Individual at Peterborough

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING
THE DEATH OF A MAN IN HOSPITAL IN DECEMBER 2005
WHILST IN THE CUSTODY OF HMP PETERBOROUGH
Report by the Prisons and Probation Ombudsman for
England and Wales
April 2006
This is the report of an investigation into the death of a man in hospital in
December 2005. The man was on the second day of his remand at HM
Prison Peterborough. The preliminary cause of death was given as a
significant bleed into the abdominal cavity (retroperitoneal haemorrhage due
to ruptured right common iliac artery aneurism.)
One of my Investigators conducted this investigation. Greater Peterborough
Primary Care Partnership was commissioned to conduct a clinical review into
the man’s care and treatment whilst at Peterborough.
I would like to extend my condolences to the man’s family for their loss. I
would like to thank the Director in charge of HMP Peterborough and his staff
for their help and co-operation during this investigation.
I make recommendations in this report relating to the care and support of
prisoners in healthcare, in particular, to the basic standard of cleanliness that
protect an individual’s dignity. I also draw attention to the prison’s response to
deaths in custody.
Stephen Shaw
Prisons and Probation Ombudsman April 2006
CONTENTS
Summary
The investigation process
HMP Peterborough
Events prior to the man’s death
Events after the man’s death
Clinical review and post mortem
Findings and conclusions
Recommendations
Summary
In December 2005, the man died in hospital. After being charged with
shoplifting in December 2005, he was remanded in custody at HMP
Peterborough. The man was a long term drug user, who was estranged from
his family and who had chosen to live an itinerant lifestyle. Although he
entered prison with some health issues he was not considered to be duly
unwell but was suspected of carrying MRSA. He had also tested positive for
drugs and was placed on the detoxification regime. He was located in a
shared cell in the male healthcare unit with another prisoner.
On the second night of his remand at Peterborough at about 3.30am, the man
became incontinent and confused to the extent that his cellmate demanded to
be moved to another cell. Whilst his cellmate was moved in the early hours of
the morning, the man remained in the cell. He was not considered to be in
any particular distress despite the foul condition of his cell. Due to the
reduced numbers of staff on duty at this time of day a decision was made not
to assess him or clean his cell until later on in the morning when there was
more staff on duty. Staff reported to have seen him sitting up on his bed at
5am and at 7.10am.
At about 7.15am, day healthcare staff went to the man’s cell in order to clean
him up and to assess his needs. He was discovered to be lying on his quilt on
the floor, semi-conscious and breathing erratically. The nurse attending his
cell was concerned about his condition and requested that a 999 ambulance
be called. The ambulance arrived within five minutes and attended to the
man who was semi-conscious. He was taken to hospital at around 8.12am,
under escort. However, his condition continued to deteriorate and despite the
efforts of medical staff he was pronounced dead soon after. The preliminary
cause of death was given as a significant bleed into the abdominal cavity
(retroperitoneal haemorrhage due to ruptured right common iliac artery
aneurism.)
The man’s death is the first death at Peterborough, since it opened in Spring
of 2005. The clinical review into the man’s care and treatment has
established that his behaviour and presentation would not have naturally led
healthcare staff to believe that something was wrong. However, the review
does state that given the change in his condition from the previous night it
would have been prudent to have observed him more closely and regularly,
and to have recorded the findings. I have also drawn attention to the need to
address prisoner’s basic hygiene needs. In general, the clinical review has
highlighted a number of issues that the Director in conjunction with his
Healthcare Manager will want to consider which will assist in establishing an
equitable level of healthcare to that which can be found in the wider
community.
The investigation process
1. One of my investigators visited HMP Peterborough on 13 December 2005,
to open the investigation into the death of the man who is the subject of
this report. Notices were issued to staff and prisoners informing them
about the investigation and giving them the opportunity to speak with my
investigator. One response which was not specific to the death of the man
was received.
2. The Director and his staff produced the man’s core record, his Medical
Record and a number of other documents for examination. Various
members of staff at Peterborough were interviewed.
