weeks imprisonment on 3 November 2008. On his
reception at HMP/YOI Parc he was assessed by a member of the healthcare team
who quickly identified the need for him to be located in the healthcare wing. He had
sores that appeared to be infected and these were re-dressed by the nursing staff.
The following day, a doctor who had been asked to see him concluded that he would
benefit from being admitted to the local hospital for his condition to be properly
assessed. He was escorted to Princess of Wales Hospital later that afternoon where
he was seen by a consultant. The hospital did not admit the man and discharged
him back to the prison with advice for medical staff on dressing the wounds on his
lower body.
Over the next few weeks, he was treated by nursing staff in line with a care plan that
had been agreed. However, it is recorded that he would often refuse to bath or allow
nurses to change his dressings despite the possibility of further infection if he failed
to do so.
He was seen by a member of the Independent Monitoring Board (IMB) on 30
December, after complaining of being assaulted by a nurse. The IMB member
spoke at length to the man and reported the complaint to the duty director who also
spoke to him. However, no formal investigation took place despite the serious
nature of the allegations. This has since been addressed by the Director of
HMP/YOI Parc.
The man was moved to a residential wing on 31 December as he had been
considered fit to do so by a doctor. His care plan remained in place and he was
taken to the healthcare unit every two days for his wounds to be re-dressed and to
use the bath. During one of these visits on 6 January, it was found that his wounds
had become further infected. He was re admitted to the healthcare wing and his
care plan revised.
At 4.00pm on 9 January 2009, a nurse unlocked him and found him lying on the floor
of his cell. The nurse called for help and, along with her colleagues, administered
cardio pulmonary resuscitation (CPR). An ambulance was called and the nursing
staff continued CPR until the arrival of paramedics. Paramedics gave further
treatment and continued first aid, but at 4.21pm they pronounced the man dead. He
was 58 years old.
He died from natural causes, but the exact cause of death has yet to be established.
Funeral arrangements were made by the prison, in consultation with a rabbi, as he
was estranged from his family.
I am satisfied that the care given to the man during his sentence was generally
appropriate and that staff made every effort to resuscitate him when he was found. I
have endorsed two recommendations arising from the review into his medical care. I
also reflect on the prison’s response to the complaint of bullying/assault he made.
4
THE INVESTIGATION PROCESS
1. The Director of Parc, provided the man’s prison and medical records for
examination. Notices were issued to staff and prisoners to inform them of the
investigation process and to give them the opportunity to speak with the
investigator. No responses were received.
2. My investigator visited Parc on 19 February and met with the liaison officer.
While at Parc, the investigator spoke at length with a member of the prison’s
Independent Monitoring Board (IMB), who had seen the man in December.
The member of the IMB raised concerns regarding allegations of bullying, and
these were looked into by my investigator. He also spoke with the nursing staff
that had been responsible for caring for the man at Parc.
3. The investigator wrote to HM Coroner to inform him of the nature and scope of
my investigation and to request a copy of the post mortem report. A copy of my
report will be made available to the Coroner to assist with his enquiries.
4. Healthcare Inspectorate Wales, conducted the clinical review of the man’s
medical care. During this process, they looked at all the available
documentation and also obtained further information that was not initially
available in relation to the wound management in place at HMP Parc. In
addition, the review has looked at the treatment the man received at Princess
of Wales Hospital.
5. A Family Liaison Officer (FLO) from my office was appointed. The man had not
had contact with his family for some time before his death. My investigator was
able to contact the rabbi in Cardiff who had known him and his family. The
rabbi confirmed to the investigator that the man’s elderly mother and sister had
been notified of his death but had no wish to be contacted further or involved in
the investigation.
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HMP&YOI PARC
6. HMP&YOI Parc is a modern prison that opened in November 1997 on the
outskirts of Bridgend, South Wales. It is operated by G4S and is the only
privately run prison in Wales. The prison holds sentenced male adults and
sentenced and remand young offenders in addition the prison also holds young
people (those under 18 years of age.)
