Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of a man in June 2009 whilst in the custody of
HMP Isle of Wight - Parkhurst
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
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.
This is the report of an investigation into the death of a 70 year old man who was a
prisoner at HMP Isle of Wight – Parkhurst. The man died on 19 June 2009 from
natural causes. Ten days earlier, on 9 June, the man was taken from Parkhurst to
HMP Brixton for his appeal against his conviction and sentence. He returned to
Parkhurst during the evening of 16 June after his appeal was rejected.
I would like to add my personal condolences to those already expressed to the
man’s family on behalf of this office by one of the Ombudsman’s Family Liaison
Officers.
The investigation was conducted by one of the Ombudsman’s investigators. In
addition a doctor was asked by Isle of Wight Primary Care Trust to undertake a
review of the man’s clinical care. I am grateful for the assistance they both received
from staff at HMP Isle of Wight - Parkhurst and would like to thank the Governor and
his staff for their co-operation.
The clinical reviewer concluded that the man’s care was equivalent to what he would
have received in the wider community. However, the review raises a number of
learning points that the prison health partnership will need to consider seriously. He
makes two recommendations which I endorse.
Jane Webb
Deputy Prisons and Probation Ombudsman January 2010
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SUMMARY
The man was born in 1939 and was 70 years old when he died at HMP Isle of Wight
- Parkhurst on 19 June 2009. The man’s death was due to natural causes as a
consequence of heart disease.
The man was remanded into custody at HMP Belmarsh in May 2007. He transferred
to HMP Wandsworth in July 2007. The man was sentenced at Crown Court in May
2008 to eight years imprisonment for conspiracy to kidnap. He transferred to
Parkhurst on 14 August 2008.
During the man’s first reception health screening interviews, it was recorded that he
had a history of hypertension (high blood pressure) and a stomach ulcer. In May
2009, the man was diagnosed with blocked arteries in his legs. He was referred to
vascular surgeons in Hampshire for further consideration.
The man was taken to HMP Brixton on 9 June so he could attend his appeal against
his conviction. When he arrived at Brixton, it appears that a health screening
interview did not take place. After his appeal was rejected, the man returned to
Parkhurst on 16 June.
During the evening of 18 June, two days after his return, the man rang his cell bell
and told staff that he had chest pains. Staff from the healthcare centre visited and
carried out observations. As it was suspected the man had indigestion he was given
Gaviscon (a non prescription medication for the treatment of heartburn and acid
reflux). The man later informed staff that he felt better as he had vomited but he did
ask for some paracetamol.
The man’s television was still switched on around 4.00am the following morning.
After staff were unable to elicit a response from him they turned off the electricity in
his cell to see if he would respond. As staff thought that they could hear him
breathing, no further action was taken at that time.
At around 5.30am, staff were still unable to rouse the man. He had not moved
position and looked very pale, so they asked for medical assistance. Both the night
orderly officer and a nurse arrived within a few minutes. They checked for signs of
life and confirmed that the man had passed away.
A doctor from the out of hours general practitioner service pronounced that the man
was dead at 7.10am.
After it was confirmed that the man had died, HMP Isle of Wight - Parkhurst activated
its death in custody contingency plan. The police visited the prison and found no
suspicious circumstances. The man’s body was released to the undertakers. The
Coroner’s officer informed the prison that he had died from natural causes.
The clinical review carried out by a doctor and a panel of his colleagues identifies a
number of issues relating to the care provided for the man. The review highlights
areas of practice that could be improved, and makes two recommendations. I also
suggest that there should be a review of health screening procedures at HMP
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Brixton.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 19 June 2009 by one of the Ombudsman’s
investigators. He issued notices announcing the investigation to staff and
prisoners. These notices included an invitation to anyone who wished to
submit information relating to the man’s death to make themself known. In the
event no one came forward. The investigator also studied all the relevant
prison records, which included the man’s main prison record and his medical
records.
2. The Isle of Wight Primary Care Trust commissioned a doctor to lead a panel
review of the man’s clinical care. I am grateful to him for undertaking such a
thorough review.