3. My investigator also interviewed an agency nurse who no longer works at
Peterborough at her home address in order to obtain her version of the
events leading up to the man’s death. One member of discipline staff who
my investigator would liked to have spoken to has not been able to be
contacted and at the time of compiling this draft the prison was not aware
of his whereabouts.
4. The Head of Nursing from the Greater Peterborough Primary Care
Partnership was contacted so that she could conduct a clinical review into
the care and treatment that the man received in prison.
5. One of my family liaison officers contacted the man’s next of kin, his
brother, by telephone offering the family an opportunity to meet with him
and the investigator to discuss the purpose of the investigation, and to
raise any concerns or questions that the family would like explored and
addressed. On 29 December, the family liaison officer and my investigator
visited the man’s brother and his step-father in Lancashire and noted their
concerns.
6. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and the scope of my investigation and to request a copy of the post
mortem report. Upon completion, the final report will be sent to the
Coroner to assist him. At the time of completion of the draft report a full
post mortem report was not available.
HMP Peterborough
7. Peterborough is a private prison run by United Kingdom Detention
Services (UKDS). It opened in Spring 2005 and is the first purpose built
Category B prison to house both men and women.
8. Healthcare is provided by the Peterborough Primary Care Partnership and
there are separate healthcare facilities for male and female prisoners. For
the male side there is capacity for 13 inpatients.
9. As the establishment has only been operating for less than one year it has
not been subject to any visits by Her Majesty’s Inspector of Prisons
(HMIP).
10. This is the first death in custody at Peterborough.
Events prior to the man’s death
The man appeared before Magistrates Court in December 2005, charged with
shoplifting. He was remanded in custody to Peterborough and was due to
reappear in court two days later.
11. On reception at Peterborough from the magistrates court, the Prisoner
Escort Form (PER) indicated that the man had a leg injury. The form also
indicated that he could be violent. He was seen by a healthcare assistant
and was asked a series of questions as part of an initial health screen the
purpose of which is to ascertain a prisoner’s health care needs. The man
stated that he was of no fixed abode and that he was not registered with a
doctor and was not in receipt of any prescribed medication. The man also
indicated that he had no particular concerns about his physical or mental
health although it was noted that he had ‘Trenchfoot’ an infection of the
right foot caused by cold, wet and unsanitary conditions. The initial health
screen, also records that whilst in police custody he had tested positive for
heroin and benzodiazepines. The man also stated that he had been
diagnosed with the MRSA virus. Although he had told his brother that he
had been diagnosed with hepatitis, he did not disclose this during his
reception at Peterborough.
12. The day senior nurse has stated that on arrival at Peterborough, the man
was coherent and did not appear unduly unwell. The clinical review
established that following a risk assessment, the man was assessed as
being capable of being in possession of his own medication in his cell and
was administering his own antibiotics. He was also able to walk about with
the aid of crutches.
13. Because the man had tested positive for drugs he was placed on the First
Night Protocol. The Protocol ensures that all new prisoners with a history
of substance misuse and who test positive for drugs are seen by the
prison doctor within 24 hours and receive the appropriate medication for
withdrawal from drugs. In light of this and due to his foot infection he was
located in a shared cell in the male healthcare unit with another prisoner
who was also a remand prisoner and an MRSA sufferer. The man’s
cellmate stated to my investigator that the man’s foot was in a very bad
way in that it looked very scabby and had been bleeding. The man found
it difficult to walk although he had the use of crutches. He told his cellmate
that he was a heroin user and the cellmate stated that when he first met
him he was ‘clucking’. This term is used to describe someone who is
withdrawing from drugs and in an agitated state. Otherwise, there were no
concerns in respect of the man on the first night that he was in prison
custody.
