Individual at Stafford

Investigation into the circumstances surrounding the
death of a man at HMP Stafford,
on 24 May 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2010
This is the report of an investigation into the death of a male prisoner at HMP
Stafford . The man died at a local hospital on 24 May 2009, having collapsed
in his cell a little under two hours previously. The cause of death was found to
be myocardial infarction (heart attack) caused by ischaemic heart disease (a
lack of oxygen to the heart muscle). I offer my sincere sympathy and
condolences to his wife and daughter, and to all who have been affected by
his loss.
The investigation was carried out by an Investigator from my office. An
independent review of the man’s medical care in prison was led by the clinical
governance manager for the local Primary Care Trust. I am most grateful for
her assistance. However, due to a delay receiving the clinical review, I am
issuing this report later than I would have wished.
I would also like to thank the Governor and staff of the prison for their co-
operation during the course of the investigation. My particular thanks go to
the head of residence and safer custody, for his work in liaising with the
investigator.
The man had several significant medical conditions when he entered prison in
March 2008. Although there were some aspects where I consider that more
could have been done, the care he received was, in general, equal to that
which he would have received in the community. Other prisoners have
alleged that prison staff did not go straight into the man’s cell when he was
taken ill. I have considered their allegations carefully and found no other
evidence to support them. In the event, when the man had the heart attack
he was already in the ambulance. The report makes six recommendations,
including the submission that all prisoners with complex care needs should
have a care plan to reflect their needs.
Jane Webb
Acting Prisons and Probation Ombudsman May 2010
CONTENTS
Summary 4
The investigation process 5
HMP Stafford 6
Key findings 7
Issues 12
Family response to the draft report 18
Conclusion 20
Recommendations 21
SUMMARY
The man was given an indeterminate sentence for public protection (IPP) on
13 March 2008, and arrived at HMP Birmingham the same day. He had
several long standing health problems including angina and lung disease.
Shortly before his imprisonment, he had undergone an operation to widen the
arteries in his legs. He was also asthmatic and diabetic.
The man had several outstanding outpatient appointments for his medical
conditions with consultants in his local area when he came into prison. It is
standard prison practice for planned appointments to be cancelled and new
appointments should be made. For security reasons, prisoners should not
know the date when they are due to go out of the prison. He was not referred
to hospitals in Birmingham as the intention was to transfer him to a prison
near his home where he could have continuity of his medical care. After
some delays a transfer to HMP Stafford went ahead on 11 July.
He settled in well at Stafford, and reportedly got on well with staff and fellow
prisoners. He was seen every day by nursing staff when collecting his
medication. However the clinical review panel notes that, despite his
significant medical conditions, no care plan was written to reflect his health
needs. The panel recommends that all patients with complex care needs
should have a care plan.
Throughout his time at Stafford, the man attended a number of outpatient
appointments at local hospitals. In most cases the nature and outcome of
these appointments was not recorded in his medical record. I recommend
that such information should be recorded and correspondence regarding the
outcome sought from the relevant hospital.
In the early hours of 24 May 2009, he woke his cell mate and said he was
having difficulty breathing. He was sick and, shortly afterwards, collapsed on
the floor and complained of chest pains. The night staff were called to the
man’s cell and requested an emergency ambulance. At around 2.45am,
whilst in the ambulance about to leave for hospital, the man suffered a heart
attack. The paramedics attempted to revive him but he was pronounced dead
at 3.32am, shortly after arriving at the hospital.
With the exception of the control room operator, all of the night staff at
Stafford work permanent night shifts. None of them have up to date first aid
or resuscitation training. There are no healthcare staff on duty overnight at
the prison. In these circumstances, I recommend that the Governor provide
training for all permanent night staff. I make one further recommendation
regarding breaking the news of the man’s death to his wife.
THE INVESTIGATION PROCESS
1. The investigation was opened on 27 May 2009, when the investigator,
issued notices announcing the investigation to staff and prisoners. The
notices included an invitation to anyone who wished to submit information
relating to the investigation to come forward. One prisoner came forward
as a result.
2. The investigator was given access to the man’s prison files, including the
medical record. He visited Stafford on 16 August, 4 September and 29
September, interviewing five members of staff and two prisoners during
the course of the investigation.
3. A clinical review of the man’s health care whilst he was in custody was led
by the clinical governance manager of the local Primary Care Trust. The
clinical reviewer accompanied the Investigator on 19 August, a visit which
included an interview with a prison nurse.
