Individual at Leeds

Investigation into the circumstances surrounding the
death of a man in March 2008
at HMP Leeds
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2010
This is the report into the death of the man found in his cell at HMP Leeds in March
2008 at 9.00am. He was unconscious, with no signs of life. Healthcare and prison
staff attempted cardiac pulmonary resuscitation (CPR). Paramedics arrived and
pronounced the man had died. He had been suffering from Maple Syrup Urine
Disorder (MSUD), a serious rare genetic condition. He was 30 years old.
A post mortem was held at the request of Her Majesty’s Coroner for West Yorkshire.
It noted that the man’s death was due to natural causes from Maple Syrup Urine
Disorder. I extend my sincere condolences to his family and friends. I am very
aware of the lateness of my report and thank the family for their patience. I hope
that the report answers their questions.
On 28 May 2008, the Ombudsman’s investigation into the man’s death was
suspended following information from West Yorkshire Constabulary. The police told
my investigator that they would be carrying out an investigation into prescribed
medication found in the man’s cell. A police file was submitted to the Crown
Prosecution Service (CPS) in 2009. The CPS judged that no action for any criminal
proceedings would follow and on 26 February 2010, my colleague resumed her
investigation.
I would like to thank the Governor at Leeds and his staff for their assistance in this
investigation. I am indebted to a Detective Inspector (DI) and a Detective Constable
(DC) of West Yorkshire Constabulary for working closely with the Ombudsman in this
case.
As well as the clinical review was originally commissioned from Leeds Primary Care
Trust (PCT), my investigator was given access to two specialist medical reports
commissioned by West Yorkshire Constabulary. Those reports have been used as
part of my investigation.
The man was suffering from a rare life threatening genetic disorder which resulted in
his death five weeks into his prison sentence. Whilst no individual was to blame, a
sad catalogue of errors contributed to his death which, I believe, could have been
avoided. I make three recommendations to the Head of Healthcare in relation to
dispensing medication, briefing healthcare staff and assessing prisoners returning to
Leeds following a stay in hospital.
In response to the draft report the prison service have noted two minor inaccuracies
which have been amended and paragraph 95 has been added to this final report.
The three recommendations have been accepted. One of my family liaison officers
tried to make contact with the man’s family and left telephone messages. Up to the
circulation of this report they have not returned those telephone calls or made
contact with my office.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman June 2010
2
CONTENTS
Summary
The Investigation Process
The man
HMP Leeds
Glossary
Key Findings
Issues
Conclusion
Recommendations
3
SUMMARY
The man was convicted of sexual offences in February 2008 at Crown Court and
sentenced to five years imprisonment. He arrived at Leeds prison later that day and
a first reception health screen document noted that he said he had suffered from
Maple Syrup Urine Disorder (MSUD) since childhood. (This is a serious and rare
genetic urine disorder.) The measurements of his blood pressure, pulse and weight
were all within the normal range. He also told the nurse that he had attempted self
harm in 2004 and so an Assessment, Care in Custody and Teamwork (ACCT) plan,
was opened. (An ACCT plan is a document that records observations, assessments
and reviews on prisoners who may be suicidal or have thoughts of self harm.) He
was moved to the induction unit in a shared cell.
The following day he was examined by the first prison doctor who saw the man. He
told the doctor that he had been diagnosed with MSUD and the special diet and
medication he would need whilst in prison. The doctor made a search on the
electronic medical record system to identify medication for the man and prescribed a
supplement of Maxamum XP. He asked the kitchen to order a vegetarian diet and
wrote to the senior officer on the induction unit, informing him that the should not eat
protein foods.
The man settled into the induction unit and his ACCT document was closed on
27 February. The first prison doctor who saw the man spoke to the man’s consultant
later that day to arrange weekly blood tests to check the man’s amino acid levels.
The man was found to have breathing difficulties on 1 March and admitted to
hospital for treatment and observation. He returned to Leeds on 11 March with his
medication except his supplement. A second prison doctor signed a prescription for
the man’s medication which included Maxamum XP.
The following day, the first prison doctor spoke to the man’s dietician. From that
conversation the doctor was made aware that the wrong supplement had been
prescribed and MUSD Maxamum was the correct one. The dietician also told the
doctor that a vegetarian diet would be too high in protein and she would send diet
sheets to manage the man’s illness. The doctor amended the man’s prescription
and made a note on his medical record.
The first prison doctor went to the pharmacy department and informed them that
Maxamum XP should not be dispensed to the man and it should be replaced by
MUSD Maxamum. The pharmacy manager checked that there was no Maxamum
XP in the pharmacy.
However, Maxamum XP had already been sent to a wing treatment room and a
nurse dispensed it to the man on 13 March.
In March at 9.00am, the man did not respond to his cell mate who was unable to
rouse him. The cell mate alerted officers who in turn radioed for urgent medical
assistance. On the arrival of healthcare staff, the man showed no signs of life.
Despite the presence of rigor mortis, healthcare and prison staff carried out cardio
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pulmonary resuscitation (CPR) until the paramedics arrived at 9.21am. Following an
examination, the paramedics confirmed the man’s death.
Several weeks after the man’s death, police photographs taken of his cell in March
were recognised as showing two partially empty tins of Maxamum XP. The
investigation into the man’s death was suspended by the Ombudsman’s office until
the police enquiries were completed.
