Individual at Wandsworth

Investigation into the circumstances surrounding the
death of a man
at HMP Wandsworth in March 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2011
This is the report of an investigation into the death of a man at HMP Wandsworth, in
March 2010. He was 51 years old. I would like to offer my condolences to his family
for their loss.
His death was caused by heart failure while he was in an agitated state during acute
alcohol withdrawal and also chronic alcohol abuse.
The man conducted the investigation on my behalf. The local Primary Care Trust
(PCT) was commissioned to conduct a clinical review into the standard of healthcare
he received while in custody. A clinical reviewer from the local PCT carried out this
review for which I am grateful. I would like to thank the Governor of Wandsworth,
and his staff for their co-operation and assistance.
The man came into custody on 23 March and died three days later. He suffered
from type 2 diabetes and also drank alcohol heavily before coming into custody.
Both facts were identified on his reception at Wandsworth, but the extent of his
drinking was not investigated and no treatment for either condition was provided. He
was of Sri Lankan origin and spoke little English. His behaviour deteriorated, and
was described by staff and fellow prisoners as “bizarre”.
On the evening of 26 March, the man’s cell mate told staff that he wished to move
cells as he was concerned about his behaviour. Staff saw the man acting in what
they perceived to be a threatening manner. A period of negotiation followed, during
which staff used another prisoner who spoke Tamil to speak with him and interpret,
in an attempt to calm him. However, this was unsuccessful, so staff went into the
cell and restrained him using Prison Service control and restraint techniques. During
the restraint the staff noticed that he was unconscious. All the restraints were
removed, he was placed in the recovery position and medical assistance requested.
Nursing staff administered cardio pulmonary resuscitation with the assistance of a
prison doctor. Unfortunately, attempts to revive him failed and at 7.32pm, the prison
doctor pronounced him dead.
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My investigation has found that there were a series of missed opportunities by
healthcare staff to identify the cause of the man’s behaviour. Most notably staff did
not correctly identify and treat his alcohol detoxification. These failures denied him
treatment and may well have caused his disruptive behaviour. I am however
satisfied that, in these regrettable circumstances, control and restraint was
appropriate and followed the approved techniques. The police investigation has
found the same. Nevertheless he must have found it a distressing and
uncomfortable experience and, had treatment been given, he might well be alive
today.
I make eight recommendations relating to clinical matters, provision for foreign
national prisoners, the induction process and cell sharing risk assessments. I am
disappointed to repeat some recommendations from earlier investigations at
Wandsworth. The Prison Service has accepted all the recommendations made, and
their response is added to page 32.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman January 2011
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CONTENTS
Summary
The investigation process
HMP Wandsworth
Key findings
Issues
Conclusion
Family response to report
Recommendations with Prison Service response.
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SUMMARY
The man went into custody at HMP Wandsworth on 23 March 2010. He was 51
years old and a Sri Lankan national with limited English.
When he arrived, a nurse assessed him and completed a medical screening. During
the screening process, the nurse recorded that the smell of alcohol was very
noticeable and, when asked about his alcohol consumption, he said that he drank six
to eight cans of lager daily. It was also recorded that he had type 2 diabetes for
which he was receiving regular medication. (Type 2 diabetes is usually found in
people over 40. It develops gradually over weeks and months and means the body
is either not producing sufficient insulin for the body’s needs or the cells in the body
do not use it properly.) He was then assessed by Prison Doctor A, who commented
that his community general practitioner (GP) should be asked to confirm the
medication he was taking. However, the doctor made no comment on the issue of
alcohol and did not refer him to other specialists.
After the reception process, the man was allocated to a shared cell in E wing. The
following day he moved to C wing. It is unclear as what information was given during
his induction and whether anything was provided in his own language. A fellow Sri
Lankan prisoner who befriended him on C wing said that when he first arrived on the
wing, he appeared confused as to what he should be doing, but physically appeared
well.
The man’s GP provided information about the medication by fax on 24 March.
Despite confirmation that he was taking regular medication, none was prescribed to
him.
On 25 March, staff and other prisoners commented that the man’s behaviour had
become “bizarre” and that he was shaking. There is no indication that any concerns
were raised with medical staff at this time. During the early hours of 26 March, the
cell mate complained that the man’s behaviour was worrying him and asked staff to
move the man. When the senior officer (SO) opened the cell, he saw that he was
wearing a sheet and a pillowcase on his head. However, he was not being
aggressive and the senior officer walked with him to E wing where he was given a
single cell. He continued to behave in a “bizarre” fashion, and an officer wrote in the
wing observation book that a referral to the Mental Health In-Reach Team (MHIRT)
might be advisable.
Despite the concerns raised that morning by the cell mate, staff allocated the man to
another shared cell on C wing just before lunchtime on 26 March. Throughout the
remainder of the afternoon, both staff and fellow prisoners commented on his
behaviour and a nurse was eventually asked to assess him. His blood sugar levels
were checked, as it was considered his behaviour might have been caused by his
diabetes, but they were normal. The senior nurse who had seen him also
commented on his behaviour and spoke to Prison Doctor B who said that he would
look at the medical record to see if any underlying cause could be identified.
However, when the senior nurse spoke to him later he said that he had identified
nothing, but said that staff should monitor the man.
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At around 7.00pm on 26 March, the new cell mate also asked to be moved as the
man’s behaviour was causing him some concern. A member of staff asked her
colleagues to help find another cell. When they returned to the cell some minutes
later, the man was standing behind the cell door and shouting in Tamil. He was also
holding a plastic knife and a waste paper bin. The staff immediately asked the
orderly officer to come up to the cell as they were unable to communicate with him
and he did not respond to their requests for him to move away from the door. (The
orderly officer is in charge of the prison at night, as there is a reduced level of staff.)
The orderly officer was dealing with something else at the time and SO A attended in
his place along with the Duty Governor. Staff explained the situation and the SO
attempted to talk to the man. When this failed, staff asked another Sri Lankan
prisoner to interpret for them. Although the prisoner attempted to calm him down, he
found that he was not making any sense. The staff then decided that it was
essential to take the cell mate out of the cell so that he was safe. They opened the
door, but as they did so the man grabbed it and it had to be closed again.
As he was still holding the knife and bin, the SO along with two other staff took out
his baton and attempted to reopen the door. He came towards them and the bin was
knocked from his hand with a baton. Staff then attempted to restrain him using
techniques approved by the Prison Service. He reportedly continued to struggle and
was eventually brought under control and handcuffs were applied.
Once the handcuffs were placed on the man, staff noticed that he had stopped
resisting and there appeared to be no response from him. They sat him up and it
became clear that he was unconscious. The handcuffs were immediately removed,
he was placed in the recovery position and medical assistance was summoned via
the radio.
A nurse arrived within a few minutes and on checking him, immediately recognised
that he was not breathing and no pulse could be detected. Staff gave cardio
pulmonary resuscitation (CPR) and called the duty GP. However, after around 20
minutes, the decision was taken to stop CPR and the GP pronounced the man dead
at 7.32pm.
Later that evening, a governor and the prison chaplain visited the man’s family to
break the news of his death. The governor remained in contact with the family and
advised them about progress on the Coroner’s actions as well help with press
coverage of the death and financial assistance with the funeral.
Staff involved were offered the support of the care team. A debrief of the staff
involved took place and other prisoners who were subject to suicide monitoring
procedures were supported following the death.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 29 March by a colleague, on behalf of the
investigator. The colleague was told that the police were treating the man’s
death as suspicious at that stage. He advised the investigator of this and
collected the relevant documentation.
2. Notices were issued to staff and prisoners informing them of the investigation
process and inviting anyone who had relevant information to come forward. No
responses were received.
3. In accordance with the Ombudsman’s terms of reference, the local PCT were
commissioned to conduct a clinical review into the care and treatment of the
man at Wandsworth. A clinical reviewer for the local PCT conducted the review
and a copy of his report is attached. In addition to the clinical review, the
investigator asked the PCT to consider commissioning a report from an expert
in alcohol detoxification, but they did not deem this necessary.
