Individual at Garth

Investigation into the circumstances surrounding the
death of a man, a prisoner at HMP Garth,
at hospital in February 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2011
This is the report of an investigation into the death of a man, a prisoner at HMP
Garth. He died in February 2010 at hospital in Lancashire. He was 48 years old. I
offer my condolences to his family and friends for their loss.
This investigation was carried out by an investigator. I would like to thank the
Governor and staff at HMP Garth for their contribution and assistance. In particular,
I am grateful to the governor who acted as liaison officer.
A clinical reviewer carried out a thorough review of the man’s clinical care on behalf
of the local Primary Care Trust and as always in such cases I greatly appreciate her
assistance.
When the man transferred to Garth in June 2008, he disclosed no personal or family
history of heart disease. He first reported chest pains in October 2009 and alerted
the doctor to a family history, but a specialist referral was not followed up. A few
months later, on 20 February 2010, he told medical staff that he had continued to
feel chest pains and he was taken to hospital two days later when his condition
worsened. The hospital confirmed that he had suffered a heart attack. Although
there was initially some improvement in his condition, on 28 February he had two
further heart attacks and died.
The clinical reviewer has identified that there were missed opportunities to possibly
diagnose and treat the man’s condition. However, it is impossible to judge whether
this would have led to a different outcome. Nevertheless, there are a number of
areas for improvement in the clinical management of prisoners at Garth and I
accordingly endorse the clinical reviewer’s recommendations. These focus mainly
on screening and referral to specialist services, as well as better management of
patients reporting chest pain. There is also a need for care plans for those admitted
to the prison’s healthcare unit and submission of medical notes for those admitted to
outside hospitals. It is further recommended that more permanent doctors are
employed and that nursing staff should make use of the telemedicine service,
particularly when there are no doctors in the prison. Finally, the Governor should
ensure that emergency ambulances are able to pass through the prison quickly.
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 February 2011
2
CONTENTS
Summary
The investigation process
HMP Garth
Key findings
Issues
Conclusion
Recommendations
3
SUMMARY
The man was born in January 1962 and died in February 2010 at hospital of a heart
attack. He was 48 years old. On reception at Garth in June 2008, he had a
healthscreen. He did not reveal any chest or heart problems; neither did he declare
any family history of such illness.
He had a long running disagreement with healthcare staff and often refused medical
attention. I understand this was because at a previous prison some of his
medication had been stopped. He first complained of chest pains on 12 October
2009. He was examined by a locum doctor who advised him have a follow up
appointment with the cardiac nurse. This follow up appointment did not take place.
During the following few months, he had consultations with several doctors who do
not appear to have consulted his previous notes.
The man complained of further chest pains on 20 February 2010. He was examined
by a different locum doctor who again appears not to have considered his previous
medical history. He was treated with an angina spray. He continued to suffer from
chest pains over the next day and was transferred to the healthcare inpatient
department on the morning of 21 February. The nurse on duty telephoned the locum
doctor and was instructed to keep observations on him and to send him to the
emergency hospital should anything change.
In the early hours of 22 February, the man’s blood pressure dropped so the nurse
telephoned for an ambulance. There was a delay when the ambulance arrived whilst
an appropriate escort was arranged. Staff used a closeting chain to restrain him. (A
closeting chain is a length of chain which is attached to one wrist of the prisoner and
an officer.) This was required because he would not complete any offending
behaviour work and his risk to the public was assessed as high. As his offences
were of a terrorist nature and there had been media attention and photographs had
been published a three person escort was required. This was due to the potential
risk of repercussions on him if he had been recognised.
When he arrived at hospital he was diagnosed as having had a heart attack. He
later transferred to another hospital to have a stent fitted and returned to the first
hospital after the procedure. (A stent is a tube which is inserted into narrow arteries
to allow the normal flow of blood and oxygen to the heart.) When he was first
admitted, the prison made arrangements for him to receive telephone calls from his
family. Over the next few days his health seemed to improve. However, he had two
further heart attacks in close succession and subsequently died.
After the man’s death the prison chaplain attended the hospital to act as both the
family liaison officer and duty care team member to support the escort staff. He also
officiated at the funeral, which was paid for by the prison and held a memorial
service in the prison chapel.
