Individual at Peterborough

Investigation into the circumstances surrounding
the death of a woman at HMP Peterborough in March 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2008
This is a report on the circumstances surrounding the sudden death of a woman at
HMP Peterborough on 5 March 2008. The woman had been recalled to prison on 6
February after breaching her licence conditions. On the morning of 5 March, she
was discovered collapsed on the floor of her cell by a fellow prisoner. The prisoner
alerted staff who quickly attended to her and established that she needed immediate
medical care. On arrival at the cell, healthcare staff administered cardio pulmonary
resuscitation until the paramedics arrived and took over. Despite their continued
efforts, the woman failed to respond and was declared dead at 8.00am. She was
only 35 years old. I would like to offer my sincere condolences to her family and
friends for their loss.
One of my colleagues carried out the investigation on behalf of the Ombudsman. I
would like to thank the Director of Peterborough Prison, and his staff for their co-
operation and assistance with the investigation. In addition, Peterborough Primary
Care Trust appointed a doctor from a nearby practice, to conduct a clinical review
into the woman’s medical care while in custody. I am grateful for his report.
The investigator wrote to HM Coroner to inform him of the investigation and request
a copy of the post mortem report. The initial post mortem was inconclusive.
Subsequent toxicology results revealed the cause of the woman’s death to have
been as a result of the combined effects of methadone and diazepam taken at the
levels she had been prescribed. There was no indication that her death was
intentional and no clear reason is apparent for her medication to have had such a
tragic and fatal effect. In the clinical review, there are references by the reviewer to
the possibility of the woman storing her medication. However, information that was
not available to the reviewer at the time of his report indicates that this would have
been unlikely.
I make one recommendation in relation to clinical record keeping, but I am satisfied
that the woman’s health needs were appropriately addressed. I am also satisfied
that the actions of prison staff caring for her were appropriate.
Jane Webb
Deputy Prisons and Probation Ombudsman October 2008
2
CONTENTS
Summary 4
The investigation process 5
HMP Peterborough 7
Key findings 10
Issues 19
Conclusion 23
Recommendations 24
3
SUMMARY
The young woman was sentenced to eight years imprisonment in 2002. She was
released on licence in November 2006, but returned to drug use and found herself
returned to custody after further offending. In July 2007, she was again released on
licence from HMP Peterborough. She resided at a probation hostel in Leicester and,
during this period, she actively engaged with the Criminal Justice Drug Team as part
of her licence conditions.
On 5 February 2008, following her arrest for alleged theft, she was recalled to
custody at Peterborough. On reception, the woman was said to be visibly upset by
her recall and was adamant that she did not know the explanation. The health
screening revealed that she had been prescribed methadone, diazepam and
tramadol for pain relief due to a back injury sustained some years earlier. The doctor
placed her on a methadone maintenance programme and a gradual reduction
detoxification of the diazepam over a four week period. The tramadol was stopped
immediately. The woman was not happy with the changes to her medication as she
felt that the tramadol should have been replaced by something else to manage her
back pain. She was also keen to cease the use of methadone for pain relief so the
nurse referred her to the pain management clinic at the local hospital.
When she returned to custody, she initially felt low and was subject to Assessment,
Care in Custody and Teamwork (ACCT) monitoring. The ACCT process provides
additional support and care for those at risk of self-harm. The woman’s mood
improved over the next few weeks. She found employment on the painting party and
was said to enjoy the work.
During the early morning roll check on 5 March, a Prison Custody Officer (PCO) saw
her lying on her bed at 5.30am. Another PCO saw her at around 6.30am, while
completing another roll check. The PCO noted a slight movement but received no
verbal response. At 7.15am, the woman’s cell was unlocked and a friend went to her
cell. When her friend tried to enter, she found the woman lying on the floor behind
the door. She alerted staff who responded immediately. They quickly established
that she required medical help and requested assistance.
The first nurse arrived at around 7.20am and began to check the woman’s
responses. The lead nurse quickly joined her and asked staff to ensure that an
ambulance had been called. The nurses then administered cardio pulmonary
resuscitation (CPR), with the assistance of the orderly officer. A defibrillator was
subsequently applied which indicated that there was no output (rhythm from the
heart or a pulse) and CPR was continued until the paramedics arrived at 7.33am.
They continued to attempt resuscitation but she failed to respond. A paramedic
declared her dead at 7.51am.
Managers at the prison visited the woman’s partner to inform him of her death. A
memorial service was held and assistance with funeral expenses was offered. I am
satisfied that the woman was appropriately cared for. I make one recommendation
regarding record keeping.
4
THE INVESTIGATION PROCESS
1. The investigator, opened the investigation on 10 March 2008. Notices for staff
and prisoners were provided to the prison informing them of the investigation
and inviting anyone with relevant information to come forward. No responses
were received.
2. The woman’s partner, contacted the office and the investigator spoke to him on
12 March. During their conversation, her partner informed the investigator of
the funeral date and the investigator explained the Ombudsman’s investigation.
He also informed the woman’s partner that one of the Ombudsman’s Family
Liaison Officers (FLOs) would make contact with him after the funeral.