4. The Ombudsman’s senior family liaison officer telephoned the man’s wife
on 18 June, to inform her of the investigation and determine whether she
had any issues she wished it to address. The man’s wife praised the staff
and prisoners at Stafford and explained that, even though her husband
was being seen by three different consultants, he was always taken for his
appointments. She gave particular thanks to the lead nurse on E wing
(where he lived), and described her as “brilliant”.
HMP STAFFORD
5. HMP Stafford was built on its present site in 1794. It currently has
capacity to hold 741 category C prisoners across seven wings. The man
lived in a ground floor cell on E wing which, together with F wing, form an
area of the prison known as the Crescent. The Crescent is designated as
accommodation for vulnerable prisoners (those who are separated from
the majority of prisoners because of factors such as the type of offence
committed).
6. Healthcare is provided by the local Primary Care Trust, who employ a
healthcare manager, nurses and support staff. The two wings on the
Crescent share a full time nurse who oversees the medical needs of
prisoner-patients on the wings, including administering treatments and
seeing patients on the wing throughout the day as necessary. There is no
inpatient healthcare facility at Stafford and no nurses work in the prison
overnight.
7. Stafford was last inspected by HM Chief Inspector of Prisons in June
2009. She found that Stafford was performing “reasonably well” in all
areas. She also found that the “provision of health services had
improved”, there was good access to primary care, and health services
staff were aware of the needs of older prisoners.
8. In their annual report for 2008, the Independent Monitoring Board (a body
of local people who independently monitor and report on the prison)
reported several “positive effects” since the appointment of the new
Governor, in 2006. However, they did suggest that “more resources
should be made available in support of healthcare arrangements”.
9. This is the seventh death of a prisoner at Stafford since the Ombudsman
began investigating all deaths in custody in England and Wales in April
2004. Four of the previous six deaths were due to natural causes. My
most recent report, regarding the death of a man who died after refusing
all food, commended staff at Stafford for the “exceptional care” they
provided. A second investigation, in 2008, commended the response of
staff following the collapse of a prisoner in his cell.
KEY FINDINGS
10. The man arrived at HMP Birmingham on 13 March 2008, having been
sentenced earlier that day. At the time of his imprisonment, he suffered
from a number of medical conditions. After a heart attack in November
2002, he continued to experience frequent angina attacks. He also
suffered from Barratts disease (abnormal cells in the oesophagus, leading
to an increased risk of oesophageal cancer), pleural thickening (hardening
of the lining of the lung as a reaction to asbestos fibres in the lung) and
asbestosis (damage to interior of the lung due to inhaled dust).
11. The man also had claudication (narrowing) of his femoral arteries (a large
artery in the muscle of the thigh) in both legs. In February 2008, he had
undergone surgery known as an angioplasty (a surgical procedure to
repair and widen the artery) and had a stent (a plastic tube used to help
keep the blood vessels open) inserted into his right leg. In addition, the
man was asthmatic, suffered from arthritis and was diabetic.
12. As a result of his many health problems, the man took a number of
different medications. These included aspirin (to thin the blood and
prevent a heart attack), prednisolone (an anti-inflammatory used to control
arthritis and asthma), atorvastatin (to reduce cholesterol and the risk of a
heart attack), GTN spray (a spray used to relieve the pain of angina
attacks), bisoprolol fumarate (to prevent heart failure), azathiopine (to treat
arthritis), lisinopril (to treat high blood pressure) and lansoprazole (to
prevent the stomach producing gastric acid). He also used a salbutamol
inhaler for his asthma.
13. The Prisoner Escort Record (PER, a form used by all the agencies which
transfer prisoners) identified the man’s medical conditions, as outlined
above. Shortly after his arrival at Birmingham, he was seen by a nurse for
a reception health screen (a routine health screen for all new arrivals into
prison). The nurse listed the man’s medication and noted that he had
reduced mobility. She referred him to a prison doctor immediately so that
his medication could be prescribed.
14. The following day, the man’s wife telephoned the prison to speak about
her husband’s health and outstanding hospital appointments. She was
asked to write in with details of the appointments. His wife subsequently
wrote to the healthcare department at Birmingham on 15 March. She
explained that he was required to take a monthly blood test, on account of
taking azathiopine for his arthritis. She went on to say that her husband’s
arthritis was quite widespread and he sometimes needed help dressing,
but he tried to be as independent as possible. She also said her husband
was waiting to receive a follow up appointment from the consultant who
fitted his stent.
