Individual at Risley

Investigation into the circumstances surrounding the
death of a man at HMP Risley
in June 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2009
April 2009
This is a report into the death from natural causes of a man at HMP Risley in June
2008.
I offer my sincere condolences to the man’s family for their loss. One of my Family
Liaison Officers made contact with the man’s brother so that he could be involved in
the investigation process. Unfortunately, the delay in receiving the clinical review
has delayed my report. I apologise for any distress this causes.
The investigation was led by one of my investigators. He was assisted by another
investigator from my office. I must thank Warrington Primary Care Trust (PCT) for
the appointment of a medical practitioner as independent clinical reviewer. I am also
grateful to the Governor and staff of HMP Risley, especially the liaison officer whose
assistance was a great help to my investigators.
As the man died from natural causes, the findings of the clinical review play a critical
part in my report. The clinical reviewer’s review shows that the man received good
care whilst in Risley after transferring from HMP Forest Bank. However, there were
some concerns both about healthcare provision and transfer arrangements at Forest
Bank. The man was not a well man, with recent evidence of heart problems. The
manner of his transfers and the way he was judged suitable first for HMP Buckley
Hall then Risley were not acceptable. I trust that any future transfers of prisoner-
patients can be arranged to the satisfaction of all parties prior to the transfer actually
taking place.
I make two recommendations to the Director of Forest Bank and one national
recommendation. I am pleased to see that the Prison Service have accepted the
local recommendations. The national recommendation was not accepted, the Prison
Service feeling that current arrangements are adequate if properly enforced. I hope
that steps will be taken to ensure that they are. The man’s family have no comments
to make further to the draft report.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2009
April 2009 2
CONTENTS
Summary
The Investigation Process
HMP Risley/HMP Forest Bank
Key Findings
Issues
Recommendations
Annexes
- Clinical Review
- Transcript of interview with the first doctor
- Transcript of interview with the first healthcare assistant
- Transcript of interview with the first staff nurse
- Transcript of interview with the first nurse sister
- Transcript of interview with the first senior officer
- Transcript of interview with the second officer
- Transcript of interview with the third officer
- Transcript of interview with the fourth officer
- Response from Office for National Commissioning to the man’s complaint
April 2009 3
SUMMARY
At the time of his death, the man was serving a four year sentence at HMP Risley.
The man had first arrived at HMP Forest Bank in September 2007. Healthcare
assessed that he was unfit for work, manual labour and gym. Whilst at Forest Bank,
the man was taken to Hospital three times as an emergency patient. He was last
admitted on March 2008, when staff successfully performed cardiac pulmonary
resuscitation (CPR). Following each admission, the man was discharged from
hospital and returned to prison.
Forest Bank then transferred the man to HMP Buckley Hall in April 2008. However,
Buckley Hall would not accept him due to his health problems, and he returned to
Forest Bank three days later. Forest Bank then transferred the man to Risley four
days after this.
The man was assessed at Risley by the first doctor who thought that the prison
would not be a clinically safe environment for him. There was no prior
correspondence from Forest Bank healthcare to Risley healthcare regarding the
man’s medical needs, although the Inmate Medical Record and a drug chart
accompanied him. Healthcare at Risley attempted to transfer the man back to
Forest Bank, but they refused to accept him. Within an hour of being at Risley, the
man complained of suffering from chest pains and was immediately taken to
Warrington Hospital by ambulance.
The man remained in hospital for 12 days before being discharged to the specialist
healthcare unit at HMP Preston on 22 April. He remained there until he was ready to
be returned to Risley two weeks later on 7 May. The first doctor, at Risley,
conducted a full medical review, requesting the man’s full medical history from the
various locations where he had been treated.
On 13 May, Prison Service Headquarters received a letter from the man. He
complained that staff from Forest Bank had failed to respond when he said that he
was experiencing severe chest pains during the journey to Risley. In addition, he
also asked why his prescribed medication had been changed.
In the late morning of a day in June 2008, a fellow prisoner alerted staff that the man
needed assistance. Uniformed and clinical staff responded quickly. The clinical staff
could find no signs of life in the man and the defibrillator (a machine that applies
electrical impulses to the heart and advises whether there is any rhythm which might
be stimulated) indicated that there no shockable rhythm. Resuscitation was thought
to be inappropriate and was not attempted. The first doctor pronounced the man
dead in his cell at 11:55.
April 2009 4
THE INVESTIGATION PROCESS
1. My investigators visited Risley and spoke to staff who knew the man. They
interviewed eight members of staff. The interviews were recorded and the
transcripts are attached to this report. Notices were also posted to staff and
prisoners about the investigation but no responses were received.
