Individual at Standford Hill

Investigation into the circumstances surrounding the death of
a man in hospital in May 2007
whilst in the custody of HMP Standford Hill
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2008
This is the report of an investigation into the circumstances surrounding the death of
a man at HMP Standford Hill. On the morning of his death, the man collapsed
outside the entrance to his wing. He was taken to hospital by ambulance where he
was pronounced dead by a hospital doctor. He was 40 years old. The cause of
death was a rare form of tuberculosis.
I offer my sincere condolences to the man’s family and friends. I must also
apologise for the delay in producing this report (this was because the histology report
was not received by the Coroner until late November 2007).
The investigation was undertaken by one of my colleagues. We would like to thank
the Governor of Standford Hill and his staff for their cooperation. Particular thanks
go to the Deputy Governor and the prison’s Liaison Officer for gathering all relevant
documentation and ensuring it was made available.
A medical practitioner, representing Eastern and Coastal Kent Primary Care Trust
(PCT), carried out a clinical review into the care and treatment the man received
whilst at Standford Hill. I am grateful to the clinical reviewer for completing the
review. I have relied heavily on the clinical reviewer’s findings for this report. The
main focus of my own investigation has been Standford Hill’s response to the man’s
collapse, and the events following his death.
This was the first death in custody at Standford Hill for many years and I am
reassured that the staff and prisoner who responded to the man’s collapse did all
they could. However, his death highlighted the resource constraints under which the
prison was working at the time. It also became clear during the investigation that
staff at the prison recognised gaps in procedures for responding to a life threatening
situation. I am pleased that the Deputy Governor has already carried out a risk
assessment on first aid training, and has laid the foundations for additional family
liaison support. An emergency code system was put in place immediately following
the man’s death.
My report makes one recommendation and makes two commendations. In light of
the cause of death, the clinical reviewer notified the Director of Public Health at
Eastern and Coastal Kent PCT of the post mortem results.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2008
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CONTENTS
Summary
The Investigation Process
HMP Standford Hill
Key Findings
Issues
Recommendation and Commendations
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SUMMARY
The man was sentenced to four years imprisonment on 6 January 2006. He was
sent to HMP Belmarsh. From there, he served a short time at HMP Brixton before
settling at HMP Maidstone. Following his progress on a drug dependency
programme, and his willingness to enrol on a victim awareness course, he was
awarded enhanced status under the Incentives and Earned Privileges Scheme. His
continued positive approach at Maidstone led to him being granted category D
status, and hence he was able to move to open prison conditions.
The man moved to HMP Standford Hill on 18 January 2007. A full history of his
mental health, medical care and drug dependency followed him and this helped the
reception healthcare officer (HCO) to carry out an initial screening. The man was
referred to a drug advisory service, and the mental health in-reach team. His mental
health was to be monitored every four to six weeks by a visiting community
psychiatric nurse (CPN). The man generally attended his sessions and spoke
openly about how he felt.
For the first two months at Standford Hill, the man appeared to settle well. He did tell
his CPN at one session that he missed the discipline and protection that he felt
closed conditions at Maidstone had provided, but remained positive and enrolled on
three education courses and joined the gym.
At both the art and IT courses, staff began to notice his behaviour change. In
February, he was given two Incentives and Earned Privileges warnings for
wandering off and failing to return to classes. On his wing, officers and prisoners
also became aware of his ongoing mental health problems and his reportedly
‘strange’ behaviour. The man was monitored by both the drug advisory service and
his CPN throughout this time. He was also referred to both services by officers on
the wing when he failed mandatory drug tests (MDTs), and when his behaviour
caused further concern amongst staff.
In March 2007, the man submitted a complaint against one of the tutors in his art
class. An internal investigation did not uphold his claim. At the same time, another
memo was sent to the mental health in-reach team about his behaviour on the wing.
He stopped going to his education classes and found employment as a wing cleaner.
At no point in the months and weeks leading up to his death did the man seem
physically unwell. There is no record of him receiving medical attention for anything
other than his mental health and prescription needs. The man’s failed MDTs and
IEP warnings temporarily lost him his enhanced prisoner status. He regained his
enhanced status after working hard as a cleaner and by demonstrating that he was
fully compliant with the regime on his wing.
