Individual at Kirklevington Grange

A report of the circumstances surrounding the death of a
man at HMP Kirklevington Grange
on 12 January 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2009
This is the report of an investigation into the circumstances of the sudden and
unexpected death of a man during the early evening of 12 January 2008 at HMP
Kirklevington Grange. The man had returned from a day release on temporary
licence and, soon after returning to the prison collapsed. Determined but ultimately
unsuccessful efforts were made by prison and ambulance service staff to resuscitate
him. A post mortem examination found that the man’s death was probably due to
natural causes, he was 53 years old. My colleagues and I would like to extend our
condolences to the man’s family and to all those touched by his death.
The investigation was led by one of my Fatal Incident Investigators. An independent
review of the man’s medical care in prison was commissioned and carried out by
Hartlepool Primary Care Trust and North Tees Primary Care Trust. I am grateful for
their assistance. I would also like to thank the management and staff at
Kirklevington for their co-operation during the course of this investigation.
The man was remanded in custody at HMP Elmley in July 2005 and in February
2006 was sentenced to seven years imprisonment. On reception he was in good
health except for a chest infection for which he was treated. Over the following
months the man was diagnosed with high blood pressure and high cholesterol levels
for which he received appropriate medication. He remained on those medicines
throughout his sentence.
The man progressed through a number of prisons, achieving category D status and
arriving at HMP Kirklevington in June 2007. At Kirklevington he was regularly
granted release on temporary licence to take part in visits in the local community and
to spend extended periods at home with his family for the maintenance of family ties.
On the morning of 12 January 2008, the man went on a local community visit
returning to Kirklevington at 6:00pm. After leaving the reception area the man
collapsed in the main prison corridor. Prison staff and then paramedics made
sustained attempts to resuscitate him but at 7:12pm he was declared dead.
It is evident that the man received appropriate and timely care throughout his
sentence and that determined efforts were made to resuscitate him after his
collapse. I have made seven recommendations, four of which are about record
keeping. The fifth recognises the actions taken by two prison staff members. The
sixth recommendation concerns training in the use of life support equipment. The
final recommendation is about the procedures adopted when news of a death has to
be given to next of kin. I must apologise for the delay in publishing this report.
Stephen Shaw
Prisons and Probation Ombudsman March 2009
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CONTENTS
Summary 4
The investigation process 5
HMP Kirklevington Grange 6
Key events 8
Issues considered during the investigation 19
Recommendations 25
Evidence considered 27
3
SUMMARY
The man, a prisoner at HMP Kirklevington Grange, died on the evening of 12
January 2008. After returning from a day release on temporary licence he collapsed
in the main prison corridor. He was 53 years old.
The man was remanded in custody at HMP Elmley for the importation of drugs in
July 2005 and was sentenced to seven years imprisonment in February 2006. On
reception he was found to be in good health except for a chest infection for which he
was treated periodically throughout his sentence when the infection recurred. In
August he underwent an electrocardiogram (ECG) and a chest x-ray was requested.
Because no results of the tests were given the man’s solicitor wrote requesting that
the results be provided and identified the man’s symptoms including that he said he
had an enlarged heart.
Over the following months the man was transferred to HMP Maidstone and then to
HMP Standford Hill. In January 2007, he was firstly diagnosed with high cholesterol
levels and later in February 2007 with high blood pressure. He received appropriate
medication for both conditions and the prescriptions were repeated until his death in
January 2008. The man was transferred to HMP Kirkham in April 2007 and after
achieving category D status (a lowered security risk level) was transferred to HMP
Kirklevington in June 2007. The man was regularly granted release on temporary
licence to take social visits in the local community and to spend extended periods at
home and maintain his family ties.
On the morning of 12 January 2008, the man was released as usual on temporary
licence for a community visit. He returned at around 6:00pm and went through the
normal reception procedure. He appeared well to reception staff and was acting
normally. At around 6:30pm soon after leaving reception the man collapsed in the
main prison corridor. Fellow prisoners witnessed his collapse and reported it to
prison staff in reception who went immediately to him. They initially thought he was
suffering a seizure but soon realised that the man was seriously ill. After moving him
out of the crowded corridor into the segregation unit, prison staff began resuscitation
attempts using cardiopulmonary techniques (CPR). Prison staff and then local
ambulance service paramedics made determined and sustained efforts to
resuscitate the man but at 7:12pm, after he had been moved to the ambulance,
resuscitation attempts were halted and the man was declared dead.
Following the confirmation of the man’s death, Kirklevington’s death in custody
contingency plan was activated and his next of kin were notified. The police visited
the prison that evening and found no suspicious circumstances. The man’s body
was later released to the undertakers who removed him to the mortuary for post
mortem examination. The following morning police informed the duty governor that
the man had died from natural causes. The man’s funeral took place on 15 January
in Huddersfield and three of his friends from the prison attended.
I make seven recommendations and am pleased that six have been accepted in their
entirety and one has been partially accepted.
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INVESTIGATION PROCESS
1. My investigator visited Kirklevington Grange on 21 January 2008. He met the
governor who gave him a full briefing about the circumstances surrounding
the man’s death.
2. My colleague offered to meet representatives of the Prison Officers’
Association (POA) and the Independent Monitoring Board (IMB). He met
representatives of the POA but was unable to meet a member of the IMB.
Notices to staff and prisoners were published prior to his visit inviting anyone
who might have information relating to the man to make themselves known to
the investigator. Two prisoners spoke to the investigator and were
interviewed formally. My investigator also met relevant prison staff.
Kirklevington provided copies of the man’s prison record and Inmate Medical
Record (IMR). The police were involved briefly but decided at an early stage
that the circumstances surrounding the man’s death were not suspicious.
3. An assistant director (Integrated Governance) from Hartlepool Primary Care
Trust and North Tees Primary Care Trust (HPCT/NTPCT) commissioned a
clinical review which she carried out with the Integrated Governance
Manager, HPCT/NTPCT. The report of the review was received on 20
February.
4. One of my family liaison officers wrote to the man’s family on 11 February to
explain the purpose of the investigation and invite them to raise any concerns
they wished to be considered and addressed as part of the investigation. At
the time of issuing this report the family had not expressed any concerns or
highlighted any issues. Unfortunately, the pressure of other cases has led to
a delay in the completion of this one for which I must apologise.
