Individual at Shepton Mallet

Circumstances surrounding the death of a prisoner at
HMP Shepton Mallet,
in Hospital on 25 April 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2006
This is the report of an investigation into the death of a prisoner who died on
25 April 2006. The man who was aged 63, was a life sentence prisoner at
HMP Shepton Mallet and had been in prison since 1971. He suffered a fatal
heart attack whilst a patient at hospital.
I offer my condolences to the man’s family and those touched by his death.
I am grateful to the Governor of Shepton Mallet, and his staff for their co-
operation during this investigation. I would also like to thank the Mendip
Primary Care Trust that conducted a clinical review into the prisoner’s care
and treatment whilst in prison.
The clinical review indicates that the prisoner was a sick man who had several
serious chronic problems. The review concludes that he was well cared for at
Shepton Mallet, and that his wishes and views about his health were
appropriately taken into account.
I make one recommendation in respect of maintaining a prisoner’s next of kin
details. A failure to keep up-to-date records of next-of-kin is by no means
unique to Shepton Mallet and I have made similar recommendations in at
least twelve previous reports.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2006
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CONTENTS
Summary………………………………………………………………….........4
The investigation process….………………………………………………..5
The prisoner……………………………………………………………………6
HMP Shepton Mallet ………………………………………………………….8
Events from 20 May 2005 to 20 April 2006 ……………………………….9
Events from 20 April leading up to the prisoner’s
death……………………………………………………………………………12
Events after the prisoner’s death………………………………………….14
Clinical review and post mortem report…………………………….……15
Issues considered during the investigation……………………………..16
Recommendation……………………….. ……………………………………18
Annexes………………………………………………………………………...19
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SUMMARY
The man was pronounced dead in a local district hospital at about 9.27pm on
25 April 2006. He was 63 years old. The post mortem report indicates that
he died from Myocardial Infarction (heart attack) due to Coronary Artery
Atheroma (narrowing of the arteries).
The man was a life sentence prisoner who had been in prison since 1971. He
arrived at HMP Shepton Mallet in May 2005, having previously served his
sentence in a number of prisons.
The man had been diagnosed with angina due to narrowing of the coronary
arteries in 1988, following a mild heart attack. He also had age onset
diabetes that was controlled with diet and medication. He frequently failed to
comply with advice regarding diet, exercise or self-testing of his blood-sugar
levels.
On 20 April 2006, the man complained of chest pains. Prison healthcare staff
were contacted and he was taken to a local district hospital under escort for
further investigation. Following a period of assessment, he was then taken to
another hospital on the morning of 25 April for an angiogram. Following the
angiogram, the prisoner was told that he would need corrective surgery at the
Bristol Royal Infirmary in the near future. However, his condition was
unstable and he was returned to the local district hospital later that day.
During the course of the day, the prisoner’s condition deteriorated and at
9.05pm he suffered a heart attack. Medical staff attempted to resuscitate him,
but sadly this proved unsuccessful.
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THE INVESTIGATION PROCESS
1. The investigation into the circumstances surrounding the prisoner’s death
was opened by one of my investigators, at HMP Shepton Mallet on 8 June.
My investigator spoke to staff that knew and cared for the prisoner.
Notices had been issued to staff and prisoners informing them of the
investigation and giving them the opportunity to speak with my
investigator. In fact, no prisoners or staff came forward in response to my
notices.
2. The Governor and his staff produced the prisoner’s core record, his
Medical Record and a number of other documents for review.
3. Mendip Primary Care Trust was commissioned to conduct a clinical review
into the care and treatment that the man received whilst at Shepton Mallet.
A doctor conducted the clinical review.
4. One of my Family Liaison Officers, has attempted to contact the prisoner’s
family to offer them the opportunity to meet with him and the investigator to
discuss the purpose of the investigation, and to raise any concerns they
would like addressed. This included an attempt to contact the man’s
younger daughter who has expressed an interest in the investigation.
