Individual at Shepton Mallet

The death in custody of a male prisoner
at HM Prison Shepton Mallet on 6 July 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2005
Contents
Part One 1. Introduction
2. Summary
3. Investigation methodology
4. The deceased
5. Shepton Mallet prison
6. Events leading to the prisoner’s death
7. Concerns expressed by the prisoner’s family
8. Emergent issues
.
9. Conclusions
10. Recommendations
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This is the report of an investigation into the circumstances surrounding the
death of a male prisoner at HM Prison Shepton Mallet on 6 July 2004. The
prisoner collapsed and died in the prison at approximately 12:57 that day.
A post mortem examination showed that the prisoner’s death was caused by
a pulmonary embolus and deep vein thrombosis.
The investigation was carried out on my behalf by my colleague. An
independent clinical review was commissioned into the management of the
prisoner’s health needs while he was at Shepton Mallet prison. This was
carried out by a representative of the South West Dorset Primary Care Trust.
My thanks go to the Primary Care Trust for their valued contribution to this
investigation and to the Governor and staff of Shepton Mallet whose ready
cooperation has been much appreciated.
I make six recommendations.
I understand that the symptoms of pulmonary emboli are difficult to detect.
The independent clinical review suggests that this may be particularly so
when a patient also presents - as did this prisoner - with symptoms of anxiety,
a tendency to over-breathe, and suggestions of asthma. In this respect, as in
other aspects of his life, the prisoner was not blessed with good fortune.
Stephen Shaw CBE
Prisons and Probation Ombudsman
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2. Summary
The prisoner was born at Ashton under Lyne, Lancashire, in 1948. He was
handicapped from birth by a cleft palate, poor eyesight, and a degree of
deafness.
In 1969, he was found guilty of arson and sentenced to life imprisonment. He
was released on a life licence in 1977 but recalled to prison in 2002 after a
further offence. After being recalled, the prisoner was initially held at
Manchester prison, but was transferred to Dartmoor in June 2003. He was
moved to Shepton Mallet in July 2003.
Whilst at Shepton Mallet, the prisoner developed breathing difficulties and
chest pains. He collapsed and died in the prison on 6 July 2004 at the age of
56. A post mortem examination concluded that he died from pulmonary
embolus and deep vein thrombosis.
The recommendations made in this report derive in large part from the clinical
review. They relate to the improvement of routine and emergency medical
management procedures, diagnostic and referral issues, and record keeping.
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3. Investigation methodology
The investigation was opened by my colleague on 8 July 2004 when notices
to staff and to prisoners announcing the investigation were issued within the
establishment.
On 15 July my investigator met with the Governor, the Head of Custody, the
chairman of the local branch of the Prison Officers’ Association, and the
chairman of the establishment’s Independent Monitoring Board. They were
briefed on the nature and scope of the investigation and asked to encourage
staff and prisoners to submit any concerns or views they had to my
investigator.
An independent clinical review of the management of the prisoner’s
healthcare needs whilst he was in custody at Shepton Mallet was carried out
by a representative of the South West Dorset Primary Care Trust.
My investigator met with the prisoner’s sister and her family at Shepton Mallet
on Sunday 18 July 2004. They raised a number of concerns that they wanted
the investigation to address.
No staff or prisoners were interviewed.
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4. The deceased
The prisoner was born, one of three siblings, at Ashton under Lyne,
Lancashire. Prior to entering prison in 1969, he had lived with his mother and
father. The prisoner was born handicapped by a cleft palate, poor eyesight,
and a degree of deafness. He had little social life beyond his family and the
church and never had a girlfriend. He had also suffered from epilepsy for a
number of years.
The prisoner had been in trouble with the police since the age of 11. In 1962,
he was sent to an Approved School for offences of arson and malicious
damage. He left Approved School at the age of 16 with no qualifications, but
was nevertheless always employed, normally in the retail trade.