15. The man attended a well man clinic (a general health assessment for
men) on 15 March. His medical history was recorded again and he was
given advice about accessing various services. It was also recorded that
he was not fit enough to attend the gym.
16. Three days later he was reviewed by a prison doctor. The doctor
telephoned the rheumatology department at the man’s local hospital
where he had previously received treatment. She was told that the man
was last seen in December 2008 and required further follow up. He had
missed two appointments and his next, scheduled for 27 March, had been
cancelled. The doctor noted that there was a plan to transfer him to a
prison closer to his home to enable continuity of his medical care.
17. On 18 April, the man missed an outpatient appointment at the department
of respiratory medicine at another hospital local to his home. It is not clear
if staff at Birmingham were aware of this appointment. A follow up letter
was sent from the hospital to the man’s home address to say that a further
appointment would be arranged in three months time.
18. A decision was made in late May or early June (the exact date is not
clear) not to transfer the man to any prison local to his home. This was
noted as being for “security reasons”, although no further information was
provided. The prison doctor therefore wrote a referral to the City Hospital,
Birmingham, on 6 June. In her referral, she noted that the man’s follow up
appointment following the insertion of his stent was “long overdue”. She
went on to say that “delays in attempting transfer have resulted in a
complete failure of follow up for his numerous problems”.
19. The referral was not sent, however, as the decision not to transfer the
man to Stafford was reversed. This decision was made by the head of
residence at Birmingham, so that he could continue to attend
appointments at hospitals in his local area. A transfer was arranged for 16
June, but was cancelled at short notice as there were no places available
on the Crescent.
20. The transfer eventually went ahead on 11 July. A reception health screen
was carried out by a staff nurse shortly after the man’s arrival to Stafford.
His medical history and ongoing conditions were noted, and he was
allocated a ground floor cell on E wing.
21. Three days later, the man attended a review with a prison doctor. He said
that his claudication was worsening and the doctor therefore referred him
to a local consultant for a peripheral arterial assessment (peripheral
arterial disease is the narrowing of the arteries in the legs). The prison
doctor also referred him to a rheumatology specialist (who treats
conditions affecting the joints and surrounding tissue) and a chest
specialist.
22. He reportedly settled in well on E wing, where he was described as being
“polite and no problem”. On 18 August, a local community nurse whose
care the man had been under before he was imprisoned, telephoned the
healthcare centre. She requested that blood tests be taken monthly and
the results faxed to her. The first test was taken the following day, with
the results faxed to the community nurse on 28 August.
23. On 1 September, the man went to an outpatient appointment at a hospital.
There are no details recorded in his medical record as to the nature of this
appointment. He attended another appointment on 24 September, at a
local hospital. He underwent a scan of his legs to determine the level of
blood flow through the arteries. The results of the scan and any
subsequent changes to his treatment are not recorded in the man’s prison
medical record.
24. At the end of October, he attended a review with a prison doctor. He told
the doctor that he had felt angina pains two days previously and was
experiencing chest pain at night. The doctor requested that a new
appointment be made with a chest specialist, which was subsequently
made for 5 January 2009. The prison doctor also prescribed a course of
tramadol (a painkiller) for the man’s chest pain, and advised him to stop
smoking. As tramadol is a controlled drug (meaning that it has high
potential to be misused), prisoners have to collect it every day and take
the medicine in front of the dispensing nurse. He kept all of his other
medication in his cell and was given a 28 day supply at a time.
25. A rheumatology nurse visited Stafford on 16 December to assess the
man. It emerged that he had not been taking some of his medication as
instructed. He was advised and encouraged to do so. Despite these
problems with his medication, the nurse told healthcare staff that she was
happy with his progress.
26. The man had a family visit booked for 5 January 2009, the day of his
appointment with the chest specialist. He therefore decided not to attend
hospital. A second appointment was booked for 16 February. Although
he attended this appointment, there is no record of the outcome in the
man’s medical notes other than a request for blood results to be sent to
the local hospital.
27. Two days after the appointment, on 18 February, a nurse was called to E
wing at around 11.30am to see the man who had said that he felt
breathless. All prisoners had been asked to go to their cells so that the
roll (the number of prisoners held in the establishment) could be counted
and confirmed. As such, he had to hurry back to his cell without resting as
he normally would. The nurse took his pulse, oxygen saturation level (a
measure of the amount of oxygen in the blood) and blood pressure, all of
which were within normal levels. She told the investigator that he
recovered after five or ten minutes and, as a result, she did not think it
was necessary for him to see a prison doctor.