5. The man’s family received a copy of my draft report in December 2008. In
their response, they raised a number of issues regarding the delay in contact
from the prison following the man’s death and concerns about the way in
which the news of the man’s death was broken, the use of defibrillators and
discrepancies in the accounts of eye witnesses to the man’s collapse.
Paragraphs 57, 58, 87 and 88 of this report have been amended to reflect the
family’s concerns about contact from the prison following the man’s death.
The other concerns have been addressed in the report or in separate
correspondence with the family.
5
HMP KIRKLEVINGTON GRANGE
6. HMP Kirklevington Grange is a resettlement prison in Yarm on Teesside. It
holds 220 adult male prisoners and prepares them for release into the
community.
7. Healthcare was provided at the time of the man’s death by Hartlepool Primary
Care Trust and North Tees Primary Care Trust (a combined body which, in
August 2008, became Stockton-on-Tees Teaching Primary Care Trust).
Kirklevington has a community based visiting doctor who with three part-time
nurses provide primary care at the prison. Secondary care, at the time of the
man’s death, was provided by the Tithebarn Medical Centre, a doctor’s
practice close to the prison. It provided community based medical services
and, once accepted for outside work or visits, prisoners used them like any
other member of the community. The medical service contract has since
moved to another supplier and general practitioner services and primary
nursing services are now provided in the prison. Other medical services are
still provided by referral to outside healthcare centres. At Kirklevington
prescribed medication is normally held in-possession by the prisoner.
8. Healthcare at Kirklevington at the time of the man’s death was a part time
service. On weekdays part time nursing staff attended daily to see prisoners
reporting sick, administer treatments and run clinics. In the event of non
emergency care being required when nursing staff were not in the prison, the
local doctor’s surgery provided a service. Emergency care was given via the
ambulance service and the local accident and emergency service. Out of
hours medical services were contracted from Primecare who provided care
from 5pm until 8am daily and at weekends. At weekends a staff nurse
attended for three hours on alternate Saturday mornings. On Saturday 12
January 2008, a staff nurse was not scheduled to attend.
9. Kirklevington operates a protected time staff training scheme, each week on a
Tuesday, which provides up to date basic life support and resuscitation
training. A defibrillator is situated in the Healthcare Department which is
accessible out of hours to staff.
10. The resettlement regime is based on sentence plan targets and a robust
release on temporary licence (ROTL) risk assessment. Emphasis is placed
on personal responsibility and addressing offending behaviour. Prisoners are
encouraged to maintain and strengthen family ties.
11. The Independent Monitoring Board (IMB) report for 2007 (published in
February 2008) noted that the previous year’s report (2006) had raised
concerns about healthcare provision at Kirklevington and prisoner access to
appointments and prescriptions at the local doctor’s surgery. The IMB
recorded their pleasure at the improvement in nearly every area of the
healthcare service, including those mentioned above, since their previous
report. The man’s was the first death in custody at Kirklevington in the last 15
years.
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12. HM Chief Inspector of Prisons (HMCIP) in her 2005 report found that
Kirklevington was carrying out its task very successfully and paid tribute to the
staff, managers and prisoners at the prison. HMCIP commented that the kind
of work done at Kirklevington should be more widely replicated elsewhere.
HMCIP also reported that the healthcare department had limited opening
hours and there was a lack of systems, policies and protocols.
7
KEY EVENTS
Leading up to 12 January 2008
13. The man was born on 1954 in Pakistan, he was a British citizen. He was a
married man and, before imprisonment, lived with his wife and adult children.
At the time of his remand the man was a shop keeper. He was a long term
smoker. He named his wife as his next of kin.
14. The man was first remanded to prison custody at HMP Elmley on 19 July 2005
and was subsequently sentenced on 10 February 2006 to seven years
imprisonment. This was not his first time in prison. He was also subject to a
Travel Restriction Order (TRO) for two years to commence on the day of his
release
15. On the man’s first reception screening at Elmley no indicators of suicide or self
harm were identified. He reported that he had seen a doctor on 18 July,
when in the custody of HM Customs, because of a suspected chest infection.
He had been prescribed Amoxicillin (an antibiotic) and E45 cream (used for
skin irritations). The man was in good health except for the chest infection for
which he was referred to a doctor and was seen on 20 July. He reported no
other concerns about his health. The man signed the Elmley Medication
Compact on 19 July naming his wife as next of kin. He gave consent for his
confidential medical information to be shared with his doctor, solicitor and
other specialists.
16. The man reported to the Nurse’s Triage Clinic on 11 August, complaining of
chest pain in the left side. The nurse noted that the pain did not worsen when
he moved and that he had previously suffered a chest infection. She referred
him to the doctor who saw him the same day. The doctor noted on the man’s
Continuous Clinical Record that he was a smoker, had “filthy sputum” and
shortness of breath. He also noted that the man had a 5kg loss of weight and
no appetite. (No other record of the man’s weight is evident other than a
single record made at reception when he was 11.5st. The doctor requested a
chest x-ray and an electrocardiogram (ECG).
17. An ECG test printout dated 11 August bearing the man’s name is filed in his
Inmate Medical Record (IMR). The printout bears the words “Sinus Rhythm”,
“Atrial Premature Complex (es)”, “otherwise Normal ECG” and “Unconfirmed
Report”. No interpretation of the printout was subsequently noted and there is
no indication as to whether the x-rays took place. A letter dated 16 August
from a solicitor to Elmley healthcare centre enquires about the outcome of the
ECG because the man had not received the results. They also requested that
Elmley contact the man’s doctor, provided contact information and mentioned
their belief that the man suffered from high blood pressure, high blood sugar
levels and had said that he had an enlarged heart. The investigator’s
enquiries of HMP Elmley healthcare centre and the solicitor were unable to
discover what the outcome of the ECG was or whether the x-rays took place
and the outcome. The man’s surgery was contacted by my investigator but
there is no record of any contact with Elmley healthcare staff about the man.
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It is unclear where the information regarding an enlarged heart originated and
enquiries by the investigator indicate that the man’s family doctor had no
recorded knowledge. No further information on these issues is recorded in
the Inmate Medical Record.
18. The man saw a healthcare officer again on 31 August when he complained of
an infection under one of his teeth. He was again prescribed Amoxicillin and
Ibuprofen for the pain. He was also referred to the chiropodist for a foot
problem.