At about 9.15am on the day of his death, and after failing to start work on time, one
officer and the wing manager saw the man contorting his body and mumbling to
himself. The wing manager sent another memo to the healthcare unit. At 10.20am,
the man left the wing and began kicking out at one of two prisoners who were
making their way back from healthcare. Witnesses said it was an unprovoked
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attack. The man was escorted back to the wing by officers and told to go to his room
to calm down.
The man was next seen propped up outside the wing entrance. At about 11.00am,
another prisoner was seen talking to him when he fell backwards and collapsed,
hitting his head. The prisoner placed him in the recovery position before officers and
healthcare staff arrived. The man was given life support until paramedics arrived 20
minutes later. He was transferred to hospital where cardio-pulmonary resuscitation
(CPR) continued.
The man was pronounced dead by the hospital doctor at lunch time. The post
mortem confirmed that he died from a rare form of tuberculosis. The man did not
display any physical symptoms that would have led healthcare staff to refer him for
further tests, and his condition had not been diagnosed.
This report includes one recommendation and commends the actions of two
members of staff and one prisoner.
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THE INVESTIGATION PROCESS
1. On 29 May 2007, my investigator opened the investigation and was briefed about
the circumstances leading to the man’s death. The investigator requested all
prison and medical files in advance of a visit to Standford Hill on 20 July. At the
prison, she met the deputy governor and visited the man’s wing. The investigator
began the process of identifying the key issues and the staff who had interacted
with the man during his time at Standford Hill. She interviewed a number of
prison staff and one prisoner. On a second visit to Standford Hill on 15
September, she interviewed the deputy governor.
2. .A medical practitioner representing Eastern and Coastal Kent Primary Care
Trust (PCT), was asked to conduct a review of the clinical care the man received
whilst at Standford Hill. The review was completed and sent to my office on 29
November.
3. The Coroner was informed of the Ombudsman’s investigation. The post mortem
report concluded that the man’s cause of death was as follows:
1a miliary tuberculosis.
The initial finding of cause of death was delayed pending a histology report.
This, in turn, caused a delay in conducting a clinical review of the man’s
healthcare. The Coroner received the result of the histology report on 22
November 2007 and a copy was forwarded to my office. I am grateful to the
Coroner’s Officer for sharing this information. At time of writing, the inquest date
has not been set. The Coroner will receive a copy of this report to assist with his
enquiries.
4. One of my family liaison officers (FLOs) contacted the man’s next of kin shortly
after the investigation was opened. The FLO explained her role and that of my
office, and provided information about the investigation process. She also
offered the man’s family the opportunity to meet to discuss any issues or
concerns. The FLO and a colleague met the man’s family at their home. During
the visit, the family raised several concerns and asked for further information
about certain events. Subsequently, and following the post mortem result, the
family asked about a number of clinical issues. These were as follows:
(cid:131) Did the man contract (Miliary) Tuberculosis (TB) whilst in prison? Why
was he not diagnosed with this illness in custody before it got to an
advanced stage? Why was he not given the opportunity to be treated
for the condition?
(cid:131) When the man complained of feeling unwell, he was not given
sufficient medical attention. He was found outside the healthcare
centre three days before he died and all reports indicate that he was
behaving strangely in the last few weeks of his life. The man’s family
want further information on whether his condition was taken seriously.
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(cid:131) Given that he died of a rare form of TB, his family asked whether there
were other cases of the disease reported at HMP Maidstone and HMP
Standford Hill.
A draft copy of this report was sent to the man’s family and the prison service.
The family made no further comments on the draft. I will send them a copy of
this report. The prison service accepted both the recommendation I make
and the commendations. The prison service response can be found on page
25 of this report.
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HMP STANDFORD HILL
10. HMP Standford Hill is a category D male resettlement prison and forms part of
the Isle of Sheppey ‘cluster’ of three prisons. Its function is to prepare adult
men for their return to the community.