At the time of the offence which resulted in his imprisonment in 1969, the
prisoner was living with his parents and two sisters in Middleton. He was
charged with setting fire to an extension building at the rear of the family
house. He was found guilty and, aged 21, was sentenced to life
imprisonment. He was released on a life licence in 1977 but recalled to prison
in 2002 after committing a further offence. The prisoner was initially held at
Manchester prison, but was transferred to Dartmoor in June 2003 and moved
again to Shepton Mallet in July 2003.
Staff described the prisoner as a polite but quiet person. He was friendly with
a select group of other prisoners, regularly attended church services, and
undertook the offending behaviour work he was set, as well as education
classes.
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5. Shepton Mallet prison
Shepton Mallet is a small closed prison for life sentenced prisoners, and is
located in the market town of the same name in Somerset. The establishment
can hold up to 186 prisoners.
Her Majesty’s Chief Inspector of Prisons carried out a short unannounced
inspection of Shepton Mallet in November 2003. No recommendations were
made in respect of healthcare.
Three prisoners have died at Shepton Mallet in the last two years: two from
natural causes and one by suicide.
Healthcare at Shepton Mallet is provided by the Mendip Primary Care Trust.
The prison has a very small healthcare centre with no in-patient facilities. At
the time of the investigation, the healthcare staff complement comprised:
A healthcare manager
A registered general nurse
A registered mental nurse
Two doctors
Administrative support for the healthcare centre is provided for only 16 hours
per week.
The centre is open from 7:30am until 5:30pm seven days a week and the staff
remain on call to the prison outside working hours.
The establishment’s role as an all-lifer establishment is relatively new.
However, my investigator saw evidence of good staff/ prisoner relationships
and a positive regime.
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6. Events leading to the prisoner’s death
The following events are recorded in the prisoner’s Medical Record (IMR):
25 July 2003
The prisoner arrived at Shepton Mallet from Dartmoor.
He told the doctor that he suffered from blackouts. He was
located in a shared cell in the main prison.
28 July 2003
The prisoner told the doctor that he had become increasingly
short of breath on exertion.
15 August 2003
The IMR recorded that there had been no improvement in the
prisoner’s breathing and that he actually felt worse. The doctor
suggested that he should try salbutamol inhalations, as a result
of which the prisoner’s peakflow increased from a previous
reading of 450 to a new reading of 520.
14 September 2003
The prisoner had a persistent dry cough.
23 September 2003
The prisoner suffered a mild epileptic fit during the night.
27 September 2003
The prisoner went to the healthcare centre and wanted to talk
about his situation. He told staff that he was not eating well,
was worried about the fact that his parents were about to move
into sheltered accommodation, and that he would have
nowhere to live on release, and that he found it difficult to get
on with his cellmate. He was re-located to a single cell.
8 February 2004
Healthcare staff were called to the chapel to see the prisoner
because he had become short of breath and was suffering
chest pains. The doctor doubled his dose of inhaled steroids.
16 March 2004
Healthcare staff were asked to see the prisoner in his cell.
He had experienced a severe asthma attack. He was advised
to rest.
20 March 2004
The prisoner complained that his mood was low, that he
felt dizzy and could not eat. He was given advice about how to
deal with his anxiety and it was suggested to him that he should
drink plenty of water.
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9 April 2004
The prisoner was seen by a doctor in a workshop after
he had collapsed. The prisoner stated that this had been one
of his “usual turns”.
25 May 2004
The prisoner asked to see the healthcare staff as his
breathing had been difficult. He was referred to the doctor.
26 May 2004
The doctor referred him to the chest pain clinic in
Bristol for further assessment because of his breathing
difficulties and chest pains after exertion. The details of the
referral were faxed to the chest pain clinic the next day.
29 May 2004 ( a bank holiday weekend)
The prisoner reported to the healthcare centre very short of
breath. A nurse wrote in his IMR:
“Presented at H/C 09:45 V SOB (very short of breath). Grey.