3. The investigator visited HMP Isle of Wight - Parkhurst on 23 June, 29 July and
19 August 2009 and discussed aspects of the man’s treatment with staff. He
interviewed staff and the man’s co-defendant who had previously been his
cellmate when they first arrived at Parkhurst. The investigator also carried out
joint interviews with the clinical reviewer. They interviewed two members of
healthcare staff and the Lead General Practitioner at Parkhurst. The
investigator also wrote to HMP Brixton to inform them of about the findings of
the investigation.
4. The investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of the investigation and to request a copy of the post mortem report.
Upon completion, this report will be sent to the Coroner to assist in his
enquiries into the man’s death.
6. One of the Ombudsman’s Family Liaisons Officers contacted the man’s family.
This gave them the opportunity to discuss the purpose of the investigation and
raise any concerns or questions that they wanted to be addressed. They chose
not to raise any concerns at that time. I hope that this report provides them with
a better understanding of the events leading up to the man’s death.
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HMP ISLE OF WIGHT - PARKHURST
8. HMP Isle of Wight was inaugurated on 1st April 2009. It is the organisational
amalgamation of the former Albany, Camp Hill and Parkhurst prisons. HMP Isle
of Wight holds approximately 1,700 prisoners on the three sites. The prison is
governed by Mr Barry Greenberry, who took up post following the
amalgamation. Each site has its own Director, who reports to Governor
Greenberry.
9. The Camp Hill site is a category C training prison and Albany is a category B
training prison for sex offenders. Parkhurst was a high security prison until the
mid 1990s when it was converted to its current role. It now caters for long-term
and life sentence category B prisoners and remands from the Isle of Wight
courts. Parkhurst has five wings. All the cells have in cell power and integral
sanitation. A and D wings hold vulnerable prisoners. F wing is for prisoners on
remand and is the induction wing.
10. After the evening roll call to confirm prisoners are all accounted for, the prison
enters what is called patrol state. This is defined as follows: ‘Prisoners are
locked up and staff numbers are reduced to the minimum needed to patrol. The
main role of staff at this time is to maintain the security of the prison.’
11. When the night patrol officer arrives on the wing, a hand-over is given by the
officer on evening duty and a sealed packet containing keys is passed from one
to the other. The keys in the sealed packet are only to be opened in an
emergency. When the officer on duty the next day arrives, he or she receives a
hand-over from the night patrol officer and another roll check is carried out
before the night patrol officer leaves the wing. When staff were unable to rouse
the man on the morning of 19 June 2009 and had to enter his cell, the prison
was in patrol state.
12. Health services at HMP Isle of Wight are commissioned by the Isle of Wight
Primary Care Trust (PCT) and healthcare is clustered with both Albany and
Camp Hill. A new inpatient unit was completed earlier this year and is situated
at Albany. There are three nurses on duty at Parkhurst from 7.30am to 6.00pm
from Monday to Friday. General Practitioners (GPs) from a local community
practice attend Parkhurst for four three-hour sessions each week. Evenings and
weekends are covered by on call GPs from the same community practice.
Prisoners with more serious conditions or clinical needs are referred to the local
hospital.
5. During 2009, there was one other death from natural causes at Parkhurst but
this investigation has not been completed. The investigator reviewed reports
from earlier years but found no common factor between the circumstances
surrounding this investigation and those into previous deaths.
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Independent Monitoring Board
6. Each prison has an Independent Monitoring Board (IMB). IMB members are
independent and unpaid. They monitor day-to-day life in their prison and
ensure that proper standards of care and decency are maintained. Each IMB
produces an annual report. The report for Parkhurst for the year 2007/08 has a
section on healthcare provision in the prison. It highlights the constraints under
which healthcare staff worked during this period:
“Throughout the year there have been administrative problems and
lack of staff who are practiced in dealing with the health care demands
peculiar to the prison community, in both mental and physical
conditions. The few established staff have worked excess hours and
are dedicated to deliver a reasonable level of health care. However,
there have been a number of areas of concern with peripheral medical
services that have spasmodic problems in delivery.”