11. Standford Hill was opened in 1950 and has one induction wing (A wing), and
two residential wings (B and C), with a total operational capacity of 464
prisoners. All residential wings are single cell occupancy. Prisoners are
given ‘privacy keys’ to their cells and have communal bathroom facilities.
12. Her Majesty’s Chief Inspector of Prisons has inspected Standford Hill twice in
the last five years. The report she published in 2002 was critical of most
areas of the prison. However, when HMCIP returned in August 2004, she
commented more positively and reported that significant progress had been
made. On arrival at Standford Hill, the reception, first night in custody and
induction procedures gave prisoners a good introduction to prison life, and
multi-lingual information was now available. Staff and prisoner relations were
also good. The lack of a recognised personal officer scheme had been
addressed, and staff were generally willing to help and support prisoner
needs. In short, around 90 per cent of the recommendations made in 2002
had been achieved within those two years.
Healthcare
13. Standford Hill has a type two healthcare facility, which means health service
provision is clinic based and akin to a doctor’s surgery in the community. In
April 2004, the healthcare centre began the transition to the local Primary
Care Trust (PCT). For the next year, the local PCT embarked upon
commissioning all health services and conducted an evaluation of the specific
needs of the prison’s population before introducing NHS policies and
procedures.
14. HMCIP complimented the healthcare centre in 2004 for its cleanliness and
welcoming staff. The Chief Inspector of Prisons reported that prisoner access
to doctors was excellent, and found that most prisoners were seen on the
same day they reported sick. In talking to prisoners, without exception
inspectors found positive comments about the drop-in approach at the centre,
and about the healthcare staff and the care they delivered.
15. The most recent Independent Monitoring Board (IMB) Annual Report on
Standford Hill was published in 2006. The report echoed the findings of HM
Chief Inspector in relation to healthcare provision. The IMB added that
prisoners were seen promptly, but access to the out-patient care facility
mirrored the waiting times experienced in the community. However, the IMB
was critical of the physical environment in which healthcare was located and
highlighted the inappropriate use of a prefabricated building.
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Substance use and drug misuse services
16. In her report, HMCIP found that the recommendation she had made in 2002
for officers to form part of the CARAT service (Counselling, Assessment,
Referral, Advice and Throughcare) had been achieved. Her 2004 report
found that one full time Senior Officer (SO), two Principal Officers (POs) and a
CARAT worker were trained and detailed to deliver drugs support services at
the prison. In addition, a drugs strategy had been reviewed and updated to
better meet the needs of Standford Hill’s population. The strategy was led by
an SO, responsible for overseeing all drugs services and implementing the
changes. HMCIP said that the team in place was enthusiastic and effective.
Compared with 2002, prisoners now had good access to the support on offer.
Whilst alcohol misuse support had not been given the same focus, the Chief
Inspector summed up drugs services at Standford Hill as follows:
“Standford Hill should be commended for its efforts to control
substance misuse in the very difficult situation of an open prison.”
Race Relations
17. The Chief Inspector also said that Standford Hill had made encouraging
progress in the two years between her inspections. In 2002, the prison faced
criticism but, on her return to Standford Hill, HMCIP reported that the newly
appointed Race Relations Officer had formed good relationships with
prisoners and was committed to this area of work. Her 2004 report
commented that prisoners seemed trusting and confident that their concerns
would be addressed. However, prisoners perceived that they might be moved
to another wing if they made a formal complaint via the internal complaints
system. The Chief Inspector said that there was no evidence to support that
fear.
Complaints
18. The 2006 IMB Annual Report said that, in the year up to and including 30 April
2005, there were 759 formal complaints, of which 132 were made under
confidential access. Both the IMB and the Chief Inspector commented
positively on the complaints system at Standford Hill. In 2002, the Chief
Inspector had said that, “prisoners should be able to make complaints without
obstacles being placed in their way”. This had since been achieved. Her
2004 report found evidence that prisoners generally received timely and
helpful replies. Both B and C wing had secure boxes installed and
confidential complaints forms had become freely available.
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KEY FINDINGS
The man’s arrival at HMP Standford Hill
19. During his time at HMP Maidstone, the man progressed well, particularly with
his drug programme and the mental health in-reach team. On 16 January
2007, he was awarded category D status and was considered suitable for
transfer to open prison conditions. He transferred to Standford Hill two days
later.