28. On 27 February, he went to an outpatient appointment at a local hospital.
Again, no information is recorded as to the nature of this appointment.
However, at an appointment with a prison doctor three days later it was
noted that he had recently seen a rheumatologist. The man told the
doctor that he was still smoking and was again advised to stop.
29. He next saw the prison doctor on 23 March, having made an application
for an appointment one week earlier. He told the doctor that he had
experienced pain in his abdomen when lying down for around a month.
He added that he had been taking ibuprofen for the pain but it did not
help. The doctor asked for a referral to be made to a gastroenterologist
(stomach specialist).
30. At around 3.10pm on 6 April, he was taken ill with chest pain in the visits
hall. He was brought to healthcare and seen by a nurse, who noted that
he was very pale. He had not taken his GTN spray to the visits hall with
him and was given one by the nurse. After five minutes, he said that he
felt much better. The nurse told the investigator that this was an angina
attack and she advised him to carry his GTN spray with him in future so
that he could use it when he started to feel pain.
31. Ten days later, he saw the prison doctor for a review. He told the doctor
he had experienced back pain for several years and sometimes had
“spasms” in his back. The man also said that he was still getting pain in
his chest, and in his abdomen when lying down. The prison doctor
examined him and heard creps (crackling noises) in his chest. He
prescribed a course of amoxicillin (an antibiotic).
32. The man attended outpatient appointments on 30 April and 18 May.
Again, no information is recorded in his medical record as to the nature or
outcome of these appointments. The man’s wife later told the
Ombudsman’s senior family liaison officer that her husband was very
upset as he had been told at hospital on 18 May that he might have to
have a leg amputated.
33. On the evening of 23 May, the man played pool with his neighbour who
lived in the cell next door to him (Prisoner A). Prisoner A told the
investigator that the man seemed well that evening and he was not
concerned about him. He remembered that they had to move the pool
table to get it into the right position, which the man was able to do without
any problem.
34. As usual, at around 7.30pm, the prisoners were locked in their cells for the
night. During the night at Stafford, a Senior Officer (SO) is in charge of
the prison, with the title ‘night orderly officer’. Along with three officers, he
patrols the prison at night and responds to emergencies. Senior Officer A
took this role on the night of 23-24 May 2009. In addition, an operational
support grade (OSG, the grade below a prison officer) is stationed on
each wing overnight. On this occasion Operational Support Grade A was
working on E wing and he carried a radio which he could use to contact
colleagues. The OSG also carries a cell key in a sealed pouch, which
they may only open in an emergency. An unsealed key is carried by the
night orderly officer, who would normally be called should the OSG feel
that he may need to open a cell.
35. Operational Support Grade A’s shift started at 8.30pm and, as is standard
practice, he carried out a roll check straight away. He told the investigator
that he did not recall having any cause for concern about him at this time.
The man’s cell mate, Prisoner B, told the investigator that they played
cards and dominoes together until around midnight. He recalled that the
man seemed “fine” at this time. At around 1.30am, the man woke
Prisoner B and said that he “could not breathe”. The man was still fully
dressed and was sitting in a chair. He got up to use the toilet but
collapsed on the floor and was sick. Prisoner B told the investigator he
tried to pick the man up off the floor but was unable to do so. He therefore
sat him up against a chair. Prisoner B asked the man if he would like him
to call for assistance, but he said that he was “fine”.
36. Shortly afterwards, them man turned “yellow”. Prisoner B therefore
pressed the cell bell to call for assistance. The cell bell records for the
night are unavailable due to a computer fault so it is not certain what time
the cell bell was pressed. Operational Support Grade A, who responded
to the bell, thought it was around 1.35am. Prisoner A, who was awake in
the cell next door, thought it was around 1.50am.
37. On his arrival at the cell, Operational Support Grade A was told by
Prisoner B that the man was suffering chest pains and had been sick.
Operational Support Grade A then returned to the wing office to telephone
the control room and ask for the Night Orderly Officer (Senior Officer A)
and colleagues to assist him. The control room log records this telephone
call as being made at 1.54am.
38. Whilst Operational Support Grade A was in the wing office, the man was
sick for a second time and collapsed on the floor. Prisoner B again
pressed the cell bell for assistance. Operational Support Grade A
returned to the cell and recalled that the man’s condition had changed
“dramatically”. He was now collapsed on the floor and in a lot of pain.
Operational Support Grade A therefore used his radio to again call for
assistance. The control room log records this call as being made at
1.57am.
