Individual at Woodhill

Investigation into the circumstances surrounding the
death of a prisoner
at HMP Woodhill on 3 January 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2010
This is the report of the investigation into the circumstances surrounding the death of
a prisoner, who had been suffering from a number of chronic illnesses for sometime
and was located in the healthcare unit at HMP Woodhill. At 8.25pm on 3 January
2010, officers discovered him collapsed and unconscious in his cell. They called for
an emergency ambulance and nursing staff began cardio pulmonary resuscitation
(CPR) which was continued by the paramedics when they arrived. Despite their best
efforts, the man was pronounced dead by the prison doctor at 9.14pm. He was 74
years old.
I would like to offer my personal condolences to the man’s family, friends and
everyone affected by his death.
An investigator from my office undertook the investigation. In addition, Milton
Keynes Primary Care Trust (PCT) undertook a review of the man’s medical care,
and I am grateful for their contribution. I would like to thank the Governor of
Woodhill, and his staff for their participation in the investigation.
The prisoner’s family asked about prison transfers, the period before his death and
the cause of death. These areas are covered in the report. The family indicated that
they had no further comments to make after reading the draft report.
Improvements in medical record keeping and chronic disease management
highlighted in the clinical review have already been included in an action plan by
Milton Keynes PCT. I make no further recommendations in relation to the man’s
care as a result of my investigation, but commend the staff at Woodhill for the care
that he received.
Jane Webb
Deputy Prisons and Probation Ombudsman May 2010
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CONTENTS
Summary 4
The investigation process 6
HMP Woodhill 8
Key findings 10
Issues 15
Conclusion 17
3
SUMMARY
The man was 71 years old and suffering from a number of chronic illnesses when he
was remanded to custody in September 2005. A medical assessment carried by a
nurse on his reception at HMP Bullingdon, recorded his medical conditions, which
included, chronic obstructive pulmonary disease (COPD), ischaemic heart disease
(IHD) and diabetes. He received appropriate treatment and was admitted to the
local hospital when his conditions needed to be stabilised.
He was subsequently convicted in August 2007 and sentenced to nine years
imprisonment. As his health deteriorated, staff considered that he would benefit from
a transfer to a prison better suited to his complex needs. They initially sought a
move to HMP Norwich, which has a specialist unit for elderly prisoners, but this was
not possible due to a long waiting list. A move to HMP Woodhill was arranged as it
has inpatient care facilities and the man transferred in August 2009.
Woodhill recorded his medical history and care needs on his reception. He settled in
well to the regime and healthcare staff reviewed him regularly. However, he was not
keen to follow instructions on ways to improve his mobility and preferred to remain in
his cell and watch television. He was also unwilling to follow advice on his poor diet,
which was considered unhealthy for someone suffering from diabetes.
While at Woodhill, the man was admitted to the local hospital on a number of
occasions when his conditions worsened and, after treatment, returned to the prison.
In October, a purpose built disabled cell became available in the healthcare wing and
he was the first prisoner to occupy it. The cell was equipped with a disabled access
shower and a personal emergency call button that the man could use to call for
assistance should he require it. Nursing staff continued to treat his legs and improve
his mobility and he was offered support and advice about his diet, which he was not
always keen to take.
On 3 January, the prisoner alerted staff via his personal alarm at 5.30pm, and when
they attended his cell, they discovered that he had fallen from his wheelchair. He
told the nursing staff that he did not have any injuries, and had fallen while reaching
for his nebuliser. After being checked by a nurse, helped back into his chair and the
nebuliser placed in a better position, staff left him watching television.
At 8.25pm, staff went into the man’s cell after they had become concerned about him
during a count of prisoners. They discovered him lying unconscious on the floor
between the wall and the toilet. His appearance indicated that he had been going to
the toilet at the time of his collapse. Staff immediately radioed for medical
assistance and cardio pulmonary resuscitation (CPR) was started. Following the
initial call for medical assistance, an ambulance was also called. The resuscitation
attempt was prolonged and continued for some time after the arrival of paramedics.