Her Majesty’s Chief Inspector of Prisons’ report
7. The most recent inspection by Her Majesty’s Chief Inspector of Prisons, Dame
Anne Owers, was an unannounced inspection carried out in December 2008.
In her report, Dame Anne wrote that:
“Staff-prisoner relationships were distant and there was no meaningful
personal officer scheme. Too many issues that ought to have been
resolved informally by staff were the subject of formal complaints … In
many ways, Parkhurst is a failing prison: prisoners feel unsafe and
poorly treated, and neither the environment nor the regime are suited
to the role of a modern training prison. Matters are compounded by a
demanding population, many of whom resent being housed in what
they view as an isolated establishment with little to offer them.”
8. Dame Anne also wrote that:
“Staffing levels in primary [health] care and inpatients were minimal,
and there were vacancies across the cluster. This resulted in a limited
health service for prisoners. There was only one member of the health
services team on duty at night, based on the inpatient unit [a new
inpatient unit has now opened at Albany], who was expected to attend
to incidents at Parkhurst and provide telephone advice to staff at
Albany and Camp Hill. Staff did not have easy access to ongoing
training or support to maintain their professional registration. There
was no lead nurse for older prisoners, despite the age profile of the
population.”
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KEY EVENTS
13. On 4 May 2007, the man was remanded into custody at HMP Belmarsh. This
was not the man’s first experience of prison. He transferred to HMP
Wandsworth on 27 July 2007. The man was sentenced at Crown Court on 2
May 2008 to eight years imprisonment for conspiracy to kidnap. On 14 August
2008, the man moved to HMP Isle of Wight - Parkhurst.
14. During the man’s first reception health screening interviews, it was recorded
that he had a stomach ulcer and a history of hypertension (high blood
pressure). He received medication for his blood pressure (ramipril) and
stomach problems (lansoprazole). The man was allowed to keep his
medication in his own possession.
15. In a letter dated 11 May 2007, the National Offender Management Service
Directorate of High Security informed Belmarsh that the man was re-
categorised as a category B prisoner. (All adult male prisoners are classified
on reception into prison and put into one of four security categories based on
the likelihood of escape and the risk to the public if they did escape. The
categories are: Category A: prisoners who would be highly dangerous to the
public, police or national security if they were to escape. Category B: prisoners
for whom the highest security conditions are not necessary, but for whom
escape needs to be made very difficult. Category C: prisoners who cannot be
trusted in open conditions but who are unlikely to make a determined escape
attempt. Category D: open conditions, prisoners who can be trusted not to try
and escape.)
16. On 16 March 2008, it was noted in the man’s prison record that he had been
given enhanced prisoner status. (The Incentives and Earned Privileged
Scheme (IEPS) is a scheme that is designed to encourage and reward good
behaviour in prisons. There are three tiers – Basic, Standard and Enhanced.
Incentives include access to in-cell televisions, more money to spend, wearing
their own clothes, more time out of the cell and community visits.)
17. In a letter dated 22 July, the Border and Immigrations Agency (now known as
UK Borders Agency) confirmed that deportation action would not be taken
against the man.
18. The man was assessed by a prison doctor on 24 February 2009 as he had a
rash all along one side of his body. The doctor diagnosed the rash as shingles
(this is a reactivation of the virus which causes chickenpox) and she prescribed
Aciclovir (an antiviral medication).
19. On 30 March, the man’s personal officer (each prisoner is allocated a personal
officer, who is the first point of contact for them) made the following entry in his
prison record:
“Is one of the more senior members of B wing and this shows in his
behaviour and attitude towards staff and other prisoners. He has never
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shown any concerns from staff regarding his behaviour and adheres to
all rules set out to him.”
