Individual at Rye Hill

Investigation into the death of a man at HMP Rye Hill
on 21 November 2004
Prisons and Probation Ombudsman for England and Wales
March 2006
In the early hours of 21 November 2004, the man was taken ill in his cell at HMP Rye
Hill. He complained of chest pains and was taken to St Cross Hospital for treatment.
Shortly after 8.00am, he suffered a serious cardiac arrest and was pronounced dead at
8.45am. He was 48 years old.
The man had a history of heart problems and was on regular medication for his
condition.
This investigation was carried out on my behalf by one of my investigators. A clinical
review was conducted. I am grateful to the then Director of Rye Hill and his staff for
their co-operation throughout the investigation. I regret the long delay in issuing this
report.
The man had not given the name of anyone as his next of kin and, poignantly, no
members of his family have been found.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2006
2
SUMMARY
The man was a 48 year old single man serving a long sentence for serious sexual
offences. He had an extensive criminal history and had spent several years of his life in
Europe where he had also offended. He had no contact with any family members and
few friends in this country.
Whilst on the continent, the man had developed serious heart problems. He had
undergone a heart valve replacement shortly before returning to England and
committing the offences for which he was imprisoned. Throughout his sentence, he
received treatment for his condition and had to take regular medication to maintain the
fragile state of his health. There is some evidence to indicate that he was not diligent in
adhering to his prescribed treatment regime, although he was generally cooperative and
compliant when reminded of it.
In the early hours of 21 November 2004, the man rang his cell bell in HMP Rye Hill and
alerted staff to the fact that he was suffering severe chest pains. The duty nurse
attended and examined him. After consultation with the duty doctor, arrangements
were made for him to be taken by ambulance to the local hospital. During the course of
the next few hours, his condition grew steadily worse and shortly after 8.00am he
suffered a fatal cardiac arrest.
3
INVESTIGATION METHODOLOGY
1. My office was contacted following the man's death and a formal investigation was
initiated. I appointed as my investigator. At the same time, a police investigation
was opened on the instructions of the Coroner. The purpose of the police
investigation was to determine if there were any suspicious circumstances
surrounding the death of the man and to assist the Coroner’s inquest.
2. In order to ensure that the police inquiries were not hampered or compromised in
any way, no formal interviews or detailed discussions were carried out by the
investigator until after the police inquiries had concluded. This took a considerable
length of time due to a long delay in obtaining a full medical report from the prison.
3. A review of all the available documentation relating to the man was examined. At
the end of March 2005, the final medical report was received by the police and their
investigation formally concluded. There were no suspicious circumstances
identified. Copies of all the interviews and information obtained by the police were
made available to the investigator.
4. The post-mortem established that the man had died from a myocardial infarction
(heart attack). This investigation is therefore concerned primarily with the medical
care the man received during his time in prison. A clinical review of the care and
treatment of the man has been conducted by an experienced clinician appointed by
my office.
4
HMP RYE HILL
5. HMP Rye Hill is a purpose-built category B adult training prison, opened in 2001 and
run by a private company, GSL, on a contract with the Home Office. The certified
normal accommodation is 600, but this can be increased to a maximum operating
capacity (maximum crowded capacity) of 664 if needed.
6. All the prisoners are male, serving over four years and there is capacity to hold up
to 120 life sentence prisoners.
7. In the four years after the prison opened there were nine deaths in custody in
addition to that of the man. There were no deaths in 2001, four in 2002, three in
2003 and two other deaths in 2004. The investigations found no serious
shortcomings and made only minor recommendations regarding procedures.
8. The last Standards Audit report were satisfied with the procedures and plans for
dealing with prisoners at risk and for handling deaths in custody.
5
KEY EVENTS
9. On the night of 20 November 2004, two Prison Custody Officers were on duty in
Andrews Wing. Shortly before 1.30am, there was a call from one of the cells. Both
the officers were in the wing office at the time, together with a third officer from
another wing. He had been on the unit to carry out some administrative tasks. One
of the officers went to answer the call, which is known to have been made by the
man.