7. Primecare Forensic Medical Services provide healthcare services at Parc and
employ three doctors and 25 nurses. The healthcare centre has 24-hour
primary care and 13 in-patient beds.
8. HM Chief Inspector of Prisons, Dame Anne Owers, last inspected the prison in
2006. In her report on the inspection, Dame Anne said of healthcare:
“An impressive and varied range of healthcare services was available,
although prisoners’ perception of provision was poor in comparison to
the benchmark. Primary care clinics were well established and all
nursing staff had individual responsibility for specific clinical areas.
Inpatients had long periods out of their cells and good levels of
interaction with staff. Dental services were very good and the waiting
list had been significantly reduced over the previous six months. There
was excellent support from the mental health services, which were well
established but struggling to meet the needs of prisoners because of
insufficient staffing. Relationships with local NHS organisations were
extremely good and there was evidence of good joint working.”
9. The Independent Monitoring Board at Parc published their last annual report in
August 2008. In concluding their report the IMB said of Parc:
“During the current reporting period, HMP & YOI Parc again made
conspicuous ongoing efforts to ensure that all prisoners felt safe and
were treated humanely and with dignity and fairness by all those
charged with their care.”
10. As noted above, my investigator spoke with a member of the IMB who had
spoken to the man following a complaint he had made about bullying. She told
my investigator that she had concerns about the investigation carried out by the
prison following the man’s complaint. However, it is also right to say that in
their most recent report the IMB commended G4S on the rigour of its approach
to bullying at Parc.
11. I was given responsibility for investigating all deaths in prison custody in April
2004. During this time, there have been nine other deaths at Parc attributed to
natural causes. Recommendations that I have made as a result of these
investigations are not repeated in this report.
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KEY FINDINGS
12. The man had been made the subject of an Anti-Social Behaviour Order (ASBO)
in February 2004. This was in relation to abusive and threatening behaviour
towards medical staff, particularly female nurses at his local surgery. In view of
this, his medical appointments had to be at a specified surgery, with notification
to the local police. He breached the order in June 2008 when he became
abusive during a medical appointment. He was subsequently convicted on 6
October and remained on bail awaiting sentence. On 3 November 2008, he
was sentenced to 50 weeks imprisonment and went to HMP/YOI Parc. This
was the second time that the man had been in custody. He had previously
served a 28-day sentence at HMP Cardiff in 1994 in relation to non-payment of
fines.
13. On arrival at Parc, the man went through the normal reception procedures, part
of which involved a health screen conducted by a nurse. When asked by the
nurse whether he had seen a doctor in the last few months, he said that he had
been admitted to University Hospital of Wales (UHW) in Cardiff to be treated for
septicaemia in August 2008. (Septicaemia, also known as blood poisoning, is
the presence of bacteria in the blood stream that can lead to sepsis – a serious
medical condition which affects the vital processes of the body such as blood
pressure, breathing and organ function and can lead to death.) The man also
told the nurse that he was allergic to penicillin and had received treatment for
depression some four years earlier. The nurse recorded on the health screen
that the man’s general appearance on reception was unkempt and he had
extensive sacral (lower body) wounds. In view of his physical condition she
referred him to the doctor and arranged for him to be located in the healthcare
wing.
14. Once the reception process had been completed, he was located on the
healthcare wing and a second nurse continued the medical admission process.
The nurse recorded the following during her assessment:
“… Appears flat in mood. When discussing sacral/buttock wounds
appeared unconcerned and said that, he had had them for years.
Appears to of (sic) had a very transient lifestyle. No current GP. No
thoughts self-harm or suicidal intent. Openly admits to being unable to
care for himself or his flat, does his own shopping but survives on
ready meals and pizza.
Refer to doctor reference pain relief and wounds. Wounds to be
dressed daily and referral to Social Services.”
15. After completing the admission process, a third nurse assessed the wounds on
the man’s buttocks and lower body. The nurse wrote in his medical record:
“… Different stage wounds, superficial to Dermis depth. Surrounding
skin macerated. Appears to have been redressed with only allevyn
[type of dressing]. Areas cleansed, swabs taken left and right,
redressed with aquacell [moisture retaining dressing].