West Yorkshire Constabulary commissioned two expert medical reports into the
man’s death. One report was written by a consultant paediatrician with knowledge of
MUSD, a second report by a forensic physician. Both reports have been used in this
investigation. In January 2010, the Ombudsman’s investigation was re-opened
following completed enquiries by the police.
I make three recommendations for the attention of the Head of Healthcare in relation
to dispensing medication, briefing nursing staff and assessment of prisoners’ health
following an inpatient hospital admission.
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THE INVESTIGATION PROCESS
1. My investigator visited Leeds on 3 April 2008. Notices and the Ombudsman
terms of reference had been sent to the prison in advance of her visit. She
met the Prison and Probation Compliance Officer and one of the prison’s
Family Liaison Officers. My investigator also spoke to the man’s cell mate.
2. No members of the Independent Monitoring Board (IMB) or the Prison
Officers Association asked to see my investigator. Leeds has previous
experience of death in custody investigations. Furthermore, there was no
response to the notices of investigation from staff or prisoners
3. One of the Ombudsman’s family liaison officers, contacted with the man’s
foster mother informing her of our investigation. An appointment was made
to see her. On 8 May 2008, my investigator and my family liaison officer
visited the man’s foster mother. She gave a history of her foster son’s rare
medical condition, the diet and medication he followed to control his illness.
On 28 May, on receipt of information from West Yorkshire Constabulary the
investigation was suspended.
4. My investigator met a Detective Inspector (DI) and a Detective Constable
(DC) at Leeds police station on 12 September. The officers outlined the
process of their investigation and it was agreed that no further interviews or
investigation would be undertaken by my investigator until the police had
completed their enquiries.
5. On 26 January 2010, my investigator met the DI again at a police station in
Bradford. The DI informed my investigator that the police enquiry was
complete. No further action for any criminal proceedings would be taken by
the CPS. The DI gave my investigator two medical reports commissioned
by West Yorkshire Police, and a summary of the police investigation, to
assist with her report. The DI also gave my colleague contact details of one
of the man’s family members who the police had been liaising with.
6. Another of my family liaison officer contacted the newly identified family
members to inform them that the Ombudsman’s investigation was being re-
opened. My investigator and the family liaison officer visited the family on
15 March 2010 and, after discussion, agreed to look at some additional
issues. Their first concern related to a letter shown to the man’s family by a
police officer. They asked about an entry in his medical notes on 15 March,
and lastly they wanted to know if the first prison doctor had replied to a letter
from the man’s solicitor, acknowledging his MSUD and the complexity of
treating his condition.
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The man
7. The man was born in Manchester, he was 30 years old. He was raised by
foster parents with his birth parents also live in the same area. He was a
single man and, for the last four years lived alone, sometimes homeless
until he was given a tenancy in council accommodation. At the time of his
arrest he was unemployed.
8. The man had suffered from Maple Syrup Urine Disorder (MSUD) since birth.
He had regular appointments with a dietician and received his medication
from a hospital. However, it was noted in one of the expert medical reports
that he did not always adhere to his diet and medication and regularly
missed his hospital appointments.
9. In February 2008, the man was sentenced to five years imprisonment at
Crown Court, for serious offences and received into Leeds prison. It was his
first time in prison.
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HMP LEEDS
10. HMP Leeds is a category B local prison serving courts in West Yorkshire.
(A local prison takes prisoners who have been remanded by the courts and
those on short sentences.) The vulnerable prisoners’ unit (VPU) is located
on A wing. This wing is for those prisoners who request to be separated
from other prisoners for their own safety.
11. There are 24 beds in the healthcare centre, with provision for those with
both physical and mental health needs. Healthcare at Leeds is provided by
the Leeds Primary Care Trust.
12. Leeds was last inspected by HM Chief Inspector of Prisons, in December
2007. HM Chief Inspector of Prisons found that Leeds had some significant
problems and was underperforming in several key areas. However, there
had been progress in all areas and managers were seeking to introduce
further improvements.
13. Half of those prisoners surveyed by the Inspectorate felt that health services
at Leeds were either good or very good. However, HM Chief Inspector of
Prisons identified several areas for improvement. Among these, she felt
that waiting times to see a prison doctor were too long. She also noted that
not all healthcare staff had received resuscitation training in the last 12
months.
14. In their annual report for 2009, the prison’s Independent Monitoring Board
commented that the healthcare team had improved the service provided to
prisoners over the course of the previous year. They reported that
healthcare was a “well managed and forward thinking department”.
15. Up to the time of the man’s death, there have been 11 natural cause deaths
at HMP Leeds since the Ombudsman took over responsibility for
investigating deaths in custody. The man’s death was the first death in the
prison as a result of this rare genetic condition and the first that the
Ombudsman has investigated.
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GLOSSARY
Maple Syrup Urine Disorder
16. The MSUD family support group describes Maple Syrup Urine Disease
(MSUD) as a disorder in the body's ability to use three of the essential
amino acids in protein. These three essential amino acids (leucine,
isoleucine and valine) are often called the branched-chain amino acids
(BCAAs). Protein in the body is made up of 20 amino acids, 11 are
essential and nine are nonessential. The essential amino acids must be
supplied in the daily diet. The nonessential amino acids can be obtained
from the diet or produced in the body from other amino acids. In MSUD, the
enzymes necessary to break down leucine, isoleucine and valine are either
absent, inactive or only partially active. Because of the enzyme deficiency
in MSUD, the BCAAs and their by products, called ketoacids, become
elevated. It is these elevations that cause an infant or child with MSUD to
display symptoms of the disease. MSUD is a serious disorder with life-
threatening consequences unless it is addressed promptly. However,
MSUD is manageable, just as diabetes is manageable. Careful monitoring
and adherence to dietary restrictions are essential. Even minor illnesses
and infections must be taken seriously and require special care. Treatment
for MSUD has improved greatly over the past few years.