3. On 19 March, the investigator visited HMP Peterborough where he met a
manager who was acting as the liaison with my office. The investigator visited
the residential unit where the woman had lived and saw her cell. The manager
told him that the funeral had taken place the previous day and both he and the
Director had attended. The manager also confirmed that the woman’s personal
property had been returned to her family, apart from some items that remained
in her cell.
4. Having been assured that all necessary documents had been sent to him, the
investigator found it necessary to contact the prison on numerous occasions
over the following two weeks as the documents had not been delivered. It was
eventually established that owing to some confusion, the courier service had
returned them to the prison. The investigator arranged to visit Peterborough
again on 31 March in order to collect the paperwork. It is unfortunate that these
problems led to my investigator being unable to arrange staff interviews at an
earlier stage.
5. As well as reading the records, the investigator also viewed closed circuit
television coverage (CCTV) of the part of the prison occupied by the woman.
6. The same day as the visit to Peterborough, an FLO, from the Ombudsman’s
office, visited the woman’s partner, accompanied by the investigator. Her
partner, spoke of his concerns about the reasons for her recall to prison, as well
as issues relating to her medical treatment. He provided my investigator with
copies of letters he had sent on the woman’s behalf regarding her medication
and other matters after her recall. He also spoke about the woman’s son, who
at the time was a serving prisoner at another prison. He explained that her son
had asked him to be the point of contact for my office in matters relating to the
investigation.
7. On 9 April, the investigator contacted the woman’s probation officer, who had
been supervising the woman, in order to gain some background to the reasons
for her recall. The probation officer explained that he had known the woman for
some time and talked at length about his dealings with her. He agreed to
forward to the investigator information that he felt might be helpful to the
investigation.
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8. A doctor representing Peterborough Primary Care Trust (PCT), was asked to
conduct a review of the clinical care the woman received at Peterborough. The
review was completed without the benefit of a post mortem report and sent to
the Ombudsman on 10 June. The investigator subsequently received the post
mortem report and forwarded a copy to the doctor. In the light of the post
mortem and toxicology results, the investigator requested further information
from him. However, at the time of publishing the draft report no response had
been received. The doctor’s report is attached as an annex to this report.
9. A member of the Independent Monitoring Board (IMB) at the prison in which the
woman’s son was being held contacted my investigator on 12 June. The
woman’s son was concerned about the investigation process. The
Ombudsman’s FLO, and another investigator, visited the woman’s son to
discuss his concerns.
10. Following the visit the investigator telephoned the son via staff at his prison to
explain the investigation process in more detail and to clarify points he had
raised. The investigator also contacted the coroner’s officer on the son’s behalf
to notify him that he wished to be treated as an interested party and to arrange
for a copy of the post mortem report to be sent to him. It was also arranged for
the son to receive a copy of the report and for his Senior Officer at the prison to
help him with it.
11. I would like to thank the Senior Officer for his help in ensuring the woman’s son
has been able to contribute to this investigation and obtain all relevant reports
immediately.
12. After the draft report was issued, both the Prison Service and the woman’s
family responded identifying some factual inaccuracies that have now been
rectified. The woman’s family also had further questions regarding aspects of
her treatment. I have where possible attempted to address these points and
provide more clarity where possible. However, there were a number of
questions raised in relation to the findings of the post mortem on which I feel
unable to make further comment.
6
HMP PETERBOROUGH
13. HMP Peterborough is privately run by Kalyx (formerly UK Detention Services).
Opened in March 2005, it is the newest purpose built prison in the United
Kingdom. It is also the only prison that holds both men and women, who are
kept separate at all times. This factor makes it a very complex prison to
manage. Its role is that of a category B local prison serving the counties of
Cambridgeshire, Nottinghamshire, Lincolnshire, Leicestershire,
Northamptonshire, Norfolk and Suffolk.
14. HM Chief Inspector of Prisons, Ms Anne Owers, conducted an announced
inspection in October 2006. One of the main concerns of the inspection team
was the provision of healthcare, of which the team concluded:
“Among the worst we have seen for some considerable time. At every
level from the administration of medicines through to primary and in-
patient care there were serious deficiencies, with under trained and
inadequately managed healthcare staff unable to provide a safe and
decent service.”
15. Since the inspection, efforts to improve the provision of healthcare services at
Peterborough have been made. My investigator found the level of care and
quality of documentation was good.
16. The inspection team also commented on the provision of substance misuse
workers. In relation to methadone, Ms Owers said:
“Methadone regimes were fairly positive, offering a six-day period of
stabilisation followed by a review and leading to detoxification or
maintenance. The latter, however, was available only while women
were on remand or for up to three months post-sentence. At the time
of the inspection there were 102 women receiving methadone, 29 on
detoxification and 73 on either stabilisation or maintenance.”
17. The Independent Monitoring Board (IMB) at Peterborough published their first
report on the new prison in March 2006, a year after it opened. Previously
known as the Board of Visitors, the IMB independently monitors all aspects of
day to day prison life, including considering prisoners’ complaints. Each board
will produce an annual report focusing on the strengths and weaknesses of
their particular prison. In relation to the provision of healthcare the
Peterborough IMB’s report said:
“The development of the healthcare services in the new prison with a
population including male and female prisoners, and a Mother and
Baby Unit has been a major challenge for UKDS. Unlike Public
Prisons where the responsibility for the provision of the service is the
local NHS trust, Contracted Prisons are the responsible providers.