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Numerous stage 1 &2 wounds to right calf. Previous mesh dressing
still in place. Cleansed, redressed with iodine and dressing secured.
Offered entonox [pain relief often referred to as ‘gas and air’] but
declined. He said that he was being treated at Cardiff Royal Infirmary
(CRI) twice a week but did not know the name of the doctor.”
16. A care plan was put in place for nursing staff to treat and dress the wounds.
The day after his arrival, he was seen by a prison doctor who felt that the
wounds needed to be assessed at the local hospital. The doctor wrote to the
hospital indicating that the man had previously had septicaemia. In order to
obtain some further background on his treatment at University Hospital Wales,
a nurse also contacted the records department.
17. He was escorted to Princess of Wales Hospital, Bridgend, later that afternoon.
He was initially assessed by a triage nurse, then a doctor, skin specialist and a
nutritionist. Swabs of his wounds were taken and the areas were again
cleaned and dressed. Initially, the doctor told him that he was likely to remain
in hospital for a few days. The man was unhappy about this. However, at
around 5.50pm that day the prison escort staff contacted the healthcare
department at Parc and advised a nurse that the man was being discharged.
18. A nurse was asked to contact the hospital to enquire why they had decided not
to admit him. She was told by the senior nurse in the Accident and Emergency
Department that the man had been seen by a consultant who was content for
him to be discharged back to Parc. The senior nurse said that the doctor had
suggested that iron supplements be added to the man’s medication and that he
must have a high red meat diet. The nurse was also told that a tissue viability
nurse had reviewed the wounds on his body and considered them to be
superficial and exacerbated by incontinence of urine. Dressings would be done
prior to his discharge and a detailed letter would be sent back with him to Parc
outlining the treatment given.
19. The nurse who had spoken with the hospital spoke with the man later the same
evening on his return from the hospital. She noted that he looked tired and that
he asked for some toast and crisps. She suggested to him that he should
make a list of the foods he liked and those he was unable to have due to his
Jewish faith. Healthcare staff also ordered a special mattress, recommended
by the hospital specialists, to relieve the pressure on his wounds.
20. On 6 November, the man was interviewed by a forensic psychiatrist. During
the interview, he discussed his family history and the breakdown of the
relationship with his family. He said that he had suffered from the sores for
around eight years and had seen a wound specialist, at UHW, but did not
mention receiving any treatment. He described his mood as “alright” but also
spoke of attempting suicide in September 2008. He said that he had taken an
overdose of pain killers but then felt sick and called an ambulance.
21. When asked about his life before he entered custody, the man said that he had
lived alone in a rented house since 1995, after having to sell his own property.
He regretted losing his fortune and described himself as having no friends. He
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said he did not cook for himself. The psychiatrist recorded that there was
evidence of self-neglect and lack of motivation. It was concluded that more
information was required from the local health authority before the possibility of
anti-depressant medication could be considered. The psychiatrist planned to
review him in a week.
22. The healthcare team at Parc continued to try and obtain his medical records
from Cardiff Royal Infirmary. Some information they received indicated that on
15 September 2008 he had been admitted to Whitchurch Hospital in Cardiff as
a result of drinking bleach, but later discharged. The prison was also told that
the man had been extremely violent in the past towards NHS staff and non-
compliant with treatment offered to him.
23. On 20 November, a psychiatric review was completed which recorded that he
was settled and feeling better. The man said that he spent the majority of his
time watching television and that he liked football and soap operas. Although
he was still having physical health problems, he was more mobile. He told the
psychiatrist that he wanted to move on and start his life again. It was decided
that the man did not require anti-depressants at that time but this should be
kept under review and he would be seen again in one to two months.
24. During the remainder of November and the early part of December, healthcare
staff continued to encourage him to tend to his personal hygiene but he often
declined. His wounds were dressed in accordance with the care plan but again
there were times when he would refuse to have this done, despite the possible
consequences being explained to him. The clinical reviewer mentions this in
their report, and says that “slow improvements were noted to the wounds, but
there was still some infection noted on 22 December. No swab was taken and
he was not given antibiotics to try and treat the infection.”