4. The investigator telephoned the Governor, who was acting as the contact point,
on 31 March. He introduced himself as the investigator and discussed the
initial concerns surrounding the man’s death. They agreed that he would
arrange interviews with staff once the outcome of the police investigation was
known.
5. On the same day the investigator also contacted the Detective Inspector (DI)
who was leading the investigation for the Metropolitan Police. They agreed to
share relevant information with each other, such as police statements and the
report of the clinical review. The DI confirmed that the PPO investigation
should run in tandem with that of the police. The investigator contacted the DI
during the investigation, so that they could update each other on their findings.
The police investigation focused on the use of restraint, and following
interviews with those staff involved, concluded that there were no further
actions to be taken.
6. One of my family liaison officers (FLOs) contacted the man’s family and
explained the role of my office in relation to the investigation. She and the
investigator visited the family at their home on 11 June. The family shared their
concerns and questions about his care. They are summarised below and are
addressed within the body of this report:
• He does not appear to have been given any alcohol detoxification or
any medication to manage his existing health conditions while he was
at Wandsworth.
• Why his diabetes does not appear to have been considered as the
reason for his strange behaviour and why no further healthcare
intervention was not requested?
• The appropriateness of using other prisoners to act as translators.
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• The accuracy of information provided by Wandsworth following his
death.
7. The family have also responded to the initial draft report and their response can
be found on page 31 of this report.
8. The investigator wrote to HM Coroner to inform him of the nature and scope of
the investigation. The initial post mortem was inconclusive and further tests
were requested. Toxicology tests proved unremarkable. The tests relating to
the man’s heart indicated, in the absence of a toxicological explanation, that he
had been suffering from “excited delirium” leading to sudden cardiac arrest.
The issue of excited delirium is explained further in the issues section of this
report. The official cause of death is given as:
1A – Sudden cardiac death while in an agitated state during acute alcohol
withdrawal.
1B – Chronic alcohol abuse.
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HMP WANDSWORTH
9. HMP Wandsworth is a local prison in South London. It has the capacity to hold
up to 1,644 sentenced or remand adult males. The prison has two main wings,
Heathfield that comprises five separate wings and Onslow which houses
vulnerable prisoners. In addition, there is a healthcare unit with inpatient
facilities.
10. In July 2007, Wandsworth Teaching PCT commissioned a private company,
Secure Healthcare, to provide healthcare services at Wandsworth and employ
the medical staff. However, the company went into liquidation in September
2009. The healthcare team is currently employed by the part of NHS
Wandsworth which provides services, rather than commissions them.
11. Healthcare provision is divided between primary care (treating physical health
problems), substance misuse (treating drug and alcohol users) and the Mental
Health In-Reach (MHIRT) team (treating mental health problems), which is
funded by South West London and St George’s Hospital Mental Health NHS
Trust. The MHIRT has the equivalent of one full-time consultant psychiatrist
and one staff grade psychiatrist post. The team also includes three community
psychiatric nurses (CPNs), one of whom acts as the team manager.
12. The Addison Unit is a 12 bed inpatient unit accommodating prisoners with
severe and enduring mental health needs who are experiencing acute
difficulties. The unit won an award in 2009, recognising the service it provides.
There are no inpatient facilities for prisoners with physical health problems.
There are two treatment rooms on the Onslow Centre. The prison pharmacy
uses a number of technicians to carry out its functions.
13. HM Inspectorate of Prisons (HMIP) published a report into the the most recent
inspection ofWandsworth in September 2009. The former Chief Inspector was
critical of Wandsworth but much of her report focussed on issues that do not
relate to this investigation. She also reflected on other areas that are relevant
to the man’s care.
14. Commenting on first night and induction procedures, the Chief Inspectorate
said:
“ … All new arrivals were moved to the first night unit, which was next to
the reception area, thus facilitating speedy movements. They were
interviewed in private by a first night officer, who focused on safety issues,
including completing the cell-sharing risk assessment. Prisoners were not
located to a cell until this had been completed. Four prisoner Insiders,
some of whom were Listeners and a Prison Advice and Care Trust
(PACT) worker also worked on the first night landing. They provided a
range of support, information and advice about the prison, including some
induction materials. Relationships were observed to be positive and
respectful and the general atmosphere relaxed and welcoming. All new
prisoners received an initial health screening on the first night centre from
a nurse and also had the opportunity to be seen by the GP …”
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“…Newly arrived main location prisoners were moved to C wing on the
afternoon of their second day at the prison, and formal induction
commenced on the next working day. Induction was comprehensive and
split into four elements: an interactive computer program providing
information about the prison, followed by sessions covering resettlement,
skills assessment, and health and safety and the gym. The computer
package used had been developed specifically for Wandsworth and
contained opportunities to test out learning and receive feedback.
Delivery of this element was heavily dependent on induction orderlies,
who provided ongoing support to prisoners, with supervision from
dedicated induction officers. Each element of induction was delivered on
a different day to allow time for reflection and consolidation, but this could
be spread over a two-week period. A parallel induction was run for
vulnerable prisoners on Onslow unit, but there were significant delays in
these prisoners receiving the health and safety and gym element. A
written induction booklet was available, but some information in this and
the computer program was out of date. Despite the large number of
prisoners held with little or no use of English, much of the induction
information specific to the establishment was not available in any other
languages. An assessment of resettlement needs was completed and
resulted in referrals to a range of interventions. A system had recently
been introduced to ensure that all elements of the programme were
complete before movement on to another wing …”
15. The man was a foreign national prisoner who had a poor grasp of English. On
provision for foreign national prisoners, the Chief Inspectorate made the
following comments:
“ … Wandsworth had been identified as a main centre for foreign national
prisoners, and there was a large foreign national population. The full-time
foreign national’s coordinator had not been formally trained. A foreign
nationals committee met quarterly but did not use monitoring to inform its
work. A network of orderlies provided a valuable service, but insufficient
attention had been given to ensuring that the specific needs of foreign
nationals were reflected in all aspects of prison life. Prisoners were able
to provide interpreting services, but were sometimes used inappropriately
and the professional interpreting service was underused. A lack of
translated documents left some prisoners feeling isolated and uninformed.
Some foreign nationals were unaware of facilities for keeping in touch with
families because of their poor understanding of English …”
16. The Chief Inspectorate also commented on the healthcare provision:
“ … Patients received thorough reception screening, but there were gaps
in the provision of care, with only one life-long condition clinic being run
and no immunisation clinics. There were a number of staff vacancies on
the primary care team, resulting in an over-dependence on bank and
agency staff and an inconsistency of approach to prisoners. Healthcare
staff did not work as an integrated team. There were links with outside
care providers, but too many external appointments were cancelled or
missed. Dental services were good. There were a considerable number
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of pharmacy issues requiring attention. There were no inpatient services
for prisoners with physical illnesses. Mental health services appeared
good and were responsive to prisoners’ needs …”
17. She made a number of recommendations to the prison. It is apparent from my
investigation that some of the issues remain outstanding and I make similar
recommendations on the subjects of healthcare, foreign national prisoners and
first night/induction procedures.
18. Every prison and immigration removal centre has an Independent Monitoring
Board (IMB), comprising members of the public. IMB members are volunteers
and they monitor the day-to-day life in their local prison or removal centre to
ensure that proper standards of care and decency are maintained. They
publish an annual report to the Secretary of State for Justice which outlines
particular areas of concern or good practice at their particular prison. The IMB
published a report for the period June 2008 to May 2009. They drew attention
to a lack of major languages on the induction computer programme, and said
some prisoners depended on others speaking their language to operate the
system.