UKDS has had the foresight to work closely with the Peterborough
Primary Care Partnership (PCP) and has established a Service Level
7
Agreement with the PCP using NHS staff at all levels and specialities
to provide the service. The model for the service is that of a
community general practice with recognition of the special problems in
a prison population, and the need to provide a similar service to two
units.
“The male/female Health Care Centres both offer daily GP Clinics,
nurse led Clinics, and Wing triage rounds as well as dispensing listed
drugs in the Centres to prisoners requiring observation during
administration. The typical workload is about 35 seen by GPs, and 45
by the nurses daily on each side. Unlike community practice the major
issues are substance abuse, depression and anxiety and other more
serious mental health problems. The Board congratulates the Staff,
often with no experience of working in prison, in the progress that has
been made to achieve a level of service comparable, and in some
cases exceeding, that of NHS care in the community.
“There are some areas requiring further development. The GP/Nurse
waiting list times is about three days which does not meet the NHS
guidelines although more urgent problems are seen sooner. It is
sometimes difficult for the staff to have accurate information about new
prisoner’s health issues and medication, which can lead to problems
and result in delays and often complaints. A greater effort to establish
Health Promotion is needed.
“However we welcome the new Well Woman/Man Clinics that have
been set up as well as the specialist nurse led asthma and diabetes
clinics. There is a need to get more substantive IT services in order to
conduct better audit and clinical governance practices. The IMB is
represented on the Health Needs Assessment Group which will report
to the PCP/HMP Partnership.”
18. Since Peterborough opened in 2005, there have been three previous deaths in
custody. One of these was self inflicted and the other two attributed to natural
causes. There are no previous recommendations from these deaths that relate
to this investigation.
8
KEY FINDINGS
The woman’s custodial history
19. As mentioned earlier in this report, the woman began offending in her early
teens and it became progressively serious and culminated, in 1993, in
consecutive custodial sentences totalling ten years. Despite this lengthy period
of custody, she returned to crack cocaine and heroin use when she was
released in 2001. This resulted in her re-offending, but on these occasions she
was given Drug Treatment and Testing Orders (DTTO’s) in February and
March 2001, as an attempt to tackle the roots of her offending. However, while
subject to these orders, the woman committed further offences that resulted in
the DTTO’s being revoked on 20 July 2001.
20. As a consequence of the breach of the DTTO’s and further offences of theft,
the woman was remanded for three weeks to HMP Holloway. She was sent to
Crowley House Probation Hostel in June 2001 for a period of bail assessment.
In the first few days, the woman responded positively to the opportunity she
had been given and settled in well at the hostel. However, after the first week
she started to use heroin again, which resulted in a final warning by staff at the
hostel. At the end of June, the woman breached her licence by committing
further offences. When she found out that she would have to return to custody,
she absconded from the hostel and remained at large in the Birmingham area.
21. In July 2001, the woman was arrested for serious offences and again found
herself in custody. She later said that they had been committed while under the
influence of drugs. She was sentenced in February 2002, to eight years
imprisonment.
22. She was released on licence from HMP Peterborough in November 2006.
Following her release, she again returned to drug use and was arrested for
theft. After her arrest, she tested positive for both opiates and cocaine. For
these offences, the woman was sentenced to 28 days to be served with the
remainder of her sentence. In July 2007, when she was released on licence
from Peterborough, she went to a probation hostel in Leicester.
The woman’s period at Kirk Lodge from 25 July 2007 – 5 February 2008
23. Following her release from custody, the woman indicated that she wanted to
address her drug habit. Her supervising probation officer, who had known her
since her previous period of licence in 2006, was supportive. He told the
investigator that she had not been so positive on previous periods of licence.
24. The woman’s drug tests were negative and she was free of drugs for the
longest period since the age of 13, actively engaging with the Criminal Justice
Drug Team (CJDT). She also started to work for an employment agency, in a
temporary position, with a view to being offered a permanent position after 13
weeks. This was the first time in her life that she had been given a job.
9
25. However, this period was not without problems and, in October, she was
arrested for theft. While in police custody, the woman tested negative for class
A drugs. In explaining her reasons for the offence, she told her probation
officer that she had been threatened by people who she used to know as she
owed money to them. In recognition of her improvements, no action was taken
regarding her breach of licence. Her supervising officer, prepared her pre-
sentence report and emphasised the change in her character and the positive
steps that she had taken to address her drug addiction. The court gave her a
Suspended Sentence Supervision Order (SSSO), when she appeared on 29
October 2007.
26. Following the court case, the woman’s positive progress continued. She also
met her partner, with whom she travelled to and from work. They became
close which offered her the stability she had not had before and they had
discussed marriage. However, her partner was forced to give up work due to
illness. Subsequently, she was unable to travel to work as she could not drive
and had to give up her job as well. Nevertheless their relationship progressed
and they made plans to move in together when she was given permission to
leave the probation hostel.