However, to date we have not received a reply from any members of the
family and I am not aware of any issues or concerns that they might have.
5. My investigator contacted Her Majesty’s Coroner by letter to inform him of
the nature and scope of the investigation and to request a copy of the post
mortem report. My final report will be sent to the Coroner to assist him
with the inquest into the prisoner’s death.
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THE PRISONER
6. The man was born in 1943 in Warwickshire. He was the eldest of three
children, his parents separating when he was seven years old.
7. He left school at the age of 15 with no qualifications. His probation report
noted that he was unable to sustain employment because of prison
sentences. The prisoner described himself as lonely and isolated and he
had learning difficulties. He had a sister who also has learning difficulties,
but he had not been in contact with her for many years.
8. The man was married in 1967, divorcing in 1972. He had three children (a
son and two daughters) but had not been in touch with them for a long
time. In prison, he had named his son as his nominated next of kin. I
understand that the prisoner’s youngest daughter was born after he went
to prison. After her father’s death, she was curious to find out more about
him, although this was in contrast to the wishes of her siblings.
9. In October 1971, the man was sentenced at Crown Court to life
imprisonment for a very serious crime. He had spent his sentence in
numerous prisons. Psychiatric assessments had determined that
heremained a risk to the public, despite his taking part in various
programmes to address his offending behaviour. He was not considered
eligible for treatment under the Mental Health Act and was next due to be
reviewed for parole in February 2007.
10. In prison, he was described as someone who did not present a discipline
problem to staff, but who did not interact with fellow prisoners or staff to
any great extent. He was a quiet and courteous man who developed a
passion for calligraphy and was keen to attend education.
11. In May 1988, whilst at HMP Maidstone, he was diagnosed with angina
following a mild heart attack. This was controlled with a GTN (Glyceryl
Trinitrate) spray.
12. In 2000, the prisoner was also diagnosed with age onset diabetes
(diabetes mellitus, type 2), controlled by diet and medication. However, it
was noted in his medical record that he was often erratic in his compliance
with food or self testing of his blood-sugar levels. He was also diagnosed
with hypertension, having had a transient ischaemic attack in 2001, and
had also been diagnosed with an under-active thyroid in 2002.
13. The prisoner was described in his medical record as a clinically obese
man, who smoked 20 cigarettes a day, and who did not take exercise
regularly despite encouragement from staff. It had been noted in his core
record that he elected to spend a significant proportion of time in his cell
doing calligraphy.
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14. In December 2005, following a psychiatric assessment, the prisoner was
diagnosed by psychiatrists from Rampton Secure Unit with Asperger’s
Syndrome (a form of autism).
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HMP SHEPTON MALLET
15. In 2001, Shepton Mallet became the first category C prison exclusively for
life sentence prisoners. It is a small jail and can hold up to 189 prisoners.
16. Her Majesty’s Chief Inspector of Prisons carried out an unannounced
inspection of Shepton Mallet in July 2005. The inspection report says that
prisoners were very positive about all aspects of healthcare. Healthcare
staff were well qualified, professional and caring. They had responded
well to the healthcare needs of the lifer population, many of whom were
older and had long term chronic conditions. The report confirmed that
prisoners had good access to primary care and an appropriate range of
visiting specialists.
17. Healthcare is provided by the Mendip Primary Care Trust (PCT). The
prison has a very small healthcare centre with no in-patient facilities. My
investigator was told that the prison enjoyed a good and supportive
relationship with the PCT.