14. On 11 December, the man was seen by the prison doctor and was
prescribed antibiotics and cream for his foot as well as Methadone and
Diazepam. He was also given Immodium for diarrhoea. During the course
of the day nothing untoward was recorded and the duty manager for the
weekend stated that there were no issues that were brought to her
attention that weekend, although she was aware that there were two
prisoners with MRSA sharing a cell. However, according to the man’s
cellmate, after the man had seen the prison doctor around 11am, to
receive his Methadone, he seemed to act in a bizarre manner constantly
talking to himself and trying to walk around the cell. The cellmate said that
he tried to reassure him and calm him down. My investigator established
that all prisoners in the healthcare wing are checked at least once an hour
by staff, irrespective of whether they are subject to the self-harm
prevention regime. This usually entails a cursory look by a member of
staff through the flap of the cell door.
15. At about 7pm, the senior nurse reported for duty and received what she
described as a brief and inadequate handover from the day staff and that
she had to refer to the notice board for information. She was told that the
man and his cellmate were sharing a cell and that both had MRSA,
although she was unaware of his foot infection. At interview the senior
nurse and the healthcare assistant told my investigator that there was
some misperceptions of MRSA among staff and that it was natural for
some staff to be wary of dealing with prisoners who have it, although there
is some documented guidance that is available.
16. The senior nurse recalled that the unit was very noisy that night, with some
prisoners banging on their cell doors and shouting which caused some
disruption to the rest of the unit. She recalled that she and the night duty
healthcare assistant were busy and rushed off their feet. However, neither
the man nor his cellmate came to her attention, save to complain about the
noise on the wing. No medical issues were raised at this point.
17. At 1.10am on 12 December, the observation log for the male healthcare
unit records that the man’s cellmate told night duty staff that the man was
harassing him and acting in a very strange way and that he could not
sleep. At 2.50am, the cellmate told staff that the man had soiled himself
and had thrown his soiled jogging bottoms into the middle of the cell floor.
He was lying on the floor trying to set fire to himself. The man was told by
the night duty prison custody officer (PCO) to get back on his bed and not
to disturb the others. Unfortunately, my investigator was unable to speak
to the PCO who has been registered sick for some time. The PCO has not
kept in contact with the prison and despite their efforts to locate him, his
whereabouts are presently unknown. It was also unfortunate that following
the man’s death, the PCO did not provide a statement. This would have
assisted in establishing his level of involvement with the man.
18. The man’s cellmate told my investigator that in the early hours of the
morning, the man was talking ‘gibberish’ and kept trying to get up from his
bed as if he wanted to go somewhere. He recounted that the man kept
saying “I am off to Lion Walk” and that he would try to get up and walk
around the cell without the use of his crutch and then collapse on the cell
floor. He was also very incontinent and was unable to make the toilet on
several occasions, messing the floor.
19. At about 3.30am, the senior nurse, was aware that the man’s cellmate had
alerted staff by shouting and had threatened to kill the man if he was not
moved to another cell. The cellmate told my investigator that the cell was
in a deplorable state, with faecal matter all over the floor and that he could
not stand it any longer. The man seemed oblivious to his condition and his
surroundings.
20. At about 3.45am, the PCO responded to the cellmate’s calls from the cell
door and contacted the senior officer on night duty by radio requesting
assistance for the removal of the cellmate from the cell. To unlock a
prisoner’s cell at that time of the night would have required the senior
officer to be present with additional assistance from discipline staff. This is
in compliance with the prison’s security operating procedures. The duty
SO stated that the PCO said that the man’s cellmate had threatened to kill
the man unless he was moved. The SO thought at the time that the two
prisoners had just fallen out.
21. At approximately 4.30am, The man’s cell was unlocked and his cellmate
was moved to an unoccupied four bedded dormitory in the Healthcare unit.
In view of the fact that both prisoners had MRSA and the risk of cross
infection, staff entering the cell wore disposable gloves and gowns. The
cellmate told my investigator that when he left the cell, the man was lying
on the floor near to the toilet, wearing a pair of trainers and a tee shirt.
However, the duty SO who supervised the unlocking of the cell stated that
the man was sitting on the toilet and that when asked if he was okay, he
replied that he was alright. The SO told my investigator that he had
attributed the smell of the cell to the man’s use of the toilet.