I am unable to judge whether earlier intervention in the man’s case would have
affected the outcome. However, the clinical reviewer has identified the need for a
number of clinical improvements at Garth, which I endorse. These relate to
specialist referrals, the management of chest pain, care plans for inpatients in the
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healthcare unit, transfer of records to outside hospitals, employment of permanent
doctors, use of the telemedicine service and enabling ambulances to pass urgently
through the security system.
5
THE INVESTIGATION PROCESS
1. The man died in February 2010. My investigator opened the investigation on
15 March when she visited HMP Garth. She received copies of his personal
and medical records and met the deputy governor and the Coroner’s officer.
She also spoke informally to the nurse who was on duty the night the man
was taken to hospital and visited the healthcare department.
2. HMP Garth issued notices to staff and prisoners informing them of the
investigation and inviting anyone who had relevant information to contact the
investigator. No one responded. My investigator returned to Garth on 4, 27
and 28 May to interview staff and prisoners.
3. The local Primary Care Trust (PCT) commissioned a clinical review of the
healthcare provided to the man. The purpose of the review was to establish
whether the care he received in prison was comparable to that which he
would have received in the community. I am grateful to the clinical reviewer
for her review, which is attached as an annex to this report. She comments
on the standard of healthcare provided to him and highlights issues for
consideration.
4. The investigator contacted the local Coroner’s office to inform them of the
nature and scope of the investigation. A copy of my report will be sent the
Coroner. The post mortem concluded that the cause of the man’s death
was:
1a Acute posterior myocardial infarction (heart attack)
1b Coronary artery atherosclerosis
5. One of my family liaison officers contacted the man’s family to explain the
purpose of my investigation and to provide them with an opportunity to raise
any questions or concerns for consideration. His family raised no issues of
concern at the outset of my investigation. They were also offered the
opportunity to receive and comment on the draft version of the report.
However, to date, they have chosen not to do so. I hope that the findings of
my investigation answer any questions they may have should they review the
report in the future.
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HMP GARTH
6. HMP Garth is a category B training prison which opened in 1988. Prisoners
are risk assessed and given a category based on their offence and the risk
that they pose to the public should they escape. There are four categories:
A, B, C and D, with category A being the most dangerous. Category B are
prisoners for whom the highest security conditions are not necessary but for
whom escape must be made very difficult. Garth accommodates male
prisoners who have been sentenced to four years or more. This includes life
sentenced prisoners. Additional units were built in 1997 and 2007. The
current capacity is for 847 prisoners.
7. The commissioning of healthcare at Garth is the responsibility of the local
primary Care Trust (PCT). The prison has 24 hour nursing cover, seven
days a week and an inpatient facility comprising eight beds. The majority of
healthcare staff work between 8.00am and 5.00pm during the week. Staffing
is reduced from 5.00pm through the night. When the man was in healthcare,
prior to his admission to hospital, there was one nurse covering the night
shift.
8. Doctors hold surgeries at Garth on weekday mornings. A full-time nurse
practitioner (who has more advanced training than a general nurse) is on site
during the week. At other times, the local out of hours telephone service,
Care UK, is consulted if nursing staff either require a doctor’s advice or
consider that emergency treatment is needed. This means that any one of a
number of doctors can be called to the prison.
9. Since April 2004, this office has investigated five deaths from natural causes
and one self-inflicted death at Garth. The investigations into two previous
deaths invite comparison with some of the man’s experiences. I
recommended that the healthcare team should look at their communication
and record keeping systems. There were also delays referring the previous
prisoners to the relevant specialist departments, which occurred again in the
case of the man. The prison previously accepted that further improvements
needed to be made in these areas.
Independent Monitoring Board (IMB)
10. An IMB is appointed to each prison by the Secretary of State for Justice. Its
members are wholly independent of the prison service and the prison’s
management team. Each IMB is required to produce an annual report to the
Secretary of State about the prison, highlighting good practice and any areas
of concern.
The most recent annual report published by the IMB at Garth covers the year
from 2008 to 2009. In relation to healthcare at Garth it comments,
“The introduction of telemedicine within the prison setting and prisoners
having external hospital contact with a range of different consultants should
improve the initial investigation of primary assessment and subsequent follow
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on treatments necessary. There have been concerns regarding prisoners’
hospital appointments being cancelled by the hospital authorities on multi
occasions causing frustration and extension of waiting times for prisoners;
this is being strictly monitored by the healthcare administration staff.
There are on-going issues with waiting lists for both the doctor and dentist. A
rectification notice has been served on the holder of the GP contract who
repeatedly did not attend. Following a needs assessment, the PCT have now
declared the in-reach provision is unsafe.