25. During the night of 24 December, it was recorded in the man’s medical record
that he had become verbally abusive and aggressive in his nature, but that this
was not his normal character. The nurse who made the entry, also highlighted
possible underlying infection as the cause of this behaviour and that there was
a need for a blood test to be carried out. The clinical reviewer has said in their
report that “there is no evidence in the medical record that wound swabs or
blood was taken for investigation to eliminate a medical cause for the man’s
confusion.”
26. On 30 December, the man made an application to see a member of the IMB
who visited him that afternoon. The man told the IMB that on 23 December he
had been forced to have his hair and beard cut by one of the nursing staff. He
alleged that he had been told that he would be held down by the orderly to
have his hair cut if he refused. (An orderly is a prisoner who is placed in a
position of trust and is employed to carry out tasks for which he is given a
bonus payment. They are also referred to as red bands or trusties.).
27. The IMB member was concerned by what they had been told. They
immediately reported the complaint to the Duty Director, who went to see the
man later that day. The IMB were also told that an investigation would take
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place into the allegations. The Duty Director subsequently wrote to the IMB to
explain that he had spoken to the man regarding missing property and had also
asked him about the allegation regarding his haircut. The Duty Director told the
IMB in his memo that the man had said that he did not wish to pursue the
complaint as long as he received new clothing on his release. When my
investigator visited Parc he spoke at length with the IMB about the allegations
made by the man. The IMB were concerned that the prison did not appear to
have taken the allegations seriously and that no investigation had taken place.
The only apparent action was that the healthcare orderly had been removed
from the wing for the remainder of that day but was reinstated the following day.
28. The day after making the complaint to the IMB, the man was reviewed by the
doctor and considered to be fit for normal location. My investigator asked
nursing staff whether the decision to move him out of the healthcare wing had
been influenced by the complaint he had made. He was told that this had not
been the case, and the doctor had considered that the man no longer needed
to be an inpatient. The man was moved from the healthcare wing and located
on a normal houseblock. The care plan recorded that he was to attend the
healthcare wing every other day to bath and have his dressings changed.
29. There is little recorded information about how he interacted with staff and
prisoners on the residential wing. His medical record shows that he went to
healthcare as planned to wash and have his wounds dressed.
30. The man was readmitted to the healthcare wing on 6 January 2009 as there
had been a deterioration in his wounds, and a revised care plan was put in
place. On 8 January, it was recorded that he should not be seen alone as he
had attempted to lunge at staff and had become aggressive.
31. At 4.00pm on 9 January, a nurse went to unlock him for association and found
him lying on the floor of his cell. (Association is when prisoners have time out
of their cells to make telephone calls, use the shower, interact with each other,
or watch television.) The nurse immediately shouted for assistance from other
nursing staff who were close by and called a code red via her radio. (Various
coding systems are used in prisons to alert staff to emergencies, with code red
usually indicating a medical emergency involving bleeding.)
32. A senior nurse and a second nurse went to the cell. The man was lying on his
left side. There was blood around his mouth and he had also been incontinent
of urine. In her statement, the second nurse said that the man was
unresponsive, with no pulse or breath sounds and his pupils were fixed and
dilated. The second nurse and a third nurse (who had also responded to the
code red call), and the senior nurse commenced cardio pulmonary resuscitation
(CPR). Defibrillator pads were placed on the man’s chest. (Defibrillation is a
method of delivering a therapeutic dose of electrical energy to the heart.) The
machine indicated no shock and CPR resumed. Emergency paramedics
arrived in healthcare at 4.13pm and inserted an airway into him while nursing
staff continued to administer CPR. The paramedics gave the man adrenaline
and intravenous fluids before taking over the CPR from the nursing staff.
10
Efforts to revive him continued until 4.21pm when he was pronounced dead by
the paramedics.