20. When the man arrived at Standford Hill, he was interviewed by the healthcare
officer (HCO) before being located on B wing. His most recent medical
history and CARAT referral history from Maidstone were recorded. These told
the HCO that the man had received mental health in-reach support every four
to six weeks. The man’s current medication was listed (Amisopride 200mg,
an anti-psychotic drug). He was referred to Standford Hill’s mental health in-
reach service and CARAT service. His medical record confirmed that he was
fit for transfer and had no outstanding medical appointments.
21. The man settled well on B wing. On 22 January 2007, he completed a
Physical Activity Readiness form in order to use the gym. The form stated
that he had no physical conditions that would prevent him from using the
facilities. The man signed the form and agreed to notify staff of any changes
in his physical health. He also enrolled with the Education Department during
his induction but, two days later, turned up in the classroom by mistake. An
entry in his wing history book set out the problem and confirmed that he could
start an information technology (IT) course the following day.
22. On 25 January, the man had his first mental health in-reach assessment. He
told the registered mental nurse (RMN), that he had no problem sleeping or
eating. The man also confirmed he had started his IT course and was settling
in well. Four days later, he had his first CARAT review. The man told his
drugs worker that he had not wanted to transfer to Standford Hill and felt he
needed the discipline and protection at Maidstone. His case record for the
review on 29 January said that the man admitted using cannabis but
appeared stable and did not want further intervention.
23. The man’s next appointment with the in-reach team was on 13 February.
When he spoke to the RMN, the man said he was collecting his medication
weekly and did not have any problems. His care plan said he would be
reviewed in four weeks and should continue with his current medication.
24. Throughout the rest of the month, the man attended IT, Art and Spanish
classes. His behaviour in class worried staff and he was given two Incentives
and Earned Privileges Scheme (IEPS) warnings on 20 and 26 February. The
man’s wing history book explained that both warnings were for leaving class
without permission. Two days later, the man failed a Voluntary Drugs Test
(VDT) and was removed from the drug free side of B wing. The VDT officer
referred him back to the CARAT team for testing positive for cannabis.
10
25. On 1 March, the man submitted a formal complaints form. His complaint
focussed on his experience in art classes and his relationship with the tutors.
The man said that he felt intimidated and bullied, and had heard the tutors use
a racist term ‘under their breath’. His complaint was submitted to the deputy
governor, who in turn, asked the diversity manager, to speak to the man and
conduct an internal investigation into his claims.
26. On 3 March, the man’s behaviour caused concern again. During mealtime, a
B wing officer saw him ‘staring into space’ at the hotplate for approximately 40
minutes. The officer recorded in the wing observation book that other
prisoners on the wing were also worried about his behaviour. Shortly
afterwards, the same officer sent a memo to the healthcare centre to inform
the mental health in-reach team.
27. The RMN had a conversation with the man on 6 March as a result of the
memo. The man said he felt bullied in the art class and told the nurse that he
had made a formal complaint about one of the art tutors. The RMN compiled
another care plan. This gave the man the next two days off work to ‘rest in
cell’. The RMN also suggested that he attend his IT class, but not his art
class, and booked another review for 8 March. At the review, he told the
nurse that he felt much better.
28. On 11 March, the man received a third IEP warning for failing to remain in his
art class. He was reported for receiving three warnings in one 28 day period.
At his mental health in-reach review on 15 March, the man told the RMN that
he had no problems.
29. The diversity manager concluded his investigation into the man’s complaint
and wrote to the Governor on 22 March. He mentioned in his report that he
had interviewed the man, the art tutor and students from the class. His report
concluded that there was no evidence to support the man’s complaint.
30. The man went to his IT class on 26 March as usual, but was escorted back to
the wing by two officers. His instructor rang the wing and said he was very
concerned about the man’s state of mind and asked for him to be removed.
Two wing officers made their way to the classroom, having already informed
healthcare. They collected the man and began to make their way back to the
wing. En route to B wing, the man walked off towards one of the gates and
was asked to stop. When he carried on walking, the first wing officer stood in
front of him and held onto his arm. Both officers then took him to the
healthcare centre. The first wing officer made an entry in his wing history
which said that the principal officer (PO) and the wing SO had been informed.