The majority of the prisoners were pleased with the treatment given by the
primary care team and the quality of professional care and respect shown in
personal health care matters. The 8 bedded inpatient units provide 24 hour
care to prisoners who need continuous monitoring for medical - post hospital
treatment and mental health care. The majority of the prisoners on the unit are
in need of mental health care provision and are complimentary of being well
supported by the dedicated health care team.”
8
KEY FINDINGS
11. The man was sentenced to six years imprisonment on 25 January 2008 for a
serious offence. He transferred from HMP Manchester to Garth on 2 June
2008. At his first healthscreen during the reception process, he told
healthcare staff that he was registered disabled after an injury to his ankle
approximately ten years before.
12. All prisoners entering the prison complete a questionnaire regarding heart
disease. In the questionnaire, the man said that he was unaware of any
problems with his heart and was not taking in heart related medication. He
also said that none of his family had any heart problems. He refused any
preventative injections for hepatitis B and C, tuberculosis or HIV. He told
staff he did not want to be referred to any support services and had never
used drugs but had used alcohol for approximately five years before his
imprisonment.
13. He said that he had previously had contact with psychiatric services and had
been diagnosed with anxiety and depression. This was attributed to the
tragic death of his youngest son who died in a car accident in 2004. He was
therefore prescribed paroxetine (an antidepressant medication) and referred
to the mental health in-reach team.
14. The man told staff he had no dependents and was single. Although he had
two sons and a large number of siblings, he said he did not want family visits
at that time. Healthcare staff did not carry out a secondary healthscreen as it
is not necessary to do so for prisoners who transfer from other
establishments. (A secondary healthscreen is completed some days after
the first. It gives the prisoner an opportunity to discuss any remaining health
concerns when they are more settled into the prison regime.)
15. During his time at Garth, he was seen by healthcare staff on various
occasions, mainly for pain in his ankle from an old injury. He had previously
made a complaint about healthcare at another prison, so had a mistrust of
healthcare. This resulted in a long running disagreement with healthcare
staff at Garth and he often refused medical attention. When he went on
hunger strike in January 2009, he was monitored by healthcare staff but he
refused any treatment. He did not appear to suffer any ill effects and he
started to eat again in February 2009.
16. The man refused to take part in any offending behaviour work throughout his
time at Garth. In March 2009, he continued to refuse to see his offender
manager or to engage with his sentence plan in any way. He therefore
remained a category B prisoner. On 4 July he said that he did not want early
release and would complete his sentence by working in the prison
workshops.
17. On 12 October, he told the locum general practitioner (GP) that he had
suffered from chest pains intermittently for some time, with episodes every
two to three weeks. He also told the GP that he had 12 siblings and that one
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of them had heart problems. The medical records show that the GP advised
him to book an appointment with the cardiac health nurse at the prison and
smoking cessation information was given to him. There is no entry to say
whether an appointment was ever made for him to see the cardiac health
nurse.
18. When my investigator interviewed the GP, he told her that he was normally
accompanied by a nurse when he examined prisoners and that he assumed
the nurse would have made the follow up arrangements. There is no record
of which nurse accompanied him on that date and he could not remember
who it might have been.
19. An entry in the medical record on 7 January 2010 says that a medication
review took place. It was also recorded that the man had seen four different
doctors in the previous four months and his medication had been changed
several times. He was upset that his repeat prescription for co-codamol had
been reduced. (Co-codamol is a pain relief medication, which he had
received for some time for his ankle injury.) The clinical reviewer drew
attention to the fact that over a period of time, he was examined by several
doctors who do not appear to have reviewed his previous medical
consultations.
20. On 15 January, the man refused to have a blood test and refused to be re-
listed. It remains unclear who referred him for these tests or why they were
arranged.
21. Five days later, he told staff he had further chest pains which had been on
and off for the last few months. A locum on call doctor examined him and
booked blood tests for 22 February. He was unaware of the man’s previous
history and he did not mention it to him.
