Individual at Rye Hill

Investigation into the circumstances surrounding the
death of a man, who was a prisoner at HMP Rye Hill,
on 5 October 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
November 2006
This is the report of an investigation into the death of a man who was a
prisoner at HM Prison Rye Hill. The man died on 5 October 2005 at a local
hospital. A post mortem examination concluded that he died of
cardiopulmonary arrest due to infective endocarditis and cardiomegaly, due to
a prosthetic aortic valve.
During his time in hospital, the man was visited regularly by his family. I wish
to take this opportunity to offer my sincere condolences to them for their loss,
and to apologise for the delay in producing this report.
The investigation was carried out on my behalf by one of my Investigators. An
independent review of the man’s medical care in prison was carried out by my
Deputy Ombudsman.
I would also like to thank the Director and staff of HM Prison Rye Hill for their
full and ready co-operation during the investigation.
I make one recommendation.
This version of my report, published on my website, has been amended to
remove the name of the deceased and the names of staff and prisoners who
were involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2006
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CONTENTS
Summary
Investigation methodology
Background
HM Prison Rye Hill
Key Events
Issues
Recommendations
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SUMMARY
The man was first received into custody on remand on 8 September 1986. He
was convicted and sentenced to life imprisonment on 17 December 1986. He
spent time at a number of prisons, before transferring to HMP Rye Hill on 6
May 2005.
The man had suffered a number of problems with his heart since childhood.
On two occasions in 2002, whilst at HMP Full Sutton, he collapsed on the
wing. An Echo Cardiogram (ECG) taken after the second of these indicated
cardiac changes consistent with ischaemic heart disease. Following this, he
underwent an aortic valve replacement on 3 October 2003.
In January 2004, the man began to complain of pain in his left hip. An x-ray
on 30 June 2004 revealed severe osteoarthritis and, around a month later, he
began a course of physiotherapy. Despite the physiotherapy, the man’s
osteoarthritis deteriorated and, on 6 April 2005, he was placed on a waiting list
for a total hip replacement. This was scheduled for 8 August, but was later
cancelled. No further appointment was made before his death.
On 15 September 2005, the man was admitted to the healthcare centre at
Rye Hill after complaining of shaking and sweating overnight. In the early
morning of 16 September, he contacted the night nurse, to say that he could
not stand up on account of a loss of strength in his left leg. The night nurse
also noted that the man’s left arm was limp and the left side of his face
appeared ‘dropped’.
The night nurse contacted the on-call doctor to discuss the man’s condition,
and was advised to observe him regularly through the night. At around
8.00am, the morning staff noted that his condition had deteriorated and an
ambulance was called. The man was taken to a local hospital. Sadly, his
condition continued to deteriorate, and he died at 11.50pm on 5 October
2005. The cause of death was recorded as cardiopulmonary arrest due to
infective endocarditis and cardiomegaly due to a prosthetic aortic valve.
The clinical review concludes that the man was treated appropriately whilst at
Rye Hill. I make one recommendation, with regard to establishing contact
with next of kin.
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INVESTIGATION METHODOLOGY
The investigation was opened on 6 October 2005, when my investigator
issued notices announcing the investigation and its terms of reference to staff
and prisoners at Rye Hill. The notices included an invitation to those who
wished to submit information relating to the man’s death to make themselves
known. One prisoner came forward as a result.
On 10 November 2005, my investigator visited Rye Hill and familiarised
himself with the Healthcare Centre and the wing on which the man had lived.
He was given access to the man’s prison files, including the Medical Record.
An independent clinical review into the man’s health needs whilst he was in
custody at Rye Hill was carried out by my Deputy Ombudsman, a qualified
clinician. My Deputy Ombudsman visited Rye Hill on a number of occasions
and interviewed staff.
One of my family liaison officers contacted the man’s sister, on 16 November
2005. She said that she did not have any issues to raise about the man’s
care whilst he was in prison. However, she did express concern that it had
taken the prison a week to let her know that the man was in hospital.
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BACKGROUND
The man was born in 1948, and was 56 years old at the time of his death. He
had problems with heart disease throughout his life, including childhood
surgery for a coarctation of the aorta (a narrowing of the aorta, the main artery
taking blood from the heart to the rest of the body), and was epileptic.
The man attended a comprehensive school, leaving at the age of 15 to take
up employment as a store man. He did not stay in the same job for long and
worked for a number of different employers, mostly as a labourer, until 1980,
after which he was unemployed. He was convicted of a number of offences
over this period, mainly for theft and burglary, although he did receive a
sentence of five years imprisonment in 1970, following a conviction for arson.