19. The man was well thought of at Elmley and was noted as being helpful when
foreign national prisoners had communication problems. He achieved
enhanced status in the Incentives and Earned Privileges scheme on 28
October.
20. On 13 March 2006, the man was transferred to HMP Maidstone where he
underwent a healthcare reception screening which gave no cause for
concern. The man’s weight was recorded as 13st. He was assessed as
suitable to be in possession of his own medication and again named his wife
as his next of kin. He was deemed by the healthcare centre to be Fit 1A,
meaning that he was eligible to take part in all work and sporting activities.
Over the following three months the man suffered minor ailments including
chronic constipation for which he received appropriate treatment. On 30
June, a non urgent chest x-ray was requested after the man reported sick with
a chronic cough and breathlessness. The x-ray took place on 11 July and the
results were received at Maidstone on 25 July. The radiologist wrote that his
lungs were clear. The man’s weight was recorded on 1 December as 12.8
stones.
21. The man underwent blood tests on 4 October which were repeated on 6
December and the results were returned on 12 December. As a result, on 2
January 2007, the man was prescribed Simvastatin for raised cholesterol.
Regular repeat prescriptions followed until the time of his death.
22. Following the outcome of a confiscation hearing at Canterbury Crown Court
on 16 February, the man was transferred to open prison conditions at
Standford Hill. He underwent a healthcare reception interview on the same
day and his weight was recorded as 13st 7lb. His illnesses were high
cholesterol, previous depression, constipation and possible hypertension (his
blood pressure was recorded as 211/99). His current medication was
recorded as Simvastatin 20mgs (for high cholesterol level) once daily and
Bisacodyl suppositories (for constipation). The interview notes also record
that he was again designated as fit for all categories of work, smoked ten
cigarettes daily, used cannabis and was short sighted. He was advised
regarding the cessation of smoking.
23. The man’s Continuous Clinical Record notes on 19 February that he had
raised blood pressure (hypertension) and that it should be monitored for the
following three days. A further note indicates that he might need medication.
His Prescription and Administration Chart records that on 22 February he was
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prescribed Amlodipine for hypertension which he continued taking until
several months prior to his death. The man was also prescribed laxatives and
Daktarin for athletes’ foot. On 14 March the man’s family doctor, wrote to the
Governor at Standford Hill requesting, because of the health of his patient, the
man’s wife, that the man be granted home leave. The man remained at
Standford Hill until 19 April 2007 when he was released on temporary licence
to transfer to Kirkham prison in Lancashire.
24. On arrival at Kirkham the man went through the induction procedure, his
previous medical history was recorded and his work grade was reduced to 1B
meaning that he was fit and well but over the age of 35years. His weight was
recorded as 14st. He continued to smoke and requested a course of
preventative Hepatitis B vaccinations. He was placed on the waiting list for
the dentist. A North Lancashire PCT In-Possession Risk/Safety Algorithm
was completed resulting in an assessment that the man was suitable to
receive in possession medication. His wife was again identified as his next of
kin. The man was prescribed Amlodipine, Simvastatin, and Bisacodyl on 21
April. All were given in-possession. On the same day the man made an
application for resettlement overnight release (ROR) to be taken at his family
home between 15 and 18 June.
25. On 23 April, the man’s application for ROR was approved but his application
was dependent on the outcome of enquiries made of the Immigration Service
regarding his Travel Restriction Order. He was also assessed by the prison’s
physical education department who noted that he was considering exercise
for cardio vascular (CV) improvement and weight loss. He was advised to
start gently on CV exercises and then include light resistance machines. He
was not approved for the use of free weights and was advised to see PE staff
when starting his weight loss programme.
26. Following completion of a work application form the man was allocated to work
at Kirkham Food, a food handling work area. On 28 April, he complained of
loss of sensation in two of his fingers and was referred to see the doctor. A
nurse’s note indicates that he was working in the cold storage area. He was
seen by a medical doctor on 1 May who concluded in a note on the
Continuous Clinical Record that the man’s problem might be carpal tunnel
syndrome (a restriction of the nerves in the wrist). He also noted that the man
was known to have hypertension and his blood pressure was 159/76. The
doctor prescribed Frusemide, which is a diuretic that removes excess fluid
from the blood, for a trial period of four weeks starting on 2 May. It was given
in possession but the prescription was not repeated.
27. On 4 May, the man applied to transfer to Kirklevington Grange. He had
achieved category D status and, on 26 May, was allowed an unaccompanied
community visit to Blackpool with his son and brother. On 7 June,
confirmation was received that the man’s passport was held by the London
Passport Office and they had no objection to him being released on
resettlement overnight release (ROR).
10
28. On 8 June, the man was transferred to Kirklevington Grange and on reception
was interviewed by throughcare staff. The Kirklevington regime was
explained to him and his offender management team was identified. The man
was first seen and assessed by medical staff at Kirklevington on 11 June.
They registered him on their computerised healthcare database and noted his
current medication regime. During the interview the man said that he might
have a chest infection. He was referred to a contracted general practitioner
from a private healthcare provider, for a check up and a medication review.
The man signed that he understood the Kirklevington healthcare consent
form, the Prisoner Medication Policy document and completed a Medical
Screening for Food Handling document. There is no record that any first or
second health screening was undertaken at Kirklevington Grange. A first
health screening takes place when a prisoner arrives at a prison. The
purpose of the interview is to gain a brief confidential medical and psychiatric
history and to ensure that other immediate healthcare issues are addressed.
The second health screening is a more in depth follow up interview ensuring
that all medical issues are addressed.
29. The man’s release date notification was issued on 11 June and identified his
release date as 17 January 2009. He was also told that his resettlement day
release date was 19 April 2007, which had already passed, and his
employment in the community date was 3 March 2008.
30. The contracted medical practitioner and another doctor saw the man on 14
June and made repeat prescriptions for Simvastatin 20 mg (one tablet daily)
for 28 days, Amlodipine 5mg (one tablet nightly) for 28 days and Bisacodyl
5mg (two tablets nightly) for 21 days. His weight was recorded as 13st 5lb.