39. Within a minute, Senior Officer A arrived at the cell along with two fellow
officers. Senior Officer A told the investigator that he opened the cell and
went in with his colleagues. He described the man as “lying on his back
completely flat, complaining of chest pains”. The Senior Officer asked the
officers to pick the man up and sit him against a locker door. In contrast,
Prisoner B told the investigator that, although the cell door was unlocked,
none of the officers went inside the cell and he had to look after him on his
own. Prisoner A, who was watching through the crack in his cell door,
also said that none of the staff entered the cell.
40. Once the man was sitting up, Senior Officer A used his radio to contact
the control room and asked for an ambulance to be called. This radio call
is recorded in the control room log as having been made at 1.58am. A
lone paramedic arrived at the prison at 2.09am and was escorted to the
cell by a fellow Officer. The Senior Officer A recalled that the man’s
condition did not change in this time, although he was talking to the staff
and said that he was in pain.
41. The man’s condition remained stable during the time that the paramedic
was present. At 2.35am, an ambulance arrived and he was taken to the
ambulance by stretcher. At 2.44am, whilst in the ambulance, he suffered
a heart attack. The paramedics immediately started cardio-pulmonary
resuscitation (CPR). The ambulance left the prison at 3.09am, arriving at
a local Hospital shortly afterwards. The hospital resuscitation team
continued to work on him, but were unsuccessful. He was pronounced
dead at 3.32am. A post mortem later established the cause of death as
myocardial infarction (heart attack) caused by ischaemic heart disease (a
lack of oxygen to the heart muscle).
42. The police were asked by the prison to break the news of the man’s death
to his wife, and visited her on the morning of 24 May. The wife and her
son visited the prison later that afternoon, and met the duty governor, and
a nurse who knew the man well. The funeral was held on 5 June, and the
investigator found that the prison’s contribution to the funeral costs was in
accordance with PSO 2710 (the Prison Service Order that sets out the
actions to be taken following a death in custody).
ISSUES
Cancelled appointments following reception to HMP Birmingham
43. The clinical review panel finds that the man received medical care in
prison that was “comparable with care he would have received in the
community”. However, they note that the man’s outstanding hospital
appointments were cancelled when he first came into prison. It is
standard practice throughout the Prison Service to reschedule any
outstanding hospital appointments when a prisoner is received into
custody. This is for reasons of security, as a prisoner is not permitted to
know in advance of any time when he will be outside of the prison.
44. Although initially imprisoned in HMP Birmingham, he was not referred to a
local hospital by Birmingham’s healthcare department. From his first days
at Birmingham, it was planned to transfer him to a prison closer to his
home so that he could continue to be seen by the consultants who knew
him and hence ensure continuity of care. A transfer to Stafford was
arranged for 16 June 2008, three months after the man’s arrival at
Birmingham. However, this transfer had to be cancelled as there were no
places available in the Crescent wing for vulnerable prisoners. The
transfer eventually went ahead on 11 July. He was referred to a local
hospital three days after his arrival at Stafford.
45. The clinical review panel makes the following comment:
“These cancellations resulted in delays in the man’s treatment and the
ongoing management of his care. The medical reviewers in this case
thought this would not have contributed to the man’s death.”
I make no recommendation concerning the continuity of healthcare by staff
at HMP Birmingham but will draw my report to the attention of the
Governor.
Care plans
46. The clinical review panel comments that “it is not clear if there was a care
plan and a co-ordinated approach to the man’s care in either prison”.
There was no care plan in the man’s notes. The deputy healthcare
manager at Stafford told the clinical reviewer that if there was no care plan
in the notes then “it can be assumed he did not have one”.
47. The man had several significant medical conditions. Although he was
seen every day by nursing staff when he collected his tramadol, and was
apparently well known to nurses who worked regularly on E wing, there
were some periods during his time at Stafford in which no entries were
made in his medical record for several weeks. The clinical review panel
makes the following comment:
“When a prisoner is seen by a consultant of any speciality, they should
have an active care plan and a co-ordinated approach to care. Seeing
a prisoner when dispensing medications does not constitute a review
or health assessment, especially when anecdotal evidence suggests
that during these periods time is limited and can be quite pressurised.
Therefore it does not facilitate the opportunity to converse with
prisoners about their needs. However, it could be argued the man was
given the opportunity to request a further assessment.
“Healthcare staff should use a planned approach for prisoners with
complex care needs. A care plan is essentially a contract between the
patient and main carer. It sets out what interventions the healthcare
staff will deliver and what the patient will do for themselves.”