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EVENTS FROM 10 MAY 2005 TO 20 APRIL 2006
18. In May 2005, the prisoner was transferred from HMP Usk to Shepton
Mallet. My investigator confirmed that the man’s full medical record was
received when he transferred from Usk. On arrival at Shepton Mallet, he
was allocated to a shared cell on B wing. On 11 May, he was seen by the
medical staff as part of the initial health screen. It was confirmed through
his medical records and at interview that he suffered from diabetes,
hypercholesterolemia, an under-active thyroid, sciatica, osteo-arthritis, and
unstable angina. The question had also been raised as to whether he had
Asperger’s Syndrome. He was receiving appropriate in possession
medication and regular monitoring for his conditions. Healthcare staff told
my investigator that he always attended healthcare when required to do
so. The medical record indicates that the prisoner was clinically obese
weighing 82kg. A nurse told my investigator that healthcare staff gave
encouragement and support to the man and other prisoners to lose weight,
cease smoking and take more exercise. However, this had little effect and
remains a source of frustration to healthcare staff.
19. The medical record notes that, on 20 June, he was told by healthcare staff
that he was to be interviewed and assessed by staff from the Rampton
Secure Unit. He was seen by staff on 5 July who later confirmed that her
could be suffering with elements of Asperger’s Syndrome.
20. On 26 June, the prisoner was seen by healthcare having complained of
dizziness. He was advised to take paracetamol, to drink plenty of fluid and
to stay out of the sun.
21. On 17 July, the wing history sheet indicates that the prisoner had not
received his property upon transferring from Usk. This mainly consisted of
materials for calligraphy. In consequence, the prisoner wrote to me as
Ombudsman in July seeking redress. He was advised by my office to
raise his complaint through the prison’s internal complaints procedure. On
14 September, he received his outstanding property.
22. On 31 August, the man was reviewed by the prison doctor. He told the
doctor that he was still suffering from daily bouts of angina. He was given
advice in regard to smoking and diet and was prescribed a higher dosage
of medication for his angina. The medical record states that, if there was
no improvement in his angina, he would be referred back to healthcare.
Healthcare staff told my investigator that the prisoner was not a man who
was prone to complain.
23. The wing history sheet for 13 September indicates that the prisoner was
interested in continuing education. However, because of his ill health he
felt he was unable to attend education sessions because the Education
Wing is located up several flights of stairs. Although there is a goods lift in
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use, my investigator established that this is used primarily for the delivery
of heavy goods to the workshop and not by prisoners. In instances where
prisoners are unable to attend education because of ill health, in-cell
education is made available. Staff told my investigator that the prisoner
had elected to attend the Education Wing as this gave him a break from
his routine. He was also encouraged by staff to attend education as a
form of exercise. Staff told my investigator that, when they are aware that
prisoners who have mobility problems or suffer shortness of breath are
attending education, chairs are provided on each landing to enable them
to rest and get their breath back. Staff told my investigator that prisoners
who want to attend the Education Wing, and who may experience difficulty
in climbing stairs, are advised to take their time in getting to classes.
Some provision and flexibility is also made to allow elderly prisoners
access to education at different times of the day.
24. On 23 September, the medical record again notes that the prisoner was
seen at the specialist diabetic clinic where he told the nurse that he had
not been testing his blood sugar levels for several weeks. Following the
clinic, the specialist nurse suggested to healthcare staff that he could be
prescribed Metformin at night to reduce his blood-sugar levels. The
clinical review established that the prisoner was not prescribed Metformin
by the prison doctor, as his blood sugar levels were considered to be
within an acceptable range. Staff also told my investigator that he was
reluctant to change his medication.
25. On 24 October, the medical record notes that the man was given advice
about his diet to control his diabetes. He was also advised to exercise
more. It was apparent to staff that he was spending a lot of time in his cell.
26. The medical record notes that, on 15 December, the prisoner told staff that
he and his cell mate had given up smoking for three weeks. Advice was
given once again about his diet and he was told to drink more water.
27. On 19 December, the man was moved from B wing to a single cell on C
wing. The prisoner had asked for a single cell some time previously, but it
appears that none was available.
28. At about 3.44pm on 5 January 2006, a nurse was called to see the
prisoner in the Education Wing. He complained of dizziness and
shortness of breath, although he was not suffering chest pain. He told the
nurse that he had been suffering bouts of angina, but had not used his
GTN spray as this seemed to make the pain worse. He was referred to
the doctor who suggested that the man might have experienced a gastric
episode.