2. In addition, the investigators studied all relevant prison records relating to the
man. They included his main prison record, medical records and statements
made by staff. The investigators visited the man’s cell. In addition, they wrote
to the Director at Forest Bank, spoke to the Deputy Director on the telephone,
and exchanged a number of e-mails with the prison. They also contacted HM
Prison Service Office for National Commissioning to obtain the response to
the complaint made by the man.
3. Warrington Primary Care Trust identified a medical practitioner to carry out a
review of the man’s clinical care. I am grateful to the clinical reviewer for
undertaking this review. My investigators discussed aspects of the man’s
treatment with healthcare staff at Risley and with the clinical reviewer.
4. We wrote to Her Majesty’s Coroner for Cheshire to inform him of the nature
and scope of my investigation. A copy of the Post Mortem report was made
available. Upon completion, my report will be sent to the Coroner to assist in
his enquiries into the man’s death.
5. One of my Family Liaison Officers contacted the man’s brother at the
beginning of the investigation and offered the opportunity to raise questions
and concerns for us to consider. The man’s brother had no matters he wished
to be considered. A copy of my report will be made available to him on
completion.
April 2009 5
HMP RISLEY
6. HMP Risley is a modern, purpose built prison that opened in 1964. It is a
category C training prison. Since the opening of a new wing in 2003, it has a
capacity of 1,085, making it the largest category C prison in the country.
Healthcare
7. Healthcare staff are available in Risley 24 hours a day. By day, there is a
doctor in the prison; at night, cover is provided by nursing staff. Prisoners who
require in-patient treatment are referred to other prisons or to outside hospital.
Oscar 1 and Hotel 1
8. These are two radio call signs within the prison. “Oscar 1” is the radio call
sign allotted to the orderly officer. The orderly officer is the prison officer in
charge of the routine operational functioning of the prison at any one time.
This role is normally undertaken by either a senior officer or principal officer
grade. “Hotel 1” is the radio call sign to request medical assistance from the
duty nurse.
Assessment, Care in Custody and Teamwork
9. Assessment, Care in Custody and Teamwork (ACCT) is the Prison Service’s
set of procedures designed to support and monitor prisoners considered to be
at risk of suicide or self-harm.
Hot Debrief and Critical Incident Debrief
10. Hot debriefs are held as soon as possible on the same day after a death in
custody. They are held to ensure that staff involved have an opportunity to
discuss any issues arising. Minutes are not normally taken of these meetings.
A critical incident debrief is carried out within five to ten days. Usually
organised by Employee Support, a critical incident debrief is held in order to
give staff an opportunity to understand the circumstances in greater detail,
review their thoughts and feelings, and to help with the reactions some people
may experience after being involved in a traumatic incident.
Previous deaths at Risley
11. This is the fourth death that my office has investigated since I became
responsible for investigating all deaths in prison custody in April 2004. The
circumstances of the man’s death are different to the previous three.
Her Majesty’s Chief Inspector of Prisons (HMCIP)
12. The most recent HMCIP inspection was unannounced and took place in
February 2006. None of the issues raised in that report are relevant to the
circumstances of the man’s death.
April 2009 6
Independent Monitoring Board (IMB)
13. Each prison in England and Wales has an Independent Monitoring Board
responsible for monitoring day-to-day life in the prison and to ensure that
proper standards of care and decency are maintained. The most recent
annual report published by the IMB for Risley does not contain any issues
which need to be reflected upon here.
HMP FOREST BANK
14. HMP Forest Bank is a modern contracted out prison in Salford, run by Kalyx
(formerly UK Detention Services), which opened in 2000. It has a capacity of
1,124, serving the courts of the North West (the prison takes adults and young
offenders). Forest Bank has a 21 bed in-patient facility in the healthcare
centre, which includes an observational cell. Forest Bank is a category B
establishment. When sentenced prisoners are re-categorised it is normal for
them to be reallocated to other establishments in line with their security
category.
April 2009 7
KEY FINDINGS
15. In September 2007, the man was convicted at Bolton Magistrates Court of
driving while disqualified and other offences and sentenced to a total of ten
months imprisonment. He was taken to Forest Bank to begin his sentence.
16. The Prisoner Escort Record (PER) is a record of all escorted journeys made
by a prisoner. It also includes a section highlighting any known risks involved
in moving that prisoner, including potential medical issues. A PER was
completed on 21 September by Greater Manchester Police prior to the man’s
journey from Bolton Police Station to Bolton Magistrates Court. It clearly
indicated that the man had a medical condition identified as “heart attacks”.
17. On his arrival at Forest Bank, the man underwent a healthcare assessment
during the reception process. It noted that he had had two possible
myocardial infarctions (heart attacks) requiring hospital admission in 2002, an
angina attack three weeks previously, and had an appointment at the Royal
Bolton Hospital on 2 October for an angiogram. The screening indicated that
the man was “unfit for work, for manual labour and gym”.