10. When he arrived at the cell, the officer opened the door flap and saw the man
standing by the door. He told the officer that he was suffering from chest pains. He
also said they had been going on for about half an hour, but had been so severe
that he could not get off the bed to ring his bell. Eventually they had eased
sufficiently to allow him to call for help. The officer went back to the office and
called the Healthcare Centre, asking the duty nurse to attend. He then contacted
the Night Manager, informing him of the situation and requesting his attendance.
11. On receiving the call, the nurse contacted the Communications Centre asking for an
officer to collect him and take him to the wing. This is normal procedure at Rye Hill
during the night when only identified officers carry keys. The nurse then gathered
together his equipment and within a few minutes the Night Manager arrived.
Together they went to Andrews Unit, arriving five to ten minutes after the initial call
had been made.
12. The Night Manager had to contact the Duty Director for permission to open the cell.
This too is normal procedure at Rye Hill although, in life-threatening situations,
officers are instructed to open the cell immediately. The nurse, Night Manager and
officers entered the man's cell where they found him sitting on his bed. He
complained of pains down the left side of his body and seemed to be short of
breath. The nurse was aware of the man's medical condition and checked his blood
pressure, pulse and heart rate. She then asked him when he had last used the
GTN spray that he had been given to assist him with his heart problem. The man
said that he had used it only about ten minutes earlier. However, when the nurse
asked him to use it again, the man had to search for it. He eventually found it in a
cardboard box under several other items.
13. The man used the spray as instructed by the nurse, who then re-checked blood
pressure, pulse and heart rate. On both occasions, these were within normal limits.
However, the nurse was concerned about the man’s condition, suspecting that he
might have suffered an angina attack. She informed the man and the other staff
that she would contact the Duty Medical Officer for advice. Everyone then left the
cell. The nurse spoke to the Duty Medical Officer who instructed thattThe man
should be taken to the outside hospital for assessment and treatment.
14. The Night Manager made arrangements for an ambulance to be called and for
escorting officers to be made available. The Duty Director was then informed of the
situation. Having done so, the Night Manager returned to he man's cell with the
6
nurse and officers to inform him and get him ready. On opening the cell again, they
found the man sitting on his bed smoking a cigarette. The officers thought that he
seemed a bit better, but the nurse felt that his clinical condition had not changed
sufficiently that he should not attend the local hospital.
15. The man was informed that he would be going to hospital and was asked to get
dressed. One member of staff fetched a wheelchair and the man was able to walk
slowly down the stairs. The man was holding a hand to his chest and appeared to
be in some pain and discomfort. He was taken to the Healthcare Centre at about
3am to await the arrival of the ambulance. The ambulance arrived some five
minutes later and he was put onto it, escorted by the two custody officers. The
ambulance left the prison at 3.15am. During the journey, one of the paramedics
tried to put some electrodes on to the man's chest, at which he became quite
agitated. The officers managed to calm him down and the rest of the journey
passed without incident.
16. On arrival at the hospital, the man underwent several tests and clinical examination,
but his condition gradually worsening. At about 5.20am, the doctors decided that he
should be admitted to the Critical Care Unit. An Electro-Cardiogram (ECG) was
taken at 7.45am which indicated that his condition had worsened further. At around
8.00am, he suffered a cardiac arrest from which he did not recover. The man was
pronounced dead at 8.45am.
7
FINDINGS AND CONCLUSIONS
17. The man had a long history of offending behaviour. He had spent a considerable
length of time travelling and living in other European countries. He apparently had
no contact with any family members and did not list anyone as his next of kin.
Despite many efforts, no family members have been found.
18. The man had a history of heart problems, dating back several years. In 2003, whilst
living in Italy, he underwent an aortic valve replacement operation. When he
returned to England, he continued to receive medication and regular treatment for
this heart condition.