His height and blood pressure were also recorded. The man had no other
symptoms and was no longer concerned that he had a chest infection. An
appointment was made for 27 June for blood tests. A later appointment was
made for 1 August to attend the doctor’s surgery for a spirometry test (to
measure the volume of air inhaled and exhaled). Secondary healthcare was
at that time provided by medical services in the community once the prisoner
was accepted as eligible for outside work or visits. From that point, prisoners
accessed healthcare in the same way as any other member of the community.
31. The man was interviewed on 16 June by a member of the OASys (Offender
Assessment System) team who viewed him as a mature individual who had a
clear path planned for his future. Part of that plan was his desire to train as a
light goods vehicle (LGV) driver and take the relevant tests. Soon after this
date he also completed an OASys education form indicating that he wanted to
study for English and Mathematics qualifications. He was also pursuing
funding for the LGV course.
32. Nursing staff at Kirklevington were unable to take a blood sample on 27 June
because of the difficulty in accessing the man’s veins. The sample was finally
collected on 13 July and sent for analysis. The results were normal, except
for the test for glucose which was out of date and had to be repeated. The
same day the man complained of intermittent shoulder pain which worsened
with exercise. He was examined by the contracted medical practitioner who
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prescribed paracetamol. The blood sample for glucose was obtained from the
man on 20 July and sent for analysis. He also complained of a headache for
which he was also given paracetamol and was given advice by the clinical
staff on the amount of the drug he should take and the frequency. No results
from the last blood test are evident in the clinical record.
33. The man took part in a Challenging the Dealers Perspective Group on 28 June
and received a positive report from the CARAT (Counselling, Assessment,
Referral, Advice, Throughcare) group facilitators. On 10 July, the man,
because he had a limited history of ROTL, was recommended for a period of
structured release, working and attending approved appointments in the
community. On 16 July, he started work in the community at a local charity,
Independent Living for Older People (ILOP) and was released daily during the
week until 30 July. On 28 July, he asked for resettlement leave from 31
August to 1 September.
34. The man was moved on 6 August from ILOP, because of staff holidays, to
another charitable project, Home Start – Teesside, where he attended each
week day until 6 September. During August he was released twice for
community visits. On 24 August, following a successful period of structured
release, he was approved category D for all activities. The man underwent a
course of three Hepatitis B vaccinations during August and a booster was
scheduled for August 2008.
35. On 31 August, the man took his first ROTL but failed to comply fully with the
residency conditions. He returned to Kirklevington on 1 September, was
subsequently charged with a disciplinary offence under the Prison Rules and
pleaded guilty on 7 September. The penalty imposed for the offence included
restriction of his use of temporary release. He was required to undergo
another period of structured release and a process known at Kirklevington as
“gating” (not permitted to leave the prison). He successfully completed the
period and on 6 November resumed his pattern of approved appointment and
community visits.
36. During the man’s gating he attended the prison medical centre for minor
complaints. On 21 September, he complained of a headache for which he
was given 16 paracetamol tablets. He had his blood pressure checked and
was advised to rest and drink more water. He was also given advice on
taking exercise and reducing his food intake. He again complained of a
headache on 25 September and was given the same prescription. On 26
September, the man saw a doctor and had his blood pressure recorded. He
was re-prescribed Amlodipine 10mg at a rate of one tablet daily for 28 days.
He also reported that he had swelling of his right eye and had double vision in
that eye. The symptoms were recorded as being much better when his
glasses were worn. The man is noted to have had operations on his eye prior
to imprisonment but, apart from seeing an optician periodically, no further
action was necessary.
37. The man applied on 20 September for a further ROTL to a friend’s address for
a period of resettlement home leave on 20 and 21 October In order to see his
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friends and family. Reservations were raised by prison staff about the
proposal and his outside Probation Officer did not support the application
which was refused. The man was also refused ROTL for home leave on 9 to
11 November on similar grounds. He was granted, but then cancelled the
next ROTL, for 23 to 25 November. No reason for the cancellation is
recorded.
38. He continued to be regularly released, on a weekly basis, for local community
visits and medical appointments throughout this period. He reported sick at
Kirklevington on 8 and 26 October and was given 16 paracetamol tablets on
each occasion. They were recorded on the Prescription and Administration
Record Chart as being for self care. On 31 October and 29 November, the
man received repeat prescriptions of Bisacodyl for 28 days and on 31
December he received another prescription for 30 days. On 6 November, he
was treated with Terbinafine tablets and a cream for athlete’s foot. His
Prescription and Administration Record Chart records that he was given
paracetamol for self care purposes but the dosage is not mentioned. The
man’s prescription for Simvastatin 20mg was repeated on 29 November to be
taken for 28 days. No further prescription for this medication is then recorded.
39. To address the man’s offending behaviour, he undertook a Think First course
in the community from 8 November until 18 December. Following the course,
and after receiving positive reports from prison and probation staff, the man
was granted a ROTL to his family home from 24 to 28 December, for the
purpose of maintaining and increasing family ties, which he completed
successfully. On his return he continued taking weekend community visits
locally.
40. At 8:00am on Saturday 12 January 2008, along with 79 other prisoners the
man left Kirklevington on his normal local community visit. The first officer
working in the prison reception area booked the man out of the prison at
8:00am. He thought that he was his normal quiet self and appeared to be
alright. He was due to return at 6:00pm.
41. Six officers were on duty in reception during the early evening processing
prisoners returning after temporary release. An Acting Senior Officer (A/SO)
was the Orderly Officer (OO) that evening. At 5:40pm the A/SO was in
reception, it being a normal part of the OO duty to be the supervising officer
during the return of ROTL prisoners. All returning prisoners are given a rub
down search and ten percent are randomly selected for a full search. The
man was due to receive a full search that evening. The intention was to
search him in reception then to allow about ten minutes for him to get back to
his room, when searching staff would then follow with a search of his room.
42. The man and the other returning prisoners arrived at Kirklevington on time.
According to the A/SO, the man arrived in reception at around 6:15pm. After
giving some cash to the first officer, which was entered in the records, he was
taken to the search room by second and third officers. They found nothing
and reported at interview that the man seemed well and was acting normally.
After the search the man returned to the reception counter and signed the
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private cash book. He was then free to leave reception returning to the main
body of the prison. The first officer saw the man at about 6:25pm and also
thought that he appeared to be alright. The A/SO remembered that the man
appeared to be fit and well and there was nothing out of the ordinary about
him. The normal reception routine continued with the remaining prisoners
after the man left.