18. In the early hours of 22 September, a nurse was called to the wing by the
night orderly officer as the man was complaining of chest pains. He was
taken to the healthcare centre and kept in overnight for observation. An
electrocardiogram (ECG, an electrical recording of the heart used in the
investigation of heart disease) had been undertaken, and the nurse took blood
tests and recorded his blood pressure as high. She also noted that the
hospital angiogram appointment needed pursuing. The man was reviewed by
a second doctor the following day when the blood tests and ECG results
proved negative for signs of heart pain. The second doctor noted the
outstanding angiogram appointment. Two days later, the man’s doctor was
contacted in order to obtain further medical history.
19. It is unclear from the man’s medical records whether the angiogram
appointment at the Royal Bolton Hospital was followed up. The man was
recorded as having only minor symptoms of oedema (swelling to the legs) on
2 November. On 14 November 2007, healthcare assessed him as medically
fit to attend court that day.
20. Records show that in early 2008 the man was transferred from Forest Bank to
Hope Hospital on three occasions by ambulance after reporting severe chest
pains. On 20 January, he was taken following prolonged chest pains and
concerns that he might be having a heart attack. There is no discharge record
following this admission. The prison transferred him again by ambulance to
hospital following chest pains on 15 March. On this occasion, the hospital
discharged him back to prison the same day with a diagnosis of “non-cardiac
chest pain”. The man was again taken to Hope Hospital by ambulance on 23
March. During assessment at the hospital, the man collapsed and had to be
given cardiac pulmonary resuscitation (CPR) by hospital staff. He was
admitted to the hospital and remained there until discharged and returned to
Forest Bank on 26 March. The hospital diagnosed the possibility of the
April 2009 8
respiratory condition Chronic Obstructive Pulmonary Disorder (COPD). The
discharge summary from Hope Hospital dated 24 March (sic) indicated the
need for a follow up appointment to review the COPD diagnosis and
undertake further tests within four weeks.
21. Whilst in prison the man had been charged with further offences. He was
convicted of affray and numerous public nuisance offences (making hoax
telephone calls to the emergency services), and sentenced to four years
imprisonment on 31 March 2008. Three PERs completed for escorted
journeys to the courts between 14 November 2007 and 27 February 2008 had
not identified any medical risks. However, following his last admission to
hospital, the PER completed by Forest Bank for his journey to Bolton Crown
Court for sentencing on 31 March did identify that the man had a medical
condition, but without specifying what the condition was.
22. The man returned from Bolton Crown Court to Forest Bank following his
further convictions. An Initial Categorisation and Allocation document (ICA1)
was completed on 3 April 2008 by the Observation Categorisation and
Allocation unit at Forest Bank. The man was assessed as a category C
prisoner and identified as suitable for allocation to Risley. The man signed to
indicate that he agreed to this assessment. However, there is no evidence in
the documentation that any medical assessment of his needs was undertaken,
nor that an outstanding hospital appointment was taken into consideration
when planning the move.
23. On 4 April, Forest Bank transferred the man to HMP Buckley Hall, another
category C prison. The PER document for this move identified that his
medical condition was a risk. Following the reception healthcare assessment,
Buckley Hall declined to accept the man because of his health problems. The
nurse recorded that he was “going back, not fit to be here”. The healthcare
screenings undertaken at Buckley Hall noted that the man reported having
severe bodily pain in the previous four weeks. The pain had interfered with
his normal routine and he related it to “heart problems and chronic bronchitis”.
Following liaison between the prisons, the man transferred back to Forest
Bank, which has 24-hour healthcare cover, on 7 April. On this occasion,
Forest Bank accepted him back due to an “understanding of the geographical
nature” of HMP Buckley Hall (the prison grounds have steep inclines).
24. Forest Bank transferred the man to Risley four days later on 11 April. The
PER document prepared for that transfer identified no known risk under the
medical condition category. The man’s van cell was checked once during the
transfer and was recorded as “all okay”.
25. On the man’s arrival at Risley, the first healthcare assistant undertook the
initial health check in reception. She reviewed the man’s medical records and
noted that he had suffered an apparent heart attack some three weeks earlier,
and that there was an outstanding out-patient appointment at Hope Hospital.
In interview, she told my investigators that the man was visibly unwell, moving
slowly and with a poor colour to his skin. She noted that he was under
prescription for medication indicative of cardiac failure. She was not happy
April 2009 9
with his condition and took him for an immediate assessment to the first doctor
in the healthcare centre. At 2.17pm, the first doctor assessed the man as
being “clinically unsafe” to remain at Risley. He based his assessment on his
recent cardiac arrest, the need for close monitoring and the lack of in-patient
facilities to provide this. The first doctor noted there had been no prior
telephone call from healthcare at Forest Bank. He asked the first nurse to
contact Forest Bank to arrange an immediate transfer back.