Sadly, he did not respond to treatment and at 8.57pm, paramedics decided to stop
CPR. The prison doctor confirmed that the man had died at 9.14pm.
I am satisfied that the prisoner received good care during his illness and that the
actions taken following his collapse were appropriate. I make no recommendations
as a result of this investigation and those made by the clinical reviewer have been
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taken up by Milton Keynes PCT. I commend all the staff involved with the man for
the high level of care they provided.
5
THE INVESTIGATION PROCESS
1. The investigator, telephoned Woodhill on 6 January and spoke with a member
of the Senior Management Team to arrange for the prisoner’s prison and
medical records to be made available to him.
2. Notices were issued informing both staff and prisoners of the investigation.
They invited anyone who had information about the man’s death to contact the
investigator. No responses were received.
3. The investigator visited the prison on 3 February, where he viewed the
healthcare centre and spoke with nursing staff that had cared for the man. He
also collected further documentation and spoke with the safer custody team.
4. Milton Keynes PCT were asked to commission a review of the medical care
provided to the man while he was in custody. The investigator attended a
review panel at Milton Keynes PCT on 10 March, to discuss the PCT’s report.
The panel concluded that the report had covered in depth the care that was
afforded to the man and had highlighted areas for improvement within
healthcare at Woodhill.
5. One of the Ombudsman’s Family Liaison Officer’s (FLO), contacted the man’s
family on 3 February. She spoke with his grandson, who was acting on behalf
of his wife and explained the role of the Ombudsman as well as the purpose of
the investigation. The FLO asked the grandson if there were any issues that
the family wanted the investigator to consider during the investigation. He
raised some issues which are listed below:
• The family were aware that the man was seen at around 6.00pm on the
evening of his death and was seemingly well at this time. However, they
were concerned that he was not seen again until he was found collapsed
on the floor of his cell. The family asked whether he should have been
checked sooner.
• The family would like to know the cause of his death and whether this was
solely due to his heart or whether there were any other factors.
• The family asked why he had transferred from HMP Bullingdon to HMP
Woodhill. They were not sure, whether this was for medical reasons or if
bullying was a factor. The family said that the move had made it more
difficult for his wife to visit him.
6. The FLO offered the family the opportunity for both her and the investigator, to
visit them at the family home to discuss the issues, but they did not feel that this
was necessary.
7. The investigator also contacted HM Coroner, to inform him of the nature and
scope of the investigation. At the investigator’s request, the Coroner sent a
copy of the post mortem report. The post mortem, conducted on 6 January,
concluded that the man died as a result of a heart attack, brought on by
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ischaemic heart disease, coronary artery atherosclerosis (term given to
coronary artery disease) and emphysema (a progressive disease of the lung
that primarily causes shortness of breath).
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HMP WOODHILL
8. HMP Woodhill is a local prison holding all categories of male prisoners,
including Category A (those considered to pose the greatest risk to the public).
The prison is also one of two that has a close supervision centre, designed to
hold the most dangerous prisoners who cannot safely be held elsewhere, which
means that some of the security arrangements are particularly rigorous. The
prison serves the courts in Northamptonshire, Hertfordshire, Buckinghamshire
and Bedfordshire.
9. A follow up inspection in 2007, by HM Chief Inspector of Prisons, Dame Anne
Owers, found that the prison had improved since an earlier inspection and she
commended the good reception and first night procedures. Dame Anne and
her team have recently carried out a further full inspection but the findings are
yet to be published.
10. The National Offender Management Service (NOMS) produces quarterly data
driven assessments of the performance for both public and private prisons.
The assessment takes account of all 131 prisons (including 11 private prisons)
by looking at performance in 34 indicators. It awards a score to each individual
prison ranging from 1to 4, with 4 indicating exceptional performance. In the
most recent published performance tables, Woodhill was considered to be
performing at level 3.
11. The Prisons Act 1952 requires every prison to be monitored by an Independent
Monitoring Board appointed by the Secretary of State from members of the
community in which the prison is situated. Their role is to ensure that proper
standards of decency and care are maintained. The most recent report by the
Independent Monitoring Board (IMB) at Woodhill was published in May 2008.