43. The first prisoner at Kirklevington was standing outside the fitness suite talking
to friends just after 6:00pm. The fitness suite is situated off the main prison
corridor, where the accommodation areas, the segregation unit, the
association room and the reception area are also situated. Outside the
segregation unit there is a metal gate across the main corridor. At that time
the gate was open and locked back to allow the free flow of people along the
corridor. The first prisoner estimates that he was standing outside the fitness
suite about ten to 12 yards from the segregation unit. The first prisoner
looked down the corridor towards the reception entrance and saw the man,
whom he knew, enter the corridor from reception and turn right towards him.
44. The second prisoner was walking down the main corridor towards the
reception area at about 6:10pm. He reached a point between the fitness suite
and the association room and saw the man, whom he knew, turn right into the
corridor from reception and walk towards him. As the man passed the metal
gate outside the segregation unit, he fell into the gate. As he did so, he
grabbed the gate to hold himself up but fell forward, turning as he fell. The
man hit his head on the floor and came to rest on his back with his hands out
to the side of his body and his legs splayed. He lay diagonally across the
corridor with his head towards the segregation unit door and his feet through
the gateway.
45. The first, second and other prisoners immediately ran to the man. The first
prisoner arrived at the man’s side first. He shouted at the man, asking if he
was alright but got no response. Both men observed that the man was
making a gurgling noise, and was struggling for breath. The first prisoner said
the man’s eyes were open but were not focussed. The second prisoner said
that another prisoner put his hands on the man’s chest and told to him to keep
breathing. The first prisoner thought it best not to touch the man because of
the possibility that he had sustained head and neck injuries. He ran the few
yards to the reception office where he knew he would find staff and also
pressed an alarm bell to attract attention. The Communications Room log
records the alarm at 6:30pm.
46. Just after the man had left reception, staff heard the alarm sounding in the
main corridor and received a radio call that the general alarm had been
sounded on H unit. Simultaneously the first prisoner arrived at reception and
shouted to the staff present that the man had collapsed. The first prisoner
immediately turned round and ran back to the man with prison staff following.
One officer stayed in reception. The first officer arrived outside the
segregation unit a few seconds later and thought the man was having a fit and
appeared to be vomiting. The A/SO immediately turned him on his side into
the recovery position to preserve his airway. He began checking the man’s
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vital signs but was unsure whether he was breathing and he was
unresponsive. The fourth officer sent a radio message to the
Communications Officer asking for an emergency ambulance to be called.
The Communications Room log records that the call was made at 6:31pm.
The A/SO asked the fifth officer to move the large number of prisoners
assembling away from the corridor. He also made the decision, because the
man’s condition was deteriorating, to move him into the segregation unit,
which was empty at the time, to give more room for resuscitation attempts and
to preserve the man’s dignity.
47. The A/SO, first officer and the second officer carried the man into the
segregation unit and remained there with him. Once inside the unit, the man
was placed on his back on the floor with his head towards the far end of the
unit and his feet nearest the entrance. No other prisoners were present and
initially the doors were open to the main corridor. The fourth officer asked the
second officer to open the unit’s exercise yard door to allow more air to
circulate. The fourth officer then left the Unit, closing the main corridor door
behind him. He sent a radio message to the communications officer
requesting that the duty governor, be contacted. The Communications Room
log records that call at 6:38pm.
48. The first officer checked the man’s breathing by watching his chest for
movement and placing his cheek close to his nose and mouth. He also tried
to get a response by shouting his name and talking to him. The man’s
breathing was very shallow and intermittent and there was no other response.
The A/SO noted that the colour of the man’s face had darkened from his
normal complexion. The A/SO and the first officer turned the man on his side
into the recovery position to make it easier for him to breathe. The man
vomited and the two officers then tried to clear his airway. The man ceased
breathing. The first officer told an Officer Support Grade (OSG), who was
standing in the segregation unit doorway, to fetch his respirator from the staff
locker room. She returned with it about 30 seconds later. During those 30
seconds the first officer and the A/SO continued trying to get a response from
the man. They checked his breathing and pulse again. His breathing was
intermittent and shallow but they could find no pulse. A short time later, the
man’s breathing stopped altogether.
49. Because of the man’s deterioration, the A/SO and the first officer started
cardiopulmonary resuscitation (CPR) using the respirator. The first officer
blew into the respirator and confirmed that the man’s chest was rising. He
again checked for a pulse and unaided breathing, but could find neither. The
A/SO started performing chest compressions and, after the first 15, they again
checked the man for pulse and breathing. Again neither was present and
they continued for several cycles of CPR at a rate of 15 compressions to two
breaths.
50. Both the A/SO and the first officer were aware of a defibrillator in the
healthcare department. Both men had up to date first aid training, but neither
was trained in the use of a defibrillator. The defibrillator was not collected or
used.
15
51. The man’s throat became obstructed with vomit so the first officer and the
A/SO turned him onto his right side to clear his airway. They continued CPR
and clearing his airways for several more cycles. The respirator became
ineffective because the first officer could not get a seal between the respirator
and the man’s face. The first officer continued CPR using direct mouth to
mouth resuscitation and the A/SO continued chest compressions. They
continued and exchanged places between each set of breaths because they
were now being hampered by the physical effects brought on by sustained
CPR. The officers performed several cycles of CPR, during which they
continued to clear the man’s airway by turning him onto his side after every
sequence. The man’s chest wall ceased to rise after six or seven cycles. The
two men could no longer clear the man’s airway effectively but they continued
the compression sequence until paramedics arrived.
52. Two local ambulance service paramedics arrived at the prison at 6:45pm. The
fourth officer met the ambulance and took them to the segregation unit where
they took control of attempts to resuscitate the man. The first paramedic had
difficulty getting an ambulance service airway into the man’s throat and tried
unsuccessfully to clear it using a suction device. The second paramedic
worked around the A/SO while he continued chest compressions. The
second paramedic attached heart monitoring equipment to the man’s chest
and instructed the A/SO and first officer to continue chest compressions. The
first paramedic attempted to assist the man’s breathing with a resuscitation
bag and the suction device to clear his airway.