26. The first nurse telephoned healthcare at Forest Bank at 2.39pm, advising that
they did not agree that the man had been fit for transfer. She said that he
should be on medical hold (not transferred to another prison until medical
issues were resolved) as he had an outstanding out-patient appointment. She
requested that they arrange for the man to be transferred back to Forest Bank.
The member of healthcare staff she spoke to said she would arrange for his
return. She further asked that the Risley orderly officer arrange his escort.
27. In the meantime, the man had been taken back to reception. The first nurse
had not received a return call, so she telephoned reception at Forest Bank at
3.05pm. She spoke to a male prison officer and was told that Forest Bank
would not accept the man back, and the gate had been informed that he
would not be admitted to the prison. My investigators asked Forest Bank to
identify who this officer was, but they were unable to do so. As a
consequence my investigators were not able to speak to or interview him.
The first nurse reported this to the first doctor. There was contact later that
afternoon between the Deputy Director at Forest Bank, and the first duty
governor at Risley. The Deputy Director told my investigator that there had
been problems in the past over transfers between Forest Bank and Risley,
with some prisoners being sent back in taxis with no prior warning. The
Deputy Director told the first duty governor that they considered the man fit for
Risley and they would not accept him back.
28. At 3.19pm, the man started complaining of chest pains. The first nurse
immediately retrieved his GTN spray (used to relieve the symptoms of angina)
from his property and gave it to him. She then called healthcare to summon
the first doctor and other assistance and telephoned for an ambulance.
29. The first doctor and other healthcare staff arrived quickly and attended to the
man, finding that he had an increased heart rate. He was given more of the
GTN spray, and staff ensured that other medication was brought over in case
it was needed. First responding paramedics arrived at 3.40pm and took over.
They took an ECG which showed no significant signs of a heart attack, and
gave the man other medication which had some immediate effect. The
ambulance arrived and the man was transferred at 4.40pm to Warrington
Hospital where he was admitted as an in-patient.
30. The man was admitted to Warrington Hospital under the care of a Consultant
Cardiologist. Due to the persistence of the chest pains, the Consultant
Cardiologist decided to perform a diagnostic angiogram. Records indicate
that the procedure showed there was no significant disease present in the
man’s coronary arteries. The Consultant Cardiologist identified that the man
April 2009 10
suffered from kidney problems, recommended that his renal function should
be monitored, and that he be referred to a renal specialist.
31. Healthcare staff at Risley spoke to the hospital on three occasions between 14
April and 21 April. Risley’s Head of Healthcare referred the man to the
specialist healthcare unit at HMP Preston for respite care on his discharge
from Warrington Hospital. He was discharged to the unit at Preston on 22
April. Subsequently, healthcare staff at both prisons liaised closely in order to
plan his return to Risley on 7 May.
32. During his period at Preston, a Well Man Assessment was undertaken and the
man was kept under observation. The Continuous Medical Record shows that
a doctor (name illegible) saw the man on 25 April and explained that there
was no evidence of myocardial infarction, but that he had a problem with his
kidneys. He was told that he needed to reduce weight, and that his kidney
function would be monitored.
33. A Discharge Care Plan was prepared at Preston healthcare unit on 28 April. It
identified that there was no evidence of current cardiac problems, that any
episodes of angina should be treated with the GTN spray, that his kidney
function should be monitored, and that he should be recommended a weight
reducing diet and remedial gym.
34. Following his transfer back to Risley on 7 May, the first doctor began a full
medical review the next day. He wrote to the Consultant Cardiologist querying
whether his cardiac medication could be stopped following the results of the
angiogram. He contacted the man’s doctor’s surgery to acquire further
detailed medical history, undertook preliminary medical tests for a referral to a
renal specialist, and also wrote to another Cardiologist at a Royal hospital
requesting that she should undertake a full review of the man’s cardiac
medication. The first doctor maintained the man on his current medication,
pending the outcome of these reviews.
35. The man failed to attend three healthcare appointments on 9 May, 29 May,
and 3 June. However, the records do indicate that he was in ongoing contact
with healthcare throughout this period. He received a Hepatitis B vaccination
on 6 June.
36. The man wrote a letter of complaint regarding his healthcare, general
treatment, and decisions surrounding his transfer whilst at Forest Bank which
was received by HM Prison Service Headquarters on 13 May. As this related
to a contracted out prison, the complaint was forwarded to the Office for
National Commissioning (ONC). The ONC required a response to the man’s
concerns from Forest Bank and asked the man to sign a disclosure of
information form, which was received at Risley on 3 June. The man signed
this on 4 June, and it was faxed back by the Offender Management Unit at
Risley on 6 June.