20. When he was interviewed as part of this investigation, the personal officer said:
“The man was far from a difficult prisoner. He was polite to everybody,
polite to staff, polite to prisoners. He was very popular on the wing with
everybody because of that you know, and he was, he was a real
pleasure he really was, very polite man. The man was employed in the
Picta workshop which was a workshop designated to people who wish
to learn how to use computers. During that time he was asked on
several occasions if he would be interested in being a wing cleaner
which is a very trusted job, but obviously he was enjoying his work in
the workshop he was in. Once he had finished his course in the
workshop we did actually take him on as a wing cleaner.”
21. The man attended an appointment with a visiting chiropodist on 1 May. The
chiropodist noted that the man appeared to suffering from claudication (this is
the name given to pain in the leg caused by "furred up" or blocked arteries).
Two weeks later, on 15 May, after the man saw the prison doctor, a referral
was made to the Vascular Surgery Department at a local hospital. The man
passed away before he was able to attend the appointment at the hospital.
The prison doctor also prescribed simvastatin (a drug commonly known as a
statin which is used for lowering control cholesterol levels and preventing
cardiovascular disease).
22. On 1 June, the following entry was made by an Offender Supervisor in the
man’s prison record:
“The man showed me some paperwork he received to say his case will
be heard at the Court of Appeal on 12th June 09. He was extremely
happy about this and feeling positive about a good result.”
23. Just over a week later, on 8 June, the man transferred to HMP Brixton for his
appeal against his conviction and sentence.
24. Prison Service Order (PSO) 3050 Continuity of Healthcare for Prisoners
outlines a prison’s responsibility when a prisoner is transferred between
establishments. It is not clear what clinical action was taken by Parkhurst to
facilitate the man’s move to Brixton whilst he attended his appeal. A record of
continuation of care did not exist for him. The man’s co-defendant was
interviewed as part of this investigation. He had shared a cell with the man at
Brixton and confirmed that they both took their medication with them when they
moved prisons.
25. The Court of Appeal considered the man’s case on 12 June and refused his
appeal application. The man returned to B wing at Parkhurst four days later, on
16 June (at 9.30pm after leaving Brixton at 2.30pm).
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26. In his interview with the investigator, the personal officer said:
“While I was away on leave the man and his co-defendant did actually
travel up for a court appeal. They were very positive that they were
going to have a good outcome for it, before leaving, although I didn’t
really have a proper chance to have a conversation with the co-
defendant or the man about it. The co-dependant was upbeat when I
spoke to him. I never had the opportunity to speak to the man. It could
have raised the stress levels a little bit I would imagine.”
27. In his interview, the co-defendant said that he thought the stress of their appeal
failure may have led to the man’s death. He said:
“ … we were told that we were getting out on appeal because our
appeal was that strong and we were expecting to get out. Our legal
teams and all were expecting us to get out. They told us there was no
problem and we were expecting to get out and we got up there and it
didn’t happen. I think the man was badly stressed about it. I was
myself too you know what I mean but I am not 70 years of age and I
think that is what it was.”
28. The co-defendant also said:
“I know it was the Court of Appeal that he [the man] had this problem
and I think it was the shock on the way we were treated and he
shouldn’t have been in prison at all. We were both expecting to get out
and it didn’t happen. We were just ignored. I won’t go into it now but
we are going to fight it on you know. And actually the day before he
died we were both talking about our next appeals and what we were
going to do and how we were going to appeal. And he was into that in
a big way and he was pretty annoyed about the way we were treated.”
29. Around 8.15pm on 18 June, the man rang his cell (B2-09) bell and complained
of chest pains (after being locked up for the night prisoners use their cell bell
when they need to ask staff for help). Staff on the wing contacted healthcare
and asked for their assistance. A general nurse immediately came to the wing.
He carried out observations and, as he suspected the man had indigestion,
gave him some Gaviscon (a non prescription medication for the treatment of
heartburn and acid reflux).