27. On 5 February 2008, the woman was arrested on suspicion of theft. Although
not formally charged, she was bailed to appear on 26 February. Following her
release from the police station, the woman contacted her probation officer to tell
him what had happened and admitted that she had committed the offence. In
view of this information, he discussed the situation with his supervisor and an
Assistant Chief Officer. It was decided that, in view of her further offences, it
was necessary to impose a curfew denying her the right to go out at night. The
curfew also affected her move on from the probation hostel. The probation
officer and his managers considered that, when faced with these decisions, it
would be clear to her that her recall to custody was inevitable. Ultimately, the
decision to recall the woman was made by the Early Release and Recall (ERR)
Section based on the information supplied to them.
The woman’s return to HMP Peterborough
28. Following the recall decision on 5 February, she returned to Peterborough the
next day and was taken through the normal reception procedures. It is normal
practice for prisoners sent to Peterborough to be located initially in the
healthcare centre for observations.
Following sight of the draft report, the woman’s family asked about an entry in
her medical notes referring to a request by her for a pregnancy test on 7
February, and whether this was carried out.
It is normal in female prisons for women to be routinely offered a pregnancy
test as part of their health screening on entry into prison. The woman would
have been offered one during her second health screening and notes indicate
that she requested it. However, the investigator has been unable to find any
indication that the test was carried out.
10
29. She had taken methadone for a number of years, since it was originally
prescribed at HMP Foston Hall. The reason for the initial use was to manage
her opiate addiction. However, methadone is also used to manage chronic
pain. The woman had sustained a back injury in a car accident some years
earlier and methadone was prescribed to relieve her continuing pain.
30. Drug tests performed by healthcare staff at reception proved negative for
everything other than prescribed medication. This was significantly different to
other periods in custody when she had tested positive for illicit drugs on
reception. A second health screen was carried out the following day. The
woman was put on a methadone maintenance programme in which she would
receive 40mls a day. Due to the risks of becoming dependent on diazepam,
she was also put on a diazepam detoxification programme, which involved a
gradual reduction from 10mg to 4mg over a four week period. Prior to custody,
she had also been receiving tramadol but this was stopped following her
reception. The screening also recorded her other medical history, which
included asthma, hepatitis C and swelling in her legs, believed to be as a result
of intravenous drug use.
31. Following the observation period on the healthcare wing, the woman was
placed in A wing. She was visibly upset when she went to the wing and an
ACCT document was opened as a result. During the assessment, she said she
did not understand why she was back in custody, despite her conversation with
her probation officer after her arrest. She appeared very frustrated and tearful
but said that she had no thought or intention to self-harm. The woman was
also concerned that no one including her son knew that she was in custody.
32. After the assessment, a review was held with the woman and the unit manager.
The woman was upset throughout the review. She was adamant that she was
not going to self-harm but was frustrated at her recall. She requested a move
from A wing to the Voluntary Drug Testing (VDT) landing and was provided with
the necessary application form. She also asked about contacting her son, but
was told that proof would be required that he was being held at the prison
specified. When the investigator spoke to the woman’s partner, he said that
this decision caused her some frustration. He explained that she had made
contact with her son on previous sentences. It was known by the prison that he
was in the prison she had stated and she could not understand the need for
further confirmation. The decision was taken to keep the ACCT open for the
time being.
33. On 13 February, a Security Information Report (SIR) indicated that the woman
was acting in a strange way which made staff think that she might be under the
influence of drugs. (SIRs can be submitted by any member of staff working
within a prison who has concerns about anything related to the security of the
prison.) Other remarks were made during her first few weeks in custody
relating to her possibly using drugs. However, they were not substantiated and
the woman’s drug tests were negative, rendering her eligible for a move to the
VDT wing. This was the longest period that she had abstained from illicit drugs
as she had used drugs heavily during previous prison sentences.
11
Following sight of the draft report the woman’s family asked whether other
avenues should have been explored to explain her behaviour, given that there
was no evidence that she was using illicit drugs.
I do not think staff could have been expected to make any further enquiries into
this matter on the basis of so little information. The woman had provided
negative urine samples and had not mentioned any other concerns to staff.
34. Over the next week, her moods fluctuated and she mentioned to staff several
times that she was confused about the reasons for the recall. It is evident from
the ACCT document that staff tried to advise her about this but she would get
herself “very wound up”. An ACCT case review, held on 15 February, said that
the woman interacted well, but still appeared very emotional. She remained
concerned about her recall, as well as issues with some women on another
wing which meant that she was worried about moving.
35. On 18 February, she submitted a request and complaint form in relation to her
medication. She was concerned that the diazepam was to be withdrawn and
said that she needed it for her back pain. She also said that she wished to stop
taking methadone and be prescribed tramadol instead. It is clear from the
complaint form that the woman thought her concerns about her healthcare were
not being taken seriously.
36. Her probation officer wrote to her on 18 February, to set out the reasons for her
recall. He explained that he remained optimistic and recommended her release
on the same licence conditions. He explained how positively she had
progressed during her licence period. Her probation officer went on to explain
that he would visit soon but she should know that he would continue to do his
best for her.
37. ACCT entries indicated that she appeared happier and was told that she could
move to the VDT wing. She had been pursuing the plan since returning to
custody. However, an entry in her medical record on 19 February gave a
different view. It was recorded that during an appointment the woman had
been “very distressed and anxious” and that she had “become quiet and
withdrawn but she was not thinking of self-harm”. She also reiterated that she
did not know why she had been recalled.