53. The second paramedic told the A/SO to stop chest compressions while he
used the heart monitor. There was a faint heart rhythm. The second
paramedic then put an intravenous line into a blood vessel in the man’s right
arm to enable saline fluid to be administered. The A/SO carried on with chest
compressions.
54. The paramedics decided to move the man into the ambulance to continue
resuscitation attempts. The first officer and the first paramedic collected a
trolley from the ambulance. The first paramedic took the man’s head and the
first officer took his feet, with the second paramedic and the A/SO either side
of his waist. They lifted him onto the trolley and transferred him to the
ambulance. Throughout the time the man was on the trolley and
subsequently in the ambulance the A/SO continued performing chest
compressions. Once inside the ambulance the paramedics administered
drugs through the intravenous line and continued trying to resuscitate the
man. At 7:12pm the second paramedic halted attempts at resuscitation
because the man was not responding. He declared that the man had died.
After the man’s death
55. Following the man’s death the ambulance containing his body remained inside
the prison. Kirklevington immediately implemented their contingency plan for
a death in custody. The duty governor and the governing Governor were
informed of the man’s death and attended the prison soon afterwards.
16
56. The duty governor identified the man’s body and a Detective Sergeant (DS)
from the local police arrived at 8:15pm, followed by Scenes of Crime Officers.
At 9:55pm a police surgeon and a nurse attended. The doctor certified the
man’s death and they left Kirklevington at 10:00pm.
57. As part of the death in custody contingency plan, the duty governor began the
process of informing the man’s next of kin. Because of the distance from the
prison to the man’s home, the duty governor planned to contact HMP Leeds
and ask one of their family liaison officers to travel to the man’s home and
break the news. Before the duty governor could contact Leeds, he received
information from prisoners at Kirklevington that the man’s family no longer
lived at the address recorded on his prison record. No family telephone
number was recorded and a delay resulted while the duty governor tried to
verify the new information.
58. At about 8.00pm, the man’s daughter contacted Kirklevington after receiving
information, from a friend of the man, that her father had died. It appears that
a prisoner at Kirklevington had used the prison’s PinPhone system to inform
the man’s friend of his collapse. The man’s daughter contacted Kirklevington
to confirm the information. Staff who received her call were unable to give her
any information but took her contact number telling her that someone would
call her back. Twenty minutes later, in the absence of a return call, she
telephoned the prison again and received the same reply. The man’s
daughter then spoke to her brother who at about 9:20pm telephoned the
prison.
59. The prison received a telephone call from the man’s son who enquired about
his father and left his mobile telephone number. The duty governor returned
the call, at about 10:00pm, using the telephone number given. The duty
governor established that he was indeed speaking to the man’s son and
confirmed that his father had died. The man’s body was removed by
undertakers at 10:40pm and the ambulance crew and police left at the same
time
60. Immediately following the man’s death the duty governor arranged meetings
to inform all prisoners of his death. Because of the movement restrictions
imposed as part of the contingency plan he repeated the meetings in each
part of the prison. During each of the meetings the duty governor offered the
assistance of Listeners and the chaplaincy. He also opened the prison prayer
room for those prisoners who wished to use it. On the following day the
chaplaincy team also offered support to prisoners and staff who were affected
by the man’s death.
61. The governing governor and duty governor held a hot debrief for prison staff
before they went off duty. A Care Team member spoke to all staff who were
on duty at the time of the man’s death and offered them support.
62. The man underwent a post mortem examination at 9:45am on Sunday 13
January at the University Hospital of North Tees. During the preliminary
17
examination £40 in cash and a wrap containing a brown substance was found
in the man’s left sock and another containing a quantity of brown and green
powder on the mortuary floor. At about 11:00am the same day, a detective
sergeant informed the prison that the man’s death was due to natural causes.
63. The man’s family discussed with the prison whether they wished the Governor
or deputy governor to attend his funeral. They appreciated the offer but
declined and asked if it was possible for the man’s closest prisoner friends to
attend the funeral representing the prison. The Governor agreed to the
request. The deputy Governor maintained telephone contact with the man’s
son over the days prior to his funeral which took place on 15 January in
Huddersfield. Three of the man’s friends from Kirklevington attended. The
man’s property was removed from his room on 14 January and recorded. The
Governor wrote a letter of condolence to the man’s wife the following day.
64. The man’s family asked to visit the prison and collect his property, meet the
Governor and be shown where the man had died. His son, daughter and a
cousin visited the prison on 23 January. The events of the night of the 12
January were fully discussed with the family who were shown the relevant
parts of the prison by the Governor. The man’s property was returned to his
family. One of my family liaison officers wrote to the man’s family on 11
February. My liaison officer received no reply then but was able to make and
maintain contact with the family in December when they received a copy of
my draft report.
18
ISSUES CONSIDERED DURING THE INVESTIGATION
Medical care
65. A review of the clinical care provided for the man was commissioned from
Assistant Director (Integrated Governance) at Hartlepool Primary Care Trust
and North Tees Primary Care Trust (HPCT/NTPCT) on 15 January 2008. The
Assistant Director and the Integrated Governance Manager, HPCT/NTPCT
undertook the review.
66. The clinical review judges that appropriate health screening was undertaken
on the man’s initial reception into Elmley and he was referred to the doctor for
treatment of a chest infection. He reported no history of heart disease. After
complaining of chest pain in August 2005 he was referred to a doctor and
underwent an ECG test. The ECG trace printout is filed in his Inmate Medical
Record (IMR) but no interpretation of the printout is provided. Five days later
the man’s solicitor wrote to the prison to enquire as to the outcome of the
ECG because the man had not been informed. The letter contained contact
information about the man’s doctor, which was already in Elmley’s
possession, and reported the solicitor’s belief that the man suffered from high
blood pressure and high blood sugar levels. The solicitor also wrote that the
man had informed him that he had an enlarged heart, a fact confirmed in the
post mortem report.
67. Because of the lack of explanation in the IMR and subsequent unsuccessful
enquiries of Elmley and the man’s solicitor, it has not been possible for my
investigation to ascertain whether the requested x-ray took place. It is
similarly not possible to know what the ECG revealed or whether any follow
up action resulted. The man’s surgery in Huddersfield has no record of any
contact with Elmley healthcare staff regarding the man.
I recommend that the healthcare manager and PCT at HMP Elmley
remind clinical staff of their responsibility to maintain professional
standards of record keeping.