22. The senior nurse recorded in a statement following the man’s death that
whilst she recommended that the man be showered an officer reminded
her that such a task could compromise the safety of others if there was
another incident that required medical assistance elsewhere in the prison.
There are conflicting accounts as to how a decision was reached but the
senior nurse acknowledged that the man had gone back to bed, appeared
settled and was not showing any obvious signs of distress. She told my
investigator that in light of the man’s presentation, a collective decision
was taken to leave him until later when day staff reported for duty so that
the task of cleaning him and his cell and assessing his needs could be
completed safely. The senior nurse told my investigator she felt that this
was a reasonable decision to take. My investigator found that whilst the
cellmate could be moved, there was no other cell in which to place the
man as the unit was full to capacity. The duty manager has confirmed to
my investigator that in her opinion that at 4.30am there were enough staff
on duty to assess and deal with the man’s needs, although the task of
assessing him and cleaning him up needed to be taken in context of
perceived events that could happen elsewhere in the prison that needed to
be dealt with as priority.
23. The night duty SO also confirmed that at the time of the cell being opened,
the man told staff that he felt alright. In his opinion, the man was fully
conscious, aware of his surroundings and settled and his presentation
gave him no cause for concern. At about 4.45am, when the SO left the
unit to attend to his normal duties, he recalled looking through the window
of the cell and receiving an acknowledgement in the form of a wave from
the man. It was also reported to the SO that at about 5.30am, he had
asked the PCO for a cigarette which he felt showed that he was not in any
obvious sign of distress.
24. At 5am, the senior nurse was told by the PCO that the man was sat up in
his bed. However, in light of his physical condition during the night she
deemed him unfit to attend court that day and noted this in the medical
record.
25. At about 6.45am, the senior nurse handed over to her day duty
colleagues, the day senior nurse and the healthcare assistant. She gave
them a printed handover sheet and a brief report on the key events of the
night. The senior nurse indicated to her colleagues that the man would
need to be cleaned and clinically assessed as he had been incontinent,
confused and disorientated during the night. The senior nurse then left the
unit at about 7.10am, having completed her handover. As she was being
escorted off of the unit, she noted that the man was sitting upright on his
bed. At around the same time, the day PCO came on duty, taking over
from the night PCO. The day PCO told my investigator that at about
6.50am, he glanced through the flap of the cell door and saw the man
wrapped in a blanket. The man looked up at him and nodded in
acknowledgement. The PCO described the cell as messy and smelly but
the man gave him no cause for concern.
26. At around 6.45am, the duty manager reported for duty and spoke briefly to
the duty SO, who had finished his night duty. He told her that the man’s
cellmate had to be moved in the early hours of the morning because the
man had become incontinent and confused but the man had remained in
the cell which was in a foul state. The man and the cell required cleaning.
27. At 7am, the duty manager visited the male healthcare unit in order to
assess the situation for herself. She was aware that there were two
prisoners on remand who had MRSA who were due to attend court that
day and enquired with nursing staff whether it was acceptable that they
should appear in court with the condition. The day senior nurse confirmed
that it was acceptable in the cellmate’s case, although the man had not
been deemed fit to attend. The duty manager requested that the man
should be cleaned up and then arrangements made to clean up his cell.
28. At about 7.15am, the day senior nurse, the healthcare assistant and the
day PCO attended the man’s cell to unlock him, clean him up and assess
his needs. When the nurses entered the cell they noticed that the man
was laying half on and half off his duvet on the floor, not wearing any
trousers. The duvet and the cell floor were covered in faecal matter and
the senior nurse told my investigator that she was surprised at the state of
the cell. The man did not respond to her questions. She then checked his
vital responses. She said he was pale, clammy, short of breath and he
was semi conscious. The healthcare assistant began to clean up the man
in order to give him some dignity and comfort. In the meantime, the day
senior nurse became very concerned at the man’s presentation and
shouted to the PCO who was standing at the doorway to call for an
ambulance. The PCO immediately informed the duty manager who was in
a nearby office to telephone the control room for an emergency
ambulance. She did this immediately. Having ensured that an ambulance
was on its way, the duty manager returned to the cell to see if she could
be of any assistance.