22. The locum on call doctor told the investigator that, in his clinical judgement,
he did not think the man needed to go to hospital at that time because he
had walked to the healthcare centre and was not displaying symptoms of
severe pain such sweating or difficulty breathing. It appeared to be more like
discomfort. He thought it was muscular pain and prescribed co-codamol for
pain relief. He noted that his chest was clear, there were normal heart
sounds and that his abdomen was soft and not tender. An electrocardiogram
(ECG) (a device which measures the electrical impulses within the heart)
was taken and the reading was normal. The doctor’s notes were typed
electronically by a nurse. He said that he was unable to access the
electronic system as he had not been trained or authorised to log into the
system. The man complained of further chest pains that same evening.
23. His pains continued on 21 February, when at 3.00pm, he reported pain
across the centre of his chest, radiating to the left side and tingling in his left
arm. Staff Nurse A, a registered general nurse (RGN), assessed his
condition and took his blood pressure, which was within the normal range.
He was slightly pale and on breathing had a slightly prolonged expiratory
(breathing out) phase. He was able to talk in sentences. He was given a
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glyceryl trinitrate (GTN) spray twice and this relieved the pain. (GTN is a
spray which is used for relief of pain from angina.)
24. At 8.23pm on the same day, the man complained of further chest pain when
he was sitting up but said it eased when he was lying down. He was
assessed by Staff Nurse B (RGN) in his cell. He did not have tingling in his
arms on this occasion and had no shortness of breath. She said she thought
that he was not using his GTN spray correctly and subsequently helped him
to use it properly. She also took his blood pressure. It had dropped slightly
in comparison to the reading taken at 3pm. As she was the only member of
healthcare staff on duty, she decided to admit him to the healthcare centre
for a 24 hour observation and arranged for him to be seen by the doctor the
morning after. He was accommodated in a gated cell. (A gated cell has a
locked gate which staff can easily see through, rather than a solid door.)
25. Nurse B did not complete a nursing assessment or care plan. Nor did she
use a pain assessment tool. In interview, she said that as she was the only
nurse on duty she did not have time to complete them and because she was
aware of his situation she did not consider it a priority.
26. Throughout that night the man’s pains worsened, so Nurse B telephoned the
locum on call doctor. He advised that the man continue to use the GTN
spray and if anything changed to send him to hospital. The nurse kept hourly
observations on him. The observations consisted of blood pressure and
temperature checks. He complained of a dull ache which was relieved by
the spray.
27. At 2.17am on 22 February, the man’s blood pressure dropped. Nurse B
contacted control to call an ambulance. According to ambulance records,
the call was received at 2.21am but there was an unexplained delay of ten
minutes before it started towards Garth. On arrival at Garth, there was
another nine minute delay before the ambulance arrived at healthcare. A
governor said this was because the risk assessment for the man was revised
and three escorts were needed instead of the planned two.
28. The paramedics took another ECG, which indicated that he had suffered a
heart attack. They gave him morphine (a strong painkilling medication) for
chest pain relief. The clinical review notes that the paramedics did not
thrombolyse him. (Thrombolysis is when a drug is administered to dissolve
blood clots and restore blood flow to the heart following a heart attack.)
However, in his case it was deemed too late for this procedure because he
had been suffering chest pain for too long.
29. A full risk assessment was carried out with regard to the man being taken to
hospital. His offences were political and terrorist related and took place in
the North West of England. At the time of his arrest, many photographs were
produced in the local and national press. The extra escort was required to
ensure his safety should there be repercussions from anyone who
recognised him as well as to protect the public. It was also assessed as
11
necessary to use a closeting chain. This is a chain which is attached by a
handcuff to one wrist only and allows treatment to be given.
30. The man was taken to hospital. At 3.54am, the hospital staff told Nurse B
that he had experienced a heart attack but he was stable and would be
staying in hospital for at least the next three days. They also asked for a
copy of his ECG taken on 20 February and his recent medical notes. She
had given paramedics a short note about his recent medical history but no
‘Transfer of Care’ document was completed, nor were his medical records
transferred to hospital with him.
31. Later that morning, 22 February, officers recorded in the bedwatch log at
10.25am that the man wanted to discharge himself and return to prison
because he was unable to have a cigarette. (A bedwatch log is a history,
recorded by escort officers, of time and events which take place while a
prisoner is out of the prison as an inpatient at hospital.) The doctor told him
he had suffered a “massive heart attack” and that the first 48 hours after this
were crucial to his survival. This shocked him and the record says he then
began to co-operate better with staff.
32. The governor contacted the man’s family and told them that he was in
hospital and could receive telephone calls. Garth’s protocol for visiting
prisoners in hospital is that no visits will be authorised for the first seven days
and then must be booked through the prison and authorised by the deputy
governor. The only exception would be urgent compassionate visits, again
authorised by the deputy governor. The next day, he received a telephone
call from his brother and he was able to tell him how he was feeling.