April 2009 11
Events of the day of death
37. On the day of the man’s death, the second officer unlocked the man’s cell at
8.00am for breakfast and locked it again at 8.30am. The man had been
allocated a single cell due to his medical condition and was on normal
location. The second officer had found him sitting on his chair as usual, and
did not notice anything unusual. As is standard practice, no further checks
were made on prisoners during the morning lock-up period, with prisoners
having an emergency cell bell to call for assistance should any concerns arise.
The wing was unlocked again for lunch at 11.30am. The second officer said
when interviewed that this was a simple unlock for lunch and checks are not
made on prisoners during this process.
38. At 11.40am, the fourth officer was on the wing near the man’s cell. Another
prisoner alerted the fourth officer that something was wrong with the man and
that he was not breathing. The fourth officer went straight to the cell. As the
first to arrive, the fourth officer told my investigator that he found the man lying
on his bed with no visible signs of life. He found no pulse, no sound of
breathing, and he was cold to touch.
39. As he had no personal radio, the fourth officer instructed some prisoners who
had gathered by the door to seek staff assistance. The wing alarm bell was
directly outside the man’s cell, and was activated by one of the prisoners. The
third officer arrived within seconds, closely followed by the first senior officer.
The third officer told my investigator that he quickly radioed the control centre
to ask for medical assistance.
40. Within a few minutes, the first nurse, the second nurse and the first staff nurse
arrived in response to an immediate emergency call for medical assistance.
The first senior officer instructed officers to clear the landing of prisoners to
allow a clear passage for healthcare, and asked an officer to speak
immediately with the prisoner who alerted the fourth officer, who was clearly
upset. The fourth senior officer told my investigator that, on entering the cell,
he formed the view that there was no sign of life as the man was blue
(cyanosed – a bluish tinge to the skin that occurs following death). The first
senior officer had received first aid training as part of his initial training four
years previously but had not had any refresher training since. As healthcare
staff were about to arrive, he made no attempt to resuscitate the man. He
then kept control over the area until the fourth officer arrived at the same time
as the healthcare staff.
41. When the second and the third nurses arrived it was approximately 11.45am.
They had met the first staff nurse en route, and between them they arrived at
the man’s cell carrying a defibrillator (a machine that applies electrical
impulses to the heart) and other equipment. The second staff nurse told my
investigator that officers informed her on arrival that the man was dead. She
immediately asked the third nurse to call for an ambulance and to ask the
doctor to attend. An emergency ambulance call was made at 11.47am and
shortly afterwards the first doctor arrived. The first staff nurse found no pulse
April 2009 12
and, having requested officers to move the man on to his back, applied the
defibrillator with the first nurse. The defibrillator showed no sign of a
shockable heart rhythm, and indicated that no shock should be applied. The
first doctor repeated the checks and, finding no other signs of life, pronounced
the man dead at 11.55am. The first doctor told my investigator that the man
looked as if he had been dead for a little while and estimated that he might
have died more than half an hour previously.
42. Paramedics arrived at the prison at 11.55am, but left as the man had been
pronounced dead. The cell was then locked and sealed. The Duty Governor
ensured that Risley’s action plan in the event of a death in custody was
followed. This included immediately informing the police and the Coroner’s
office, ensuring the reviews of prisoners on open Assessment, Care in
Custody and Teamwork (ACCT) plans, and arranging visits by the orderly
officer to wings holding prisoners on open ACCTs. All staff and prisoners
were notified about the man’s death, with condolences expressed. A hot
debrief providing immediate support for staff involved in dealing with the man’s
death was held at 12.50pm. Additionally, staff were made aware of further
support available to them from the prison’s staff care and welfare service. No
Critical Incident Debrief is recorded as having been arranged.
43. The first senior officer told my investigator that action was taken to provide the
prisoner who had found the man lying on his bed, with support, and he was
seen by the chaplain the same day. All prisoners were informed that anyone
affected by the death could have support from the Samaritans and Listeners.
(Listeners are prisoners who have been trained by the Samaritans to provide
support for other prisoners.)
44. A Family Liaison Officer was appointed and left Risley at 2.00pm in order to
make contact with a friend of the man, whom he had nominated as his next of
kin. This friend had been recorded on Risley’s LIDS (Local Inmate Data
System) as the man’s next of kin and had also been recorded on the prison’s
F2050 Personal Inmate Record as the person to contact in the event of an
emergency. The Family Liaison had considerable difficulty contacting the
friend who no longer lived at the address given. However, she eventually
spoke with her by telephone and ascertained that she was no longer involved
with the man. She was aware that he had a mother and a brother but could
not help with their names and addresses. Over the following days, with the
assistance of the police and following contact with the man’s former wife, his
mother and brother were identified and notified by telephone of his death. The
Family Liaison, together with the prison chaplain, then visited the family on 18
June.