30. When interviewed as part of this investigation, the general nurse said:
“As I entered the cell he [the man] stood up and came towards me
which I didn’t expect … I asked him to sit down and I then asked him to
explain his chest pain. I said have you got that pain now, he said no. I
said can you explain what it was, he said he had not had it before and I
just ran through and said just describe what it is, where it was. He
explained that it was a pain in his chest, I then went on and said was it
radiating anywhere, did he have any other pains, how did he feel. He
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was still sat on the bed, he was moving and just talking normally. His
blood pressure I took which was raised but he had a history of
hypertension as far as I can recall. He was not unduly distressed or
agitated so I talked to him and he wasn’t sweating or anything like
that.“
31. The general nurse then re-checked the man’s symptoms:
“Then I just went back to his chest pain and asked him to go over it
again just to confirm what he had said originally. He again said that it
was in the centre, he hadn’t got it now but then he did say that it
actually came when he was laying down and I said oh. So I said well
what happened when you sat up and he said it went. I said have you
got the pain now and he said no, how do you feel, I feel fine. I grabbed
hold of his hands and said can you just squeeze me. I was aware of
his age but he looked for a man of that age quite fit. He talked all the
time without any break or pause for breath even. Basically I had got
some Gaviscon with me because my thoughts were that it was a sort of
epigastric [the epigastrium is the area of central abdomen lying just
below the sternum] or something like that where he was lying down
and then when he said up it was gone.”
32. At around 9.20pm whilst patrolling the wing, an Operational Support Grade
(OSG) checked on the man and he told her that he had vomited and now felt
okay. Around 10.00pm, the man asked the OSG for some paracetamol. She
telephoned a staff nurse who confirmed that the man could be given the
paracetamol.
33. When interviewed as part of this investigation, the staff nurse said:
“I had a phone call at about ten past ten I think something like that I
think it was saying that he has requested paracetamol for a headache.
I said that is fine because they have paracetamol on the wing, because
Oscar 1 [radio call sign for the Night Orderly Officer] the first line in
command will say don’t come across they have got it. I will check that
he has got no allergies, if he has not had any during the day has not
overdosed or anything like that, and that is fine. I said how is he in
himself and the Operational Support Grade who was working on the
wing said he gave me two thumbs up and said he is feeling a lot better
and I thought great that is good but phone me if there is a problem.”
34. Around 4.00am on 19 June, the OSG contacted an officer on a neighbouring
wing as the man had not moved and his television was still switched on. The
officer came over to B wing and, as she was unable to elicit a response from
the man, rang the staff nurse to seek advice on next steps. The staff nurse
advised her to switch off the electricity in the cell and see if there was any
response. After they did this, both the officer and OSG thought that they could
hear the man breathing.
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35. When interviewed as part of this investigation, the officer said:
“So we got the electric keys, switched the electric off, did call him,
knocked on the door, no response but I could hear a breathing which I
was adamant was from his cell, obviously it wasn’t. The OSG also
listened at the door and she thought it was coming from him as well.
Throughout the rest of the night she continued to monitor him.”
36. Around 5.30am, after she had carried out the roll call on the wing, the OSG was
contacted by the officer. They checked on the man who had not moved
position. They were still unable to rouse him and, as there was now more
natural light, they saw that his skin was very pale and there was no chest
movement. They requested medical assistance and the Night Orderly Officer
(radio call sign Oscar 1) who was in charge of the prison during the early hours
of 19 June, and the staff nurse arrived on the wing within a few minutes. The
Night Orderly Officer opened the man’s cell and both he and the staff nurse
checked for signs of life. They were unable to find any signs of life and
confirmed that the man had died.
37. The officer told the Ombudsman’s investigator:
“At six o’clock in the morning after I had done my roll check on Charlie
Wing I went in to B and G wing where the OSG was working and asked
her if she had done her roll check. She said she had and I asked if the
man was still in the same position and she said he was but she could
still hear him breathing. I went back up to the door and had a check
and although I could still hear the breathing it was really quite deep
breathing and I couldn’t see any movement. We could actually see at
six o’clock in the morning because it was then light I could see there
was no movement from his shoulders or his chest or anything, his left
hand looked purple and his face was very white. So I actually had my
suspicions that he had actually died. We then contacted Oscar 1 who
immediately attended, opened the door, called the man’s name, no
response. I believe he actually touched his neck. It was either his
neck or his wrist I can’t really remember but looked at me and said he
has gone.”