29. On 23 January, the medical record notes that the prisoner was
complaining of pains in the centre of his chest when lying down. He was
also asked why he had not attended the diabetic clinic. He told the nurse
that he could not be bothered.
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30. The medical record for 9 February records that the prisoner was again
feeling dizzy. He said that he had not had breakfast that morning. The
nurse noted in the medical record that the man was generally non-
compliant with a healthy diet or the daily testing of his blood-sugar levels.
31. On 13 March, the prisoner complained to healthcare staff that he was
feeling dizzy at night. He was told to eat meals earlier in the evening and
it was noted that he was still failing to test his blood-sugar levels. He was
asked by healthcare staff to keep a food diary, which he did. He was also
asked by healthcare staff to maintain a record of his dizzy episodes
32. On 20 March, the prisoner was seen by a nurse. It was noted in the
medical record that he was no longer suffering from dizziness at night and
that his blood-sugar levels had improved.
33. A nurse told my investigator that in the weeks preceding his referral to
hospital, he had attended an acupuncture session as he was feeling low in
mood. The nurse asked the prisoner if he was alright, as in her opinion he
did not look well. The man responded that he was okay. There was
nothing about his demeanour or response at the time that would have
prompted the nurse to seek further advice or a referral, although she
reminded the prisoner that he could make an appointment to see the
doctor if he required it.
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EVENTS FROM 20 APRIL 2006 LEADING UP TO THE PRISONER’S
DEATH
34. At about 8:15am on 20 April, the medical record indicates that a nurse was
called to C wing by a prison officer as the prisoner was suffering from
chest pains. On the nurse’s arrival on the wing, the prisoner told her that
he felt as if someone was sitting on his chest. He told the nurse that the
pains had been getting worse in the previous few weeks but he had not
considered telling healthcare staff. He had used his GTN spray, but the
pain remained. The nurse asked the prisoner if he could walk to the
healthcare centre to enable further examination and observations to take
place. He was then assisted by the nurse and a prison officer and taken to
the treatment room. There he was connected to the ECG monitor (an
electrocardiogram is used to monitor the electrical activities of the heart).
35. Healthcare staff told my investigator that the ECG reading was not
abnormal, and the man was not displaying the classic signs of someone
who had suffered a heart attack (greyness to the skin and clamminess).
However, the nurse thought that something might be wrong and sought
advice from a nursing colleague.. In the meantime, the prisoner was
relaxing on a chair and told the nurses that the pain in his chest seemed to
be easing. After a brief discussion between the nurses, they decided that
the man’s condition warranted further investigation. Healthcare staff
telephoned the control room and requested an ambulance.
36. At 10am, the prisoner arrived at the local district hospital. He was
escorted by a prison officer, in line with the Prison Service’s operating
procedures, but was not handcuffed. Throughout his stay in hospital, a
bedwatch log (an observation log completed by the escorting officer) was
maintained.
37. At 10.40am, the log records that the prisoner was undergoing tests,
including treadmill tests. Following these tests, he was told that he would
be required to stay in hospital overnight. In light of this information, the
man’s cell was sealed to protect his property until his return to Shepton
Mallet. The log states that, at 5.35pm on 21 April, he was in good spirits
after having had a bath and something to eat.
38. However, at 10.17pm on 22 April, the prisoner was experiencing severe
pains in his chest and medical staff were called to his bedside. The log
indicates that he again suffered severe bouts of pain at 11.05pm and
again at 12am. He was given oxygen.
39. At 8am on 23 April, clinical observations were taken for the prisoner and
he was given pain relief. At about 8.45am, he was given another ECG. At
4.25pm, the escorting officer alerted medical staff that he was feeling
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unwell. He was given oxygen again and at 6:00pm was reported to be
feeling much better and was able to have his tea.