31. The PO spoke to the man at length and said that he was not to leave B wing
until he saw the mental health in-reach team. The PO also spoke to
healthcare about the man’s behaviour. The doctor confirmed that he was
aware of the man’s behaviour, but had no immediate concerns about his
mental health. An appointment was made for him to see the in-reach team on
28 March.
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32. At the appointment, the man was told not to attend education classes any
more. The RMN 2, told wing staff that he could remain at Standford Hill and
she would contact the induction unit to arrange suitable employment for him.
The man’s IEPS review took place a few days later. The SO and the officer
on duty reviewed his warnings and downgraded his status from enhanced to
standard regime. The decision was properly recorded and communicated to
staff on the wing.
33. Both staff and prisoners continued to worry about the man’s behaviour and he
was referred to the in-reach team and the CARAT team again. On 12 April,
after prisoners approached the landing officer on B wing, the officer spoke to
healthcare. The officer also moved the man to a cell on the first landing to
make it easier for staff to monitor him. He saw a drugs worker on 17 April and
they discussed his medication. The possibility of arranging for his family to
take him on a ‘town visit’ was also discussed.
34. Following his removal from education classes, the man began working as a
wing cleaner. A prison officer completed his first IEPS review assessment
since being downgraded. The report said that the man had been fully
compliant with the wing regime and was a good worker. The prison officer
stressed how hard the man worked and wrote, “I sometimes have trouble
stopping him working! Always on time, works hard.” As a result of his own
efforts, no further positive drug tests and no recent adjudications, he was
upgraded to enhanced status at his next review board on 28 April. He was
located in a ‘self help’ cell on the enhanced side of the wing.
35. On the same day, the man got into an argument with another prisoner outside
B wing. One of the officers separated them both and recorded the incident in
the wing observation book. It is not clear what the argument was about, but
the officer said that he felt the argument could continue and informed the wing
manager.
36. The man tested positive for cannabis again on 8 May and was referred back
to CARAT by one of the officers. At his IEP review board on 12 May, the
second wing SO agreed that, despite his positive VDT, the man could remain
on the enhanced side of the wing and noted how hard he continued to work
as a cleaner.
37. The man did not come to the direct attention of staff again until mealtime on
19 May. The second wing SO and the wing officer observed the man
displaying a ‘poor attitude’ on the wing. The man then brushed past the wing
officer and tried to stab the officer with a pen. The wing officer also reported
that the man was staring. The officer took the pen from the man and wrote in
the wing observation book that staff should be aware of his behaviour.
38. At some point the same week, and during evening roll check, officers noticed
that the man was not in his room. Another officer on B wing, told my
investigator that she remembered an occasion where the man and a few other
prisoners did not return to their cells but could not remember the exact date.
12
The officer explained that this sometimes happened and was usually the
prisoners’ way of ‘testing the staff a little bit’. The officers filled in IEPS
warning forms but used this to get prisoners to comply. The B wing officer
told my investigator that, although the man had refused to return to his room,
officers had agreed to ‘let it go’ because they felt his failure to comply with the
regime was not deliberate. The officer went on leave and when she returned
to work a few days later, the man approached her with his IEPS form. The
officer told my investigator that he seemed ‘distressed’ about receiving the
warning. She assured him that it was probably nothing to worry about.
39. The man was charged on 21 May under Prison Rule 61 for being absent from
the wing. He was placed on report (adjudication) and his hearing was the
same day. The charge against him was proven and he was reduced to half
pay for 14 days. He was also told he would lose canteen (use of the prison
shop) for 14 days, suspended for six months. There was no corresponding
report of the incident in the wing observation book or his wing history sheet.
40. The officer on B wing returned to work on 22 May. She told my investigator
that B wing was hectic that day. She recalled that she was supervising the
movement of prisoners going to work that morning when the man approached
her in the wing office. He seemed distressed that he had been placed on
report. She told him that she was too busy to deal with the problem at the
time and would speak to him later that day. This was the last time she saw
him.