33. As part of his treatment, staff at the hospital arranged for him to be
transferred to another hospital, to have an angiogram and, depending on the
results, possibly to have a stent fitted. (An angiogram is an x-ray of blood
vessels.)
34. That night, he asked for his drip to be removed as it was making him feel sick
and bloated. He agreed to go back on it in the morning. At 8.30am the
following morning, medical staff instructed ‘nil by mouth’, prior to his
angiogram. A nurse attempted to carry out blood tests but he refused to let
her do this. Records say that he was not happy that he could not have
breakfast but he then calmed down after staff spoke to him.
35. In the operating theatre, the man was escorted by just one officer, with two
outside the room. He remained handcuffed to this officer. After the
procedure, he was informed that he had a blockage and that a stent would
be fitted into his heart. This took place immediately and at 1.25pm, he was
told that if everything was alright there was a possibility he could return to
Garth, the next day.
36. At 9.15pm, he wanted to use the toilet but was told that he had to use the
commode because he was attached to monitors. He unplugged the
machinery and went to the toilet. Later that night, he refused to have his drip
12
changed and became very agitated with the doctor and nurse. Two hours
later, he agreed to have the drip re-fitted. He also told doctors that he would
not co-operate with any further blood tests, although later that morning he
agreed to one, when he was reminded that if it was okay he could return to
Garth.
37. At 11.35am blood samples were taken, as well as a further ECG and an x-
ray. After this, the man was told by the nurse that they wanted to keep him
in hospital over the weekend, because he had an irregular heart beat.
Records show that he had an unsettled night, but chatted with prison staff
and watched television.
38. On 28 February, he refused his breakfast but had a cup of tea. He took his
medication and was sitting on his bed reading the newspaper at 10.10am
when he started to have a seizure. His restraints were removed but were re-
applied 30 minutes later after he had been given medication. Nursing staff
approved this re-application of restraints.
39. At 10.55am, the man started to deteriorate and again had a seizure,
requiring the defibrillator to be used. The restraints were removed. He
remained unresponsive on this occasion. Nursing staff then telephoned his
brother and a visit was authorised by the governor.
40. At 11.40am, he had another cardiac arrest and staff continued resuscitation
attempts. At 11.45am, nursing staff contacted his son to inform him of his
father’s deterioration. At 11.55am, his death was confirmed by the doctor.
41. The man’s family arrived at the hospital at 12.55pm and the prison chaplain
spoke to them in his capacity as the prison’s family liaison officer. In
interview, he told my investigator that he had not received formal family
liaison officer training. He fulfilled a dual role at the hospital as he also
supported staff in his role as a member of the care team.
42. The chaplain gave the man’s family his address book from his personal
belongings and then he arranged to see them again to make plans for the
funeral. He presided at the funeral which had been paid for in full by the
prison. A memorial service was also held in the prison chapel and most of
the prisoners on his wing attended.
13
ISSUES
Clinical care
43. The man attended the healthcare centre on 15 October 2009, complaining of
chest pains. The locum GP examined him and advised him to book an
appointment with the cardiac health nurse. He does not appear to have
made an appointment and this was not followed up by a referral or any
further appointment with healthcare staff. The GP said that he assumed that
the nurse would make the arrangements for follow up. There were no notes
by the nurse and it is unclear who that nurse might have been. The clinical
reviewer suggests this was a missed opportunity for diagnosis and treatment
of his heart problems. She adds that locum doctors do not all undertake an
induction programme and are therefore not familiar with usual prison
healthcare practices. She comments that this can lead to a failure in referral
to the appropriate professionals. There is clearly confusion regarding the
responsibility for arranging follow up referrals and I have drawn attention to
this in a previous case at Garth, where follow up appointments did not take
place.
The Head of Healthcare should ensure that all staff are clear about who
is responsible for arranging follow up referrals and appointments and
that action taken should be clearly recorded. Prisoners should be
encouraged and reminded to attend.
44. Garth does not have a permanent doctor and when one is needed, a locum
doctor is called. This means that any one of a number of doctors might
attend the prison. The clinical reviewer comments that this results in a lack
of consistency and leadership and overview of care, by lead medical
practitioners. Also, it seems that doctors did not always review the previous
medical consultations.