On 17 December 1986 the man was convicted of the murder of two people,
and sentenced to life imprisonment with a tariff of 20 years. He was initially
held at HMP Birmingham and had spells at Gartree, Long Lartin, Nottingham,
Whitemoor and Full Sutton before transferring to Rye Hill on 6 May 2005.
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HM PRISON RYE HILL
HMP Rye Hill is a privately managed category B training prison, for adult male
prisoners serving sentences of four years or more. It is run by Global
Solutions Ltd (GSL) and has been operating since early 2001. Rye Hill has an
eight bed in-patient Healthcare Centre, which is not included in the certified
normal accommodation of 600 prisoners.
Healthcare in Rye Hill is delivered by contract from Primecare FMS and
accountability is to the Area Operational Manager for Primecare. Healthcare
staff working in the Healthcare Centre are all medically qualified. A local
General Practitioner provides a surgery each week-day. Medical cover is
provided during the weekends, evenings and overnight by the local practice.
Nursing care is provided on a 24 hour basis.
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KEY EVENTS
The man who died was initially received into HMP Birmingham on remand on
8 September 1986, before being convicted and sentenced to life imprisonment
on 17 December. He attempted suicide by cutting his wrists around three
months after sentencing. Over time, however, the man became accustomed
to his situation, and was generally regarded as a polite and well-mannered
prisoner at each jail where he was located.
Since childhood, the man had had problems with his heart. At the age of 14
he had surgery for a coarctation of the aorta. During the first 15 years or so of
his sentence he endured a number of different health problems, including hip
and back pain, each of which was dealt with at the time.
On 13 September 2002, whilst at Full Sutton, the man collapsed on the wing
and was admitted to healthcare for a review. He told the nurse who saw him
that he had collapsed five weeks previously, but had not reported this. He
had also previously fainted in the kitchen at Gartree in November 2000. On
24 December 2002, the man again collapsed on the wing and was
unconscious for around three minutes. An ECG was taken by a GP at Full
Sutton, which indicated cardiac changes consistent with ischaemic heart
disease. Despite this, and advice to the contrary, the man refused admission
to the Healthcare Centre and returned to the wing. Advice was given by the
GP at Full Sutton that if he suffered any further dizzy spells he should be
admitted to hospital.
On 3 October 2003, the man underwent an aortic valve replacement at a
major hospital in the area. Following the operation, he was reviewed on a
weekly basis until the end of the year. He reported no significant problems,
other than pain on either side of his chest scar which, on examination, was
found to be a muscular rather than a cardiac problem.
In January 2004, the man complained of pain in his left hip, groin and upper
leg. He was prescribed a course of aspirin to ease the pain. An x-ray on 30
June revealed that he had severe osteoarthritis. He was kept on the same
medication and, at a review on 26 July, was prescribed a course of regular
physiotherapy.
Despite the physiotherapy, the man’s osteoarthritis got worse and his pain
increased. On 6 April 2005, he was placed on a waiting list at a local hospital
for a total hip replacement. The procedure was scheduled for 8 August, by
which time he had transferred to Rye Hill on a progressive move (whereby a
prisoner moves to an establishment with a lower security category in order to
undertake the offending behaviour programmes necessary to facilitate his
future release on licence). He therefore returned to Full Sutton on 4 August in
preparation for the hospital admission, only for the operation to be cancelled
by the hospital. The man was transferred back to Rye Hill on 16 August. No
further appointment was made before his death.
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On 15 September, the man was admitted to the Healthcare Centre at Rye Hill
after complaining of shaking and sweating overnight. He was noted to have
swelling down the left side of his face and was very pale. On arrival at the
Healthcare Centre at 1.45pm, his temperature was recorded as 40.3° Celsius
(the normal body temperature is around 36.9°C). Fan therapy was therefore
applied in an effort to cool him down. The prison GP was contacted and he
advised the commencement of paracetamol and amoxicillin.
At a later assessment at 3.30pm, a nurse recorded a drop in temperature to
39.6°C. Fan therapy was continued, and the man was encouraged to take on
more fluids. He was assessed again at 7.00pm, by which time his
temperature had dropped further to 38.9°C. He also said that he felt very
tired. At the same time, the man refused food but took two cups of water.
At 12.35am on 16 September, the man alerted the night nurse that he could
not get up to go to the toilet. He complained of a loss of strength in his left leg
which meant that he was unable to stand. The night nurse also noted that the
man’s left arm was limp and that the left side of his face appeared ‘dropped’.
His blood pressure and pulse were taken by the night nurse. His blood
pressure, at 80/50, was below the normal average of 120/80, and his pulse
was slightly elevated at 95 beats per minute. The man’s temperature was
also taken, and it had fallen to within normal limits.