Friday 23 May 2007
41. The employed prisoners on B wing went to work as normal that morning. The
man remained on the wing and was expected to start work as wing cleaner.
At approximately 9.15am, the duty officer noticed him walking around in
circles on the first landing. She spoke to him but he did not reply. The officer
recorded his behaviour in the wing observation book and mentioned that the
man had not been taking his medication, but it is not clear how she knew that.
The officer telephoned the wing manager and reported that the man was
acting strangely. The wing manager made his way to the landing and spoke
to the VDT officer on the way. The officer repeated the concerns about the
man’s behaviour and reported that he was not doing his job as wing cleaner.
42. Both the wing manager and the VDT officer found the man on the first landing.
The wing manager said that he saw the man ‘contorting his body’. When
asked if he was okay, he gave a ‘mumbled response’. The man then said that
he could not start work because he did not have any mop handles and was
escorted by the VDT officer to get some from storage. At around 10.00am,
the wing manager telephoned the healthcare centre to report the man’s
behaviour. He filled in a memo and referred the man to a member of the
mental health in-reach team.
43. One of the prisoners on B wing, prisoner A, was working in the prison gardens
that morning. He took his tea break at approximately 10.10am and, in his
statement to police, said he started walking towards the healthcare centre.
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He was turned away and told to come back when he had a movement sheet
permitting him to walk to healthcare unaccompanied. Prisoner A began the
walk back and met another prisoner, prisoner B, coming the other way. As
they passed A wing together, they noticed the man on the other side of the
road.
44. The man walked towards them, shouting as he approached. Prisoner A could
not understand what he was saying. He asked the man if there was a
problem and heard him say, “You know, you know.” Prisoner A said in his
police statement that he knew the man had mental health problems and did
not think he was being serious at first. As he shouted at Prisoner A, the man
started to kick out. Prisoner B told my investigator that it looked like a ‘kung fu’
kick but that prisoner A did not retaliate and attempted to get out of the way.
The man tried to kick out several times and continued to shout at him.
45. A civilian bricklayer employed by the Works Department at Standford Hill, had
just finished some construction work at the administration block. In his
statement to the police, he said that at approximately 10.30am he was driving
back to his department and passed A wing on the way. As he approached the
wing, he saw the man on the steps and prisoner A and prisoner B and walking
back from the healthcare centre. His description of what he saw echoes the
recollections of the two prisoners. He described how he tried to stop the man
from kicking prisoner A by asking him what he was doing. The civilian
bricklayer said that the man began to “scream and shout” and did not make
sense. The man turned his back on him and walked away with his hands in
the air. The bricklayer told the police that the man seemed angry and, as
prisoner A mentioned, he did not know if the man was being serious.
46. An officer, who worked in the education department, was walking from A wing
back to the education building. At 10.30am, she passed B wing and saw the
man walk across the road and through a gap in the hedge. She reported the
man’s behaviour. In a security form, the officer said his behaviour was ‘a bit
odd’, but she was aware that he had mental health problems.
47. At approximately 10.40am, the civilian bricklayer saw two officers and told
them what had happened. The officers followed the man back to B wing and
asked him about his altercation with prisoner A. The man told the officers that
he thought he was going to be attacked. One of the officers then took him
into the wing office, tried to calm him down and told him to go to his room.
The man remained outside the office.
48. The wing manager came down to the office to speak to the man and told him
again to go to his room. In his incident report, the wing manager said that the
man accused the two prisoners of trying to attack him and said that he
defended himself by kicking out. The duty officer, the VDT officer and the
second landing officer were also in the office and saw the man leave on the
instructions of the wing manager.
49. The man went to his room but did not stay there long. The third landing
officer said that a few minutes later he saw him leave B wing by the main
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entrance and prop himself up outside. Prisoner C, another prisoner from the
same wing, was already outside with two other prisoners, rolling a cigarette.
He saw the man leaning against the rubbish bin and recalled that he was
looking at the floor with his head down, humming to himself. The man agreed
to a cigarette and prisoner C rolled another one whilst reading his newspaper.