45. The man had a medication review in the healthcare centre on 7 January. He
complained that he had been assessed by four different doctors over the
previous four months and his medication changed frequently dependent on
which doctor assessed him. The clinical reviewer makes a recommendation
to the PCT and Head of Healthcare, which I endorse.
There should be less reliance on the employment of locum general
practitioners and NHS Central Lancashire should work with the Head of
Healthcare to employ permanent general practitioners at the prison.
46. Some of the man’s medical records were handwritten. However, subsequent
notes were recorded electronically. The locum on call doctor had to ask a
nurse to log into the electronic system under their own log in details, to
record electronically. He told my investigator that he did not have his own
log in details and did not know how to use the system at that time.
47. A nurse told the investigator that since the man’s death all records are now
completed electronically and all doctors should be able to log in on their own
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account. I am satisfied that records are now managed appropriately and are
available to all medical staff. However, I would suggest that the Head of
Healthcare and the Governor satisfy themselves that all medical staff,
including locum GPs are trained to use the electronic system as part of their
induction process at the prison.
48. When the locum on call doctor assessed and examined the man on 20
February, his clinical judgement was that he did not need to go to hospital.
He arranged for him to have an ECG at the prison. The clinical reviewer
commented on this practice in her root cause analysis:
“The healthcare unit have not followed the local pathway or NICE
recommendations for treatment of acute chest pain. It was stated that
the unit used a 10 lead ECG machine this should be a 12 lead
machine. This should be addressed at the earliest opportunity.”
(NICE is an abbreviated term for the National Institute for Health and Clinical
Excellence. It is an independent organisation responsible for providing
national guidance on promoting good health and preventing and treating ill
health.)
49. The clinical reviewer comments:
“It is very unfortunate that the GP did not refer him for early treatment
to the acute hospital. This resulted in him being a late presentation for
treatment for an acute myocardial infarction.”
However, I note that he did not appear to staff to be in a great deal of pain,
nor did he complain of intense chest pains. The clinical reviewer makes two
recommendations in respect of the treatment of chest pain, which I endorse.
The Head of Healthcare should ensure that all staff follow the NICE
guidance for acute chest pain and develop a robust pathway for patients
who are complaining of chest pain.
The Head of Healthcare should ensure that the healthcare unit has a 12
lead ECG machine as recommended in the NICE guidance for acute
chest pain.
50. When the man was admitted to the healthcare unit on 21 February, staff did
not complete a nursing needs assessment or care plan, nor was a pain
assessment tool utilised. When he subsequently transferred to hospital, staff
wrote a short note regarding his recent medical history. There was no
evidence of a “Transfer of Care” document. In the circumstances, as the
nurse was the only member of clinical staff in the healthcare centre it is
reasonable that she would not have had time to complete a full document.
She ensured that information was sent to the hospital with him in the form of
a written note. Nevertheless, the clinical reviewer makes two
recommendations in respect of this, which I have slightly amended and
endorse.
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The Head of Healthcare should ensure there is a robust nursing needs
assessment and individual care plans for all inpatients when they are
admitted to the healthcare unit.
The Head of Healthcare should ensure that when prisoners transfer to
an outside hospital a copy of their recent electronic medical record is
sent with them or follows at the earliest opportunity.
51. Healthcare staff called an emergency ambulance at 2.17am on 22 February.
The ambulance control recorded the call as being received at 2.21am and
the paramedics recorded being with the man at 2.45am. Ambulance control
said that there was a delay getting through the security gate at Garth. When
the investigator asked the governor why that had happened, she was told
that there had been a last minute adjustment of his risk assessment. This
was related to the nature of his offences and the potential risk to him should
it be publicised that he was out of prison. Instead of two escorts three were
required and it took some time to arrange for a third person. The clinical
reviewer comments that although this may have caused a delay leaving the
prison, it should not have delayed the emergency paramedics attending to
him. I agree with the clinical reviewer’s comments and endorse her
recommendation, slightly recast.
The Governor, in consultation with the Head of Healthcare should
develop a protocol to enable emergency ambulances to pass rapidly
through the security system.
52. The clinical reviewer makes one further recommendation about the use of a
telemedicine service, which enables staff to obtain guidance and support
from skilled Accident and Emergency (A&E) consultants, when there is no
GP within the prison. This may have impacted on the length of time it took to
transfer him to an emergency department.