45. At that meeting, the Family Liaison Officer apologised for the delay in notifying
the family of the man’s death and explained the reasons. She informed them
of the circumstances, and that there had been a post-mortem and the cause
of death was believed to have been a heart attack. The Family Liaison Officer
explained there would be an investigation including a clinical review into the
man’s care, and that there would be a Coroner’s inquest. She provided the
family with local information on support and advice organisations.
April 2009 13
46. On behalf of Risley’s Governor, the Family Liaison Officer offered financial
support to the family to cover funeral expenses and said that the Governor or
his representative would like to attend the funeral. The prison chaplain was
available to perform the funeral service if the family so wished. The prison
chaplain also told the family that a memorial service for the man had been
held in the prison chapel and that 20 of his friends had attended. The Family
Liaison Officer made arrangements to return the man’s property as requested,
and gave the family a letter of condolence from the Governor. The family
expressed appreciation for the visit and support given.
47. A medical practitioner conducted the post-mortem examination on 10 June.
He found the cause of death to be i) ischaemic and hypertensive heart
disease and, ii) morbid obesity. He concluded that the man’s extensive,
severe heart disease could have caused his collapse and death at any time.
He concluded that death was due to natural causes.
48. The Office for National Commissioning replied to the man’s complaint on 24
June. They had not been informed of his death. The response said that
Forest Bank staff had confirmed that the man had neither suffered a
myocardial infarction (heart attack) nor an acute cardiac problem whilst there,
but had been eventually diagnosed with a “chest infection”.
April 2009 14
ISSUES
Clinical Care
49. As noted above, a clinical review was undertaken by a general practitioner on
behalf of Warrington PCT. The clinical reviewer concludes that the man died
of heart disease and that his death could not have been prevented. He
indicates that the man was known to suffer from hypertension and cardiac
failure, but that at the time of his death they had been under adequate control.
While the man’s death was foreseeable, its timing could not have been
predicted.
50. I am satisfied, as is the clinical reviewer, that the man received a high
standard of care at Risley. The liaison and communication between
healthcare staff at Risley and at Preston, and with Warrington Hospital, was
considered and satisfactory. Healthcare staff at Risley sought to ensure the
man was in an appropriate prison setting with sufficient facilities for his
medical needs. This was true both at the point of his initial reception and,
subsequently, when he had respite care at Preston following his discharge
from hospital and before his return to Risley. Following his return, the
healthcare staff, and the first doctor in particular, fully reviewed the man’s
medical needs and appropriately planned for his future care.
Prison Transfers
51. However, I agree with the clinical reviewer that communication between
healthcare staff at Forest Bank and Risley at the point of the man’s initial
transfer was inadequate. I note that the man’s Inmate Medical Records and
an up to date drug chart and medication arrived with him. However, given the
very recent history of repeat emergency transfers to hospital, healthcare staff
at Forest Bank should have ensured there was a full case discussion with
Risley prior to his transfer. That the man had been transferred back to Forest
Bank from Buckley Hill on medical grounds only four days before transferring
to Risley only reinforces the point that there should have been clinical
consultation beforehand.
52. The clinical reviewer makes recommendations that protocols should exist for
the transfer of prisoners with health needs, and that relevant information must
be obtained about a prisoner’s previous admission to another acute trust. I
fully endorse both the clinical reviewer’s recommendations in respect of prison
transfer protocols and obtaining information regarding previous acute
admissions
53. The man was further sentenced on 31 March 2008, having previously been
held at Forest Bank on a shorter sentence and on remand. As required
following sentence, an Initial Categorisation and Allocation (ICA) assessment
was undertaken by Forest Bank on 3 April 2008. My investigator found no
recorded evidence that account was taken of the man’s medical needs in
determining his allocation. Prison Service Order (PSO) 0900 dated 24 July
2000 clearly states that, while security categorisation will be the main factor in
April 2009 15
determining prison allocation, account must also be taken of the prisoner’s
“medical and/or psychiatric needs that may require a particular type of level or
care” (para: 1.6.4). Furthermore, para: 1.7.4 of the same PSO requires that:
“A doctor, registered nurse or healthcare officer must advise on the level
of healthcare required by individual prisoners. This advice must be
recorded at section 6.9 of the [form] ICA 1. The need for confidentiality
must be respected. Reference must be limited to fitness category and
any special needs that may require special consideration when deciding
on appropriate allocation.”
My investigator found no evidence that section 6.9 of the ICA1 document
contained this advice.