17. The medical report from the consultant paediatrician, states that a food
supplement used to treat Maple Syrup Urine Disorder is MUSD Maxamum,
to be taken with other special low protein foods, vitamins and minerals. A
similar metabolic disorder is phenylketonuria (PKU). There is a similar
dietary approach to that of MSUD, and food supplement of Maximum XP is
prescribed. However, a person with MSUD who takes Maximum XP would
expect their circulation to fail and suffer brain toxicity as a result of taking the
incorrect supplement.
The Bolam Test
18. In cases of alleged negligence involving medical treatment, the Bolam test is
used to determine the standard of care owed to a patient by doctors. The
case Bolam v Friern Hospital Management Committee (1957) 1 WLR 583
established that there can be no breach in the duty of care so long as the
doctor acted in accordance with a responsible body of medical opinion.
Subsequent cases have challenged this test, requiring the doctor to behave
‘reasonably’ or ‘logically’ regardless of the body of medical opinion.
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KEY FINDINGS
19. The man was arrested in February 2008 at a hospital following his discharge
from an inpatient stay. The warrant stated that he had failed to appear at
court. During his stay in hospital, the diagnosis of Maple Syrup Urine
Disorder (MSUD) was confirmed. The hospital had contacted medical staff
at another hospital to confirm his medical history and treatments. He was in
possession of his supplement MUSD Maxamum which was recorded on his
hospital discharge form.
20. On arrival at a police station, he was examined by a police doctor who noted
that he had in his possession MUSD Maxamum. He was given this
supplement whilst in police custody waiting for his court appearance.
21. A consultant, at the man’s local hospital wrote to the man’s solicitors after
hearing that he was in custody, to inform the police and prison services of
the man’s complex medical condition, the medication and diet he would
need to stabilise his condition. The man had been prescribed MSUD
Maximum, (a supplementary powder for nutrition) that was an essential part
of the man’s medication to control his illness.
22. The next day, the man arrived at Leeds prison following his conviction at
Crown Court. A first reception health screen document was completed.
The document noted that he suffered from MSUD he was under weight and
had attempted to harm himself in 2004. His blood pressure and pulse rate
were noted and within the normal range. He had a tin of MUSD Maxamum
with him, which was noted on the first reception health screen document. (It
is not recorded whether the man took this tin of MSUD Maxamum into the
prison.)
23. An Assessment, Care in Custody and Teamwork (ACCT) plan was opened.
(An ACCT plan is a document that records observations, assessments and
reviews on prisoners who may be suicidal or have thoughts of self harm.) It
was recorded in the ACCT that the man attempted suicide with an overdose
in 2004, although he was vague about this incident and date. An
assessment noted that he still had thoughts about harming himself. The
man was placed in the first night centre, in a double cell and to be checked
hourly by staff.
24. At 4.25pm the following day, the man saw the first prison doctor. The doctor
noted the man’s medical condition of MSUD, the details of his dietician and
doctor at a hospital. The doctor had little previous knowledge of MSUD and
searched the internet service provided by EMIS. (EMIS is the clinical
software used by healthcare services that record patient details, medical
notes and offers medical information.) Following a search, the doctor
prescribed a dietary supplement of Maxamum XP . (This supplement is not
the correct medication for MUSD and is contradictory in treatment for
MSUD.)
10
25. The prison doctor added to the man’s medical notes that his foster mother
may be able to assist with information about his medication and her
telephone number was added to the notes. The pharmacy did not have
Maxamum XP in stock and ordered the supplement from their supplier.
Although the man had MUSD Maxamum in his possession when he arrived
at Leeds, it is not known if he told the doctor which supplement was
appropriate for his illness.
26. The first prison doctor wrote a memo to the senior officer on D wing
(induction wing) where the man was located. The memo noted that the man
was suffering from MSUD and would become unwell if he ate foods
containing Protein. The doctor said a vegetarian diet would be sufficient for
the man who had been prescribed a supplement to take daily. The doctor
asked the senior officer to ensure steps should be taken to avoid any meat
products being included in the man’s diet.
27. On 26 February, it was recorded that the man complained twice to
healthcare staff, saying he had not had his medication and was feeling tired.
28. The following day, the first prison doctor spoke to the consultant at a
hospital by telephone and he suggested to the prison doctor that the man
should have weekly blood tests to check his amino acid concentration. This
could be arranged through a hospital and the consultant at the hospital
would confirm this later. The man’s ACCT plan was closed following a
review meeting with staff and the man. He said he had no thoughts of self
harm and was getting used to prison life. However it had been noted that he
had seemed to be disoriented, vague and “spaced out”.
29. The man’s solicitor faxed a letter to the first prison doctor outlining his
medical condition on 28 February. The doctor replied to the solicitors saying
that he was aware of the man’s illness and all necessary steps to support
him had been taken. No reference was made in this letter as to what
medication the man was receiving. (The letter written by the prison doctor
was dated 4 March.)