68. After transferring to HMP Maidstone in March 2006, the man’s reception health
screening records that his past medical history did not include coronary heart
disease. In July, the man had a chest x-ray after reporting sick with a chronic
cough and breathlessness. The results showed that his lungs were clear and
there is no reference to heart disease in the IMR. During October and
December the man underwent several blood tests and, on 2 January 2007,
was prescribed medication for raised cholesterol.
69. The man was transferred to HMP Standford Hill on 16 February where he
underwent a further healthcare reception interview that recorded he had
previously suffered from high cholesterol, previous depression, constipation
and possible hypertension. His medications were recorded and he was
designated fit for all categories of work. The reception interview sheet also
records that the man smoked and that he was advised to cease. His blood
19
pressure was checked, and after further monitoring over the following four
days, he was prescribed medication for high blood pressure.
70. The man remained at Standford Hill for two months until 19 April 2007, when
he transferred to Kirkham prison and his previous medical history was
recorded. He was assessed as fit to use light resistance cardio vascular
exercise machines but was not approved to use free weights. He was
advised to exercise gently and to see gym staff when starting his exercise
regime. The man was known to have hypertension and the doctor at Kirkham
prescribed Frusemide for a trial of four weeks. The outcome of the trial is not
recorded and the prescription was not repeated.
71. On 8 June, the man transferred to Kirklevington Grange and was first seen
and assessed on 11 June by medical staff who registered him on the prison
computerised healthcare database and noted his current medication. The
man was referred to the doctor for treatment of a suspected chest infection
and for a medication review. He was re-prescribed medication for high
cholesterol, hypertension and constipation on 14 June but the suspected
chest infection was no longer a concern.
72. It was not recorded by Elmley or by any of the other prisons that the man had
heart related problems. At no time did he report that he knew he had heart
problems. The only reference was in a letter from his solicitor which
mentioned that he had an enlarged heart, which is not in itself an indicator of
heart disease. It is not clear where that information originated and the man’s
family doctor’s surgery has no record of it. It was however a fact borne out by
his eventual post mortem.
73. After his initial reception, the man was in regular contact with medical staff and
underwent medical examinations at every establishment he was transferred
to. The clinical reviewers comment that he complained of, and was properly
treated for, several chest infections and other more minor ailments. His high
blood pressure and raised cholesterol levels were diagnosed promptly and
were appropriately treated. It is evident that when allocating work and
allowing him to use physical training equipment, appropriate account was
taken of his age and physical condition. At no point was there any indication
that the man was suffering from heart disease.
74. The clinical reviewers noted that the last record of the man’s blood pressure
was on 26 September 2007 when he was prescribed appropriate medication.
They also write that there was no follow up blood pressure recording, and it is
unclear if the medication was stopped. The reviewers recommend that the
issue is investigated and a response provided to the Primary Care Trust.
75. The man’s last recorded medication for high blood pressure (that is
Amlodopine for 28 days) and last recorded blood pressure reading are both
dated 26 September. The man’s last recorded medication for high cholesterol
levels was prescribed and issued on 29 November (Simvastatin for 28 days).
No explanation for the cessation of these medicines is apparent in the man’s
medical record.
20
I recommend that the healthcare manager at HMP Kirklevington
investigate whether the man’s medications were stopped after the last
recorded prescriptions and provide a report to the Primary Care Trust
76. The property removed from the man’s room following his death was recorded
on a Cell Clearance Form. It records the medication removed and includes
entries for 28 Simvastatin (20mg), 36 Bisacodyl (5mg) and ten paracetamol
tablets. No Amlodopine was found. The form also lists a 100mg tube of
aqueous cream.
77. This quantity of medication appears to indicate that the man was either
hoarding his medication, obtaining it from outside the prison or that healthcare
staff omitted to record what they issued. Given the man’s recent medication
history, the fact that the medicines found correspond exactly with those he
regularly used and the quantities involved, the likeliest explanation is that
Kirklevington healthcare did not record a repeat prescription in late December,
probably around the time of his last release on temporary licence.
78. The treatment the man received throughout his sentence was generally timely
and responsive to his needs. It was comparable to that available to members
of the general public. Indeed at Kirklevington healthcare was delivered to the
man in the community when he was eligible to receive it. There is however a
lack of clarity in the recording of treatment and outcomes in parts of his prison
medical record.
79. I repeat my recommendation here and direct it to the healthcare staff at
Kirklevington Grange.
I recommend that the healthcare manager and PCT at HMP Kirklevington
Grange remind clinical staff of their responsibility to maintain
professional standards of record keeping.
Kirklevington patient records
80. The clinical reviewers begin their report by saying:
“Kirklevington Grange has recently moved to a paper light system, using
System One for patient records. As such the current record keeping audit
tool needs to be adapted to audit records which are now on the computer
system. However we can confirm that the records which we have had
sight of are appropriate, factual and provide current information on the
care and condition of the patient.”
81. They also note that:
“Upon review of the medical record it was established that the
contemporaneous record was complete and dated and the name of the
practitioner was assigned to each entry. The man had been in several
21
establishments since his initial remand, and there was evidence of medical
assessments and records from these establishments within the notes.”
82. The clinical reviewers recommend that:
“A system is established to follow up requests for medical records from
other establishments in a timely way.”
I recommend that the healthcare manager and PCT at HMP Kirklevington
develop a system to follow up requests for medical records from other
prison establishments in a timely way.
83. The clinical reviewers also recommend that, “An audit tool is established to
undertake record keeping audits on the clinical system.”
84. Since the man’s death the contract with Tithebarn Medical Practice has
expired and has been let to another supplier which has resulted in general
practitioner services and primary nursing medical services now being
provided in the prison. Other medical services are still provided by referral to
outside healthcare centres. Record keeping should therefore be simplified,
avoiding duplication or omission. In October 2008 the PCT commissioned a
single computerised system and installed it at Kirklevington. I am pleased to
confirm that the change to a single centralised system addresses the
reviewers’ recommendation.
Delivery of emergency care to the man on 12 January
85. It is evident that prisoners and prison staff involved on the evening of 12
January acted in a timely manner by recognising the seriousness of the
situation, summoning appropriate help and rendering what assistance they
could personally. It is apparent to me that prompt, determined and sustained
efforts were made by the first officer and the A/SO to preserve the man’s life
despite the increasingly difficult circumstances in which they had to work.