54. PSO 3050 of 10 February 2006 sets out standards and guidance for continuity
of healthcare for prisoners between establishments. Whilst the expectation is
that all prisons will provide equivalent primary healthcare, there are occasions
when “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”. Such planning may include consideration
of applying a medical hold when the sending establishment holds on to a
prisoner as there is an outstanding urgent hospital appointment. Restrictions
on transfer or refusal to accept transfer are discouraged except in cases
where, for example, a receiving establishment can identify that it does not
have adequate secondary healthcare provision, such as in-patient
observational facilities.
55. My investigator found little evidence that these standards and guidance had
been applied in the decision to transfer the man to Risley. The first doctor
raised immediate concerns about the man’s transfer there regarding the
significance of his recent hospital admissions and Risley’s lack of suitable
secondary healthcare facilities, an outstanding follow up appointment, and
lack of prior consultation. In the event, the fact that Forest Bank refused to
take the man back was immediately overtaken by the need to admit the man
to hospital. I commend the first doctor for his initiative and practice at this
point, and throughout the period for which he was responsible for the man’s
care, including his decision to undertake a full review of his medical needs on
his transfer back to Risley.
56. My investigator wrote to the Director of Forest Bank asking for clarification of
the circumstances of the man’s transfer from Forest Bank’s perspective. The
Deputy Director did speak to my investigator on the telephone. He undertook
to provide a written response but wanted to acknowledge the letter and
provide the basic details. In the event no written response was received,
although the Deputy Director and my investigator did exchange further e-mails
about the reason for the man being transferred out of Forest Bank.
57. I find that there was sufficient evidence to suggest that the man had complex
healthcare needs which warranted, at the minimum, direct communication and
consultation with Risley healthcare staff in advance of transfer. The man had
April 2009 16
an outstanding hospital appointment to review his Chronic Obstructive
Pulmonary Disorder and a previous hospital appointment for an angiogram
which is not recorded as having been followed up. Whether such consultation
would have resulted in a medical hold or a restriction on transfer will not be
known. However, it would have much improved the continuity of care
between the establishments and enabled Risley to have given Warrington
Hospital more timely information on the man’s admission.
58. Forest Bank’s refusal to take the man back was based on their view that he
met Risley’s allocation criteria. Insofar as Risley is a category C training
prison this is correct. However, it does not take into account the question of
whether there are sufficient secondary healthcare facilities at Risley. In my
view, this suggests that the Prison Service should review and clarify their
agreed allocation criteria for inter-prison transfers.
59. Given these issues I make the following recommendations:
The Director of Forest Bank should ensure that all Initial Categorisation
and Allocation assessments and decisions take account of prisoners’
medical needs, and that the healthcare advice in respect of these is
appropriately recorded on the ICA1 document.
The Director of Forest Bank should ensure that a system is in place to
provide for prior communication and consultation with the receiving
prison’s healthcare department on proposed transfers of prisoners with
complex health needs, particularly where there is an outstanding follow
up hospital appointment.
The Prison Service should undertake a review and, if necessary, clarify
the agreed allocation criteria for individual prisons, to take into account
which prisons have adequate secondary care facilities. This should in
turn ensure that a protocol is in place for inter-prison transfers which
makes sure that prisoners with complex health care needs are allocated
to establishments with the necessary healthcare facilities.
Raising Alarms
60. When the man was found lying in his cell, the fourth officer asked prisoners
gathered at the cell door to seek the assistance of staff. He did so as he was
not equipped that day with a radio and thought that he should remain in the
cell with the man. As a matter of good practice I would say that prison officers
should not ordinarily rely on asking prisoners to raise an alarm or seek staff
assistance in these circumstances. However, on this occasion I note that the
wing alarm button was just adjacent to the man’s cell and, given this, the
request was justified. I make no recommendation in this regard, beyond
drawing this general point to the attention of the Governor.
April 2009 17
Family Liaison
61. There was a delay of some seven days in informing the man’s mother,
brother, and immediate family of his death. This was due to the electronic
LIDS database at Risley recording only his friend’s details as next of kin (this
was repeated on the Personal Inmate Record as the person to be notified in
the event of an emergency). Risley staff, in conjunction with the police, went
to considerable lengths to identify contact details for the man’s immediate
family. However, my investigator did find on other prison paper records the
correct next of kin details for the man’s mother which, had they been read
earlier, might have reduced some of the delay in informing the family. Beyond
making the point that it is worth reviewing paper records for next of kin details,
I make no formal recommendation as it is clear that Risley staff displayed
much effort and sensitivity in their contact with the man’s family. Indeed, I
would wish them to know that their actions reflected well on themselves, their
jail and their Service.