30. On 1 March at 11.30am, healthcare staff were called on the radio to a code
blue alert, (the prison’s term for a medical emergency involving breathing
difficulties) to see the man in his cell. He was sweating profusely and
having difficultly in breathing. The man’s mattress was pulled onto the cell
floor and he was placed on the mattress in the recovery position. An
ambulance was called and oxygen was administered. The man’s breathing
was better by the time the paramedics arrived.
31. The paramedics advised that the man should be taken to the healthcare unit
until the doctor arrived. At 12.30pm, the doctor saw the man and an
ambulance was called to take him to hospital. The man was escorted by
two officers and was restrained. (An escort chain is a 1.8 metre length of
chain with one cuff attached to the prisoner and the other cuff attached to an
officer.) At 8.35pm, the man was returning from having an x-ray in the
11
hospital when he attempted to get off the trolley bed and had to be placed
back on it. He was then admitted to a ward.
32. The following day, the man was placed on an intravenous drip and given
insulin. He was escorted by two officers during his stay at the hospital. The
man was discharged from hospital at 4.30pm on 10 March and he returned
to Leeds. He was located on D wing, as A wing was full. On discharge the
man was given medication by the hospital of an antibiotic, thiamine, Polycal
and Calogen but not MSUD Maximum. There is nothing recorded that
healthcare staff had been made aware that the man had returned to the
prison.
33. On 11 March, the man saw the second prison doctor who noted that he was
receiving a course of anti-biotic medication prescribed by the hospital. The
doctor reviewed the man’s medication and wrote a new prescription for all
his medication including the previously prescribed Maxamum XP.
34. The following day, a dietician from the hospital spoke to the first prison
doctor by telephone. She advised the doctor that the man would need
MSUD Maximum as well as other dietary supplements. The dietician from
the hospital told the doctor that a vegetarian diet would contain too much
protein for the man. The dietician said that XP Maxamum should be
stopped as it was the incorrect supplement for MSUD . It was noted that the
first prison doctor told the dietician that MSUD Maxamum would now be
ordered for the man.
35. The doctor noted the man’s low protein diet and weekly checks should be
made of his amino acid levels by blood tests. His medication was reviewed
and a new prescription completed.
36. Having spoken to the dietician at the hospital, the first prison doctor
contacted the pharmacy department and told them that the wrong dietary
supplement had been previously prescribed. The doctor made an entry on
the man’s medical notes to that effect. He should not be dispensed XP
Maxamum and the prescription was altered to MSUD Maxamum.
37. The pharmacy manager recalled the conversation with the first prison
doctor. She told a member of the pharmacy staff to cancel the orders for XP
Maxamum and instructed that any which had arrived should be returned to
the supplier. However, a supply of XP Maxamum had already been sent to
the wing medication room. (Furthermore it had been confused with a
prescription for another prisoner whose name was similar of the man’s but
fortunately this medication had not been dispensed.)
38. On 13 March at 9.40am, a nurse gave the two tins of XP Maxamum from the
wing medication room, as prescribed by the first prison doctor on the man’s
reception into Leeds on 23 February and the second prison doctor on 10
March. The man took the medication back to his cell. He had made a
complaint that day that he was not receiving his medication. (The complaint
was received by the complaints clerk on 17 March two days after his death.)
12
39. The man’s medical notes record that his dietary information was passed to
the prison’s kitchen on 14 March. He also told the nurse who had given him
two tins of EP Maxamum when he went to collect his antibiotic medication,
“his special drink” (thought to be XP Maxamum which had been dispensed
to him by the nurse the previous day) was the wrong flavour and made him
feel sick. The man’s medical notes do not indicate that he had yet received
MSUD Maxamum, as prescribed the previous day by the first prison doctor.
At about 6.30pm that day, the man moved from D wing to A wing where he
shared a cell with another prisoner.
40. The cell mate who shared the cell with the man went onto the landing for
association time whilst the man stayed in his cell. On return to his cell, the
cell mate saw the man asleep on the bottom bunk bed. About 8.15pm, the
man woke up and told the cell mate that his hands were hurting. He also
told him he had been in hospital and had drips in his hands. Both men then
watched television, with the cell mate falling asleep at around 10.00pm.
Shortly after midnight, the cell mate switched off the television and cell light
then went back to sleep. The cell mate saw that the man was asleep. In
the early hours of the next day, the cell mate heard the man groaning in his
sleep, but could also hear him breathing so he went back to sleep.
41. At about 9.00am, the cell mate was woken by an officer asking if he wanted
to go out for exercise. The cell mate looked at the man and saw he was not
moving. He rang his cell bell and called for an officer. An officer responded
to the cell bell and, on entering the cell, saw that the man was lying face
down on the bed. The cell mate was told to wait outside the cell. A second
officer then joined the first officer who had responded to the bell in the cell.
The officers spoke to the man, but there was no response and no signs of
life.
42. The second officer and the first officer moved the man onto his back on the
floor. The second officer then put out a code blue call on his radio (a code
blue indicates a medical emergency where someone is not breathing), and
asked another officer to get the nurse from the A wing treatment room. The
first staff nurse on the scene joined the officers in the man’s cell observed
he was showing no signs of life. The first staff nurse on the scene
requested radio assistance and an emergency ambulance was requested.
The second officer began cardio pulmonary resuscitation (CPR), whilst the
first staff nurse on the scene tried to make an airway for oxygen to be
administered. Due to rigor mortis, the nurse was unable to place an oral
airway into the man’s mouth.