Actions after the man’s death
33. Following his death, the prison was unable to contact any next of kin. However,
prison staff spoke to the rabbi in Cardiff who knew the family and he said that
he would inform his mother and sister of his death. The rabbi said that they did
not wish to be contacted or to be involved in any funeral arrangements. The
prison arranged the funeral with the help of the rabbi and met all the costs.
34. The post mortem indicates that a life threatening bacterial infection was present
in the man’s wounds. However, no definitive cause of death had been
recorded at the time of issuing this report and further toxicology results are
awaited by the Coroner.
11
ISSUES
Healthcare provision
35. When the man arrived at Parc his health needs were quickly identified and a
care plan put in place. The medical staff acted swiftly to try and obtain further
medical information. The clinical reviewer also recognises this and the clinical
review says that:
”... Nursing staff were conscientious about obtaining the correct
mattress and diet for the man and dressing his wounds, as prescribed.
Improvements in his self caring, wounds and diet were noted in his
medical record until 25 December, when he became confused. In
hindsight the cause of the confusion should have been investigated
more thoroughly by medical staff to eliminate a medical cause ...”
With regard to the medical records provided by Parc following his death, the clinical
reviewer says that these were in good order but the review would have benefited
from having copies of the pathology results of tests carried out at Princess of Wales
Hospital on 4 November. The clinical reviewer also observes that, on the man’s
discharge from the hospital on 4 November, a handwritten note was sent with him
and this should have been followed up by a typed discharge summary. In view of
this, the reviewer makes the following recommendation which I endorse and the
Director may wish to raise this at the Prison Health Partnership Board.
The NHS should ensure that comprehensive, typed discharge summaries
are sent to the prison following a prisoner’s attendance at hospital.
36. As noted, the post mortem indicates a life threatening bacterial infection was
present in the man’s wounds. This has caused concerns regarding the
infection control in place in the healthcare wing at Parc. The reviewer makes
the following recommendation which I endorse:
The Head of Healthcare should perform an urgent review of infection
control procedures in healthcare to ensure cross infection is always
minimised.
Complaint of bullying made by the man
37. When he was seen by the IMB member, on 30 December he was very
distressed and upset. The IMB were concerned that what had allegedly taken
place constituted an assault and spoke to a senior manager. They were
assured that a full investigation would take place but it later became clear that
this did not happen. The IMB told my investigator they had gained the
impression that Parc felt that, as the man had died, there was no need to take
the complaint any further.
38. Following his visit to Parc, my investigator wrote to the Director, on 23 February
2009 to advise her what he had been told by the IMB and to ask what action
the prison had taken in relation to the matter. The director responded on 30
12
March. In relation to the man’s allegations about being physically threatened,
the director confirmed that a formal investigation was to be carried out. She
further explained that a formal investigation had not been instigated at the point
he made his complaint as the concerns had not been brought to her attention or
that of her deputy. The director gave the reasons as a breakdown of
communication on all sides, for which she apologised.
39. It is clear that the prison should have carried out a more timely and thorough
investigation into the serious allegations made by the man. However, I am
satisfied with the action to be taken now by the director and judge that the
prison has learnt from its failings. I therefore make no further recommendation
on this matter.
Conclusion
40. The man had, by his own admission, not cared for himself for a number of
years before entering prison, and this had affected his overall health. He had
lived alone and, apart from visiting betting shops and going to buy takeaway
food, had little contact with anyone else. When he came into the healthcare
wing at Parc, this was likely to have been the most one-to-one contact he had
enjoyed for some time. I have no doubt that he benefited from the care and
support that he was offered.
41. The man’s death was sudden and unexpected. The precise cause of death is
not yet known, but it seems clear that – in general – his existing medical
conditions were addressed promptly and appropriately by the prison. However,
I note the clinical reviewer’s recommendation about infection control. I also
note their concern that the cause of the man’s confusion should have been
investigated more thoroughly to eliminate a medical cause.
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RECOMMENDATIONS
1. The NHS should ensure that comprehensive, typed discharge summaries are
sent to the prison following a prisoner’s attendance at hospital.
2. The Head of Healthcare should perform an urgent review of infection control
procedures in healthcare to ensure cross infection is always minimised.
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