38. The Clinical Lead Nurse, responded to the woman’s request and complaint on
20 February, advising her to make an appointment to discuss her problems.
The Clinical Lead Nurse had known the woman for some time and saw her
regularly in the clinic for blood tests. The investigator spoke to the Clinical
Lead Nurse about the woman’s medication. She said:
“The woman was taking methadone, not because of heroin addiction
but because she had pain in her back, so that was an ongoing situation
with her. She wanted to be detoxed off it, and our detox nurse was
reluctant to do it at that time as she felt her back pain could get worse,
12
and she wanted her to be seen by the Pain Specialist Nurses prior to
detox.”
39. On 22 February, the woman began working on the painting party. Her personal
officer, recorded that at first she was surprised to be allocated to this job, but
appeared to enjoy the work. It also gave her more time out of her cell. The
personal officer scheme allocates prisoners a particular officer who they should
go to regarding any immediate concerns or issues. The personal officer will
usually be responsible for commenting on the individual’s behaviour for reports
and accompany them during reviews of ACCT documents. Most importantly,
they are a point of contact if a prisoner just needs to talk.
40. The investigator asked the woman’s personal officer about her contact with her:
“I would see the woman on a regular basis, I was also available for her
should she need to call for me to come and speak to her, which I would
do if I was available to do so. It would be fair to say that we had a
close relationship. On this sentence, she appeared to me to be very
much the same as I had previously known her. However, the licence
recall caused her quite a bit of distress and she was upset about why
she had been recalled when she first came in.”
41. The personal officer attended an ACCT review with the woman on 22 February.
She interacted well during the review. Her only concern was that she would be
moved from A wing and was awaiting a decision on whether she could go to C
wing. However, an earlier entry in her ACCT suggested that she had already
been notified that she had been accepted. A date was set for the next review
to take place on 3 March.
42. On 23 February, one of the prison chaplains and the woman discussed the
possibility of her marrying her partner whilst she was in prison. The chaplain
agreed to speak to her partner and the local priest about her request.
43. The woman went to see the doctor on 25 February about swelling in her legs.
The doctor acknowledged that she had previously suffered from severe
swelling in her ankles, but this was not present during the examination. He
recorded that she had minimal swelling in her left ankle. She was prescribed
the anti-inflammatory drug, diclofenac, to treat the swelling. She was advised
by the doctor that diclofenac can aggravate asthma in some patients. After
seeing the doctor, the ACCT document says that the woman was feeling down.
However, the document says that she was happier when she returned from
work in the afternoon as she enjoyed being on the painting party.
44. While in custody, she received regular visits from her partner, and would often
talk about them when she returned to the wing. On 28 February, a member of
the chaplaincy team spoke to her and her partner during a visit and briefly
discussed their plans to get married. It is recorded in the ACCT document that
she became upset during the visit and, when she returned to the wing, she told
staff it was because she missed her partner.
13
45. Her partner wrote to the Clinical Lead Nurse on 28 February. He was
concerned that no one in the healthcare department was listening to the
woman’s concerns about medication. When my investigator interviewed the
Clinical Lead Nurse, she acknowledged that she had received this letter.
However, the woman’s partner did not receive a reply to this letter or indeed the
questions asked and he felt that this was discourteous.
46. On 29 February, the woman replied to her probation officer’s letter of 18
February. She discussed the offence that had led to her recall and how she
had tried her hardest, but accepted she had been foolish. She also spoke
fondly of her son and her partner and said that she was determined to remain
positive. The woman closed the letter by thanking her probation officer for
doing his best for her and said that she knew that he would do so again.
47. Over the next week, she continued to be in good spirits. She spent time
laughing and joking with other prisoners and staff. She asked on a number of
occasions for her ACCT monitoring to be stopped as she felt a lot better. The
painting party kept her busy during the day and proved positive for her. On 30
February, the woman told staff that her solicitor had written to her local Member
of Parliament about healthcare staff not allowing her to take an alternative to
methadone. However, the investigator was unable to substantiate whether she
had sent this letter.
48. The woman’s next ACCT review took place on 3 March. During the review, she
interacted well and her mood was very positive. She said that she was
enjoying the painting party but was disappointed that there was to be a two
week break. She said that she was awaiting authorisation for an inter-prison
video link communication with her son. (Many prisons now use video systems
to link to Crown and Magistrates’ courts. Prison Video Links [PVLs] allow
offenders to appear in court via a live video link from prison. PVLs are primarily
used for court hearings and legal visits, but they can also be used for a number
of other purposes such as probation and official visits, inter-prison visits and
staff training.)
49. Healthcare confirmed that they had no concerns regarding the woman and the
decision was taken to close the ACCT. She was pleased about this and a post
closure interview was planned for 10 March. The post closure interview is used
to check on anyone who has been the subject of an ACCT document, and it
should be conducted within seven days of closure.
50. Following a request from the woman to speak with a member of the
Independent Monitoring Board (IMB), two members went to see her on 4
March. The woman raised a number of concerns, the first regarding the recall
documents she said she had completed, but had not been received by her
solicitor. She was also concerned that her probation officer had not yet been to
see her and showed them the letter written by him on 18 February. The woman
also discussed her prospective marriage to her partner and said that she had
submitted the paperwork to the Deputy Director for it to go ahead. Finally, she
told the IMB members about her concerns about the methadone she had been
14
receiving. She was insistent that she had no intention of using drugs again and
therefore did not want to be prescribed methadone.