19. During the course of his sentence he behaved well and gave no cause for concern.
He generally followed the advice and treatment regime prescribed for him, although
he may have been a little lax in adhering to it at times.
20. There had been no noticeable deterioration in the man’s state of health just prior to
him becoming seriously ill. A routine appointment had been made for him to go to
outside hospital for examination, but he died before this appointment was due.
21. The man rang his cell call bell at about 1.30am on the morning of 21 November and
told the officer that he had severe chest pains. These had apparently been going on
for about 30 minutes, but he had been in too much pain to get to his bell earlier.
The officer called for the duty nurse to attend and informed the Night Manager who
also attended.
22. The nurse had to wait for someone to take her to the wing, since she is not allowed
to carry keys. Although not critical in the man's case, the inevitable delay could
have potentially serious consequences. The present practice whereby the nurse
must wait for a designated officer to get her from the Healthcare Centre to a cell
may create a delay which could prove crucial in saving life.
Rye Hill’s procedures for dealing with medical emergencies at night should be
reviewed to ensure that there is no unnecessary delay in the nurse attending a
prisoner in his cell.
23. When the nurse got into the cell to examine the man, she formed the opinion that he
might have suffered an angina attack. She asked him about the GTN spray which
he had been prescribed and he said that he had used it only ten minutes earlier.
However, when she asked him to use it again he had some difficulty finding it. It
seems entirely possible that he had not in fact used the spray at all.
8
24. The nurse was sufficiently concerned about him that she decided to speak to the
duty doctor. She called him from the wing office at about 2am. The man was
locked up in his cell whilst she did so. No member of staff stayed with him during
this time. Although there was no clinical need for someone to monitor the man
continually, it is surprising that no-one stayed with him to offer reassurance.
Leaving a sick and worried prisoner alone in his cell is likely to increase the stress
and concern, and may exacerbate the situation. In this case, a prisoner with a
serious heart condition, complaining of chest pains, was left unattended and
decided to smoke a cigarette. Clearly, this was not in the man’s best interests, and
the presence of an officer might have prevented him from making his condition
worse.
The director should draw my comments on this matter to the attention of his
senior colleagues.
25. The doctor instructed that the man should be taken to outside hospital. The Night
Manager prepared the documentation and arranged for the two wing officers to
accompany the man. One of the officers went with the nurse to tell the man and
they found him sitting on his bed smoking. Although the officer thought he seemed a
little brighter, the nurse correctly felt that his clinical condition had not improved.
The man got dressed and walked slowly down the stairs to a wheelchair that had
been brought from healthcare. He was then wheeled to the Healthcare Centre to
wait for the ambulance.
26. In an emergency, the Night Manager can arrange transfer to hospital without
seeking prior permission from the duty director. In non-emergency situations, as
with the man, prior permission must be obtained. This meant that there was a
period of one and a quarter hours from the time the doctor ordered the transfer to
hospital to the ambulance arriving at the prison. It seems illogical that there should
be a difference when a medical instruction has been given that requires a prisoner
to be transferred to secondary care services. Furthermore, the joint guidance from
the Prison Service and Department of Health, issued in March 2004, highlights the
need to ensure that a protocol exists to ensure immediate access to hospital
treatment.
Rye Hill’s procedure for summoning emergency medical assistance should be
reviewed and an appropriate protocol drawn up to maximise patient care.
27. The ambulance left the prison about 3.15am, arriving at St Cross Hospital about
fifteen minutes later. At the hospital, the man was immediately examined and
underwent treatment. It appeared that his condition was deteriorating and he was
admitted to the Critical Care Unit. He died just after 8.00am that morning..
9
Additional recommendations from the clinical review:
All Healthcare staff should be reminded of the requirements of accurate and
contemporaneous record keeping in accordance with the requirements of the
GMC and NMC.
A local policy should be developed and implemented for the management of
prisoners who refuse to comply with prescribed treatment.
10