43. About two minutes later, the first staff nurse on the scene and the second
officer were joined by three other nurses who brought resuscitation
equipment with them. A defibrillator (a machine that sends shock waves to
re-start the heart) was attached to the man’s chest. The defibrillator advised
not to shock so the first staff nurse and the second officer continued with
CPR.
13
44. At 9.21am, the paramedics arrived at Leeds and went straight to the man’s
cell. He was examined by the paramedics and pronounced dead a few
minutes later.
45. A retrospective entry was made on 15 March in the man’s medical notes by
the nurse who had given him two tins of XP Maxamum saying:
“Inmate complaining that the specialist drinks [the supplement] supplied
are not the right flavour and making him feel nauseous and has vomited
once. Advised to let nurse know if vomiting continues.”
46. At about 3.00pm that afternoon, a Governor and Healthcare Officer went to
the home of the man’s foster mother to tell her of his death. On arrival the
prison staff were unable to find her at home. Through neighbours they
traced a relative living in the same road, who told them that the man’s foster
mother was away for the day. The staff were then given an address where
his blood parents lived. They went to the address and were able to tell the
man’s parents of their son’s death. Later that day they spoke to the man’s
foster mother.
47. The Healthcare officer and the Governor paid their respects, and that of
Governor at Leeds, at the man’s funeral on 20 March. The prison offered
financial assistance towards funeral expenses.
48. Several weeks following the man’s death the police liaison officer based at
the prison, reviewed photographs taken by the police of the man’s cell on
the day of his death. The DC saw two tins of opened Maxamum XP on a
table beside the man’s bed. The police officer knew from information held in
the man’s medical notes that he should not have been issued with this
medication and so he informed the DI of his observations.
14
ISSUES
Clinical care
49. West Yorkshire Constabulary commissioned two expert medical reports into
the man’s medical care whilst he was in custody at Leeds. The first report
by the consultant paediatrician with specialist knowledge of MSUD and a
second report by a forensic physician.
50. For the purpose of this investigation the consultant paediatrician’s report has
been used to underpin the issues surrounding the man’s death. The report
by the forensic physician offers an expert opinion as to whether the man’s
death was avoidable and comments on the actions of individual members of
staff.
51. The consultant paediatrician viewed the man’s medical notes, statements
from prison healthcare staff, prison staff, a prisoner and hospital staff. He
made a list of the events leading up to the man’s death and commented on
the issues raised from that chronology. The consultant paediatrician
reviewed and gave an expert opinion on MSUD. He further commented on
the effects of the illness and the man’s treatment in Leeds. The forensic,
was also given documents as viewed by the consultant paediatrician.
Background information
52. The man was diagnosed with MSUD at eight years old and remained in
hospital for some months whilst his illness was managed. He grew up with
foster parents and had little contact with his blood parents. He was under
the care of a local hospital with consultants, an outreach nurse and a
dietician. The consultant paediatrician commented that the man’s social life
was problematic and he had been known to have periods of homelessness.
53. From March 2005 to June 2006, five high levels of amino acids were noted
in his blood indicating that he had a poor diet. If the levels rise too high, the
brain becomes cloudy and, if the situation is not corrected, it becomes
terminal. In 2008 the man’s consultant at the hospital wrote to his doctor
that the man was not attending his out patient appointments but contact
would continue through the specialist clinical nurse and dietician.
MSUD control prior to February 2008
54. It was known from the hospital records, that the man had not been
consistent about eating a low protein diet, however he was apparently taking
the MSUD Maxamum supplement. He would have little in reserve, so any
small change in his circumstances might easily have serious consequences.
Consultant paediatrician commented:
“It seems to me that he was just getting by without decompensation
episodes but it is likely that his brain function including cognitive ability
15
would be slowly deteriorating. It is likely that his level of control would
render him vulnerable to a decompensation episode.”
55. Decompensation is the functional deterioration of a previously working
structure or system. Decompensation may occur due to fatigue, stress,
illness, or old age. When a system is "compensated", it is able to function
despite stressors or defects. Decompensation describes an inability to
compensate for these deficiencies. It is a general term commonly used in
medicine to describe a variety of situations. Decompensation would be the
result of failing to take MSUD Maxamum or not adhering to a low protein
diet by eating more protein than usual.
Prescribing and issuing protein supplements
56. The first prison doctor who saw the man prescribed Maxamum XP on 22
February, after an internet search via EMIS for a supplement to the man’s
diet. It is now known that this was not the correct treatment for MSUD. The
doctor, quite reasonably, relied on the information held within the EMIS
system which indicated that Maxamum XP should be taken as a
supplement. MSUD Maxamum did not appear as an alternative medication
and he prescribed Maxamum XP.
57. It is unknown what happened to the tin of MUSD Maxamum that the man
brought into Leeds on his reception. It is unusual for prisoners to retain any,
medication which they bring in with them.
58. The forensic physician made enquiries with Egton Medical Information
Systems (EMIS) in Leeds, who installed the electronic medical record
system at the prison. He noted there was a lack of information on this
system and the incorrect information contributed to the wrong supplement of
Maxamum XP being prescribed. I understand that as a result of the man’s
death, prescription advice to doctors in relation to MSUD has now been
amended on EMIS.
59. Following a discussion with the dietician at the hospital on 12 March, the
first prison doctor amended the prescription from Maxamum XP to MSUD
Maxamum. He then went to the pharmacy and told staff to cancel the
Maxamum XP. Pharmacy Manager, the pharmacy manager recalled their
conversation and, in turn, told her staff to return any Maxamum XP to the
suppliers. The forensic noted that the pharmacy manager said in her
statement to the police that pharmacy staff would only consult the electronic
medical record system (EMIS) if there was a particular query with a
prescription.