51. Following their meeting with the woman, the IMB members returned to the IMB
office. One of them attempted to contact the woman’s probation officer but he
was unavailable, and so left a message expressing the woman’s concern. In
the record of their meeting, the IMB member’s say that their impression of the
woman was that she was agitated and bordered on being hyperactive. They
said that the woman appeared anxious throughout and wanted everything
sorted out. She also said that it was not possible to say whether her
expectations were realistic or if she had given adequate time for them to be
resolved.
In response to the draft report, the woman’s family said they were puzzled by
the IMB’s conclusion as to whether her expectations were realistic. The family
also asked about the role of the IMB.
The woman had said that she had sent various applications regarding a
number of issues during her talk with the IMB. I believe that when mentioning
realistic expectations, the IMB members were concerned that she was not
allowing enough time for people to respond to her requests.
The Prisons Act 1952 requires every prison to be monitored by an independent
board, appointed by the Home Secretary, comprising members of the
community in which the prison is situated. The board is required to satisfy itself
as to the humane treatment of those held in custody and the range and
adequacy of the programmes preparing them for release. The members have
the right of access to every prisoner and every part of the prison to ensure
proper standards of care and decency.
52. The investigator observed the CCTV footage of the woman’s wing filmed on the
evening of 4 March. She was unlocked for association and spent the majority
of her time in or around her cell. She left her landing on only two occasions, to
collect hot water and use the telephone. She could be seen talking to her
friend, and looked in good spirits. The cells were locked up at around 7.30pm.
The woman was seen in her cell at the final roll check around 9.00pm. During
the remainder of the night the CCTV footage shows that she made no requests
via her cell call bell for staff.
The woman’s family has also asked whether there was evidence that the cell
call system was working correctly.
Although the investigator was not provided with any evidence to show it had
taken place, a check of all cell call systems is conducted daily as part of the cell
fabric check. As previously mentioned, the CCTV showed no call being made
from her cell. Given the location of her cell, if a there had been a problem she
would have been able to raise concerns verbally. However, when interviewed,
her friend, who was in a cell next to her, said that she did not hear the woman
during the night.
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53. At approximately 5.30am the following morning, a PCO, who was on the night
shift, was conducting the early roll check. The PCO is a permanent night officer
and was familiar with the woman as he had carried out checks on her while she
was subject to ACCT monitoring. When he arrived at her cell on the morning of
5 March, the PCO checked as normal. However, the investigator noticed on
the CCTV that he appears to have done a “double take”. The investigator was
keen to know why the PCO did this and spoke with him when he visited
Peterborough. The PCO told my investigator that he had been doing his count
as normal and, on arrival at the woman’s cell, had opened the observation
panel to check before moving on. However, at first glance he was not satisfied
that he had seen her and, knowing that she had only recently been taken off
ACCT monitoring, decided to have a better look. He said that on looking into
the cell he could clearly see her lying on her bed and she appeared asleep. He
therefore had no cause for concern and moved on.
Discovery of the woman and medical treatment
54. At 6.00am, another PCO started duty as the early unlock officer. The early
unlock PCO was responsible for ensuring that all prisoners required for court
were unlocked and taken to reception, as well as carrying out a full roll check.
He began to count the woman’s wing at approximately 6.30am, but on arrival at
her cell, he could not see her in bed. He told my investigator that he looked
again and she was clearly not there so he looked to the side and could see her
on the toilet. The early unlock PCO told the investigator that having seen the
woman, he did not continue to observe as a matter of decency. He noted,
however, that she was sitting forward with her forearms resting on her lap. The
early unlock PCO said that he also noted movement of her hands.
55. Following the early unlock PCO’s roll check, there was a period of around 40 to
45 minutes before staff began to unlock the wing. At 7.15am, two day duty
PCO’s unlocked the servery workers on A wing before unlocking the remainder
of the wing. One of the PCO’s unlocked the upper landing where the woman
was located. (When male staff unlock women prisoners it is important to
ensure that levels of decency are maintained, so when they unlock the cell
doors they do not push them open.) He unlocked the entire landing and went
back downstairs.
The woman’s family asked whether it was usual practice for staff to look into a
cell to ensure that it is safe to unlock the door.
I agree that staff are usually encouraged to observe a prisoner by way of the
observation panel before entering their cell. However, it was not the PCO’s
intention to enter the cell. He was only releasing the lock on the woman’s door,
this would not have required him to observe her before doing so.
56. The woman, and her friend, who was on the same landing used to take it in
turns to go to each others cells for coffee in the mornings. The woman’s friend
told my investigator that on the morning of 5 March it was her turn to go to the
woman’s cell. When she pushed the door to the cell she saw the woman lying
on the floor right behind the door. The woman’s friend told the investigator that
16
it looked to her as though the woman had fallen from the toilet. On seeing her,
she went to the top of the stairs and called to the PCO’s to come to the cell as it
looked as though her friend had collapsed.
57. On entering the cell, the PCO found the woman lying on the floor and called the
other PCO for assistance. The woman was lying on her front and the officers
placed a blanket over her lower half. Both officers checked for a pulse and
called for medical assistance via the radio. On hearing the call for assistance
at around 7.20am, a Senior PCO (SPCO) made her way to the woman’s cell.