19. On the issue of healthcare provison, the IMB highlighted that there was a
dependence on only a few senior nurses, and they were concerned about
incidents involving handling and issuing drugs. The Board also mentioned
concern that specialist clinics had not been set up and there was no evidence
of new policies or procedures being implemented. Since the publication of both
the IMB and Inspectorate reports, a new management structure has been put in
place at Wandsworth.
20. All prison officers are trained in basic approved control and restraint techniques
as part of their initial training. All staff must take a yearly refresher course to
ensure they remain competent in these techniques. In addition to the basic
control and restraint, some staff are trained in advanced techniques, but this is
voluntary.
21. The Prison Service Order (PSO) 1600 sets out the rules regarding the use of
force. It lists four points that define the lawful use of force, these are,
reasonable, proportionate, necessary and no more force than is necessary in
the circumstances. These points must be adhered to by all staff involved in any
restraint of a prisoner.
22. The Prison and Probation Ombudsman was tasked with investigating deaths in
prison custody in 2004. Since then, there have been a total of nine deaths,
prior to the man’s, attributed to natural causes at Wandsworth. In some of the
investigations that followed these deaths, recommendations about healthcare
provision were made. I repeat recommendations relating to healthcare as a
result of this investigation.
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KEY FINDINGS
23. The man was 51 years old when he died. He was born in Sri Lanka. He lived
there until 2000, when he came to the UK as an asylum seeker. He had not
worked since arriving in the United Kingdom due to his limited English. He had
received police cautions in the past for violent and alcohol related behaviour,
but this was his first time in prison. He was married and is survived by his wife
and three daughters.
24. He went into HMP Wandsworth on 23 March 2010. He had appeared at
Magistrates Court earlier that day, where he had been sentenced to four
months imprisonment. His daughters told the investigator that they had not
seen their father before he went to court and a custodial sentence had never
been considered likely by his family.
25. On reception at Wandsworth, the man was initially interviewed by Officer A who
completed reception paperwork, including a cell sharing risk assessment
(CSRA). (The purpose of the CSRA is to find out whether a prisoner is suitable
to share a cell and to gauge the level of risk posed to a cell mate. A series of
questions are asked to find out whether the person is either racist, prone to
violent outbursts or has history of bullying etc.) He was considered suitable to
share a cell. He then moved onto the first night centre where a more in-depth
assessment of his medical history was completed by Nurse A.
26. Nurse A has been a general nurse at Wandsworth since April 2000, and has
worked in most areas of the prison. He wrote on the medical section of the
CSRA that there was “insufficient evidence to give opinion” in relation to the
man’s suitability for cell sharing prior to completing the health screen. The
escort record that had arrived with him from court indicated that he was diabetic
and had breathing problems, and the nurse confirmed that he would have been
aware of the information on it. When he completed the health screen he
recorded:
“… No obvious signs of alcohol problems, 3-4 cans daily. The man states
that he is type 2 diabetes but cannot remember the tablets he takes, he
also drinks alcohol a lot – still smelling of alcohol. Refer to GP …”
27. At interview, the investigator asked Nurse A whether he was trained to
recognise people who came into custody with alcohol or drug problems. He
said that by the nature of his work, he would come across prisoners in
reception with all kinds of problems, and refer them to either the doctor or
substance misuse team. However, he had no specific training in substance
misuse.
28. When asked about the CSRA he had completed, the nurse explained that the
man would have initially been assessed by another nurse in reception who
would have recorded details such as date of birth and registered him on to the
Electronic Medical Information System (EMIS) before he went to the first night
centre.
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29. The man spoke very little English. Nurse A was asked what provision he made
for this during the health screening and whether he felt the man had been able
to understand the questions being asked. The nurse replied that when he had
unlocked him to conduct the screening, he was in a cell with another Sri Lankan
national who spoke fairly good English. He used this prisoner to explain his
questions to the man. Prison staff have the use of interpreting services which
can be accessed via the telephone, but it does not appear that this service was
considered by the nurse.
30. During his screening of the man, the nurse said that he learned that he was
type 2 diabetic, and also noticed that he smelt strongly of alcohol. In view of
this he wanted to establish how much alcohol he drank and was told that it was
about four to six cans of lager daily. He said that because the smell of alcohol
was so strong and that he had established the man was a diabetic, he knew
that he would have to be assessed by the doctor. He explained his reasoning
as firstly the man took medication for diabetes, and secondly the strong smell of
alcohol which led him to believe that he would require some form of
detoxification.
31. Nurse A explained that, while he was not part of the substance misuse team,
the nature of his work meant that he was familiar with prisoners with drug or
alcohol issues. He said that it would be normal practice for such prisoners to
be referred to the substance misuse nurse following his screening and that of
the GP. However, the man was not referred which he could not explain, but he
confirmed that it was the normal procedure at Wandsworth.
32. In relation to the man disclosure that he was type 2 diabetic, the nurse said that
a verification form would be completed and faxed to his GP in the community to
clarify the medication he was receiving. Prison Doctor A assessed him
following the screening by the nurse. The investigator was unable to contact
the doctor but his entry in the medical record said:
“… Patient reviewed no immediate concerns. Past medical history of
diabetes. Sarcoid has OPD (out patient appointment) every 6/12. Contact
GP for past medical history and meds …”
33. Prison Doctor A made no reference to the concerns on the health screening
about alcohol despite having access to the screening form, and no mention is
made of checking the man’s blood glucose levels at that time. Neither does the
documentation indicate how the doctor conversed with him, given his lack of
English.
34. There is documentary evidence that the verification form was completed and a
response detailing all the medications was received by the healthcare
department at Wandsworth on 24 March. Despite this confirmation, which
included his diabetic medication, nothing was prescribed immediately by the
prison. Nurse A told the investigator that he could see no reason why it would
take two days for medication to be prescribed after the verification was
received.
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35. In addition to the list of the man’s existing medication, the GP also attached
letters relating to outpatient appointments that he had attended. One letter was
from the Consultant in Respiratory Medicine dated 9 September 2009 that
mentioned a history of alcohol excess with abnormal liver function tests.
Healthcare staff do not appear to have investigated this further. None of this
information was updated onto System 1 which would have provided nursing
staff with more information about reasons for the later deterioration in his
health. (System 1 is the electronic medical database that has recently been
introduced into the prison estate.)
36. Following the reception procedures, the man went to the First Night Centre, E
wing. At Wandsworth, this wing also contains the detoxification unit. (The First
Night Centre accommodates prisoners when they come into custody. While on
this unit, they will have a secondary health screen.) However, no further input
from nursing staff or substance misuse staff is recorded. On 24 March, the day
after his arrival, he moved to C wing where he took part in an induction.
(During induction, prisoners are given advice on what to expect in prison, the
prison routine, rules and, processes such as obtaining visits, goods and
services, as well as advice on completing forms.)
37. The man had been considered as suitable to share a cell. Prisoner A who
worked on the servery on C wing and spoke Tamil (one of the languages of Sri
Lanka), told the investigator that he first noticed the man on 24 March when he
went to collect his meal. He did not notice anything unusual about him, and he
appeared to be all right. He said that they did not have a long conversation, but
spoke briefly.
38. Prison staff recorded little about the man during the first couple of days that he
was in custody, but on 25 March while collecting his meal, he spoke again to
Prisoner A. He told him that he had mentioned his medication during the
reception process, but had still not been given anything. The prisoner said that
the man appeared to him to be shaking. As he was in the middle of serving
meals he was unable to leave, so he told him to wait until he had finished.
However, it appeared he was unable to stay and said to him “ok, I will go and
speak to the doctor”.
39. A short while later, the man returned to the servery and asked the prisoner if he
could write his name and prison number down for him, which he did. The
prisoner told him that he would go and see him in his cell later that evening,
and was under the impression that at this point he had seen the doctor. Their
conversations were all in Tamil. There is no evidence that suggests a doctor or
any other medical staff saw him that day. We know that he asked the prisoner
to write his name and prison number for him and this may have been in order to
complete a request form to see a GP, however, no such form was provided for
the investigator.