29. The senior nurse left the man’s cell to get some oxygen, whilst the
healthcare assistant continued to clean the man the paramedic team
arrived. The man remained semi-conscious and was breathing erratically.
30. At about 7.20am, paramedics arrived in the man’s cell. Due to their
extremely rapid response the senior nurse did not even have time to
administer oxygen before the paramedics arrived. The PCO was called
away to attend to other functions in the healthcare unit. The man was
taken by stretcher to the back of the ambulance where the paramedics
assessed his condition. A venflon tube was used to assist him with his
breathing. The paramedic staff decided that the man needed to be taken
to hospital.
31. At 8.12am, the ambulance left Peterborough with two escorting officers to
go to hospital. In light of the man’s grave and deteriorating condition he
was not handcuffed. During the journey escort staff called the prison, to
say that the man’s condition was giving paramedics extreme cause for
concern. Following this, the duty manager informed the Director of
Peterborough of the situation. At about 9.30am, the prison was told that
the man had died in hospital.
Events after the man’s death
32. Following news of the man’s death, Peterborough implemented its
contingency plan for a death in custody. The plan included arrangements
to inform the Police, the Prison’s National Operations Unit, The
Independent Monitoring Board as well as the man’s next of kin.
33. Because the man’s family live in Lancashire, the prison asked Lancashire
Police to contact the family on their behalf, through Cambridgeshire
Constabulary. At about 6pm on 13 December, Lancashire Police broke
the news of the man’s death to his brother. Lancashire police did not
know of the particular circumstances surrounding the death but gave
contact details and a reference number for the family to contact
Cambridgeshire Constabulary. Then the man’s brother contacted them.
They were also not aware of the circumstances of the death but referred
him to the prison. The brother contacted Peterborough and spoke to the
prison’s nominated family liaison officer. He confirmed that the man had
died in hospital at about 9.30am. giving brief details of the circumstances
of his death including the fact that the Prisons and Probation Ombudsman
would be carrying out an investigation.
34. My investigator contacted Cambridgeshire Constabulary in respect of the
death of this man. Their enquiries have concluded that his death is not
suspicious or the subject of any criminal investigation.
35. The man’s funeral took place on 21 December. The family stated that
people who knew him from the night shelter and the street attended. The
prison did not send a representative but did send flowers. The family told
my family liaison officer that initially there was no offer of financial support
towards the funeral expenses. However, I understand that following the
funeral, an offer of financial support towards the funeral was made by the
Director of Peterborough. The family have had little contact with
Peterborough since the man’s death. Although they have no wish to visit
the establishment they were aware that the man owned a mobile phone
when he went to prison and asked for this and any other personal property
to be returned to them as soon as possible. To date, the man’s property
has not been returned to his family despite several requests.
36. When my family liaison officer and the investigator met with the man’s
family on 29 December, it was established that the man had become
estranged from his family some years ago, although some contact was
maintained by telephone calls, particularly in the last 12 months. The
family were aware of his lifestyle. In light of the circumstances
surrounding his death the family’s main concern focused on his physical
state in the early hours of 12 December, and whether an earlier referral to
hospital or medical intervention on site might have saved his life.
Following disclosure of the man’s preliminary cause of death, the clinical
reviewer of the Greater Peterborough Primary Care Partnership stated that
the confusion and incontinence experienced by the man earlier would not
have naturally led healthcare staff to suspect that something was wrong.
However, it would have been prudent to have implemented regular, routine
observation that should have been recorded. The preliminary cause of
death was an acute and sudden event that could not be foreseen or
prevented and therefore it was reasonable for them not to have
hospitalised him earlier.
37. This was Peterborough’s first death in custody and whilst most staff have
told my investigator that they were offered appropriate support by the Care
Team following the man’s death, other staff were not aware of the support
mechanisms in place. My investigator established that a staff debrief for
those involved in the man’s care had not taken place. Staff considered
that this would have been useful as a means of supporting them and
offering reassurance.