38. In his statement to the Governor, the Night Orderly Officer wrote:
“I phoned B & G [wing], the OSG answered the phone and informed
me that she had concerns about a prisoner on B wing and not being
able to get a response. I asked is it the same one you mentioned
earlier, she said yes. I went straight to B wing looked through the
observation glass and saw the man laying fully clothed on the top of
the bed as if asleep. I unlocked the door called the man, felt the man’s
arm which was cold and from the blueness of his extremities concluded
he had died.”
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39. Parkhurst contacted the out of hours general practitioners’ service and a doctor
attended. He pronounced that the man was dead at 7.10am.
40. A Principal Officer was appointed as the prison family liaison officer. The man
was a widower and his next of kin was one of his nephews who lived abroad.
Parkhurst asked the foreign police service during the morning of 19 June to
notify the family of the man’s death.
41. The man’s nephew rang the prison later that day to confirm the circumstances
of his uncle’s death. Another of the man’s nephews and his wife came over to
the Isle of Wight on 23 June to collect the man’s belongings and view his body.
They were met by the Principal Officer but they declined an invitation to visit
Parkhurst. The Principal Officer maintained contact with the family and
assisted with the funeral arrangements. Parkhurst also offered financial
assistance with the costs of the repatriation of the man’s body and his funeral.
The man’s funeral took place on 29 June and a memorial service was held at
the prison. After the man’s death the prisoners on B wing collected over £50 in
his memory. This is to be used to purchase a memorial plaque to be placed on
a bench in the grounds of the prison.
42. A fellow prisoner wrote the following in a letter to a national magazine for
prisoners:
“For all who knew the man, our friend passed away in his sleep on 19th
June. He will be sorely missed as he was a kind and friendly guy and
one of the nicest people you’ll ever meet. He was a popular guy here
on B wing at Parkhurst and he’s going to be missed by me and many
others. God be with you. RIP.”
43. The post mortem report records the man’s death as being due to natural
causes, as a consequence of hypertensive and ischaemic heart disease. The
report says:
“The death of the man was clearly the result of natural disease. The
heart muscle had become enlarged as a result of the excess work
thrown upon it by a sustained spontaneous increase in systemic blood
pressure [hypertensive heart disease]. This would have had the effect
of increasing the demand of the heart muscle for blood. However, the
heart muscle had in addition been starved of blood over a long period
of time as the result of degenerative narrowing of the coronary arteries
supplying it (ischaemic heart disease). These two disease processes,
which are interdependent, would together have brought about a state
of affairs in which sudden unexpected defects in heart rhythm or
pumping efficiency could be expected to arise, with a high likelihood of
death. In the case of The man, sudden death could have occurred at
any time without any obvious precipitating factor, and it is clear in
hindsight that the chest pain of which he complained on the night of his
death was angina pectoris, the cramp of inadequate cardiac perfusion.
Though the treatment offered [that is Gavison] was inappropriate for
angina, it is by no means certain, in view of The man’s age and the
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severity of his heart disease, that correct treatment would have altered
the fatal outcome.”
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ISSUES CONSIDERED
Clinical care
44. As noted above, a review of the man’s medical care was undertaken on behalf
of the Isle of Wight Primary Care Trust by doctor who convened a review panel.
The panel met on 24 September 2009 and the investigator attended their
meeting.
45. It was noted that the man had suffered from significant long-term chronic
diseases. From the medical records, it was clear to the panel that the man was
seen regularly by healthcare staff and, when necessary, referred to secondary
care services.
46. The man was seen by a prison doctor following a referral by the chiropodist.
The circulation in the man’s legs was highlighted as a problem and an
appropriate referral was made. He had not complained of chest pains at that
time.