40. The prisoner said that, after he had finished his work on the servery, he went to
the man’s cell and spoke to him. The cell door was closed and he appeared to
be grabbing or scratching at the door. He went back around 40 minutes later
when the wing was unlocked for association, but his cell mate said that the man
was not there and he did not know where he had gone. (Association is when
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prisoners are out of their cells and make telephone calls, take part in other
activities and socialise together.) The investigation found no documentary
evidence to indicate he had moved cells or had been taken to see a nurse
during that time.
41. Officer B, who was working on C wing, also recalled her interaction with the
man on 25 March. She said that during the serving of the evening meal he
indicated to her that he required medication. She said that he could not speak
English and made a gesture with his hands as though he was taking a tablet
and also mentioned diabetes. When she realised what he was trying to tell her,
she directed him to the treatment room on the wing. She said that he went off
the landing and she assumed that he went to the room. She saw him on his
return, he thanked her and he was locked back in his cell. She could not recall
seeing him with any medication.
42. An entry in a wing observation book refers to the man having to be moved from
his cell during the early hours of 26 March, as he was not getting along with his
cell mate. Senior Officer (SO) B was the orderly officer that night and provided
an account of his interaction with him. He said that he was made aware by the
staff on C wing that the man’s cell mate had said he “could not put up with him”
any longer. The SO went to the cell to find out what the problem was and
spoke with the cell mate who told him, “two days of this gov, no more, get him
out”. He said that at this point the man came out of the toilet wearing a sheet
and had a pillow case on his head. He was smiling and appeared pleased to
see the SO who considered it necessary to move him to avoid any further
problems. He said that when the man left the cell he was happy. The SO felt
that he was displaying either signs of mental health problems or being very
elated, to the point that the SO said that it was “quite comical”.
43. The SO explained that, when the man left the cell, he hurried along the landing.
As he did so, he checked each cell door, before informing the SO that they
were locked. He eventually followed the SO to E wing where he was given a
single cell. The SO described his behaviour as not aggressive but quite
“bizarre”. Officer C was on duty on E wing when the man got there and he
wrote in the wing observation book.
“… From C wing not getting on with cell mate. Moved by Oscar 1.
Appears to have mental health problems. At the time of writing this he has
been rambling on in a foreign language for over 3 hours. It may be a good
idea if in-reach spoke to him. He was presenting some strange behaviour.
Has been trying to get the door open from the inside, he has tried to slide
the observation glass down. If you look at him through the observation
glass he tries to see you through solid metal …”
44. Officer C was asked during the investigation about his interaction with the man.
He said that within five minutes of his arrival on the wing he began pressing his
cell call bell. (Each cell has a bell to be used by prisoners in an emergency or if
they require staff attention.) He went to the cell and asked him what he
wanted. The man then tried to look through the door at him, he then began
saying “it’s gone, it’s gone” and appeared to be searching the cell. The officer
explained that there was little in the cell, but he lifted his mattress, looked in
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cupboards, lifted chairs and looked in the toilet. The officer tried to ask him
what he had lost, but got no response. He then sat down on his bed and,
despite attempts to engage him in conversation, he did not reply. The officer
was unsure whether he understood English, although he had said “it’s gone”,
and left him alone. He added that after around 20 minutes, the man began
talking in a foreign language. Again he asked what the problem was, but he
continued to speak in Tamil and appeared oblivious to him.
45. The officer continued to check on him. When he returned to his cell later, the
man was holding a towel and using it to try and slide the observation glass
down. (Cell doors are fitted with a panel of glass to enable staff to see
prisoners without opening their door. The panel on the cell could not be
moved.) The officer said that when attempts to move the panel with the towel
failed, he began using his hands to try and slide it down. He gripped the edge
of the door and appeared to be trying to pull it open. The officer’s impression
was that he was in a “confused state”.
46. The investigator asked whether the officer found the man confrontational during
his interaction with him. The officer said that he did not have that impression
and the man ignored him as though he was not there. He said that it was very
strange and had prompted him to make the entry in the observation book that
the man should be seen by the MHIRT. He did not make a referral himself or
contact anyone from the healthcare centre, but believed that the entry in the
observation book would be followed up by the day staff, who would make the
necessary arrangements. He left duty at 7.00am on 26 March when the man
was still talking loudly in Tamil, so he thought that the day staff would have
heard him and been aware.
47. The officer was asked whether any discussion took place about the man’s
suitability to share a cell or whether the CSRA was reviewed. He replied that
this had not been mentioned to him. Little is documented about the man’s time
on E wing after Officer C’s entries in the wing observation book, but it is known
that he moved back to C wing into another shared cell later that morning.
Events following the man’s return to C wing
48. Officer D was working on C wing when the man returned. She was responsible
for arranging the movements of prisoners. She said that prisoners were
normally moved between wings after lunch, but she recalled that he returned
just before lunch at around 11.30am. She was unaware that he had moved
cells the previous evening and there was nothing to suggest that he should not
be located in a shared cell. She said that there were no entries in his wing
history file. According to the CSRA he was considered ‘low risk’ and could
therefore be in shared accommodation. This was her only contact with him
during that afternoon.
49. In a statement given to the police, the cell mate said that the man moved into
the cell at around 12.00pm. He was quiet at first and then began to speak
broken English to himself and shake the bunk beds. They left the cell to collect
their lunch and, after returning to the cell, watched television. The cell mate
16
described him as anxious and said that he would constantly get up and press
the cell call bell, but could not seem to communicate with the officer.
50. Prisoner A told the investigator that he had seen the man in his new cell whilst
handing out visit slips. He spoke to him through the observation panel and
asked if he was alright. He gave no indication of any problems, but the prisoner
said that he was still shaking as he was when he last saw him.
51. During the afternoon, Officer B went to the man’s cell as he kept pressing his
cell bell. She said that his behaviour was very strange. She asked him what
the problem was and he replied that he wanted to go to Wimbledon. She
clarified with him what he had said and he said “yes court”. The officer
explained that he had already been to court, but said he was not listening at all
and kept saying that he wanted to go to Wimbledon.
52. She asked him not to ring the cell bell unless it was an emergency. After
leaving the cell she returned less than ten minutes later as the bell was pressed
again. She said that on this occasion it was not him, but his cell mate who had
pressed the bell. She asked him what the problem was and he replied “I don’t
know what’s wrong with him but he’s in the toilet and he’s just up and down the
cell”. When she looked into the cell, she saw that he was pacing up and down
in the toilet area. In his police statement the cell mate also mentioned that he
was behaving strangely and putting bread down the toilet.
53. Officer B went to speak to Nurse B, the nurse working on E wing and asked her
to examine the man. The officer was concerned because she recalled him
saying that he was diabetic the previous evening. She thought that his blood
sugar level might have dropped which would account for his behaviour. At
interview, the nurse said that the officer told her about a prisoner in C wing
behaving strangely who had said he was diabetic and who had not had any
medication. She asked the officer to contact the nurse in charge. She then
went to see him, taking the machine for measuring blood sugar levels. The
nurse in charge, Nurse C, followed her.
54. Nurse C told the investigator that she was the lead nurse on 26 March and had
gone to C wing to look for Nurse B. Nurse B explained that an officer had
asked her to check the man as he was concerned about him. She had tested
his blood sugar which was within normal limits. Nurse C said that the man was
not able to converse very well, but seemed pre-occupied with moving things
around in his cell.
55. On that particular afternoon, Nurse D was in the prison to conduct a weekly
diabetic clinic. He said that he went to see the man as he had recently arrived
into custody and had been listed as diabetic. He had not gone to see him as a
result of being asked by wing staff or nurses. The nurse said that he had cell
keys, but for safety reasons he would always open the observation panel to
assess who he is unlocking. When he looked into the cell, he saw him acting
strangely and holding his pillow. As he did not know him, the nurse returned to
the healthcare wing and suggested to the senior sister that maybe they should
go and see him together. However, when he returned to the cell, Nurses B and
C were already there. They told him that they had checked the man’s blood
17
sugar and that it was alright, so the nurse did not actually meet him face to
face.