48. The clinical review panel goes on to make the following recommendation:
The heads of healthcare at Birmingham and Stafford should ensure
that all prisoners with complex care needs have a care plan to reflect
all of their needs.
Record keeping
49. The man attended a number of outpatient appointments at local hospitals
throughout his time at Stafford. In the majority of cases, there is no note
as to the nature or outcome of the appointment in his medical record and
no discharge letter from the hospital.
50. In addition, the clinical review panel makes the following comment about
the standard of record keeping in the man’s medical record:
“Handwritten records in Stafford’s entries were dated but not signed
clearly or legibly in some instances, which made the audit trail complex
thus creating difficulties in determining when actions were taken.
“There should be consistent recording of any nursing or medical activity
in the [prison medical record] as writing on letters and blood results
does not give a chronological overview as these are located elsewhere
in the prisoner’s records. Standards of record keeping must be
adhered to at all times and it is therefore suggested that this is re-
audited to ensure that the standards expected are both adhered to and
maintained.”
51. In her report following her June 2009 inspection of Stafford, HM Chief
Inspector of Prisons made the following comments about clinical record
keeping at Stafford:
“The clinical records were very well managed … Entries made on
prisoners at Stafford were of high quality, contemporaneous and
generally in line with good practice guidelines, although a few were
difficult to read and did not include the staff’s designation. The head of
healthcare audited a sample of records every month and the primary
care trust carried out an annual audit”
52. It is unfortunate that the man’s clinical records did not meet the high
standards identified by the HM Chief Inspector of Prisons and I will send a
copy of this report to her office. I make the following recommendation:
The head of healthcare should remind staff that the nature and
outcome of outpatient appointments at outside hospital should be
recorded in the patient’s medical record. In addition, discharge
notes should be obtained from the hospital following each
appointment.
The head of healthcare should audit a selection of medical records to
ensure that the required standards are being met.
Timing of the man’s collapse on 24 May 2009
53. There are some discrepancies in the times given by the staff and
prisoners present when the man was taken ill. As such, it is not clear how
long passed between Operational Support Grade A being called to the
man’s cell and when he requested assistance from his colleagues.
Unfortunately the cell bell records are unavailable due to an apparent
computer fault. The timing of the telephone and radio calls are recorded
in the control room log and reproduced in the table below:
Time Event
1.54am Operational Support Grade A on E wing reports (via the
telephone) he has chest pains. Oscar One (the call sign for
Senior Officer A) informed.
1.57am Urgent message from Operational Support Grade A (via the
radio) – prisoner collapsed on floor.
1.58am Called ambulance 999 (at the request of Senior Officer A).
2.09am Paramedics arrive at prison.
2.35am Ambulance arrives at prison.
3.09am Ambulance leaves with the man and two Officers.
54. The man’s cell mate, Prisoner B, told the investigator that the man woke
him at around 1.30am when he felt ill (although Prisoner B also recalled
that the paramedic arrived at 1.50am, as opposed to 2.09am as recorded
in the log). Operational Support Grade A thought he responded to the cell
bell at 1.35am and “immediately” went to telephone for assistance, a call
that is recorded as taking place at 1.54am. In contrast Prisoner A, in the
cell next door, thought he heard the cell bell go off at 1.50am. In addition,
Senior Officer A told the investigator that he was called to the cell at
1.40am and requested an ambulance at 1.47am (in contrast to those
times recorded in the log).
55. It is perhaps inevitable that there are discrepancies in the accounts of staff
and prisoners regarding the time of events in circumstances such as
these. As the cell bell records are unavailable, I am unable to say
whether there was a delay in Operational Support Grade A being called to
the man’s cell and urgent medical assistance being requested. Although
the man was taken ill sometime before 2.00am, his heart attack did not
occur until 2.44am by which time he was already in the ambulance and in
the care of its crew.
Staff entering the man’s cell
56. Prisioner B told the investigator that there were four members of staff
present when the cell door was opened, but none of them entered the cell.
He said that he therefore had to look after the man himself. Prisoner A,
who lived in the cell next door, said he had been watching through a crack
in his door and also told the investigator that none of the staff entered the
man’s cell. Prisioner A also said that he heard staff openly discussing the
man’s offence and sentence length whilst waiting for the ambulance to
arrive.
57. Senior Officer A told the investigator that three members of staff went into
the man’s cell when the door was opened. He remembered the man was
lying on the floor at the time. Senior Officer A said he asked two of his
colleagues to sit the man up against a locker and pull his legs up, as he
thought this would be the most comfortable position if he was having chest
pains. The staff (other than one Officer who went to meet the paramedic)
stayed in the “area of the cell” after this. Senior Officer A said he was
unaware of any staff discussing the man’s offence or sentence length.