60. At this stage there is nothing noted in the man’s medical records as to what
supplement he had taken, if any, unless he had been supplied with MSUD
Maxamum by the hospital.
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61. On 13 March, the nurse who had issued the man with two tins of Maxamum
XP from the wing treatment room that were sent out from the pharmacy on
28 February. The following day he told nurse that his “special drink” was the
wrong flavour and made him feel sick. It is assumed the man was referring
to the supplement of Maxamum XP which he had given the previous day.
62. The forensic physician noted that the nurse should have checked the man’s
prescription via EMIS before she gave Maxamum XP. The nurse should
also have been made aware that the man had recently returned from
hospital, of his condition and the need for him to have the correct diet and
protein supplement. All this information should have been made available
for the nurse.
The healthcare manager should ensure that all healthcare staff are fully
brief at the start of duty with updated information on prisoners with
complex medical conditions and any prisoners discharged from
hospital.
The pharmacy department should review all prescribed medications
when a prisoner is returned from hospital and any previous prescribed
medication should be returned to the pharmacy to be part of that
review.
Diet whilst in prison
63. The man spent two periods in Leeds, his reception on 23 February to 1
March, and then 10 March until his death on 15 March. It was noted that a
vegetarian diet was ordered for the man, which was not necessarily low in
protein. However, when the first prison doctor discussed this diet with the
consultant at the hospital, he did not raise this as an issue.
64. The forensic physician commented;
“The first prison doctor needed to ensure that an appropriate diet and
medication was available - he appears to have tried to do this and has
communicated and documented these communications in the medical
records.”
65. Vegetarian diets are high in natural protein and therefore inappropriate for
people with MSUD. If the man took this diet combined with his vulnerable
physical condition on reception into Leeds, then it could lead to signs of
decompensation, lethargy, drowsiness, unsteadiness, slurring of speech, fits
and death. The dietician at the hospital told the doctor that a vegetarian diet
was unsuitable. She faxed a diet sheet to the doctor, making it clear that
MSUD Maxamum was required as well as a specialised diet. It is not known
whether any changes were made to the man’s diet following that advice.
However the doctor did inform the kitchen of the change to the man’s diet on
14 March.
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66. There is no information that the man was eating his diet or refusing it. The
DC interviewed the man’s cell mate, who told him that the man had
complained that he was not given his proper diet or medication. However, it
is known that this complaint was not received by the complaints clerk until
17 March.
67. The process for complaints is regulated by the complaints clerk. The
complaint is checked and then progressed, to a given timescale, for a
response by the appropriate person to whom it was made. In this case, the
man’s complaint was about his medication and diet and it would be
forwarded to the healthcare manager. (The man’s complaint was received
by the complaints clerk on Friday and forwarded to healthcare the following
Monday.)
68. The forensic physician commented:
“ In my opinion a complaint regarding medical or health issues should be
reviewed at the earliest opportunity by a doctor.”
Taking into account the number of complaints made every day by prisoners,
for a variety of issues, the complaint would take some time to reach the
appropriate person. I empathise with the forensics’ recommendation that
doctors should review all complaints at the earliest opportunity. However, in
a prison the size of Leeds, this would not be practical. However I draw the
issue to the attention of the healthcare manager to consider whether
complaints about medication should be reviewed by a doctor.
69. Likewise there is also no information that the man had been taking his
prescribed supplement of Maximum XP, prescribed by the doctor from 23
February to 1 March. However, it was noted by the DC, in statement, that
two partially empty tins of Maximum XP were photographed on a bedside
table in the man’s cell following his death. The tins had a prison pharmacy
label with his name on.
70. The consultant paediatrician said:
“If no (appropriate) protein substitute were made available, or if the man
was not eating supplied diet well - he may not have wanted to or knew
that it was high in protein and refused for that reason - he would be in a
position where his body protein would tend to break down and put him at
significant risk of decompensation. Low protein foods like prescribable
biscuits should have available for him and their provision was stressed
by the dietician at the hospital in her telephone(s) to the doctor. There is
no evidence that they were prescribed.”
71. The man was supplied with the wrong protein substitute in Leeds and was
supplied with Maxamum XP instead of MSUD Maxamum. The dietician at
the hospital apparently made the doctor aware of the error. However it
would seem that the man was still not given MSUD Maxamum, and two tins
18
of Maxamum XP were found to be in his cell after he died. No MSUD
Maxamum was found in his cell or the treatment room.
72. The consultant paediatrician said:
“The relatively high dietary protein load of a vegetarian diet for some
days together with supplementary enhanced protein containing
branched chain amino acids that the man was almost certainly exposed
to through being given the wrong protein substitute Maxamum XP
instead of MSUD Maxamum. This would represent a different situation
for him that pertaining in his periods looking after himself prior to gong
into prison.”
Admission to hospital
73. The man was admitted to hospital on 1 March 2008. This was a
decompensation episode, most likely linked to poor dietary control before he
came into prison on 23 February. From then until he went into hospital, he
is likely to have had an inappropriate vegetarian diet and, or, an
inappropriate protein supplement of Maxamum XP.