56. Nurse D noted that the man had not been given any medication for his diabetes
since his arrival and thought this strange. He said that if the verification had
been received by the prison healthcare department he would have expected it
to have been prescribed. He took the prescription chart to the duty GP and
asked him to write it up, before taking the prescription to the pharmacy. He
then spoke to Nurse C, who was responsible for administering medications that
evening and asked her to ensure that he received his.
57. Nurse C told the investigator that when she saw the man it had only been a
“snapshot” of a minute or so. There was something about him that bothered
her and she shared her concerns with Prison Doctor B. She was carrying out
the role of duty nurse and she said that it was a particularly busy day, as she
had been called to numerous medical emergencies. However, she took the
time to discuss with the doctor whether she should carry out a mental health
assessment or refer him for a specialist MHIRT assessment and make sure
that nothing was missed from the mental health perspective.
58. During nurse’s conversation with the doctor she was again called away and
when she returned the doctor said that he had checked the man’s medical
history. The doctor said that he could not see anything that would have given
rise to the bizarre behaviour, but they would monitor and carry out blood tests
on the Monday. She said that her normal practice, if she had concerns about a
patient, is to read back through the medical history from when the person came
into prison to see if anything had been missed. On that day, she did not have
time to do this because of various emergencies, such as patients harming
themselves which was why she discussed it with the GP.
59. Nurse C said that she was not aware at any time that there had been mention
of alcohol on the man’s reception assessment. She said that, given that his
medical notes were relatively short, she would have expected the doctor to
have identified this when he explored his history.
60. In interview after the man’s death, his cell mate described another person
visiting the cell shortly after the nurses had left, who he thought was a
Samaritan. However, it is likely that it was actually Nurse D. When
interviewed, the nurse said that he did not actually see the man ‘face to face’
but had observed him through the observation panel, and that he thought he
was acting strangely.
61. Prisoner A said that he did not see the man while on exercise. When he
returned to the wing he saw him on the ground floor and he appeared to be
trying to get out of the door. He saw an officer standing in front of him, trying to
talk to him. As he knew that the man spoke little English, he went across to see
if he could help. He asked him what was wrong and he replied, ”I just bought
two kilos of mutton and I left it in the road, I just want to give it to my wife and
come back quickly”. The prisoner tried to explain that he was in prison, but he
did not appear to listen. He kept repeating, “I only live next door, next road, let
me go and give that mutton because some visitors are coming to my house, let
18
me go and give that mutton and come back to the room again, please tell the
officer”. The prisoner told him to return to his cell. He walked him to the gate
and he believed that he returned to his cell. He told the officer that he believed
the man required the doctor’s help.
62. The cell mate said that the man returned about 15 to 20 minutes after being
unlocked, which he thought was strange as exercise usually lasted longer.
When returned to the cell, he began to panic and continually press the call bell.
The cell mate thought something needed to be done and that the man was
going mad. He asked a prison officer who passed the cell if he could be moved
as the man’s behaviour was becoming worse.
63. The man later went to collect his evening meal along with his cell mate.
Prisoner A recalled seeing him and said that he appeared to be sweating. He
asked for chicken curry and, although it was not what he had ordered, the
prisoner ensured that he was given that meal. His cell mate said that when
they returned to the cell, initially the man was calm and resting on his bed. All
of a sudden, he began panicking again, talking incoherently non-stop and
shaking the bed. His cell mate said that he was not violent but appeared
confused. He described him as becoming more erratic. The man collected
their food bowls and wrapped them in paper. He was shouting and began
banging on the cell door and pressing the bell.
64. Officer B said that she answered the man’s cell bell again at around 7.00pm.
His cell mate asked her if he could be relocated as the man’s behaviour was
scaring him. She saw him pacing up and down the cell and shouting, but she
could not understand what he was saying. She told the cell mate to start
packing his belongings while she went to see if another cell was available. The
cell mate said that, while she was gone, the man began placing the items he
had wrapped in the waste paper bin and seemed confused.
65. The officer returned to the cell a short while later with her colleagues, Officers D
and E who were to help her relocate the cell mate. When they got there, the
man was holding the waste paper bin and stabbing at the cell door with a
plastic knife. On seeing this, they decided to contact the orderly officer.
66. Senior Officer (SO) A was on duty as Oscar 2 on 26 March, and, as Oscar 1
was elsewhere in the prison, he went to C wing at the request of staff. (Oscar 1
is the night orderly officer and Oscar 2, the assistant.) He said that when he
was asked to go to the wing, he was not aware of what the problem was. He
got to the landing at around the same time as the duty governor, who had also
been contacted. The SO said that as he walked towards the cell he could hear
raised voices and saw three members of staff outside the cell gesturing to the
occupant to calm down. He tried to speak to the man, who he had not met
before. He was unable to communicate with him, and asked staff what was
happening. Officer E told the SO that the man was agitated and had a plastic
knife that he had been attempting to sharpen. The SO could see no marks on
the knife, but the man was striking it back and forth across the observation
panel and continuing to shout.
19
67. The staff also told the SO that the man’s cell mate had raised concerns and
said that he was afraid of him, as he had been behaving erratically for
sometime. He asked the staff whether anyone on the wing who could
communicate with him in his own language and was told about Prisoner A.
Officer D went to ask the prisoner if he would come and try to speak with the
man. The prisoner said that, when he arrived at the cell, staff asked him to tell
him to move back from the door, so that they could go inside. He said that the
man kept repeating “I want to park my car and I am going to come quickly”. He
told him that he was in prison and again told him to move back from the door,
but he continued to repeat that he had keys and needed to move his car. The
investigator asked the prisoner whether he could recall anything that the man
was holding, and he replied that he was holding his bin under his arm. He
explained that the man had placed his belongings inside, which was typical of
how people in Sri Lanka would move items from one place to another. He did
not see anything in his other hand.
68. The SO told the investigator that, when he asked the prisoner what the man
was saying, he was told that the prisoner could not understand him, and no
mention was made of moving his car. The SO said that it became apparent
that he needed to remove the cell mate for his own safety. Although there was
no indication that the man had threatened the cell mate, his safety was the first
priority for staff. The duty governor said that at the same time as staff tried to
calm the man and move the cell mate, he received a radio call that there was a
fire elsewhere in the prison. At this point the SO thought that it became more
urgent to bring the problems with the man to a safe conclusion, so that he and
the SO could deal with the fire.
69. The SO said that he indicated to the man’s cell mate to be ready to leave the
cell when the door was opened. When they opened it, the man attempted to
grab at the door and it was pulled shut again. The SO said that as the man
was still holding something which he thought could be a weapon, all the staff
drew their batons to protect themselves. (Prison staff are provided with
extendable batons as part of their uniform. They are trained to use them in self
defence.) The SO said that the man was again instructed to move back from
the door before it was opened a second time. It was about 7.15pm by this time.
As the door was opened, the man came forward holding the bin which both the
SO and Officer E knocked from his hand by striking it with their batons
simutaneously. He was holding the knife which was aimed upwards towards
what the SO presumed to be his chest or throat. The SO took hold of his right
hand, which was holding the knife, and pulled it past him and then other staff
helped to restrain him.
70. The SO explained the efforts to restrain the man in some detail. He described
it as a “very protracted and somewhat impractical” control and restraint (C&R)
incident. This was because, as the man came out of the cell, all the staff
including the duty governor responded to try and control him. (The use of C&R
is closely monitored and PSO 1600 sets out the requirements that must be
followed. It is the only method approved for prison staff to restrain violent
prisoners by force.)
20
71. The SO said that the man took the staff about seven to ten feet down the
landing, by pushing backwards. The SO still had hold of his right hand and was
carried by the momentum. He wanted to take him into a situation where staff
could control him, so they used his own momentum to get him to lie on the
floor.