She also checked for a pulse and called again for medical assistance. When
asked to clarify how long it was before such assistance arrived, the SPCO said
it was “a couple of minutes perhaps not even that”.
58. A nurse was the first member of healthcare to arrive as she had been issuing
medication on a neighbouring house block. She asked staff to call Clinical
Lead Nurse, whom she had heard join the radio network as Hotel 1. (Hotel is
the radio call sign assigned to medical staff and the staff member carrying Hotel
1 is the first to respond to a healthcare emergency.) The nurse said she
checked the woman’s pulse and could detect no output. Within a couple of
minutes, the Clinical Lead Nurse arrived at the cell. She instructed the staff to
make sure that an ambulance had been called and that it was given quick
access to the wing. The nurse told the Clinical Lead Nurse what was
happening and together they put the woman onto her back. The nurse began
chest compressions and the Clinical Lead Nurse gave breaths to the woman.
The Orderly Officer (the Orderly Officer role is carried out by a senior uniformed
grade who is responsible for attending all incidents), arrived at the cell and took
over assisting the Clinical Lead Nurse and the other nurse left the cell.
59. The Clinical Lead Nurse prepared the defibrillator and placed the pads on the
woman’s chest. The machine automatically assessed her and indicated that
there was no “shockable rhythm” so staff continued cardio pulmonary
resuscitation (CPR). The Clinical Lead Nurse and the Orderly Officer continued
to administer CPR, stopping to check the defibrillator every couple of minutes.
The machine continued to show there was no “shockable rhythm” and they
continued CPR until the arrival of the paramedics.
60. The Clinical Lead Nurse told the investigator that the paramedics arrived about
ten minutes after she got to the cell. Two ambulances answered the
emergency call and a paramedic trained to recognise and pronounce death,
was with one of the crews. They treated the woman as a patient who had
suffered cardiac arrest. The ambulance records show that their treatment
began at 7.33am. However, she failed to respond and all treatment ceased at
7.51am, when the paramedic declared that the woman had died.
The woman’s family said that the report from the ambulance crew indicated that
she was last seen alive at 6.00am. They consider that this is at odds with the
evidence.
The report by the ambulance service reads “last seen at 06.00 during morning
checks”. I agree that this statement could be misleading. The PCO’s duty
17
began at 6.00am and it was approximately 6.30am when he reached the
woman’s cell during his roll check.
Following the woman’s death
61. Later that day, managers from Peterborough prison visited the woman’s
partner, at his home to notify him of her death. They informed him about the
circumstances surrounding the woman’s death as far as they were known and
about the involvement of my office. The prison also offered assistance in
meeting funeral costs.
62. The prison had a lot of contact with him during the weeks following the
woman’s death. Her partner was keen to get her personal effects back before
her funeral, along with other property, and the prison ensured that this
happened. (Some property remained in her cell, which had not been released
by the police.) The prison also arranged for her family to visit Peterborough,
where a memorial service was held, and they had the opportunity to visit A wing
and speak with some of her friends.
63. The Director of HMP Peterborough and one of his senior staff attended the
funeral. The woman’s son was also escorted to the funeral.
64. On 11 March, the woman’s probation officer, received a fax confirming that the
Parole Board had decided that the woman should be released on licence on
the basis of the recommendations made by him.
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ISSUES
The woman’s recall on 5 February 2008
65. The proposal to recall her on 5 February was taken after a consultation
between her probation officer and his managers with the final decision being
made by the ERR Section. They took account of the fact that she had received
a Suspended Sentence and Supervision Order (as well as a final warning from
the Assistant Chief Officer for a similar offence in February). Her probation
officer said that the proposal was also based on the increased risk of her
committing further offences and possibly harming herself. Although the
purpose of my office is to investigate the circumstances of the woman’s death, I
take this opportunity to comment that I believe the probation officer’s
recommendation of recall was appropriate in the circumstances.
66. The woman’s partner told the investigator that he felt that the decision had
been made too quickly. He felt that her probation officer should have waited to
see what action the police were going to take. It was clear during the
investigation that the woman had made significant progress during her period of
licence and that the decision to recall had not been taken lightly. However,
following her release on police bail she had contacted her probation officer and
admitted the offence. Her probation officer became aware that she had been
bailed and that there was a strong possibility that she would be formally
charged.
67. Despite the decision to recall the woman, her probation officer recommended to
the Parole Board that the woman could be released on licence. He considered
the progress she had made could be better continued in the community. The
Parole Board agreed with the original decision to recall her to custody, but
accepted the recommendation and, on 12 March, ordered that the woman be
released. Unfortunately, by the time this decision was communicated, she had
already died.
68. The woman’s partner also told the investigator that he felt that the recall to
prison was directly related to her death. I would like to reassure him that
although it caused the woman some distress, there is no evidence to suggest
that it was in any way linked to her death.
The woman’s family responded and said that whilst this may not have been
influential in relation to her death it did cause her extreme anxiety. The family
ask whether her probation officer had any other option other than to refer the
woman to the ERRS.
In my opinion, the probation officer was duty bound due to the woman’s earlier
offending to report the new offences to the ERRS. When ERRS made their
decision it would have been based on all the information supplied to them,
including her previous history. Despite the recall, the probation officer was
instrumental in supporting the woman’s re-release.