74. The consultant paediatrician said:
“In hospital, high leucine concentrations in blood were evident and
would be similar at discharge on 10 March 2008 though a little lower at
that stage and in association with generally better (normal for the man)
clinical position. However, this would not be a strong platform from
which to react to a return to a high intake of branched amino acids
through diet (vegetarian) and wrong supplement provision. If he were
either not eating the usual amount of food, eating too much protein
and/or having Maxamum XP, it would not be surprising if he were to
fairly rapidly (over days) return to a state of decompensation within
which death would always be a possibility.”
Return from hospital to prison
75. On his discharge from hospital on 10 March, the man was taken to D wing.
Healthcare staff were not aware that he had been discharged from hospital
and returned to Leeds. The man had been an inpatient for ten days, being
treated for a rare and serious condition. I believe that his ongoing
healthcare should have been a priority and the man should have been
assessed by healthcare staff as soon as he returned. Admission to the
healthcare unit should have been considered as it would have given staff an
opportunity to monitor his health in an appropriate setting. This was
especially important taking into account the serious and unusual nature of
his illness.
A member of the healthcare staff should assess all prisoners
returning to the prison following an inpatient stay in hospital.
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76. A discharge note is recorded in the man’s clinical notes detailing his
medication however, this is not dated. Furthermore a discharge summary
from hospital was not received into the healthcare until 23 March. The date
of the discharge letter was 17 March, two days after the man’s death.
Likely contributors to the man’s death
77. The man struggled to keep to his diet and medication whilst he was living in
the community although it was thought that he took his MSUD Maxamum
supplements. The prison doctors, perhaps not surprisingly, lacked
knowledge of his rare condition as, to a lesser extent, did the pharmacists.
However, it is not possible for doctors and pharmacists to know about all
medical conditions, particularly rare ones. Nevertheless, doctors have a
duty of care to ensure appropriate management of medical conditions
through advice and research. Some medical diets are critically important,
this being so in the man’s case. Furthermore, it is the responsibility of the
prescriber to indicate to the dispenser how important it is to provide
medication within a period of time.
78. An appropriate diet and supplements should have been readily available,
the man did not receive a protein substitute supplement or was given the
incorrect one, when he was in Leeds from 23 February to 1 March and
likewise from 10 March until his death.
79. It was assumed by hospital staff on 10 March that MSUD Maxamum would
be available in Leeds when he was discharged. All other medications were
given to him at this time with the exception of MSUD Maxamum.
80. There was clearly an error by the first prison doctor and the second prison
doctor in prescribing Maxamum XP instead of MUSD Maxamum. Whist the
first prison doctor had written up the medication, the second prison doctor
signed the prescription on 10 March.
81. The consultant paediatrician commented that neither doctor’s action was
negligent and said:
“The Bolam Test of clinical negligence is used as a test of actions by
doctors compared to what a reasonable and responsible body of other
doctors of similar grade and responsibility would do in similar
circumstances. It should not be used as a test in prescription writing as
although a reasonable and responsible body of doctors would not make
the same error in the same circumstances (Bolam test positive), most
members of that body would have been responsible individually at
another time for a similar written prescription error. It is an indictment of
the medical profession that such errors occur relatively frequently.”
82. The forensic was noted to have agreed with the consultant paediatrician’s
conclusion in regard of prescription errors.
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83. Taking into account all the issues surrounding the man’s death, the factors
of his poor health and his non compliance to his diet prior to his reception
into Leeds, the consultant paediatrician said:
“It is likely that most or all of these factors contributed to his [the man’s]
death but I cannot ‘weight’ them accordingly to relative size of their
contribution.”
84. The forensic physician summed up his report by addressing several points.
I have considered those relevant to my investigation which concern the
man’s diet and medical care whilst he was in prison.
• The man was given two tins of Maxamum XP of which approximately
three quarters of one tin was empty, 48 hours before he died. Would
he still have died if he had not been given any?
The forensic physician said:
“I do not believe it is possible to say – I note that the man also appears
to have been given Maxamum XP for some of his in patient say in
hospital, from which it appears he was discharged earlier than wanted
by the consultant at the man’s local hospital – I am still not quite clear
why he had to be discharged on 10 March 2008.”
• Was there inadequate record keeping by a number of staff members?
Can individual failings be pinpointed?
The forensic physician said:
“I cannot identify individual failings as the sequence of events and
accounts and recall is so complex.”
• Was the content of the first prison doctor’s memo to the kitchen about
the man’s diet sufficient bearing in mind the consultant at the hospital’s
advice that his diet should be based on a vegetarian diet rather than
the doctor’s instruction that a vegetarian diet should suffice?
The forensic physician said:
“I believe that many doctors would have sent a memo using the terms
described by the first prison doctor … I am not sure that the consultant
at the hospital’s advice provided enough detail of clarification.”
85. In conclusion the forensic physician said:
“I cannot identify a single point of failure. There appears to be a number
of communication failures of misinterpretations, of perhaps sub-optimal
treatment in hospital and prison all of which may have contributed. I am
unclear as to how complaint the man was with his regimen which itself,
21
either in or out of prison or hospital may have had the potential for
contributing to his death.”
Additional family issues
86. The man’s family raised three additional points for my colleague’s attention.
The first concerns a letter shown to the family by a police officer shortly after
the man’s death. The officer had told the family that the man wrote this
letter. My investigator did not see a letter in the man’s file written by him.
My family liaison officer, has advised the man’s family to take this matter up
with the police.