Looked ghastly. O2 (oxygen) given-notes revealed had not had
GTN (glycerine trinitrate tablets). Same given, and
instruction in use. Recovered 20 mins. ECG performed.
Normal. B/P 83/55. P.111.“
The nurse recorded that she discussed the prisoner’s
condition with the doctor who advised her to continue “to watch
observations at present”.
30 May 2004
The prisoner was described in his IMR as looking better when
seen in the healthcare centre.
2 June 2004
A doctor wrote in the IMR, “On reviewing his symptoms I do not
think this is cardiac pain. His risk factors for CHD (Chronic Heart
Disease) are low...........
Plan: for remedial gym to increase fitness level and improve self
confidence.......”
7 June 2004 The prisoner was due to attend a chest pain clinic in the
Royal United Hospital in Bath, but the appointment was
postponed by the hospital.
28 June 2004
The prisoner attended the chest pain clinic that had been
postponed from 7 June. In a follow up letter to the prison
doctor, the Clinical Assistant in Cardiology wrote:
“On examination of his cardiovascular system he was mildly
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dyspnoeiac at rest, even after the short walk into the clinic
room. His heart sounds were normal and his chest was clear.
There was no ankle oedema. Because of his breathlessness
we arranged an echocardiogram today which demonstrated
marked pulmonary hypertension and a reversed E:A ration with
mild diastolic LV dysfunction. The valves were normal. In view
of this we were obviously unable to exercise him but we are
arranging for him to have a VQ scan and to be seen in
outpatients by the consultant.”
There is some doubt as to when that letter arrived at the prison.
The healthcare staff reported that it did not arrive at the prison
prior to the reviews that took place on 2 and 5 July.
30 June 2004
Healthcare staff were called to the wing because the prisoner
was struggling for breath and was vomiting. He was described
in his IMR as looking pale, slightly cyanosed and suffering from
mild chest pain. Wing staff were briefed on how to manage a
recurrence.
1 July 2004 T he prisoner was seen on the wing by healthcare staff. The
following entry was made in his IMR:
“Seen on wing at 11.45. Oxygen given. C/o same symptoms as
yesterday evening-brought on by coughing which means he is
unable to catch his breath, panics and brings on asthma
symptoms. Reassurance given- advised to RIC (rest in cell)
until he sees doctor tomorrow.”
There is no evidence that he saw the doctor the next day.
2- 5 July 2004
Further entries were made in the IMR showing that
the prisoner continued to have breathing difficulties and other
concerns. Wing staff were sufficiently worried about his state
of health to call out nursing staff on each occasion.
4 July 2004 T he following entry was made in the IMR:
“Seen at 10pm last night following call from wing staff
concerned about the amount of pain he was in. On questioning
he denied experiencing any pain in his back/chest
or anywhere else! Just frustration about not being able to settle
very well and sleep. Not really an appropriate reason to call out
nursing staff. This explained. No breathing difficulties
particularly evident. Night staff advised to monitor.
Seen this morning, not managed to get dressed as finds this
too difficult. Breathing short but not really a problem despite his
saying he was having to use a paper bag frequently to control
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his breathing. He was well able to discuss the difficulties he’s
been having.
Kalms to be given to aid relaxation. See doctor on Monday
morning.
Seen later in the day, Kalms given. Has made some effort to
get dressed and came out of cell onto the wing.”
6 July 2004 T he prisoner was interviewed by a Probation Officer in a room
some distance from his wing. On several occasions the
interview was interrupted so that his panic and hyperventilation
could be brought under control. At about 11:40 am it was
decided that the interview should be terminated so that the
prisoner could return to his cell. He was given oxygen before
starting the journey. He was assisted by wing and nursing staff
as he made his way up an external flight of stairs towards the
wing, resting frequently on the way. When he reached the top
of the stairs he became increasingly weak and soon collapsed.