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The woman’s request to detoxify from methadone and her access to
medication
69. On her reception into custody, medical staff recorded all the medication the
woman had brought in with her. This is recorded as being methadone 40mls
daily, diazepam 5mg and tramadol 150mg. The doctor arranged for the
methadone to be given on a maintenance programme of 40mls a day. The
diazepam was issued on a gradual detox from 10 to 4mg over a four week
period and her tramadol was stopped. During this initial consultation, there is
no indication that the woman asked to be taken off her methadone.
In response to the draft report, the woman’s family asked whether diazepam
was the most appropriate medication for her to be prescribed given her history
of drug addiction and that diazepam is an addictive drug. Also the family were
concerned that there was no mention of the process for monitoring someone
who might be withdrawing from diazepam and asked whether the withdrawal
programme was too quick given that she was distressed.
I am unable to confirm whether diazepam was the most appropriate medication
for her, but I am aware of its extensive use for methadone users as part of
maintenance programmes. The reason the woman was placed on a gradual
reduction programme was to prevent her from becoming dependent. The detox
was also gradual to minimise the affects of diazepam withdrawal. The
detoxification nurse would closely monitor any detox programme.
70. The detoxification nurse at Peterborough, saw the woman but the entry in the
medical record is undated. The detox nurse recorded that the woman had
expressed a wish to reduce her methadone, but the nurse was concerned as
the woman used the drug for pain control. The detox nurse discussed her
concerns with both the woman and the prison doctor. The woman was aware
that a decision had been taken to refer her to the pain management clinic at the
local hospital before any reduction in her methadone would be made. At the
time of the woman’s death, the appointment had not been received.
71. The woman’s partner told the investigator that the woman felt that her concerns
about her healthcare were not being taken seriously. I am aware that she had
submitted a request and complaint form on 18 February regarding her
medication. The Clinical Lead Nurse responded to the complaint and told her
to make an appointment to discuss her concerns. When the investigator spoke
to the Clinical Lead Nurse, she confirmed that she had spoken with the woman
about medication and would see her regularly in the clinic for blood tests. She
also said that she had discussed the woman with the detoxification nurse and
that she was aware that a referral had been made to the pain clinic.
72. The woman’s partner was also concerned that the woman had been prescribed
diclofenac, an anti-inflammatory medicine. He said that, as an asthmatic, this
medication could be dangerous for the woman and also caused her concern.
The diclofenac had been prescribed on 25 February after the woman was seen
by the doctor for swelling in her ankles. The doctor recorded in the medical
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record that he had advised her regarding her asthma. The clinical reviewer
also supports this and says, ”it is a demonstration of good practice for the
doctor to have mentioned the possibility of her asthma being affected, and
there is no mention in the records that her asthma was adversely affected”.
73. I am satisfied that the woman’s health needs were appropriately addressed, but
make the following recommendation regarding the recording of medical
information.
The Director and Head of Healthcare should remind all clinical staff of
their obligations to comply with the rules regarding record keeping set
out in the relevant Nursing and Midwifery Council Guidelines.
Medical Response
74. The Clinical Lead Nurse said during her interview that she felt that the woman
“had gone” (meaning that she thought that she had already died) when she
arrived at her cell. Despite this nursing staff and officers continued in their
attempts to revive her until the arrival of the paramedics. I am aware that this
may have been traumatic for some of the staff involved and the first time that
they had been called upon to respond to what turned out to be a death in
custody. I acknowledge the professionalism shown by the staff involved and
ask the Director of Peterborough to make those staff aware of my comments.
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CONCLUSION
75. The woman had been making significant progress prior to her recall and it was
with clear regret that her supervising officer made the proposal to recall her to
prison. Despite her initial and understandable upset at her recall, she
continued to remain positive. Her goal was to remain free of illicit drugs and
ultimately stop taking methadone. The woman’s death came at a time when
she appeared to have found stability and was making plans for her future,
something she had not previously been motivated to do.
76. The pathologist has attributed the woman’s death to a combination of the
prescribed medication that she had been taking, namely methadone and
diazepam. In his report, he points out that the levels in her system were in
keeping with her prescribed doses. This indicates that her death was not
intentional. However, he gives no reason why it had a fatal effect. I am mindful
that this may leave her family with unanswered questions, which I hope will be
further investigated during the inquest process.
77. Since the issuing of the draft report, the investigator has attempted to gain
further information on how benzodiazepines contribute to fatal methadone
toxicity. The investigator found that there were recent studies that showed
benzodiazepines may contribute to deaths from methadone toxicity by
increasing upper airways obstruction. The study referred to by the investigator
also said that ‘benzodiazepines are more likely to contribute to fatal methadone
toxicity in newly admitted maintenance patients and those taking methadone
tablets for pain relief’.
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RECOMMENDATION
The Director and Head of Healthcare should remind all clinical staff of their
obligations to comply with the rules regarding record keeping set out in the
relevant Nursing and Midwifery Council Guidelines.
The Prison Service accepted this recommendation and said:
‘This has been placed as a standing agenda item on team briefings and
Notices to Staff to be issued’
The target date for completion of this is given as September 2008.
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