Clinical review and Post Mortem
38. The preliminary cause of death for the man stated that he died as a result
of a significant bleed into the abdominal cavity (retroperitoneal
haemorrhage due to a ruptured common iliac artery aneurism). The post
mortem report was not available at the time of completion of this draft
report.
39. Following disclosure of the man’s preliminary cause of death, the clinical
reviewer from the Peterborough Primary Care Partnership was asked
whether his death could have been prevented by earlier referral to
hospital. She stated that his illness was and acute sudden event. The
behaviour displayed by him would not have naturally led healthcare staff to
suspect that something was wrong. Staff had also seen him showing no
noticeable sign of distress just before he was found collapsed and this
indicates how quickly his deterioration occurred She states that it could
not be have been foreseen or prevented. However, the clinical review has
highlighted other healthcare issues with regard to the man’s care and
treatment of him in particular as well as his general healthcare.
40. The clinical review into the man’s care and treatment – has highlighted
that when the opportunity arose, the man’s clinical needs were not
assessed or recorded appropriately, especially in light of his earlier lucid
and rational behaviour. The clinical review is also highly critical of the fact
that, notwithstanding security and manning levels during the night state,
the man’s basic hygiene needs were not addressed in any professional or
dignified manner until the arrival of day duty staff. The review concludes
that in this instance, the man did not receive an equitable level of
treatment or care to that which he would have received in an outside
hospital in the wider community. However, the review establishes that
overall, the man’s care and treatment was appropriate.
41. Although some work has been carried out at Peterborough in respect of
informing staff about MRSA, the clinical review suggested that efforts need
to continue in this area, in order to improve the awareness and
understanding of all staff that may have to deal with a prisoner who has
MRSA. On interviewing the day senior nurse and the healthcare assistant
it was stated that there was some misperceptions of MRSA in which staff
were naturally wary of dealing with prisoners who had the virus. However,
this did not affect the care and treatment afforded to the man who died.
42. The clinical review also identified the need for a formalised handover
between staff in male healthcare. This should include both healthcare and
discipline staff who are, after all dealing with the same patients. The
clinical review also established that following the man’s death there was
no formal debrief of staff who had dealt with the deceased that day. This
may have helped staff to reflect on and identify any issues as well as
support staff who had dealt with the man.
43. Finally, the clinical review has emphasised the need for staff to record all
observations appropriately, as the level of activity that appeared to have
taken place on 12 December, was not adequately reflected in the man’s
medical notes.
Findings and conclusions
44. When the man entered Peterborough, it was established on reception that
he had an infected right foot that required attention and appropriate
treatment with antibiotics. He had also tested positive for drugs and was
placed on the appropriate drug detoxification regime. The man had also
stated during his reception that he was diagnosed as an MRSA sufferer
and as such he was placed in a shared cell with another prisoner suffering
from MRSA in the male healthcare unit. The man was not unduly unwell
when he went into prison on 10 December, and was described as
coherent and lucid.
45. The investigation highlighted that there was no formalised handover
procedure in the male healthcare unit and that the existing level of
handover between nursing staff was variable and did not always include
discipline staff. The clinical review suggested that handovers should be
reviewed.
46. It was established during the investigation on talking to healthcare staff
that despite guidance and advice that is available to staff in regard to
dealing with prisoners who have MRSA that there still remains a degree of
ignorance and reluctance to deal with such prisoners, the onus being on
healthcare staff to deal with them. Although there is no evidence to
suggest that this had an impact on the man’s death, the clinical review has
highlighted that there needs to be an improved awareness of MRSA by
staff. This may dispel any myths about the condition and instil greater
confidence in staff dealing with prisoners who have this condition.
47. There were no issues brought to the attention of the duty manager over
the weekend in regard to the man. However, during the course of the
night of the 11 December, the man became confused, disorientated and
incontinent which was interpreted by his cellmate as bizarre behaviour.