He was given more oxygen and placed in the recovery position.
At approximately 11:50 an ambulance was called. It is
recorded in the IMR that a paramedic crew arrived
two minutes later. It is also recorded that his pulse and
respirations were difficult to establish, and that his pupils were
fixed and dilated. CPR was commenced but discontinued after
20 minutes when no sign of life could be detected.
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7. Concerns expressed by the family
On 18 July 2004, my investigator met the prisoner’s sister along with her
husband and son after they had attended a memorial service held in the
prison. They were told of the nature and scope of the investigation and were
given an opportunity to express whatever concerns they had about their
brother’s treatment in prison.
The family explained that their concerns were related to events that happened
in the last week of the prisoner’s life. He had telephoned his sister on the
Tuesday before he died to say that he had been taken to hospital for a
treadmill test but the staff in the hospital were so concerned about his medical
condition that the test did not take place. Instead, he was given a scan the
result of which was the finding of what appeared to be a clot on his lung. He
had therefore been booked to see a consultant on 21 July, the purpose of
which was to try to rule out the presence of the clot. However, the prisoner
was partially deaf and could therefore not pick up on everything that was said
to him.
The prisoner’s relatives were not sure that what he told them on the phone
was accurate. Nevertheless they felt that if the hospital were sufficiently
concerned about the possible presence of a clot to arrange an appointment
with a consultant they should have kept him in hospital. In his last
conversation with them, the prisoner had said to his family that he was very
frightened about his breathing difficulties.
My investigator discussed these concerns with the representative of the
Primary Care Trust who confirms in his report that the prisoner was indeed
seen by a clinical assistant doctor on 28 June when it was discovered that he
had a significant problem relating to blood circulation in his lungs which
required investigation. A letter from the Clinical Assistant in Cardiology at the
Royal United Hospital in Bath, dated 29 June, also confirms this. It also
shows that no exercise tolerance test (or, in layman’s terms, treadmill test)
took place. (See entry against 28 June in Section 6 above.)
My investigator was also advised that the comments made by the Clinical
Assistant in the same letter show that he was not so concerned about the
prisoner’s condition at that stage as to recommend that he should be kept in
hospital.
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8. Emergent issues
The main issues that have emerged from this investigation are:
• Between September 2003 and February 2004, the prisoner experienced
episodes of shortness of breath. Between 8-10 February 2004, he
suffered a further episode which should have prompted a referral to
specialist services at the very least.
• On 29 May 2004, the prisoner presented in a condition of partial collapse
in the prison. He had required oxygen, and he was given glycerine
trinitrate tablets and aspirin. This indicates that the nursing staff had at
least angina if not a full-blown heart attack in mind. It is of concern that
too much emphasis was placed upon the normal ECG findings. In spite of
twice being updated by the nursing staff, no doctor saw the prisoner for
three days. The doctor who carried out the clinical review for this
investigation states in his report that the prisoner ought to have been sent
to outside hospital at this stage. However, the fact that the prisoner was
seen a month later by a specialist at the Royal United Hospital in Bath,
without being admitted for observation or for treatment, suggests that an
earlier referral to hospital may have had the same outcome.
• The Primary Care Trust representative was told by the medical staff at
Shepton Mallet that whenever a prisoner had to attend an outside hospital
under escort, the staffing levels in the prison were adversely affected. I
am concerned that in some situations this could inhibit medical staff in
making referrals to secondary care services. However, I have no specific
evidence that this occurred in this case.
• On 28 June 2004, the prisoner was seen by a clinical assistant doctor at
the Royal United Hospital in Bath. The Primary Care Trust representative
sought reassurance from the consultant cardiologist at the hospital that all
appropriate steps had been taken and that an appropriate degree of
urgency had been attached to further tests ordered because of findings on
echocardiography. He specifically asked if it might have been in order to
start treatment “blindly” for blood clots. The cardiologist felt that the
further tests ordered by his clinical assistant should have been done first,
before any treatment was started. It was therefore appropriate that the
prisoner be returned to Shepton Mallet at this time. It is reasonable to
assume that the fact that the prisoner was not admitted to hospital at the
time of this appointment was because the authorities at the Royal United
Hospital did not feel his condition at that time warranted his admission.