58. Operational Support Grade A said the staff went into the man’s cell when
Senior Officer A opened the door. They examined the man and tried to
make him as comfortable as possible whilst awaiting the arrival of the
ambulance. Operational Support Grade A also said he was unaware of
staff openly discussing the man’s offence, although they may have
discussed his risk in the wing office in preparation for the hospital escort.
59. It is clear that there is a significant discrepancy between the accounts of
staff and prisoners as to whether the staff who responded to the man’s
collapse entered his cell. I am unable to say for certain which accounts
are correct. Needless to say, however, I would be extremely disappointed
if it were the case that staff did not respond appropriately when a prisoner
was taken seriously ill. The Governor will wish to consider whether any
further enquiries should be made.
First aid training
60. Senior Officer A is a permanent night orderly officer at the prison and has
worked alternate weeks for around six years. The Operational Support
Grades are also permanent night staff, and the officers work a 12 month
period of nights before reverting back to day shifts. Senior Officer A was a
first aid trainer for 11 years before joining the Prison Service, but told the
investigator that his first aid training expired around 13 years ago.
Operational Support Grade A had worked for the Prison Service for
around four years at the time of the man’s death and was first aid trained
(including CPR) in the army prior to this. He said that he had not had any
first aid or CPR training since joining the Prison Service and his previous
training would now be out of date. There is no first aid training available to
the other night staff either.
61. The Ombudsman has observed in many previous investigation reports
that speedy intervention by properly trained and qualified staff can be the
difference between life and death. In the man’s case, staff were not
required to administer CPR as he did not suffer his heart attack until
paramedics had arrived. However, were he to have stopped breathing
prior to their arrival, he would have been cared for by untrained staff.
62. I think it is essential that discipline staff have the knowledge and
confidence to carry out CPR and first aid effectively. This is especially the
case at a prison like Stafford, where staff who work permanent nights do
not enjoy the support of healthcare staff out of hours.
The Governor should provide training in first aid and cardio-
pulmonary resuscitation for all staff who work permanent nights.
Breaking the news of the man’s death to his next of kin
63. Prison Service Order (PSO) 2710, which provides instructions for the
aftermath of a death in custody, says that Governors must:
“Arrange notification to the next-of-kin and any other person reasonably
nominated by the prisoner as soon as possible in a suitable manner,
giving an accurate factual account of what has happened.”
64. The accompanying Family Liaison Officer (FLO) Guidance recommends
that:
“The family should be informed face to face as soon as possible after
the death. Wherever possible this should be done by a dedicated
Family Liaison Officer working alongside the Chaplain, or Governor or
most senior individual available together with the Chaplain.
“The prison should demonstrate its duty of care and show that it is
taking the death seriously by making a personal visit.”
65. The police were asked to break the news of the man’s death to his wife.
Her contact details were passed to the police at around 8.50am by the
duty governor , and they visited the man’s wife later that morning. The
Governor told the investigator that the police broke the news to the man’s
wife “as a matter of course because they would want to make sure there
are no suspicious circumstances because he shared a cell”. The
Governor added that the prison was understaffed when the man died as
two of the officers were out on his hospital escort.
66. The FLO Guidance says that the police may be asked to break the news
of a death to the next of kin. However, this should be based on an
assessment of factors such as the safety of staff and the likely level of
hostility in the area to be visited. There is no suggestion that either factor
was relevant in this case.
67. The man’s wife lives around 15 miles from Stafford. Given that her
husband died at around 3.30am, I do not think it would have been
unreasonable to wait a few hours before visiting her, to avoid arriving in
the middle of the night. However, my view is that this visit should have
been made by prison staff. Such an approach would help to convey that a
death in custody is a matter of proper concern to the establishment.
The Governor should ensure that, whenever reasonable, the news of
a death in custody is broken to the next of kin by members of prison
staff, face to face, in accordance with national instructions.
FAMILY RESPONSE TO THE DRAFT REPORT
68. I received a number of comments from the man’s wife on the draft report,
which I have discussed below. In general, his wife said she thought the
care her husband received at Stafford was “very good” and she felt he got
on well with most staff and prisoners.