The night nurse administered 1g of paracetamol for the pain in the man’s left
arm. The night nurse also contacted the prison GP to discuss the situation.
The prison GP agreed that it sounded like a cerebrovascular accident (a
stroke or stroke-like incident). He advised the night nurse to give 300mg
aspirin, and to take regular observations around every two hours.
The night nurse took observations on a further four occasions through the
course of the night, the last of which was at 7.00am. The man’s observations
remained stable through this period. At around 7.30am, a day nurse took over
from the night nurse.
At 8.00am, the day nurse noted that the man’s condition was deteriorating
slowly. His speech was becoming increasingly slurred, and he was having
spells of confusion. An ambulance was therefore called, and the man was
taken to a local hospital at 8.20am.
When he was transferred to hospital, the man was initially restrained by
double cuffs as he was a category B prisoner. This was soon changed to an
escort chain as his condition deteriorated. At 8.00pm, his condition was
described as critical, by which time the man had transferred to the emergency
admissions unit at a larger hospital. On 17 September, it was confirmed that
he had suffered a major stroke and his prognosis was described as very poor.
On 19 September, the man was diagnosed with endocarditis (an infection of
the lining of the heart). On the same day, following the duty security
manager’s visit, his restraints were removed on account of his deteriorating
condition.
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The man’s next of kin were recorded on LIDS (Local Inmate Data System, the
prison-based computer system that records prisoner’s details) as being his
parents, with a contact address but no telephone number recorded. On 16
September, the local police were therefore asked to visit to inform them of
their son’s transfer to hospital. Sadly, it became apparent that his father had
passed away and his mother was not well enough to understand that the man
was ill. The police were subsequently asked to locate and inform a further
member of the family.
A note in the man’s medical record on 17 September says that his next of kin
had been established as his daughter (this should have read step-daughter),
and that she was to be informed later that day. The man’s sister was traced
through his telephone records and told of his illness on 24 September.
Sadly, the man’s condition did not improve following his move to hospital and,
at 11.50pm on 5 October, he died. The post mortem recorded the cause of
death as cardiopulmonary arrest due to infective endocarditis, and
cardiomegaly, due to prosthetic aortic valve.
The funeral was held on 25 October 2006. The prison provided funding to
help meet the costs.
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ISSUES
Quality of healthcare provided at Rye Hill
One prisoner at Rye Hill came forward to speak to my investigator during the
course of the investigation. He said that he worked as a cleaner in the
Healthcare Centre, and had seen the man when he was admitted on 15
September 2005. The prisoner said that it was his opinion that the man had
suffered a stroke on 15 September, and that he should have been taken to
hospital on that day rather than a day later on 16 September.
The clinical review, conducted by my Deputy Ombudsman, concludes that the
man was treated appropriately whilst at Rye Hill. The reviewer also notes that
the man was appropriately transferred to hospital when it became apparent
that his condition was deteriorating.
The reviewer considers the man’s clinical records from Rye Hill to be
comprehensive, and notes that they provide clear evidence of the care that he
received. However, she says that there are numerous occasions on which
staff sign after an entry, but do not provide their name in an easily identifiable
format. The reviewer makes the housekeeping point that staff should be
reminded of the need to print their name after their signature. I agree.
Contact with the man’s family
When he was taken to hospital on 16 September, staff at the prison attempted
to contact the man’s next of kin in order to tell them what had occurred. His
next of kin were recorded as being his parents, and the local police were
asked to visit them as no telephone number was registered. Sadly, his father
had passed away and his mother was not well enough to understand that the
man was ill. Prison staff were unaware of these circumstances.
The man’s step-daughter was traced on 17 September and told what had
happened and about his condition. His sister was traced through the man’s
telephone records and informed on 24 September. When my family liaison
officer spoke to his sister, she expressed concern that it had taken the prison
a week to inform her of her brother’s illness. After viewing the draft report, the
man’s sister repeated her anger that it had taken so long for the prison to
contact her.
In her clinical review, my Deputy Ombudsman suggests that it would be good
practice for the healthcare admission sheet to have a section identifying next
of kin and their contact details in case of an emergency. I agree with this
suggestion. However, I consider that it is imperative that staff throughout the
prison, not just in healthcare, have easily accessible up to date information on
a prisoner’s next of kin. Given the distress caused to the man’s sister by the
delay in contacting her, I therefore make the following recommendation.
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The Director should ensure that appropriate steps are taken to update
next of kin details recorded in prisoner’s core records, and ensure that
these are reviewed on a regular basis.
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RECOMMENDATIONS
The Director should ensure that appropriate steps are taken to update
next of kin details recorded in prisoner’s core records, and ensure that
these are reviewed on a regular basis.
Accepted – this will be completed annually in line with the OASys reviews
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