• The prisoner’s medical record contains a letter to the prison written by the
doctor who saw him on 28 June 2004. The letter is recorded as having
been typed on 29 June, seven days before the prisoner’s death. There is
no record of either when the prison medical authorities received the letter
or when they read it. The letter states that the prisoner had a significant
problem relating to blood circulation in his lungs which needed
investigating in the imminent future. The Primary Care Trust
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representative suggests that the prisoner might have been admitted to
hospital earlier if a doctor with knowledge of this letter had been involved
in the assessment of his symptoms between 2-5 July, just before he died.
However, no doctor saw the prisoner between 29 June and 5 July, the day
before he died, despite a note in his IMR from nursing staff that a doctor
should see him on 2 July.
• A member of the healthcare staff at Shepton Mallet told my investigator
that, although the IMR does not make this clear, before the prisoner died,
a follow-up appointment had been made for him to undergo further tests at
the Royal United Hospital in Bath on 12 July. The onus for arranging such
an appointment and for communicating it rested with the Nuclear Medicine
Department of that hospital and not with anyone at Shepton Mallet. The
fact that no record could be found to show when the letter had been
received and who had read it indicates poor record keeping.
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9. Conclusions
I draw the following conclusions from the investigation:
• the episode of breathing difficulties experienced by the prisoner between
8 and 10 February 2004 should have prompted a referral to specialist
services.
• the fact that three days elapsed before the prisoner was seen by a doctor
after he had presented in a state of partial collapse on 29 May 2004 is a
matter of serious concern.
• there is evidence of some poor record keeping by staff in the healthcare
centre at Shepton Mallet. I understand, however, that a new system for
date-stamping incoming correspondence has been introduced in the
centre since this investigation began.
I am also disturbed that a concern over staffing levels could, on occasions,
inhibit clinical staff from making a referral to an outside hospital. I do not
suggest that this happened in this case, but the Governor should be alert to
the possibility that this could occur in respect of other prisoners.
At the consultation stage, the Governor commented that it was important to
emphasise that the prisoner did respond well to re-breathing techniques in a
paper bag. The Governor felt that it was therefore evident that his breathing
difficulties were panic related and no indicators at examination or on testing
revealed any pathology.
The Governor also pointed out that patients are not compromised if there is
an emergency, and that the prison had been working very hard with the
Primary Care Trust to reduce the number of cancellations of routine outpatient
appointments.
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10. Recommendations
1. It is good clinical practice to assume a diagnosis of myocardial damage on
a clear history until proven otherwise by both serology and cardiography, and
so sending the prisoner to hospital on 29 May would have been more
appropriate. This should be drawn to the attention of all the medical staff at
Shepton Mallet so that different management procedures can be adopted in
the future.
2. Early referrals must be made to specialist consultants where there is any
doubt in the diagnosis of adult onset asthma.
3. Decisions on whether to admit acute cardio-respiratory cases to hospital
should be based on clinical findings rather than on the results of an ECG.
4. The risk to the life and health of prisoners, rather than staffing implications,
must be the primary factor to be taken into account when considering
emergency referral to outside hospital. The Governor of Shepton Mallet
should continue to make this clear to her staff.
5. All incoming mail must be date-stamped and passed to an appropriate
clinician for review and further action if required. The clinician must annotate
the report accordingly and ensure any requests for further clinical
management or care are implemented.
6. Adequate steps should be taken to establish protocols to guide healthcare
professionals in the management of life threatening medical conditions.
These must be developed in partnership with the PCT using existing NHS
protocols.
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