40. At 9.15am on 24 April, the prisoner was told that he would require an
angiogram at another hospital within the next couple of days. (This is a
procedure where a fine, hollow tube called a catheter is introduced into an
artery in the arms or groin and gently advanced through the blood vessels.
A dye is then injected into the blood vessels and x-rays taken of the blood
vessels.) At 6pm, he was given a packet of nuts and soft drink from his
allowance. He was described as being in good spirits and of no concern
to the escorting officer. The man apparently experienced a restless night.
41. At 11.15am on 25 April, the prisoner had the angiogram. It established
that he had extensive heart disease and would require heart by-pass
surgery at the Bristol Royal Infirmary, within the next two to three weeks.
In the meantime, attempts were made to stabilise his condition with drugs
until a date for surgery could be arranged. However, it was noted that if
his condition did not stabilise he would be taken immediately to Bristol for
an emergency operation. Following the tests, the prisoner was transferred
back to the Coronary Care Unit at the local district hospital, arriving there
at 3.30pm. The log records that, despite the pain he was in, he was in
relatively good spirits and not complaining.
42. At 4.30pm, the doctor told the escorting officer that, if the prisoner failed to
respond to the drug treatment to stabilise his condition, he would be taken
to Bristol for emergency surgery. At 4.50pm, the doctor informed the
escorting officer that the prisoner was not responding satisfactorily to drug
treatment and his condition was deteriorating. The doctor asked the
officer to contact the prison and arrange for the prisoner’s next of kin to be
told of his condition.
43. However, the prison established that there was no telephone contact
number for the man’s next of kin (his son) on file. In view of this, the duty
governor, contacted Avon and Somerset Constabulary, asking them to
arrange for the appropriate Constabulary to visit the son’s last known
address to convey the news of his father’s condition. However, the
Constabulary reported that the address no longer existed and that the
whereabouts of the prisoner’s son were unknown.
44. At 7.45pm, the log indicates that the prisoner’s condition was critical. At
about 9.05pm, he suffered a heart attack. Despite efforts by medical staff
to resuscitate him, he was pronounced dead by a doctor at 9.27pm.
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EVENTS AFTER THE PRISONER’S DEATH
45. The escorting officer was informed of the prisoner’s death and contacted a
senior officer (SO) at the prison. The SO then contacted the Duty
Governor, by telephone and passed on the news.
46. Shepton Mallet implemented their contingency plan for a death in custody.
This included contacting the National Operations Unit, the Independent
Monitoring Board, and the police. Efforts were still in hand to contact the
prisoner’s next of kin through the police. It was also established that the
prisoner had a sister. However, it was felt inappropriate to make contact
to tell her of her brother’s death as it was known that she had learning
difficulties.
47. The number one Governor was later able to confirm that the prisoner’s son
had been told of his father’s death by the police on 26 April. The
deceased’s former wife and two daughters were also told. In light of the
nature of his primary offence, as well as another offence, the family had
had no contact with the prisoner for many years. Members of the family
were understandably reluctant to contact my family liaison officer or raise
any issues in relation to this investigation.
48. The prisoner received a funeral at the public’s expense. It was attended
by the Governor and the prison chaplain. Family contact with the prison
has been through the Governor and has been limited to the disposal of the
man’s accumulated property.
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CLINICAL REVIEW AND POST MORTEM REPORT
49. The clinical review undertaken by the Mendip Primary Care Trust
concludes that the prisoner was well cared for in Shepton Mallet. His
wishes and beliefs were appropriately taken into account in managing his
health problems.