The IMB wrote about positive changes at the prison but also highlighted areas
of concern. With regards to healthcare at the prison the Board said the
following:
“ … The reporting year commenced with a health service that was
poorly run, dispirited, lacking in supervision and housed in poorly
decorated accommodation. The PCT was not fully engaged, having no
specific commissioning strategy, no recent health needs analysis and
no prison health development plan. The standard of health service
was not similar to that which prisoners could expect to receive in the
community …
“… In the New Year, a new Governor for Healthcare and Segregation
was appointed and it was like a breath of fresh air. Fundamental
changes have been detailed in a recovery plan with roles and
responsibilities of managers clarified, staff development plans,
supervision, appraisals, training, clinical governance, medicines
practice and records management addressed …”
12. The healthcare centre relocated from the wing where its decoration and
facilities had been criticised by both the Chief Inspector of Prisons and the IMB.
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It moved to a new wing that provided better facilities, more natural light and a
generally better atmosphere for patients.
13. The Ombudsman was given responsibility for investigating all deaths in custody
in 2004. Since then, there have been eight previous deaths at the prison as a
result of natural causes. Recommendations made following these deaths are
not repeated in this report.
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KEY FINDINGS
14. The man was remanded into custody at HMP Bullingdon on 22 September
2006. He was 71 years old and had been in custody once previously, around
20 years before.
15. On his reception into prison, a nurse assessed him and recorded that he had
been diagnosed with a number of chronic health problems. They included
chronic obstructive pulmonary disorder (COPD), which restricts the airflow to
the lungs. He also had ischaemic heart disease (IHD) and atrial fibrillation
(AF). Prior to custody, he had suffered two previous heart attacks and, owing
to his poor health, moved around with a walking frame.
16. Despite his health problems, the man was considered suitable to be located on
a normal residential wing. He is recorded as having settled in well to the
regime and reported no concerns to staff. Staff were made aware of his
disabilities and arrangements made for him to be located on the ground floor to
make it easier for him to get around.
17. His health problems resulted in him being admitted to the healthcare wing on a
number of occasions during the remainder of 2006. On the residential wing it
was recorded that he had a close relationship with other older prisoners and
was always polite to staff. There was subsequently a decline in both his
attitude towards staff and his personal hygiene during the early part of 2007.
His wife was in hospital, which was causing him some concern, and he was
due to begin his court case. These concerns may have led to the decline. The
wing staff contacted the hospital where the man’s wife had been admitted and
kept him informed of her progress.
18. On 22 August 2007, he was convicted and sentenced to nine years
imprisonment. Following this, it is recorded that he began to isolate himself
from the rest of the elderly community on the wing and spent a lot of time in his
cell, despite encouragement from staff to be involved in the regime. In
November 2007, the man was located in the healthcare wing for a period of
assessment and, on his return to the residential wing, staff recorded that he
seemed “more pro active” in looking after himself. The healthcare team at
Bullingdon put in place a weekly regime to help keep him active.
19. The regime initiated by healthcare was kept under regular review and his health
and attitude towards staff improved. However, it is recorded that the man once
again began to do less for himself and relied on staff and other prisoners to do
the simplest of tasks for him. Both wing and nursing staff advised him that
inactivity was detrimental to his health, but he appeared uninterested.
20. Concerns about his personal hygiene and immobility continued. Healthcare
and wing staff liaised and would advise him regularly about the importance of
keeping mobile. There were also increasing concerns about the man’s
shortness of breath, which was becoming a problem, and the retention of fluid
in his legs, which made it uncomfortable for him to move around. As the
chronic illnesses became more problematic, the man spent time in both outside
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hospital and the prison healthcare wing during his time at Bullingdon. He was
advised about healthy eating in relation to his diabetes.