47. However, the panel found that the standard of record keeping needed to be
improved. This had been raised as an area of concern in previous
investigations into deaths at Parkhurst. It was felt that the introduction of the
new electronic system (SystmOne) would help this to be achieved, and the
panel made the following recommendation, which I endorse:
The Head of Prison Healthcare at HMP Isle of Wight should review the
policies and procedures regarding prisoner’s medical records and
arrange appropriate staff training where necessary to improve the
accuracy and consistency of record keeping.
48. Prison Service Order (PSO) 3050 on Continuity of Healthcare for Prisoners was
issued in February 2006. Chapter 5 of the PSO is devoted to Transfer of
Prisoners and says at 5.3: ‘’Current healthcare needs [must be] assessed and
continuity of care ensured when prisoners are transferred between
establishments.’’
49. Chapter 5.12 of the PSO points out that ‘’patients with more complex health
care needs may require more detailed planning such as communicating directly
with the receiving health care team in advance of transfer’’.
50. The panel recommended that prior to a prisoner’s discharge or transfer, a pro
forma should be completed to summarise their health care needs. This should
include additional information on the prisoner (medication, problems,
outstanding referrals and key medical conditions). The panel felt that this
action will lead to improvements to the quality of transfer of information going to
the prison which is receiving the prisoner.
The Head of Prison Healthcare at HMP Isle of Wight should ensure that
when a prisoner is transferred/discharged that staff complete a summary
of their health care needs.
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51. Chapter 5.25 of PSO 3050 sets out the responsibilities of the prison receiving
newly transferred prisoners. It is expected that the healthcare team will ‘’make
such enquiries and undertake such examinations as appear to be appropriate
in all the circumstances as set out in the General Medical Service contract.”
Both the review panel and the investigator could find no record of a health
screening interview taking place after the man transferred to HMP Brixton for
his appeal hearing. As mentioned previously, the man’s co-defendant and cell
mate at Brixton, confirmed that they both brought their in-possession
medication with them to Brixton. The Head of Psychology and Suicide
Prevention at Brixton confirmed that when the man moved to Brixton his
medical records from Parkhurst accompanied him. As healthcare staff at
Brixton were able to see the man’s medical records, and as no issues had been
highlighted before his move, no further action was taken. I suggest that
systems are reviewed at Brixton in light of the information discovered during
this investigation.
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CONCLUSION
52. The man arrived in HMP Isle of Wight - Parkhurst in August 2008 with a history
of health problems which included high blood pressure and a stomach ulcer.
He died of natural causes in June 2009.
53. In the light of the clinical reviewer’s findings, I judge that the man’s care was
equivalent to what he would have received in the wider community. Indeed, in
his review the reviewer wrote: “The man received a high standard of care”. The
findings of the clinical review and this investigation highlight that there is a need
for some improvements to record keeping and transfer arrangements at HMP
Isle of Wight and HMP Brixton.
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RECOMMENDATIONS
1. The Head of Prison Healthcare at HMP Isle of Wight should ensure that when
a prisoner is transferred/discharged staff complete a summary of their health
care needs.
Accepted - If Prison Healthcare staff are advised of a prisoner’s transfer to
another establishment they will ensure that the receiving prison is provided
with sufficient information to enable the safe and effective continuation of any
inputs to his healthcare needs. This may be via SystmOne (where the
receiving prison uses SystmOne) or via a secure e mail/hard copy. This
expectation has been articulated to the Primary Healthcare Manager and the
Team Leaders of all the clinical areas within HMP Isle of Wight.
2. The Head of Prison Healthcare at HMP Isle of Wight should review the
policies and procedures regarding prisoner’s medical records and arrange
appropriate staff training where necessary to improve the accuracy and
consistency of record keeping.
Accepted - Training has been available during 2009 and is being provided by
the Isle of Wight NHS Primary Care Trust PCT to Prison Healthcare Nursing
staff in respect of record keeping and Information Governance. A further
programme of training is already included in the Continuing and Vocational
Education (CVE) plans agreed with the University of Southampton for
2010/11. An expectation that quality record keeping also features in staff
appraisals had also been made clear to Team Leaders.
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