48. At 1.30am on 12 December, the man had soiled himself and had
discarded his jogging bottoms on the cell floor. He appeared over the next
few hours to become more incontinent and incoherent. Due to the state
of the cell and the man’s behaviour his cellmate alerted staff and
demanded that he wanted to be moved to another cell.
49. At 4.30am, the cellmate was transferred to another cell. Because there
were no other suitable cells in the healthcare unit, the man was left in his
cell. According to staff, he was conscious, not in any apparent state of
distress and it was felt that he could wait to be cleaned up later on in the
day, when there were more staff on duty to attend to his needs. The man
also responded to staff that he was okay.
50. Whilst the man’s cellmate was transferred to another cell at his own
request, this could have been considered an ideal opportunity in which to
assess the man and ascertain the reasons for his incontinence and
confused state. It would also have been the opportunity to clean his cell.
This was discussed by staff and there are a number of conflicting accounts
on how this decision was reached. Although the senior nurse wanted to
do this she was advised that staffing levels at that time of the morning
limited this option because of the need to deal with any other incidents in
the establishment should they arise. However, she concluded that it was a
reasonable decision to have reached. The clinical review established that
given the change in the man’s condition from the previous evening,
consideration should have been given to taking some baseline
observations. It would have been prudent to have observed him more
closely and on a regular basis, and to record the findings for the duration
of the night following the cellmate’s removal from the cell at 4.30am. At
the very least this would have allowed an opportunity for the man’s
hygiene needs to be addressed and his dignity maintained. However, they
were not because of a perception of shortages of staff at night time.
51. The clinical review also determined that the man did not receive equitable
treatment compared to an outside hospital. Although there are reduced
staff on duty at night time, this should not have impeded healthcare staff in
accessing his cell in order to assess or clean him up. Notwithstanding the
prevailing security conditions and manpower limitations at that time of the
day, the clinical review suggested that some effort could have been made
to attend to the man’s basic hygiene needs and dignity. However,
following disclosure of the preliminary cause of death, the clinical reviewer
from the Greater Peterborough Primary Care Partnership has confirmed
that the man’s death was an acute and sudden event that could not have
been foreseen or prevented. His presentation in the earlier hours of the
morning would not naturally have led healthcare staff to suspect that
something was wrong.
52. The man was seen at about 4.45am and 5am by members of the discipline
staff, sitting upright on his bed which confirmed that he was conscious.
Whilst the night duty SO was able to confirm that he had seen the man,
my investigator has not been able to contact or confirm this with the night
duty PCO. The man was also seen by the senior nurse going off duty at
about 7.10am sitting upright on his bed. The clinical review has
established that although there seems to have been a lot of activity in
regard to sightings of the man, these were not documented. It was also
unfortunate that following his death, no statements were taken from the
night duty discipline staff that would have assisted in obtaining an accurate
picture of the events leading up to his death. At the time of writing this
draft all efforts to contact one discipline officer have been unsuccessful.
53. At 7.15am, the day duty healthcare team were made aware that the man
had been incontinent with faeces during the night and that his cellmate
had been moved. In light of the man’s condition he was not fitted for court
that day. His cell was entered by the nurse and healthcare assistant in
order to clean him up and to assess his needs. There they found him to
be lying on the cell floor on his duvet in a semi conscious state with no
clothes. He was pale and clammy and was unresponsive to questioning.
His breathing and vital signs were considered to be erratic and of concern
to the nurse who requested that a 999 ambulance be called. As the man
was semi-conscious cardio-pulmonary resuscitation (CPR) was not
considered by healthcare staff. Within five minutes of being called the
paramedic team arrived in his cell and took over from healthcare staff. He
was taken to the back of the ambulance on a stretcher and assessed. A
venflon tube was inserted to assist with his breathing.