21. The healthcare staff at Bullingdon reviewed him almost daily, as he had
developed ulcers on his legs caused by the retention of fluid. The dressings
were changed regularly, but staff still found it difficult to encourage him to
remain mobile, and he would often remain in his cell watching television and
rely on others to collect his meals. The man was also overweight, which added
to his medical problems. This was of particular concern given his diabetes and
a dietician provided further advice to him.
22. In view of the increasing health needs, it was decided that he would benefit
from a transfer to a prison better equipped to care for him. Initially it was
intended to try and obtain a place at HMP Norwich, which has a facility
specifically adapted to provide for the needs of elderly prisoners. However, the
facilities at Norwich are in great demand and there is a long waiting list for
placements. Due to the length of time it would have taken to secure a place at
Norwich, a transfer to HMP Woodhill was arranged instead. Woodhill has an
inpatient facility and was considered well placed to provide the care that he
required.
23. The man transferred to Woodhill on 7 August 2009. On his arrival, nursing staff
recorded his medical history. They noted that he used a wheelchair and was
able to transfer to a Zimmer frame, but his limited mobility made this difficult.
Arrangements were made for a nursing care plan to be put in place. He was
also referred to the diabetic and asthma clinic. Staff provided daily care to
assist him with his personal hygiene and to apply ointment to his legs, which
were still swollen, and causing him discomfort. They later found that the
antibiotics taken to treat cellulitis were not improving his condition and, in
October, he was referred to Milton Keynes Foundation Hospital (MKFH).
(Cellulitis is a common skin infection caused by bacteria. Risk factors include
history of cardio vascular disease and diabetes.)
24. He spent four days in hospital and returned to Woodhill on 6 October. The
problems with his legs persisted and varied in their severity, but continued to
make it difficult for him to walk around the unit. During October, a new cell
became available on the healthcare wing. The cell had recently been
completely refurbished, knocking two separate cells into one to create a
disabled facility. It was equipped with a shower with disabled access and a
hospital bed with an anti pressure mattress. In addition, an alarm was installed
that could be carried by the patient and when pressed would alert staff that they
required assistance. The man was the first person to occupy the cell.
25. Although nursing staff cared for him daily and treated his swollen legs, he also
had his other chronic illnesses that required attention. In late October, he was
reported to be short of breath as a result of his COPD and he was again
referred to MKFH. He returned to the prison the same day but was admitted
again in November. On this occasion, the man remained in hospital for six
days, before returning to Woodhill when his condition stabilised. While in
hospital, the prison appointed one of its family liaison officers, to liaise with the
11
man’s wife to arrange for any assistance that she required to visit her husband
due to her own mobility problems.
26. At the hospital, the man started having insulin injections for his diabetes as his
blood sugar was increasingly high. One of the most important factors in
controlling diabetes is a patient’s diet. Despite advice from staff, he was said to
have a weakness for chocolate, and would often order large amounts from the
prison canteen. Nursing staff at Woodhill told the investigator that, apart from
advising him about the consequences of not adhering to a proper diet, there
was little they could do about this.
27. The man’s family were concerned about his diet, particularly his consumption of
chocolate and asked the prison if he could be prevented from spending his
money on such items. The nursing staff explained to the investigator that he
had the mental capacity to make his own decisions and they could not stop him
from ordering or eating what he wished. One nurse said that the man took the
view that he did not smoke and chocolate was his ”vice” and if he wanted to eat
it he would. He ignored the advice from both hospital and prison nursing staff
about his diet.
28. He continued to receive one to one care with his daily needs. It is recorded that
he could be difficult and would often refuse to tend to his personal hygiene,
preferring instead to lie on his bed or sit in his wheelchair and watch television.
29. On 3 January 2010, at 5.30pm nursing staff were alerted by the man via his
emergency alarm. When they went into his cell, they found that he had fallen
from his wheelchair while reaching for his nebuliser. (A nebuliser is a device
used to administer medication in the form of a mist inhaled into the lungs. It is
commonly used in treating cystic fibrosis, asthma, and other respiratory
diseases.) A nurse checked him to ensure that he had no injuries and he told
her that he was fine. Other staff came to the cell and assisted him back into his
chair. A chair was brought into the cell and the nebuliser placed on it in a
position that was easier to access. He was seen again at 6.15pm by another
nurse, who saw him sitting in his wheelchair watching television. When the
nurse asked him if he was alright, he responded coherently that he was. There
were no further calls for assistance by the man.
