Individual at Woodhill

Investigation into the circumstances surrounding the death in custody of a
prisoner on 25 March 2005 at HMP Woodhill
Report by the Prisons and Probation Ombudsman for England and Wales
June 2005
This is the report of an investigation into the circumstances surrounding the
death of a male prisoner on 25 March 2005 at HMP Woodhill. He was an elderly
man whose death appears to have been entirely natural.
All deaths of prisoners in custody are investigated, including those due to natural
causes. The responsibility for carrying out these investigations traditionally fell
to the Prison Service itself, but has now been passed to me to bring
independence and greater consistency to the task.
The investigation was conducted by one of my investigating officers. My clinical
reviewer carried out an independent clinical review.
My colleagues and I would like to extend our condolences to the prisoner’s family
for their loss.
One of my Family Liaison Officers has contacted the prisoner’s ex- wife, and she
told us that she did not want any involvement in the investigation.
This report makes no recommendations. However, I have been pleased to note
the care that the prisoner received from all staff at Woodhill. This comes through
very strongly in the clinical review and I hope the Governor will make this known
to his colleagues.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2005
Contents
Page
Summary 4
Investigation Methodology 5
Background 6
HMP Woodhill 6
The prisoner 6
Events prior to the prisoner’s death 7
Events of 25 March 2005 7
Level of Compliance 9
Findings and Conclusions 10
Recommendations 11
Good Practice 11
Summary
The prisoner died on 25 March 2005 at the age of 75, in the healthcare wing of
HMP Woodhill. He was on remand facing two charges of assault. This was not
his first time in prison. He was described as an obstructive man who was unable
to deal with his most basic needs such as showering. The healthcare staff would
help him to keep clean.
He died of natural causes as a result of Bronchopneumonia caused by chronic
obstructive airway disease. His death was not connected to the fact that he was
in prison or to the level of care that he received there.
This report makes no recommendations, but commends the healthcare staff and
unit staff for their care and treatment of the prisoner.
Investigation Methodology
The prison sent copies of the records relating to the prisoner’s death to my office
on 5 April 2005, at the request of my investigator. On 6 April 2005, my clinical
reviewer visited the prison and met with the Head of HealthCare and the
healthcare management team. She also reviewed the available clinical
documentation. A further visit to the prison took place on 18 April 2005, when
they met with Governor, Chair of the Independent Monitoring Board (IMB), Head
of Healthcare, and POA Branch Secretary. They were briefed on the nature and
scope of the investigation and additional documentation was collected at this
time.
Prior to attending the prison, notices to staff and prisoners, terms of reference
and the governor’s notification letter were sent to the prison liaison officer, for
distribution and to be displayed around the establishment. These announced the
investigation and invited staff and prisoners to share with my investigator any
concerns or views they wished to express.
I received a number of letters from prisoners, but after a closer look at the
contents it became apparent they were about complaints that were not related.
The complaints that were about healthcare and treatment problems were passed
to the Head of Healthcare at Woodhill to investigate internally. My clinical
reviewer met with one of the complainants at length and there was no evidence
to substantiate the claims made.
My clinical reviewer carried out a review of the management of the prisoner’s
health needs while in custody.
One of my Family Liaison Officers has written to the prisoner’s ex wife to
establish contact with his family. She informed her that she did not want any
involvement with this investigation.
Background
The Prisoner
The prisoner was born in February 1930. He was 75 years old when he died.
He had been married for 25 years. The couple were divorced in 1999. At the
time of his death he was on remand at HMP Woodhill on two assault charges,
waiting to return to court on 29 March 2005.
This was not his first time in prison. He served his first sentence in January 1955
for assault and actual bodily harm. Between 1964 and 1990 he incurred a
further 10 charges for offences of a violent nature or with a threat of violence,
resulting in further custodial sentences.
In November 1994, he was convicted and sentenced to 10 years in prison. He
was released in March 2001 on a non-parole licence. He was recalled to custody
in May 2001 for breach of this licence. He was finally released from prison in
July 2004 at the completion of his sentence.
On 4 March 2005, he was remanded back into custody by Aylesbury Magistrate’s
Court on two charges of assault.
The prisoner had suffered from poor physical health for a number of years and
was known to have a significant number of medical conditions. Clinically, he was
difficult to manage as he was often non-compliant with his medication and
treatment.
HMP Woodhill
HMP Woodhill is a core local within the High Security Estate. It holds adult male
prisoners, both sentenced and unsentenced, including young offenders. It was
built in 1992.
Woodhill is only one of two prisons with a Close Supervision Centre designed to
hold some of the most dangerous prisoners in the system.