50. At approximately 10.55am, prisoner D left his cell and made his way to the
back field of the prison grounds. He passed the man and prisoner C outside
the wing entrance and was about ten feet away when he heard a noise. He
turned around and saw the man on the floor. He had collapsed by the
entrance to the wing.
51. A number of people saw the man fall backwards to the ground and reported
his fall. The second prison officer was one of them and immediately went into
B wing’s office where he told the wing manager and the other officers. They
made their way outside and found that prisoner C had already placed the man
in the recovery position. Prisoner C began to talk to him in an attempt to keep
him conscious. He also checked for blood because he thought the man had
hit his head in the fall. In his police statement, prisoner C said he held the
man’s head and heard one of the officers from B wing shout, “Do not touch
him.” The man began to suffer what appeared to be an epileptic fit. Prisoner
C noticed that the man’s head was getting heavy and told one of the officers.
He recalled that an officer got the man a pillow and prisoner C placed it under
his head.
52. The wing manager radioed for emergency assistance at about 11.00am. He
told my investigator that he spoke to a member of the communications staff,
explained that a prisoner had collapsed, and asked for Hotel 1 (emergency
healthcare) to attend B wing immediately. The wing manager recalled that the
communications officer had some difficulty contacting Hotel 1 by radio and
telephoned healthcare to make sure the message was relayed. The HCO
was Hotel 1 that day. He received the message at approximately the same
time and made his way to B wing.
53. Outside the administration block, the duty governor and the deputy governor
had just finished a meeting. As they walked away from the block, the duty
governor saw a few people gathered around the man. Both he and the
deputy governor approached the area.
54. When the SO based on C wing heard about the man’s collapse, he too made
his way to B wing and was met by both governors. The SO and the duty
governor realised that the man was not breathing and turned him over onto
his back. They began CPR. The SO administered breaths without using a
protective face mask. The duty governor started 30 chest compressions per
minute to the SO’s two breaths.
55. Within a couple of minutes, the HCO arrived. In his statement to the police,
the HCO said he thought the man had suffered an epileptic fit. He had not
brought resuscitation equipment and a defibrillator with him and sent prisoner
C back to the healthcare unit for the emergency medical bag. The HCO
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checked the man for signs of epilepsy and found no evidence of an epileptic
fit. According to the action checklist recording the response to the man’s
collapse, an ambulance was called at 11.04am. At approximately 11.15am,
prisoner C returned to where the man had collapsed with the equipment.
During this time, the deputy governor, the SO from C wing, the HCO, the
second HCO and the duty SO all took it in turns to administer life support.
The second prison officer cleared the area immediately surrounding the man
and made sure that prisoners went back to the wing. Staff administering first
aid continued for another five minutes, taking it in turns to administer chest
compressions and breaths in accordance with the defibrillator’s instructions.
56. The deputy governor took overall management control of the response to the
man’s collapse. She asked the third landing officer to return to B wing and
supervise the movement of other prisoners. The deputy governor had already
radioed for an ambulance and contacted communications staff another four
times to chase its whereabouts. When interviewed about the length of time it
took for the ambulance to arrive, the deputy governor explained that there
was one paramedic team on the Isle of Sheppey, and that the ambulance had
been directed to another emergency. The paramedic left that emergency and
came directly to Standford Hill, followed by an ambulance.
57. At 11.20am, the paramedic arrived, shortly followed at 11.35am by the
ambulance. The second prison officer directed both vehicles to B wing’s
entrance. The paramedic asked staff to increase chest compressions to 100
per minute and put an intravenous line into the man. When the ambulance
arrived, the man was placed on a stretcher and lifted into the vehicle. Both
prison staff and the paramedic continued to administer CPR. The deputy
governor asked the second prison officer to go with the man to the hospital.
She told my investigator that this was because the man knew the officer, and
she thought it would be better for him to see someone he knew if he regained
consciousness.
58. An officer from B wing came on duty at lunchtime and saw the ambulance in
the prison grounds. She asked a colleague what was happening and was told
that a prisoner had collapsed. The officer asked about the identity of the
prisoner. She was told it was the man and, when interviewed by my
investigator, said that she remembered feeling upset that it was him.