50. However, in respect of the man’s diabetes and blood-sugar levels, the
doctor who conducted the review says that it is generally recognised that
good diabetic control seeks to attain a level under 7.5 mmols, although
many diabetics and their doctors struggle to achieve that level. It is noted
that on three occasions the prisoner’s blood-sugar levels registered at 8.6
mmols. Following advice from a specialist diabetic nurse on 23
September 2005 that he should start using Metformin, which is known to
lower blood sugars, no adjustment of his diabetic medication appears to
have been made. The clinical review establishes that the decision not to
treat the man’s diabetes more actively was a conscious decision by the
doctor in line with local healthcare policy, and not the result of an
oversight. Staff also told my investigator that the prisoner was reluctant to
change his medication. The clinical review also highlights that providing a
diet appropriate for a diabetic in Shepton Mallet can be difficult. However,
my investigator has been told by the Healthcare Manager that every
reasonable effort is made to provide a healthy, balanced and appropriate
diet for prisoners with diabetes. The Governor has discussed the
provision of diabetic diets with healthcare and catering staff. Neither group
has received any complaints on this subject from prisoners. Prisoners
have a choice of diet with up to six or seven alternatives available,
although some prisoners do not always choose wisely, despite the advice
that they are given. The Governor and Healthcare staff consider that there
are sufficient suitable items on the Prison Shop list for prisoners to be able
to supplement their diets.
51. A post mortem was carried out on 27 April 2006 and indicates that the
man died from a Myocardial Infarction (heart attack) due to Coronary
Artery Atheroma (narrowing of the arteries).
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ISSUES CONSIDERED DURING THE INVESTIGATION
Education
52. The prisoner had complained that he found it difficult to attend the
Education Wing, as this involved climbing several flights of stairs and he
would experience shortness of breath. My investigator has established
that provision has been made for prisoners who are not capable of
attending to receive in-cell education. According to staff, the man elected
to attend the Education Wing and was encouraged to do so by staff in an
attempt to help him exercise more and reduce his weight. He was told to
take his time when climbing the stairs, and chairs were provided on each
of the landings so that he and others could rest if they became breathless.
My investigator also established that consideration had been given to a
stair lift for elderly or incapacitated prisoners. However, building surveys
have determined that the stairwell is not suitable for this and could
contravene health and safety regulations. Although there is a lift in
operation, this is used primarily for moving heavy goods to the prison
workshop.
Contacting next of kin
53. There was a delay in contacting the prisoner’s next of kin and it is
apparent that the contact details on his file were long out of date. Whilst
the prison and the police made every reasonable effort to contact his son,
it should be acknowledged that the man had been in prison for about 35
years and had not kept in contact with any members of his family. The
prisoner is not unique in this respect and, over time, many long-term
prisoners may lose contact with their relations. In some instances the
prisoner can outlive their next of kin and other family members. Following
his death, I understand that Shepton Mallet has asked all prisoners to
provide, up to date contact details for their nominated next of kin. I
commend this initiative.
The Governor should continue in his efforts to ensure that contact
details for next of kin are checked regularly to ensure they are up to
date and remain current.
Control of diabetes
54. Following a specialist diabetic clinic on 23 September 2005, it was
suggested that the prisoner could benefit from being prescribed Metformin
in order to reduce his blood-sugar levels. However, the man was reluctant
to change his medication. The clinical review indicates that the prison
doctor considered the prisoner’s blood-sugar levels to be within an
acceptable range and decided, therefore, not to change his medication.
The clinical review also points out that many diabetics and their doctors
1 6
struggle to achieve a blood-sugar level of 7.5 mmols or less in the wider
community. I am content that reasonable efforts are made at Shepton
Mallet to provide prisoners who have diabetes with an appropriate diet.
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RECOMMENDATION
1. The Governor should continue in his efforts to ensure that contact
details for next of kin are checked regularly to ensure they are up to
date and remain current.
The Governor has arranged for all prisoners to complete a questionnaire,
giving current details of their next of kin. The update exercise will be
carried out annually.
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ANNEXES
Documents considered during the investigation
A The prisoner’s medical record.
B Bedwatch Observation Logs from 20 April
C Summary note of meetings with staff
D Clinical review commissioned by the Mendip Primary Care Trust
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