Events prior to the prisoner’s death
The prisoner arrived at Woodhill on 4 March 2005. He was subsequently moved
from normal living accommodation in house block 4b to the Healthcare Centre,
because his health and general wellbeing were causing concern. This was so
that constant observation and medical help could be given.
He was receiving treatment for: -
• Bronchitis Emphysema
• Incontinence of Urine
• Varicose Eczema
During his time at Woodhill, he was unable to attend to his personal needs and
would refuse to help take care of himself. He would become difficult and decline
to take a bath or shower even when assisted by the healthcare staff. He wore
poorly fitting incontinence pads, urine soaked and stained with faecal matter,
which he refused to change.
When he arrived at the Healthcare Centre the staff opened three individual care
plans to ensure that the clinical and hygiene needs were met appropriately. This
medical care carried on through the next day.
In the evening of 24 March, he was seen to be breathing fast and his breathing
was laboured. The nursing staff gave him oxygen and a nebuliser and he then
settled down.
Events of 25 March 2005
On the morning of 25 March, at approximately 3.10am, the prisoner was seen to
have lowered himself onto the floor of his cell. Staff entered his cell to assist him
back into his chair, as he preferred to sleep there rather than on his bed. Once
the medical checks had been completed, he was given four litres of oxygen, and
at 4.00am his breathing had improved.
He refused both breakfast and lunch. However, he was drinking water and did
take his evening meal. At 7.00pm, his breathing was very rapid and shallow and
he was administered oxygen for 15 minutes until his breathing slightly improved.
It was at this point that the healthcare staff informed the doctor who instructed
that the prisoner was to be administered:
• Prednisolone 40mg Statutory Dose
• Salbutamol 5mg Statutory Dose
• Atrovent 500mcg Statutory Dose
• Erythromycin 250mg 4 Times Daily.
The duty nurse arrived on the Healthcare Centre at approximately 8.56pm, and
went to the prisoner’s cell to check on his condition. She could see that he was
having difficulty and went straight to the office to contact the duty Principal
Officer, to gain access to the cell so that medical help could be given.
A night officer arrived at approximately 9.00pm to unlock the cell. He then
assisted the nurses to move the prisoner onto the bed. The nurses then
checked his pulse and blood pressure and no reading could be found. They
then began Cardio Pulmonary Resuscitation (CPR) at a rate of 2 breaths to 15
compressions. Oxygen was given and at 9.07pm the control room was informed
that an ambulance was urgently required.
The control staff immediately called for an ambulance, as well as contacting the
Duty Governor and the on call doctor. At this time the prisoner’s watch was
removed and secured in a sealed property bag.
The nurses continued to carry out CPR and to check for pulse and blood
pressure until the paramedics arrived at 9.28pm and took over. One of the
nurses gave the paramedics all relevant information and CPR continued.
At approximately 9.33pm, CPR was stopped to allow the paramedics to use their
defibrillator and to administer medication. At 9.45pm, the nurses continued the
CPR. At 9.54pm, the paramedics confirmed that the prisoner had died.
At 10.00pm, the Duty Governor arrived at the cell. The paramedics left the cell at
10.05pm and left the prison. The prisoner’s property was removed from the cell
and placed into sealed bags, and the cell was sealed awaiting the arrival of the
police.
The police arrived at the prison at 10.40pm and confirmed that the Coroner’s
Officer need not attend the prison. The police officers were taken to the
Healthcare Centre and into the cell.
The doctor arrived at the prison at 11.03pm. He confirmed the death at 11.05pm.
The Roman Catholic priest contacted the prisoner’s niece to inform her that he
had died. An address for his ex-wife was not available. The niece informed the
prisoner’s ex-wife and they both confirmed that they did not want any
involvement in the investigation.
Level of Compliance
Standards of healthcare in prison are intended to mirror those available in the
outside community. The prisoner’s records indicate that he was given an
appropriate level of care, and his medical and social needs were recognised and
dealt with appropriately.
Prison Service Order 2710 sets out what action must be taken following a death
in custody. Woodhill fully complied with this Order.
All necessary information was collated for the purposes of this investigation.
Findings and Conclusions
The prisoner received appropriate treatment and clinical interventions for a
number of clinical conditions including:
• Bronchitis Emphysema
• Incontinence of Urine
• Varicose Eczema
Healthcare staff opened appropriate individual medical care plans to ensure that
he received the correct treatment and level of care.
He was a difficult man who was unable to attend his own needs by keeping
himself clean. He regularly refused to shower or take a bath even when assisted
by healthcare staff. I believe that the staff both in the Healthcare Centre and on
the accommodation units cared for him with compassion and sensitivity in difficult
circumstances.
Recommendations
I make no recommendations in this case
Good Practice
The prisoner’s treatment and care whilst in custody at Woodhill were managed
well. The help he received from both unit and healthcare staff is to be
commended.