30. Three officers were on night duty on 3 January. They arrived on the wing at
around 7.45pm. The officers were working on the healthcare unit and the
segregation unit that adjoins the healthcare. At 8.20pm, Officer 1 spoke with
Officer 2 who had just completed counting prisoners on the segregation unit.
He told Officer 2 that he was unhappy with the man as he could only see his
foot when he looked into his cell, and was aware that he had fallen earlier in the
evening. Officer 1 and Officer 2 agreed that it would be appropriate to carry out
a “physical check” to ensure that the man was all right.
31. At 8.25pm, Officer 2 radioed the control room and told them that he would be
going into the man’s cell with Officers 1 and 3. (Due to the secure nature of
Woodhill, the control room authorises all moves within the prison and must be
notified before staff go into a cell during the night.) When he went into the cell,
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Officer 2 immediately saw the man lying on the floor between the toilet and the
wall. Officer 1 who followed him, ran upstairs to alert the nurse. At almost the
same time, Officer 2 radioed for medical assistance and the nurse was already
responding when she met Officer 1. The nurse arrived at the cell at around
8.27pm and tried to find his pulse, but was unable to do so because of the
man’s position. With the help of Officer 2, the nurse moved the man into the
centre of his cell.
32. The man appeared to have been going to the toilet when he collapsed. To
preserve his dignity, Officer 2 pulled the man’s trousers up. The nurse asked
Officer 3 to collect an oxygen cylinder and began chest compressions. At
8.29pm, Officer 2 radioed the control room again and told them that it was a
‘code red’ emergency and medical assistance was required. (Prisons use a
coding system that enables the correct equipment to be brought quickly when
required. It also informs the control room officer whether the emergency is
likely to require an ambulance to be called.)
33. The radio message alerted other staff to the emergency and at 8.33pm, a
principal officer (PO) who was the duty Oscar 1 that evening, arrived on the
wing. (Oscar 1 is the call sign given to the PO who is responsible for any
operational emergency that arises while they are on duty.) He administered
mouth-to-mouth resuscitation and a senior officer (SO), who arrived with him,
took over chest compressions. Other discipline and nursing staff also went to
the cell. At 8.38pm, a nurse attached an automated defibrillator (AED) to the
man which indicated that there was no shockable rhythm and that cardio
pulmonary resuscitation (CPR) should continue. (An automated external
defibrillator detects the electrical activity in the heart and gives instructions to
the user on what to do.)
34. An emergency paramedic arrived at the cell at 8.40pm. The AED again
indicated that no shockable rhythm had been detected and so CPR continued.
The PO was given an ambu-bag, which enabled him to provide oxygen to the
man via a facemask without the continued need for mouth to mouth. The AED
continued to assess him and at 8.43pm, 8.45pm and 8.48pm it instructed staff
to continue CPR. During this time, the paramedics tried to find a vein in the
man’s arm so the treatment could be administered intravenously, but this was
not possible as his veins had collapsed. A third paramedic arrived at 8.53pm,
and three further assessments by the AED indicated that CPR should continue.
35. At 8.57pm, the ambulance staff assessed his condition. They decided that he
had failed to respond to treatment and CPR should stop. A doctor at Woodhill
arrived in the healthcare unit at 9.11pm. The ambulance staff told him of their
decision and the doctor confirmed the man had died at 9.14pm.
36. Following his death, the staff involved in trying to resuscitate him were offered
support from the staff care team as were other staff that had known him.
Prisoners on the healthcare unit were also advised of the support available
should they require it.
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37. Woodhill appointed a family liaison officer, who had been in contact with the
man’s family on an earlier occasion. As his wife was elderly and in poor health,
the prison decided not to inform her immediately to ensure that she was not left
alone overnight. They waited until the following morning when they could
provide better support. As well as visiting the family the Deputy Governor, also
wrote to the man’s wife on 4 January expressing the prison’s condolences for
the family’s loss and offering the opportunity to visit the prison if they wished.