Conclusion
62. The man was sick and his needs were well served at HMP Risley. However,
the way in which his transfers from HMP Forest Bank were managed was
simply not acceptable. I trust that copies of this report can be shared with the
Office for National Commissioning and with the Controller and Chair of the
IMB at Forest Bank, as well as with its Director.
April 2009 18
RECOMMENDATIONS
1. The Director of Forest Bank should ensure that all Initial Categorisation and
Allocation assessments and decisions take account of prisoners’ medical
needs, and that the healthcare advice in respect of these is appropriately
recorded on the ICA1 document.
The Prison Service have accepted this recommendation. They say that the
OCA (Observation Classification and Assessment) contact Healthcare for all
transfers. Healthcare check all ongoing needs and outstanding appointments.
2. The Director of Forest Bank should ensure that a system is in place to provide
for prior communication and consultation with the receiving prison’s healthcare
department on proposed transfers of prisoners with complex health needs,
particularly where there is an outstanding follow up hospital appointment.
The Prison Service have accepted this recommendation. They commented
that the man was not a healthcare in-patient at the time of his transfer, and
that liaison does take place between healthcare departments before transfer.
3. The Prison Service should undertake a review and, if necessary, clarify the
agreed allocation criteria for individual prisons, to take into account which
prisons have adequate secondary care facilities. This should in turn ensure
that a protocol is in place for inter-prison transfers which makes sure that
prisoners with complex health care needs are allocated to establishments with
the necessary healthcare facilities.
The Prison Service replied as follows:
“N.O.M.S and Offender Health believe a review of the allocation criteria for
individual prisons to take into account adequate secondary care facilities is
unnecessary. Any prisoner requiring secondary care would need to have this
undertaken in, or under the direction of, an NHS facility (definition of
secondary care being taken as a service provided by a medical specialist who
generally does not have first contact with patients ie referred).
All establishments should provide the same level of care as a normal general
practice. In general therefore, if the patient would be managed at home
outside of prison, then the prison should aim to provide health care on the
wing community. Transfer on health care grounds should not be requested or
reception refused unless it is clearly indicated why the care is outside the
bounds of normal primary care and why secondary care cannot be provided
locally.
Policies already exist for sharing medical information on prisoners transferring
and stricter adherence to these policies, rather than introducing new
protocols, is considered more appropriate. Prison Service Order (PSO) 3050,
Continuity of Care, and PSO 6200, Transfers of Prisoners, are quite specific.
The former, in particular, clarifies the allocation procedure, the sending
prison’s responsibility for gathering the required information and ensuring
April 2009 19
continuity of care, and the need to communicate directly with the receiving
health care team in advance of the transfer in complex situations.
Sections 5.21 – 5.23 of PSO 3050 state that with regard to the transfer of
prisoners with significant health issues:
“5.21 The following guidance should be followed where there is a
significant health issue requiring the transfer of a prisoner and local
resolution has not been possible. It should only apply if transfer to
the NHS is not more appropriate and it does not alter the general
principles and normal communication between clinicians indicated
above for routine transfers.(DN: It should be noted that transfer on
health grounds cannot be requested or refused unless it can be
clearly stated why the care is outside the remit of "normal" primary
care and why secondary care cannot be provided locally)
5.22 The sending establishment will be responsible for ensuring
standards of continuity of care and should provide the following
information:
Inmate details including age, offence, date of sentence and tariff
Short medical history – including past medical history, current
health issues, current treatment
Summary of relevant specialist opinion
Current health needs – medical/nursing/social care
Prison issues relevant to health – e.g. mobility, behaviour, risk of
self-harm
Any other factors affecting allocation – e.g. dangerousness,
requirement for offending behaviour courses
Assessment of future health needs
The prisoner’s views (with possible exception of Category A
prisoners)
Consent of prisoner to release of above information if relevant,
e.g. to Lifer Management Unit.
Concise summary of health needs. This should focus on practical
needs and avoid generalisations such as locate flat or 24-hour
health care.
Any risk of self-harm information/care plan
5.23 The process will vary between cases but may need to include a
multidisciplinary case conference. This should involve the patient at
relevant points and assessments and participation as appropriate from
the NHS, social services or other organisations relevant to the case,
including the likely receiving prison. Where the prisoner is on an open
Assessment, Care in Custody and Teamwork (ACCT) Plan (F2052SH)
any case conference must involve the ACCT Case Manager (or Unit
Manager in the case of F2052SH).
April 2009 20
Under PSO 1810 – Maintaining Order in Prisons, Area Managers agree a
yearly protocol with Population Management on the management of prisoners
between prisons. Included in these protocols is a section on the healthcare
needs of prisoners and these sections can be reinforced to ensure continuity
of health care is properly adhered to.
April 2009 21