The Head of Healthcare should encourage staff to make use of the
telemedicine service, particularly at times when there is no GP within
the prison. Telemedicine enables the medical and nursing team to
receive prompt advice from skilled A&E consultants in acute medical
situations. It also gives support and advice in managing and confirming
the diagnosis based on the ‘expert assessment’ within a remote video
based consultation.
Family liaison
53. When the man was admitted to hospital and it became clear that he was
staying, the governor contacted his family and arranged for him to receive a
telephone call from his brother. At this stage, although he had suffered from
a heart attack his health seemed to improve, giving no indication of his
imminent death. Indeed, the governor told my investigator that when he
visited the prison on 28 February at around 8.00am the man was
complaining that he hadn’t received his address book, which he had
16
requested a few days earlier. According to the governor he became quite
rude and argumentative but when he left the hospital at around 8.15am the
man said “I’m alright, you know, the usual”.
54. When the governor received a telephone call around 10.15am, from an
escorting officer to tell him of the man’s cardiac arrest, he was very shocked.
He told the IMB and also gave authorisation for his family to visit. He
received another call to say that he had rallied after this attack and was ok
and up in bed having a cup of tea and was chatting normally. He was again
shocked when he received the call to say he had died. The hospital staff
contacted the family around 10.55am. Unfortunately, by the time they could
get to the hospital he had died. I am satisfied that the prison did all they
could to inform the family of his medical situation, whilst abiding by their own
security protocol.
55. When the man was pronounced dead, the prison chaplain went to the
hospital to see staff and the family. He was acting as both family liaison
officer and as part of the duty care team. He told my investigator that he had
not received formal family liaison officer (FLO) training and used his pastoral
skills. I am concerned that he had to fulfil two complex emotive roles
simultaneously. He appears to have handled this well. I therefore make no
formal recommendation on these points, but the Governor might wish to
consider ensuring the roles are conducted separately in the event of future
incidents and that whoever undertakes family liaison is appropriately trained.
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CONCLUSION
56. When the man transferred to Garth he did not initially declare any family
history of heart disease. A further opportunity to explore his vulnerability to
heart disease and a possible diagnosis was missed when he went to the
healthcare unit reporting chest pains in October 2009. At this point, he also
revealed the family history of heart problems. This episode was not followed
up with any subsequent specialist appointments.
57. It is difficult to say whether earlier intervention and treatment would have
changed the outcome for him. However, when he had further chest pains in
February 2010, I am satisfied that healthcare staff acted appropriately, given
the information that he gave them.
58. The investigation has revealed a number of shortcomings and areas for
improvement in the provision of clinical care at Garth. I endorse and repeat
the clinical reviewer’s recommendations.
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RECOMMENDATIONS
To the Head of Healthcare
1. The Head of Healthcare should ensure that all staff are clear about who is
responsible for arranging follow up referrals and appointments and that action
taken should be clearly recorded. Prisoners should be encouraged and reminded
to attend.
2. There should be less reliance on the employment of locum general practitioners
and NHS Central Lancashire should work with the Head of Healthcare to employ
permanent general practitioners at the prison.
3. The Head of Healthcare should ensure that all staff follow the NICE guidance for
acute chest pain and develop a robust pathway for patients who are complaining
of chest pain.
4. The Head of Healthcare should ensure that the healthcare unit has a 12 lead
ECG machine as recommended in the NICE guidance for acute chest pain.
5. The Head of Healthcare should ensure there is a robust nursing needs
assessment and individual care plans for all inpatients when they are admitted to
the healthcare unit.
6. The Head of Healthcare should ensure that when prisoners transfer to an outside
hospital a copy of their recent electronic medical record is sent with them or
follows at the earliest opportunity.
7. The Head of Healthcare should encourage staff to make use of the telemedicine
service, particularly at times when there is no GP within the prison. Telemedicine
enables the medical and nursing team to receive prompt advice from skilled A&E
consultants in acute medical situations. It also gives support and advice in
managing and confirming the diagnosis based on the ‘expert assessment’ within
a remote video based consultation.
To the Governor and Head of Healthcare
9. The Governor, in consultation with the Head of Healthcare should develop a
protocol to enable emergency ambulances to pass rapidly through the security
system.
Response to draft report
In response to feedback from the prison, one recommendation regarding secondary
healthscreens has been removed. There has been no formal response from either
the family or the prison in respect of the other recommendations made in this report.
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