72. The SO was conscious of the need to protect the man’s head so, because of
the speed, he kept his arm underneath him. Officer D had control of his left
arm and Officer E had his head. The duty governor was between the man and
the rail, and tried to communicate with him. The SO said that these actions all
happened in seconds and the man was brought under control within a
maximum of two to three minutes. As soon as he was controlled, staff put
handcuffs on and he continued to shout a lot.
73. The SO again asked Prisoner A to tell the man that, if he calmed down, staff
would sit him up and find out about his problems. The SO said that he wanted
to put the man back in the cell and move his cell mate. He did not want to take
him to the Care and Separation Unit (CSU), but that became increasingly likely
and was the reason for using handcuffs. (The CSU provides temporary
accommodation for prisoners who have become violent or disruptive,
committed offences against prison rules or require protection if they are under
threat from other prisoners.) The prisoner spoke again in Tamil, but gestured to
the SO that he did not know what the man was saying.
74. All the staff said that when the handcuffs were applied, the man went from
struggling, being loud, screaming and shouting to complete silence which was
very noticeable. He stopped resisting and did not appear to respond to staff.
The SO said that, although not medically trained, he thought that he had a
pulse. He was put in an upright seating position and staff noticed that he had
passed urine. The staff thought that he was unconscious and so the handcuffs
were immediately removed and he was placed in the recovery position. Nurse
C was called, via the radio.
75. The nurse recalled that she had been contacted at 7.11pm. She was the duty
nurse and had been treating a prisoner with chest pain when she was told
about the fire. She left the prisoner with an officer and made her way to E2
landing, with her emergency bag and an oxygen cylinder. She began treating a
prisoner for smoke inhalation and had been there for around three minutes
when she received the radio call about the man. The prisoner with smoke
inhalation was well enough to leave so she took her equipment and went to C
wing. Her emergency bag contained cannulation equipment (for inserting a
tube into the body), as well as observation equipment such as a blood pressure
monitor and a defibrillator.
76. She said that it only took her about two minutes to get to C4 landing. As she
approached the staff she called out and asked what the problem was. When
she got up to the staff she saw that the prisoner was the man and the SO
explained to her what had happened. She asked the staff to place him on his
back so that she could assess his airway and circulation. She said there were
no signs of breath, no rise and fall of the chest and no carotid (neck) pulse
either. She then told the other staff that he was in cardiac arrest. She asked
21
them to start cardio pulmonary resuscitation (CPR) and notify the London
Ambulance Service. She also asked staff to get the GP, who was in the first
night centre. Officer E started CPR, but was replaced by the SO, while the
nurse put the defibrillator onto him to see if there was any heart rhythm. (A
defibrillator monitors heart rhythm and where necessary will deliver an electric
shock to put the heart back into a regular rhythm. A defibrillator cannot restart
a heart that has no heartbeat.) Once the defibrillator was in place it advised
that no shock was advisable and there was no cardiac output. As the nurse’s
oxygen was still with the prisoner in the fire, she used a protective mask to give
mouth-to-mouth breaths to him until another oxygen cylinder arrived.
77. Nurse C told the staff to carry on with the CPR while she continued to give
oxygen. At various times the defibrillator was checked, and it still showed no
output. The duty GP had arrived and the nurse asked him to try to cannulate
the man to insert the medication used in cardiac arrest. The doctor tried to do
so on a couple of occasions while staff continued the resuscitation process.
The nurse gave him all the information that she had about the man and they
attempted to revive him for around 20 minutes.
78. Another nurse who had accompanied the duty GP asked if the staff agreed that
they should stop the resuscitation attempts. The GP pronounced the man’s
death at 7.36pm.
Events after the man’s death
79. Following the man’s death, staff contacted the Governor and the prison initiated
their contingency plans. The Deputy Governor returned to the prison along with
another governor who took on the role of the prison’s family liaison officer. The
chaplain also attended and offered support to the staff as well as assisting the
family liaison officer to notify the man’s family. Due to the circumstances of the
death, the police were notified and attended the prison to interview the staff
before they left the prison.
80. The prison’s family liaison officer and the chaplain left the prison at about
10.45pm, to visit the man’s family and tell them of his death. They told the
family of the circumstances of his death as known at the time and stayed until
other family members arrived to offer support. The family liaison officer also
told the family about the role of the Ombudsman’s office and the Coroner, and
that an investigation would take place. They left the family home at 1.20am
and arrived back at Wandsworth at 3.20am.
81. Later on 27 March, the prison’s family liaison officer contacted the man’s family
and spoke to them about the special post mortem notified by the Coroner’s
officer and that a press release was to be issued. During the conversation, the
family asked him about the man’s death and he told them again what he knew
at that time. They were concerned about when they would be allowed to
arrange the funeral and he agreed to contact them again on 29 March.
82. Later that evening, the family liaison officer learnt that a news channel was
running the story of the man’s death and stating that it was linked to a hostage
22
incident. After establishing that it had not originated from the Prison Service
press office, he telephoned the family and told them of the coverage. The
man’s daughter told him later that her father’s name was on the BBC website
and asked whether it could be removed. However, the press office told the
family liaison officer that this was standard practice and it could not be
removed.
83. Later on 27 March, the Governor contacted all the staff involved at their homes.
He offered the support of the staff care and welfare team and their colleagues
at Wandsworth.
84. The prison’s family liaison officer remained in regular contact with the man’s
family. He kept them updated on progress with the Coroner’s office and also
arranged for funeral costs to be met by the prison. The family told the
Ombudsman’s investigator and family liaison officer that they appreciated the
support which he had given, particularly his help with the press coverage.
85. The family were however concerned about the accuracy of the information they
were initially given. The investigator explained that any information
immediately following a death in custody can be subject to change as more
facts emerge. He made the prison’s family liaison officer aware of the family’s
concerns and suggested that it might be advisable in future to restrict
information to that which has been substantiated to avoid confusion later. He
agreed to adopt this approach in future.
86. A debrief of the staff involved was carried out by the prison immediately after
the man’s death. In addition the prisoners who were subject to suicide
monitoring were reviewed, as is standard practice following any death in
custody.
23
ISSUES
Initial health screen and clinical care
87. When the man arrived at Wandsworth, Nurse A completed the reception health
screening process. In his notes of the assessment, he recorded that the man
had a strong smell of alcohol about him. The nurse confirmed to the
investigator that he was concerned and that the normal procedure would be for
him to refer the man to the Substance Misuse Team. He could not explain why
he did not refer him for specialist support.
88. During the investigation, all the healthcare staff interviewed were shown two
documents, ‘Clinical Management of Drug Dependence in the Adult Prison
Setting’ published by the Department of Health in November 2006 and Prison
Service Order (PSO) 3550 Clinical Services for Substance Misusers, issued in
December 2000. None were aware of either publication. The documents set
out the procedures to be followed for prisoners arriving into custody with
identified or suspected drug or alcohol problems. Although the staff were
unaware of the publications, they were familiar with the procedures in place at
Wandsworth to treat such prisoners. A member of the Substance Misuse Team
is available on the first night centre so that referrals can be made directly.
89. Following Nurse A’s assessment, Prison Doctor A assessed the man, but he
did not refer to the comments about smelling of alcohol or make any other
reference to alcohol.
The Governor and Head of Healthcare should conduct an immediate
review of the reception screening processes for identifying and following
up those prisoners arriving in custody at Wandsworth with possible drug
or alcohol problems. This should include a system for ensuring that such
prisoners are automatically referred to the Substance Misuse Team and
that the requirements of PSO 3550 are met.
The Governor should ensure that all relevant documentation and PSOs
relating to healthcare requirements for prisoners with alcohol or drug
dependency are made available to nursing staff. Consideration should be
given to allowing access to such documents via the prison intranet.