They are to be commended for their actions. The paramedics in turn made
every effort to resuscitate the man but regrettably all attempts were
unsuccessful.
I recommend that the Governor at HMP Kirklevington considers how the
actions of the ASO and the first officer should be most appropriately
recognised.
86. The clinical reviewers write that Kirklevington operates a weekly protected time
which allows staff training and updating of skills. They report that all staff
have up to date mandatory training, which includes basic life support and
resuscitation training. Unfortunately training in the use of the defibrillator was
not part of that training. Kirklevington comment that the defibrillator in the
prison at the time of the man’s death was a piece of emergency equipment for
use by trained medical staff. In addition to the mandatory training they have
extended first aid training to include the use of a defibrillator, but like all
22
prisons without full time medical cover they are unable to provide full
coverage of defibrillator trained staff across all shifts
87. On the evening of Saturday 12 January, there were no healthcare staff on duty
at the prison. A defibrillator was sited in the Healthcare Department which
was accessible to staff. The staff administering first aid sent for and used a
respirator. They knew of the defibrillator, but had not been trained in its use. I
hasten to say that I have no words of criticism whatsoever for the first officer
and the ASO. Over an extended period of time they worked to the utmost of
their ability to revive the man. It is, however, a matter of great concern to me
that the defibrillator, a potentially life-saving piece of equipment, was not used
that evening because there was no member of staff on duty with the
necessary training. Regrettably this is not the first time that I have made this
recommendation recently.
I recommend as a matter of urgency that the Governor and PCT at HMP
Kirklevington provide defibrillator training for an agreed number of staff
at Kirklevington.
Notification of the man’s next of kin
88. The deputy governor correctly followed the local death in custody contingency
plan for the breaking of such news to next of kin. However, doubt about the
address of the man’s family and their possession of information from
intermediaries about what had happened at Kirklevington meant that events
overtook him. Instead of a controlled set of circumstances where the news
could be conveyed during a personal visit to the family home, the man’s family
already had some knowledge of his condition when they telephoned to speak
to staff. The result was that when the deputy governor eventually spoke to
the man’s son he had no option but to confirm on the telephone that his father
had died.
89. It is understandable that during the aftermath of a death in custody particularly
at Kirklevington where evening staffing numbers are very low that
communication of information between those staff is pressurised. It is,
however, regrettable that the man’s daughter was unable to speak to the
deputy governor, who was dealing with next of kin issues, on the two
occasions that she telephoned and it was after his son made a third call that
contact was made some two hours after the family first became aware of the
man’s death.
90. PSO 2710 Follow Up to Deaths in Custody - Guidance Supplementary to
Chapter 4 advises (paragraphs 4.9 and 4.10) that when face to face contact to
break the news of a death is not feasible; such contact should be made as
soon afterwards as possible. This did not happen. Kirklevington’s death in
Custody Contingency plan acknowledges in section 10.6.7 that detailed
advice about dealing with next of kin issues is available in PSO 2710 but does
not refer to the guidance available.
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I recommend that the Governor at HMP Kirklevington ensures that PSO
2710 Follow Up to Deaths In Custody - Guidance Supplementary to
Chapter 4 be referred to in the Kirklevington Death in Custody
Contingency Plan.
The discovery of drugs and money after the man’s death
91. The man returned to Kirklevington from temporary release on 12 January and
was subject to a full search in reception. After giving some cash to the
reception officer he was taken to the search room by two officers who found
nothing. They reported later that the man seemed well and was acting
normally. After the search the man left reception and collapsed a few minutes
later.
92. At the start of the man’s post mortem examination the following morning £40
in cash and small quantities of drugs believed to be heroin and cannabis were
found in his clothing. It is likely that the man was attempting to bring illicit
drugs and money into Kirklevington. It is conceivable that the level of anxiety
that the man experienced during this attempt may have in some measure
contributed to the events leading to his death.
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RECOMMENDATIONS
1. I recommend that the healthcare manager and PCT at HMP Elmley remind
clinical staff of their responsibility to maintain professional standards of record
keeping.
Elmley have accepted this recommendation and comment:
“Since this recommendation was made, Electronic Medical Systems for Data
input have been introduced in order to address this issue. Nursing and
Medical Staff have been informed and advised of their responsibilities and
their accountability to meet this standard as dictated by their respective
professional bodies. A recruitment drive is being undertaken to appoint a
Data Quality/Clinical Audit manager which will further underpin this
requirement.”
This action is pending
2. I recommend that the healthcare manager at HMP Kirklevington investigate
whether the man’s medications were stopped after the last recorded
prescriptions and provide a report to the Primary Care Trust.
Kirklevington have accepted this recommendation. The target date for
submission of the report is June 2009
3. I recommend that the healthcare manager and PCT at HMP Kirklevington
Grange remind clinical staff of their responsibility to maintain professional
standards of record keeping.
Kirklevington have accepted this recommendation. The target date for
completion of this action is April 2009
4. I recommend that the healthcare manager and PCT at HMP Kirklevington
develop a system to follow up requests for medical records from other prison
establishments in a timely way.
Kirklevington have accepted this recommendation. The target date for
completion of this action is April 2009
5. I recommend that the Governor at HMP Kirklevington considers how the
actions of the ASO and the first officer should be most appropriately
recognised.
Kirklevington have accepted this recommendation and comment:
“Both Officers to receive Area Manager’s Commendations”
The target date for completion of this action is February 2009
25
6. I recommend as a matter of urgency that the Governor and PCT at HMP
Kirklevington provide defibrillator training for an agreed number of staff at
Kirklevington.
Kirklevington have partially accepted this recommendation and comment:
“There are wider issues relating to mandatory requirements for first aid
training which include CPR training and defibrillation training which also
requires first aid training. There is a wider issue concerning trained staff
availability over a 24 hour period.”
This action is pending
7. I recommend that the Governor at HMP Kirklevington ensures that PSO 2710
Follow Up to Deaths In Custody - Guidance Supplementary to Chapter 4 be
referred to in the Kirklevington Death in Custody Contingency Plan.
Kirklevington have accepted this recommendation. The target date for
completion of this action is April 2009
26