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ISSUES
Transfer to HMP Woodhill
38. The man’s family asked for clarification as to whether his move from Bullingdon
was related to bullying. The investigator found no reference to bullying or any
concerns about this being raised by him. I am satisfied that the move to
Woodhill resulted from the deterioration in his medical condition and requiring
one to one nursing care. The original plan to move him to Norwich and the
elderly prison unit would have been the preferred option. However, I am
satisfied that the care he received at Woodhill was good and that he benefited
from the move.
Medical care
39. When the man entered custody, he was in poor health, with several chronic
conditions. Initially, he received regular treatment at Bullingdon but as these
conditions deteriorated staff arranged the move to Woodhill. The facilities
provided at Woodhill ensured that his quality of life was good. The purpose
built disabled cell enabled him to access 24-hour assistance for any problems.
Despite his strong and well documented views on what he should and should
not eat, the man was advised regularly about his diet both by prison nursing
staff and those at Milton Keynes Foundation Hospital.
40. The clinical review of his medical care, conducted by the PCT, concludes that:
”… The man received a completely equitable level of care at HMP
Woodhill. Given the level of need he experienced in his last months, it is
likely that, had he not been in prison, he would have required extensive
care either at home or in a residential care setting. Hospitalisation would
also have been indicated at certain times. In this regard, he may have
received a more prompt response to his needs in HMP Woodhill than he
might have experienced elsewhere other than in hospital simply because
of the rapid access to medical intervention …”
Resuscitation attempts
41. When staff became concerned about him, they quickly went into the cell and
immediately started first aid. The prolonged attempt by both medical and
prison staff ultimately failed, but this should in no way be seen as a reflection of
the quality of the efforts made by staff. The clinical reviewer comments on the
resuscitation attempt in great detail and says:
“… There are many factors, which can influence the chances of
success in carrying out a resuscitation attempt. Firstly, it is unknown
how long the man had been in the position in which he was discovered.
The records show that he had been seen two hours before. He had
not used his cell call bell to summon help and there is no record that he
was heard shouting for attention or calling out in pain. It cannot be
accurately determined, then, when he collapsed. Successful
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resuscitation attempts are more likely when they are commenced as
soon as possible after breathing has stopped …
“… It is said that the man was not breathing when he was found and
that he was cyanosed (this refers to the pale and blue colouring when
somebody is deprived of oxygen.) These factors also give some
indication of the passage of time from his initial collapse, because the
loss of colour would become more pronounced the longer he was
deprived of oxygen …
“… It may be the case, then, that resuscitation was extremely unlikely
to succeed anyway. However, the attempt at resuscitation was started
as soon as possible, and an alert was put out immediately to summon
assistance both within and outside Woodhill. This lead to the arrival of
additional healthcare staff from within the unit and to paramedics
attending the scene fifteen minutes after the man was discovered. In
that time, CPR was continuous and oxygen was applied by way of a
facemask. A defibrillator was available but not used because on-
screen instruction indicated that CPR be continued …
”… In conclusion, the resuscitation attempt on him was full, prolonged
and carried out by staff with knowledge of the procedure and their parts
in it. The records show that resuscitation guidelines were followed, and
only after all reasonable steps had been taken or attempted was the
resuscitation attempt stopped and death was declared by the attending
doctor …”
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CONCLUSION
42. The clinical review concludes that the man’s care at Woodhill was equitable to
that which might be expected in the wider community. He had a number of
chronic conditions that required differing types of care. Nursing and discipline
staff ensured that despite his considerable medical problems, his dignity was
maintained. All referrals to outside hospital were completed as required without
unnecessary delay. The clinical review identified the need for an improvement
in medical record keeping and chronic disease management which have
already been included in an action plan by Milton Keynes PCT. I support the
views of the clinical reviewer that all staff involved in his care should be
commended.
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