90. A verification fax was sent to the man’s community GP to confirm the
medication that he was taking. The GP responded the following day, attaching
letters regarding his previous treatment at hospital. The GP confirmed that the
man was taking a number of medications for diabetes and other conditions.
The letters also referred to previous excessive alcohol use and poor liver
function. There is no evidence to suggest that this information formed any part
of subsequent clinical investigations. Despite the fax arriving at the prison on
24 March, no medication was prescribed for him until the diabetic nurse
became involved on 26 March and there is no evidence that any was
administered during the three days before he died. The clinical reviewer
describes the omission as “not ideal” but “unlikely to have contributed to his
death”.
24
The Head of Healthcare should a review the procedures for recording
information received from community doctors, to ensure that all relevant
information is updated on System 1.
The Head of Healthcare should review the process for prescribing and
dispensing medication to new prisoners to ensure that is carried out in a
timely manner.
91. The man’s disturbed behaviour began notably on 25 March. It resulted in him
moving to another cell during the early hours of 26 March, after concerns were
raised by his cell mate. The SO who arranged the move said that he appeared
“bizarre” and was wearing a pillow case on his head. The officer patrolling the
wing where he was moved to, also said that he continued to behave in a
“bizarre” manner after moving to the single cell. No nursing staff were asked to
see him at this time, despite this behaviour. The officer on E wing wrote in the
wing observation book that a referral to the MHIRT might be advisable.
However, he did not make the referral himself, his comments were not followed
up at any other time and there is no evidence of any action resulting from his
observation.
92. The man moved back to C wing on 26 March and, throughout the remainder of
the morning and early afternoon, continued to display the odd behaviour
described by staff. Officer B was concerned enough to ask Nurse B to assess
him as she felt that his behaviour could be linked to his diabetes. The nurse,
along with Nurse C, assessed him and his blood sugar was considered normal.
However, Nurse C recorded that he was behaving strangely and, although he
did not appear distressed, he was acting “bizarrely”.
93. Nurse C had not seen the man’s medical notes and was not aware of any
alcohol issues. However, she expressed her concerns about his behaviour to
the duty GP. The GP offered to check his history to see if there was anything
that could be contributing to this. He had access to all the man’s medical notes
which, given his brief time in custody, were not extensive. They included the
initial health screen, where concerns about alcohol were raised by Nurse A. He
would also have had sight of the faxed letters from the community GP. He later
told Nurse C that he had been unable to find any other possible cause for the
man’s behaviour, but recommended that he should be monitored. He did not
ask to see him and did not make a physical assessment.
The Head of Healthcare should review the system for medical
assessments of prisoners who appear to be acutely confused and ensure
that prison doctors conduct face-to-face assessments in such cases.
94. Nurse C made a referral to the MHIRT. The medication that he required for his
diabetes was finally prescribed on the afternoon of 26 March, following the visit
by Nurse D, but was not taken before his death.
95. The clinical reviewer, who completed the clinical review, concluded:
25
“ … In summary it appears that the man was suffering from acute alcohol
withdrawal, resulting in the acute confusional state of delirium tremens.
This condition has a 15% mortality rate and had it been recognised the
usual treatment would have been an acute hospital admission under the
physicians. There was a three day delay in starting his medication after
arriving in prison and although not ideal I note that his blood sugar was
checked on at least two occasions so I think this delay was unlikely to
have contributed to his death.
“Alcohol intake is often under reported by patients but I note that he
reported drinking three to four cans of lager to the reception nurse. This
may well have been an underestimate but I note the recognition of the
smell of alcohol on his breath at reception.
“It appears that the diagnosis of acute alcohol withdrawal was missed and
although this can be a difficult diagnosis it seems unfortunate that the
diagnosis was not suspected given the available past history, reception
findings and developing bizarre behaviour …”
96. I believe that there were a series of missed opportunities to investigate the
possible causes for the man’s behaviour. Given the cause of death as “sudden
cardiac death while in a state of acute alcohol withdrawal”, my
recommendations should be acted upon immediately by both the prison and the
PCT responsible for the delivery of healthcare at Wandsworth.
Translation facilities and the induction of prisoners with limited English
97. Prisons have at their disposal the use of interpreting services such as
‘Language Line’ and ‘The Big Word’. During the reception process it would be
expected that the ‘Language Line’ service would be used when dealing with a
prisoner with limited or no understanding of English. However, during the
man’s health screen, Nurse A did not use this service. Instead, he sought the
help of another prisoner who he thought spoke “the same language” and
happened to be in the reception at the same time. The health screen is a
confidential medical assessment. I question whether it is appropriate to use
another prisoner who was not even known to the man to relay questions about
his previous medical history. The most recent prison inspection by HM Chief
Inspector of Prisons also criticises the limited use of such services.
The Governor should ensure that the use of other prisoners as translators
during confidential processes such as health screens should be stopped
with immediate effect. In addition, the importance of using services such
as ‘Language Line’ and ‘The Big Word’ must be communicated to all staff,
and facilities for access to these services should be put in place.
98. As well it is not clear how effective the reception process could be given the
man’s poor command of English. The cell sharing risk assessment (CSRA)
indicates that he answered no to every question, including questions about
alcohol dependency.
26
The Governor should review the induction process and the
documentation provided to ensure that it meets the needs of foreign
national prisoners, in accordance with the requirements of PSO 2800
Race Equality. In particular, consideration should be given to the
development of an information sheet in various languages. This should
include information that a prisoner might need within the first 72 hours,
such as how to contact their families, make a request and access
healthcare.
99. In contrast, when the man began exhibiting challenging behaviour, wing staff
asked for another Sri Lankan prisoner, Prisoner A, to try to communicate. On
such an occasion the use of another prisoner was clearly the most effective
means for staff to try and find out his problems and communicate their
instructions.
100. In the documentation supplied to the investigator following the man’s death,
there was no evidence that induction documents were given to him in his native
language. It is also not clear what took place or what he was told during his
induction. Prisoner A said that the man appeared confused about what to do
and was not sure how to see the doctor or even his own prison number. Again,
the Inspectorate comments on the lack of information in other languages, which
left some prisoners for whom English was not a first language, feeling isolated.
PSO 2800 Race Equality requires information to be provided in appropriate
languages and formats.
Prisoner safety / Cell Sharing Risk Assessment (CSRA)
101. On his reception into custody, staff completed a CSRA and the man was
considered suitable to share a cell. He moved from E wing to a shared cell on
C wing the day after he arrived. On 25 March, his cell mate complained to staff
that his behaviour was worrying him and asked for him to be moved. He then
moved back to E wing during the early hours of 26 March, and was given a
single cell, where his behaviour continued to cause concern.
102. Despite his behaviour continuing to cause concern, the man returned to a
shared cell in C wing later that day without reviewing his CSRA. The CSRA is
designed to ensure that prisoners are not put into shared cells if they might
pose a risk to a cell mate. A previous cell mate had already raised concern
about his unpredictable behaviour, yet the man was taken back into shared
accommodation. The second cell mate also raised concerns about him and
told staff that he was afraid.
103. If the correct procedures had been followed in relation to the CSRA review, I
doubt that the man would have been deemed suitable to share a cell. The
investigator was told by the SO who led the C&R removal that, if he had been
in a single cell, staff would have had more time but their priority was the safety
of the cell mate. The failure to properly review the CSRA after the move to E
wing potentially placed both the man and his cell mate at risk. By being in a
shared cell staff were faced with having to consider the safety of the cell mate
and intervene quicker than would otherwise have been necessary, had it been
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a single cell. This is supported by the statement provided by the senior officer
in charge.
104. Wandsworth has a CSRA Management Booklet that is attached to the wing
history files of all prisoners. This booklet is used whenever a CSRA review
takes place. It describes situations which may necessitate a review and one of
the examples given is acute mental illness. Although, the reasons for the
man’s behaviour had not been established at the time, staff had commented
that a referral to the MHIRT would be advisable.
The Governor should review the way in which the CSRA process is
managed to ensure that the safety of prisoners is maintained.