Medical reviews following a hospital appointment
69. The man’s wife suggested that prisoners’ should be seen by a doctor or
nurse following their return from an appointment at outside hospital. She
suggested that such a review would allow staff to determine how the
appointment went and to establish whether the prisoner needed
clarification on the outcome or findings of the appointment.
70. The investigator discussed this comment with members of the clinical
review panel. They make the following comment:
“In the community it is impractical and not always necessary to review
a patient after each hospital appointment, although the patient can and
should always be able to make an appointment to discuss any issues.
“The benefit of immediate review is often limited by lack of information
if there is no communication from the hospital. Contacting the patient
to make an appointment would be good practice if any change to
treatment or care was advised by the hospital specialist.”
71. The nature and outcome of the majority of the man’s hospital
appointments are not recorded in his medical record. It is not therefore
possible to determine if any changes to his treatment were made by
hospital specialists. Nevertheless, the healthcare manager should ensure
that the assessments identified by the clinical review panel go ahead.
A review should be offered with a prison doctor if significant
changes are made to a prisoner/patient’s care or treatment by a
hospital specialist.
Staff conduct following the man’s collapse on 24 May 2009
72. The man’s wife said she was “extremely distressed” to read Prisoner A’s
comments that staff were openly discussing her husband’s offence and
sentence length whilst waiting for the ambulance. She thought that talking
about such personal information constituted “gross professional
misconduct”.
73. As I have noted previously, the Senior Officer A told the investigator he
was unaware of staff discussing the man’s offence or sentence length. He
also said he was also unaware of this, but added that they might have
discussed the man’s risk in the wing office in preparation for the hospital
escort.
74. An ambulance had been called for the man and it was very likely that he
would be taken to hospital. Prison staff therefore had to determine the
level of escort required (in terms of number of staff, use of restraints etc).
A prisoner’s offence and sentence length would be a factor in the
consideration of these matters. Given the man’s condition at the time, my
judgement is that it would be better for staff to discuss these matters near
the cell than to go to the office and leave him unattended.
75. However, officers should always remember that such information is
sensitive and they should be guarded when discussing it. Due to the
conflicting accounts I am unable to say whether staff did openly discuss
the man’s offence and sentence length. However, the Governor will wish
to remind all staff to use caution when discussing details of a prisoner’s
case.
CONCLUSION
76. The man was an older prisoner with several long standing health
problems. After initially being imprisoned at Birmingham in March 2008,
he transferred to Stafford four months later. This enabled him to continue
seeing the consultants who had been in charge of his care for several
years. He was popular at Stafford and got on well with staff and fellow
prisoners.
77. The clinical review panel finds that, in general, he received medical care
comparable to that he would expect to receive in the community.
However, there are some areas they consider could be improved. In
particular, the panel recommends that patients with complex care needs
should have an active care plan and co-ordinated approach to their care.
78. Despite his significant medical conditions, the man’s death was
unexpected. He suffered a heart attack in an ambulance on his way to
hospital after being taken ill in the middle of the night. Although not
required to administer CPR on this occasion, the investigation revealed
that the night staff at Stafford do not have up to date first aid or
resuscitation training. I recommend to the Governor that he seek to
address this.
RECOMMENDATIONS
1. The heads of healthcare at Birmingham and Stafford should ensure that all
prisoners with complex care needs have a care plan to reflect all of their
needs.
Accepted – care plans will now form an integral part of the clinical IT
system introduced last year and training is taking place in their use. These
will then be implemented for patients with complex needs regarding long
term illness.
2. The head of healthcare should remind staff that the nature and outcome of
outpatient appointments at outside hospital should be recorded in the
patient’s medical record. In addition, discharge notes should be obtained
from the hospital following each appointment.
Accepted – outpatients appointments will now be recorded automatically
on the clinical IT system introduced last year.
3. The head of healthcare should audit a selection of medical records to
ensure that the required standards are being met.
Accepted – a system of auditing electronic clinical records will be
introduced in 2010.
4. The Governor should provide training in first aid and cardio-pulmonary
resuscitation for all staff who work permanent nights.
Accepted – staff working on permanent nights will be prioritised for first aid
training.
5. The Governor should ensure that, whenever reasonable, the news of a
death in custody is broken to the next of kin by members of prison staff,
face to face, in accordance with national instructions.
Accepted – this will be done in accordance with national instructions,
whenever reasonable and following a risk assessment.
6. A review should be offered with a prison doctor if significant changes are
made to a prisoner/patient’s care or treatment by a hospital specialist.
Accepted – all staff to be made aware that patient returning from hospital
with a change to care needs to be made an appointment to see the prison
GP.