54. At about 8.12am, the man was taken by ambulance to hospital. As a
prisoner he was escorted by two members of the discipline staff in
accordance with the prison’s security and operating procedures. However,
because of his poor condition and the fact that paramedics needed to
administer treatment he was not handcuffed. During the transfer to
hospital, one of the escort staff reported that his condition was considered
by the paramedic staff to be grave. He died in hospital at 9.10am.
55. Whilst most staff were offered care and support following the man’s death,
others felt that a formal debrief of the events leading up to his death would
have been useful and reassuring. The clinical review has also highlighted
the need to provide adequate debriefing to staff following a death in
custody in line with Prison Service Order 2710 which deals with a prison’s
follow up to a death in custody.
56. The man’s next of kin was informed during the early evening of 13
December, by Lancashire Police who had been notified by
Cambridgeshire Constabulary. The man had not disclosed details of his
next of kin to the prison and in view of his itinerant lifestyle, it had taken
some time to trace his family and inform them of his death. This lapse in
time was unfortunate but unavoidable given the circumstances. However,
consideration could have been given to ensuring that Lancashire Police
gave direct contact details for the prison to the family.
Recommendations
1. The Clinical review by the Greater Peterborough Primary Care
Partnership highlighted the need for an improved awareness of MRSA by
staff. This may dispel any myths about the condition and instil greater
confidence to staff in dealing with prisoners who have this condition.
Recommendation
That the Healthcare Manager at Peterborough in conjunction with the
Greater Peterborough Primary Care Partnership raises awareness of
MRSA so that all staff feel confident and comfortable,in dealing
effectively with prisoners who have or are suspected of having
MRSA.
2. Given the change in the man’s condition from the previous evening,
consideration should have been given to taking some baseline
observations and it would have been prudent to have observed him more
closely and on a regular basis, and to record the findings for the duration
of the night following his cellmate’s removal from the cell at 4.30am. Staff
were concerned about a perceived shortage of manpower and the risk of
intervention preventing them from attending another potential incident at
that time. I do not consider that the potential for a further incident to occur
is sufficient reason to prevent staff attending to a prisoner’s basic hygiene
needs. The duty manager also confirmed that there were enough staff on
duty that night not to compromise the man’s basic hygiene needs.
Ultimately it should be within healthcare staff’s command to make a
decision about whether to do that and for others to comply.
Recommendation
That the Director and Primary Care Partnership agree protocols for
the basic standards of hygiene needs offered to all prisoners to be
maintained, to include ensuring that soiled clothing and bedding is
replaced as quickly as possible.
3. Staff were concerned about a perceived shortage of manpower and the
risk of intervention preventing them from attending another potential
incident at that time. I do not consider that the potential for a further
incident to occur is sufficient reason to prevent staff attending to a
prisoner’s basic hygiene needs. The duty manager also confirmed that
there were enough staff on duty that night not to compromise the man’s
basic hygiene needs. Ultimately it should be within healthcare staff’s
command to make a decision about whether to do that and for others to
comply.
Recommendation
In the event of a prisoner’s health deteriorating, that every
reasonable effort is made to assess, determine and record the
prisoner’s needs by taking baseline observations on a regular basis
4. Whilst most staff were offered care and support following the man’s death,
others felt that a formal and timely debrief of events leading up to his death
would have been useful and reassuring. The clinical review has also
highlighted the need to provide adequate debriefing to staff following a
death in custody.
Recommendation
That the Director give consideration to a timely formal debrief of key
staff involved in a death in custody in accordance with Prison
Service Order 2710
5. The clinical review established that although there seems to have been a
lot of activity in regard to sightings of the man, these were not
documented.
Recommendation
That the Healthcare Manager reminds all staff who have contact with
patients to record their observations, however minimal in the
patient’s medical record or appropriate observation log.
6. Whilst the night duty SO was able to confirm that he had seen the man,
my investigator has not been able to contact or confirm this with the night
duty PCO.
Recommendation
That the Director ensures that, in the event of a death in custody, a
written statement should be taken from key staff involved.
Statements taken at the time or soon after provide a more accurate
record and may reduce the need for staff to be interviewed as part of
an investigation.