Use of control and restraint
105. As previously mentioned, the need for staff to intervene and go into the man’s
cell on the evening of 26 March, was more urgent because of the presence of
hiscell mate who had already told staff that he was afraid. I am satisfied from
the information in staff statements and their subsequent interviews, that they
made considerable efforts to bring the situation to a conclusion without using
force. However, they were faced with a prisoner who was not communicating
clearly, and, from their perspective, was armed with weapons. Although, it is
unlikely that he was holding the bin and knife to use as weapons, the staff had
to respond to what they saw and his mental state made him unpredictable.
106. When the staff finally went into the cell, they realised that they would have to
use control and restraint techniques to restrain him. There is no suggestion in
the police investigation of his death, that he was subjected to any unnecessary
force. My investigation reaches a similar conclusion. Having carefully
considered all the documentation relating to the use of force and interviewed
the staff involved, my investigator has found that the staff acted professionally.
They ensured that he was monitored throughout and was not subject to
unnecessary force. All the documentation relating to the use of force was
correctly completed and detailed each individual’s involvement.
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CONCLUSION
107. When the man was taken into custody, the initial health screen identified that
he was type 2 diabetic, and concerns were raised about his alcohol intake.
However, following the screening there was limited involvement of healthcare
staff and a series of missed opportunities to identify the cause of his escalating
challenging behaviour. Had he been seen by the Substance Misuse Team, as
he should have been, then it is possible that a more in-depth history of his
alcohol consumption would have been made. At the very least, their
involvement would have been highlighted within his medical record and
signposted other staff to possible causes of his deteriorating condition.
108. However, the doctor who then reviewed him failed to comment on the concerns
raised by the nurse, or refer him to the Substance Misuse Team. In addition,
the doctor who saw him on 26 March did not conduct a face to face
assessment, despite the concerns expressed by a nurse.
109. While the prison staff interviewed during the course of this investigation were
able to explain the systems in place for dealing with prisoners with a known or
suspected medical condition, the correct processes were not followed in
respect of the man. As someone with limited ability to communicate his worries
and needs, it must have been very isolating and distressing for him.
110. I am unable to comment on whether the man’s death was avoidable. The
evidence suggests that the healthcare given to him at Wandsworth was not of a
standard to address his alcohol use even if the absence of diabetic medicine
was not significant. However, had his health been properly looked after,
circumstances might well have been different and he might well have been
alive today.
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RESPONSE FROM FAMILY TO DRAFT REPORT
111. The man’s daughters said that they were concerned to learn of the apparent
failure by both Prison Doctors A and B in their duty of care towards their father.
They feel that both doctors missed opportunities to correctly identify and treat
his alcohol withdrawal. The family have noted that the subsequent post
mortem has given alcohol withdrawal to be a contributing factor in his death
and therefore feel it is likely this could have been prevented if he was provided
with appropriate medication.
112. The family also said that they were disappointed that Prison Doctor A was not
able to be traced, despite being registered with the GMC, so that he could be
asked about the treatment he provided. The family does not wish to penalise
individuals, but they are concerned those involved are able to learn from
mistakes in order to ensure the same things are prevented from happening
again.
113. The family feel that the clinical reviewer has been non-committal in his
conclusions and are concerned this may also lead to lessons not being learnt.
They also called into question the independence of the review, as it was
completed by an employee of Wandsworth PCT, who at the time of the man’s
death was responsible for the provision of healthcare services at the prison.
114. In respect of the man being restrained by prison staff, the family feel that this
may have been avoided if he had been located in a single cell. They note from
the report that he had been moved earlier due to his behaviour and cannot
understand why he was then located back into a shared cell when his ‘bizarre’
behaviour continued to escalate.
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RECOMMENDATIONS
1. The Governor and Head of Healthcare should conduct an immediate review of
the reception screening processes for identifying and following up those
prisoners arriving in custody at Wandsworth with possible drug or alcohol
problems. This should include a system for ensuring that such prisoners are
automatically referred to the Substance Misuse Team and that the
requirements of PSO 3550 are met.
Following the draft report the Prison Service responded by accepting this
recommendation and said:
Healthcare is reviewing its procedures in reception with the
implementation of System 1. Consideration is being given to the use of
finger prick liver function screening as part of the alcohol screening
process. The alcohol screening template on System 1 is a national
agreed tool. This implementation is ongoing and will be overseen by the
Substance Misuse Team Leader & Substance Misuse Nurse.
In addition, Reception, First Night and Induction have now been grouped
under one function. The functional head will be reviewing the
admission/induction process in liaison with Healthcare. Target for this is
February 2011.
2. The Governor should ensure that all relevant documentation and PSOs relating
to healthcare requirements for prisoners with alcohol or drug dependency are
made available to all nursing staff and consideration should be given to
allowing access to such documents via the prison intranet
Following the draft report the Prison Service responded by accepting this
recommendation and said:
We are currently collating all PSO’s and other relevant policies relating to
healthcare, and in particular substance misuse. This will be made
available to all healthcare staff. Target for this is January 2011.
3. The Head of Healthcare should a review the procedures for recording
information received from community doctors, to ensure that all relevant
information is updated onto System 1.
Following the draft report the Prison Service responded by accepting this
recommendation and said:
This information will be scanned directly on to System 1 on the day of
arrival by the admin team. A hard copy will also be delivered to the
pharmacy department and the duty GP on the day the verification is
received. The implementation is ongoing and will be overseen by Head of
Administration and Practice & Governance Manager
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4. The Head of Healthcare should review the process for prescribing and
dispensing medication to new prisoners to ensure that is carried out in a timely
manner.
Following the draft report the Prison Service responded by accepting this
recommendation and said:
As part of the introduction of System 1, healthcare is also reviewing first
night medication dispensing. A protocol and worksheet will be produced.
Target for this is January 2011.
5. The Head of Healthcare should review the system for medical assessments of
prisoners who appear to be acutely confused and ensure that prison doctors
conduct face-to-face assessments in such cases.
Following the draft report the Prison Service responded by accepting this
recommendation and said:
Healthcare is currently reviewing the availability of primary mental health
services. This will include a protocol and care pathway for patients
acutely confused. Target for this is January 2011.
6. The Governor should ensure that the use of other prisoners to translate during
confidential processes such as health screens should be stopped with
immediate effect. In addition, the importance of using services such as
‘Language Line’ and ‘The Big Word’ must be communicated to all staff, and
facilities for access to these services should be put in place.
Following the draft report the Prison Service responded by accepting this
recommendation and said:
Reissue Governors Information Notice regarding use of ‘The Big Word’ –
specifying situations where this or an appropriate interpreter must be
used e.g. health screens. Healthcare will ensure that this is
communicated to all healthcare staff. Target for this is December 2010.
In addition, a review of the current facilities for using translation services
will be conducted to ensure the relevant staff have easy access. Target
for this is January 2011.
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7. The Governor should review the induction process and the documentation
provided to ensure that it meets the needs of foreign national prisoners, in
accordance with the requirements of PSO 2800 Race Equality. In particular,
consideration should be given to the development of an information sheet in
various languages. This should include information that a prisoner might need
within the first 72 hours, such as how to contact their families, make a request
and access healthcare.
Following the draft report the Prison Service responded by accepting this
recommendation and said:
Reception, First Night and Induction has now been grouped under one
function. The functional head will be reviewing the entire
admission/induction process and will liaise with the Diversity Advisor to
ensure that the process is meeting the requirements of PSO 2800. Target
for this is February 2011.
8. The Governor should review the way in which the CSRA process is managed to
ensure that the safety of prisoners is maintained.
Following the draft report the Prison Service responded by accepting this
recommendation and said:
There is currently a review being conducted locally on the CSRA process
intending to improve the current system. Target for this is January 2011.
In addition, all staff will be formally reminded of the events which should
trigger a CSRA review. Target for this is December 2010.
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