87. The nurse who had given the man two tins of XP Maxamum made a
retrospective entry in the man’s medical notes on 15 March. I am unable to
clarify two years after the man died as to why this was a late entry by the
nurse. It is not uncommon for medical notes to be made retrospectively.
However, I draw this matter to the attention of the head of healthcare to
remind staff that entries should be made in the medical notes as soon as
practicable.
88. The last point raised by the man’s family wished to raise was whether the
prison doctor was told of his illnesses by his solicitor. I can confirm that a
letter was sent by the solicitors to the healthcare unit at Leeds outlining his
illness. The first prison doctor replied to the solicitors on 4 March 2008,
saying that the man’s illness was known to healthcare staff and he was
being treated.
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CONCLUSION
89. As a child, the man was diagnosed with the rare condition, Maple Syrup
Urine Disorder. It was generally kept under control, although it was known
that he did not always conform to his strict diet and did not keep out patient
appointments with his consultant. However, he was in contact with his
dietician and I assume that he took his supplement of MSUD Maxamum
regularly.
90. On the man’s arrival at Leeds he was prescribed an incorrect supplement of
Maxamum XP and the kitchen was notified to provide him with a vegetarian
diet. However, before he was given his supplement he was admitted to
hospital as a result of MSUD symptoms and treated.
91. The man was discharged back to Leeds, and was dispensed with the
incorrect supplement of Maxamum XP despite it being withdrawn by the first
prison doctor when he was told of the prescribing error. The man died 48
hours after being dispensed Maxamum XP and it was noted that the tins
were partially empty.
92. Both medical experts agree that there were mistakes in the man’s treatment.
However, they conclude that no individual was solely at fault. A catalogue
of events led to his death.
93. It is tragic that the man died as a result of his rare medical condition. There
was little knowledge about the condition and the arrangements to support
patients with MSUD were deficient, including the EMIS database which
indicated the incorrect supplement to be prescribed.
94. EMIS has been amended to provide the correct information about the
treatment of MSUD. Nevertheless, healthcare staff should have ensured
that the man received the correct supplement particularly after he was
discharged from hospital. He should have been assessed by healthcare
staff and pharmacy checks should have made certain that the man was
receiving the correct prescription. Previous prescribed medication should
have been checked against EMIS before the man was dispensed with any
further medication.
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Response to draft report
95. In response to the drat report the following comment was made by the
prison service:
“The first prison doctor states that he did not see the man at 12:30. He
was arriving to do reception and was told he had been unwell. Nurses
were planning to cancel the ambulance. Recognising the potential
serious nature of the condition, he requested that the man was sent out
by ambulance urgently (he believes it was a nurse he spoke to).”
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RECOMMENDATIONS
For the Head of Healthcare
1. The healthcare manager should ensure that all healthcare staff are fully brief
at the start of duty with updated information on prisoners with complex
medical conditions and any prisoners discharged from hospital.
Accepted – “All complex health issues will be flagged up as an alert on
System one by Doctor on reception. All staff having any interaction with
patients refer to patient records for patient information and to record patient
interaction. All staff having contact with patient therefore have access to the
alert on system one and the medical history of the patient.
The patient will be referred by the reception GP to citywide/chronic disease
team using the system one TASK function. The team will co-ordinate care
planning and summarise notes and care including details of the complex
medical condition on system one within one working day of patient’s
reception into HMP Leeds.”
2. The pharmacy department should review all prescribed medications when a
prisoner is returned from hospital and any previous prescribed medication
should be returned to the pharmacy to be part of that review.
Accepted – “New Patients: Risk assessment documentation has been
developed to include a section for current medication. Medication brought in
by patients is now collected by admin receptionist, logged by doctor, using
patient’s own meds (POM) pathway. This pathway is in all clinical reception
rooms and laminated copy in reception. Those medications appropriate to re-
issue will go to the wing treatment room for administration. Appropriate meds
will be given back in possession i.e. inhalers, drink supplements.
Patient returning from hospital (in-hours): All patients returning from hospital
with a prescription will have all their current medications removed from the
patient’s cell and the treatment rooms by Hotel 3. Hotel 3 will take the interim
discharge papers to the duty doctor who will check, review and re-prescribe
all medications and ensure appropriate follow-up (eg blood teats etc). All
removed medication will be returned to pharmacy by Hotel 3.
Out of hours with no GP cover, a full review will be undertaken to establish a
safe mechanism for managing patients who return from hospital out of hours.
Working Group to include GP, Pharmacy Manager, Nurse, prison security
(sierra 1).”
Audit compliance with recommendation
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3. A member of the healthcare staff should assess all prisoners returning to the
prison following an inpatient stay in hospital.
Accepted - “Escorting Officers returning patients from un-planned hospital
episode contact Hotel Three (healthcare patrol nurse) who ensure a nurse
visits the patient within 1 hour of being informed of return to:
a. review the hospital discharge papers,
b. arrange appropriate monitoring and follow-up
c. flag-up to duty doctor through the System one TASK function that the
patient has returned
d. Take discharge papers to healthcare admin department to scan onto
medical notes.
e. Assessing nurse record interaction and outcomes on system one in a
timely manner.
Escorting Officer Standard Operating Procedures will be reviewed jointly
with prison and healthcare to ensure their Standard Operating procedure
describes the mechanism to contact Hotel Three
Standard Operating Procedure for Hotel Three will be reviewed to include
the duties expected as detailed in rec 3., 1a-e above.
Audit compliance of actions against recommendation”
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