59. The ambulance left the prison grounds at 11.55am. The second prison officer
continued chest compressions en route to the local hospital. He also helped
the paramedic with an ambu-bag and oxygen. When the ambulance arrived
at the hospital at approximately 12.15pm, the officer helped move the man
into the resuscitation room and saw hospital staff attempt to revive him. The
deputy governor had given the officer a mobile telephone before he left the
prison grounds. She then asked the prison chaplain, to accompany her to the
hospital and telephoned the man’s next of kin to explain that he had
collapsed. The deputy governor gave the man’s mother the hospital details
and arranged to meet his family there. As she was preparing to leave the
prison, the second prison officer telephoned. He reported that the man had
been pronounced dead by the hospital doctor at 12.45pm.
16
Events following the man’s death
60. The deputy governor spoke first to the second prison officer on her arrival at
the hospital. She then met the man’s family as arranged and told them that
the man had died. She accompanied the man’s mother to the hospital chapel
and left her in private. The man’s family then spoke to nursing staff and
asked to see his body. The deputy governor told my investigator that she had
to explain that the man’s body was still in prison custody and, until released
by the police and Coroner, this was not possible. The Coroner’s Officer was
at the hospital, and the deputy governor told the family that the Coroner would
explain the process more fully. The Coroner’s Officer spoke to his family
again. She explained that she was available at any time if there was anything
they wished to discuss. The deputy governor passed on her mobile telephone
details and returned to Standford Hill with the second prison officer. The
prison chaplain remained at the hospital with the man’s family.
62. The wing manager and several other members of staff on B wing ensured that
the area where the man had fallen was sealed and evidence preserved for the
police and Coroner’s arrival. When the police arrived, they took a number of
statements from prisoners and staff and photographed the man’s cell. In his
log of events, the wing manager said that, at 11.57am, the man’s cell door
was discovered open and was sealed at 11.59am. The SO who was an
observer that day, also noticed that the man’s cell was not sealed until around
12.00pm.
63. Later that afternoon, staff attended a hot debrief and discussed the response
to the man’s collapse. As a result of the hot debrief, the absence of a clear
emergency code system was identified as were improvements to healthcare
preparations for attending emergencies. The same afternoon, two prisoners
approached the B wing officer on the wing. The prisoners explained that they
wanted to arrange a collection for the man’s family. The officer agreed and
arranged for collection forms to be typed up and distributed around the prison.
The collection was later forwarded to the man’s family.
64. The duty governor spoke to prisoner C and reassured him that he had done
all that he could to help the man. Prisoner C was understandably shaken by
the experience and the duty governor offered him further support if he needed
it. Prisoner C requested another visiting order (VO) so that he could have
contact with his own family. The wing manager arranged the VO for him. The
wing manager also told my investigator that he offered support to his staff on
the wing and had been approached by the support team himself.
65. A few days after the man’s death, his family were invited by the deputy
governor to visit the prison. They spent the afternoon talking to her and to
prisoner C, and were escorted to the man’s cell by the duty SO. The deputy
governor told my investigator that both she and prisoner C answered the
man’s family’s questions as best they could. The deputy governor said it was
also helpful to have the duty SO’s assistance during the visit. As a trained
paramedic before joining the Prison Service, and as the senior officer who
17
responded to the man’s collapse, the duty SO was well placed to accompany
the man’s family around the prison.
66. The deputy governor contacted the man’s next of kin again and discussed
funeral arrangements. In accordance with Prison Service Order (PSO) 2710,
‘Follow up to a death in custody’, she offered to assist with the cost of the
funeral and provide ongoing emotional support. At his family’s request, no
prison staff were present at the funeral. Flowers were sent on behalf of the
prison and the deputy governor arranged for prisoner C to attend the funeral
(he was released on temporary licence for the service). The man’s property
was returned to his family afterwards.
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ISSUES CONSIDERED IN THE INVESTIGATION
67. The man’s death was sudden and unexpected and was the first death in
custody at Standford Hill for many years. His collapse tested the prison’s
contingency plans for responding to an emergency.
68. I believe that staff and prisoners acted compassionately and professionally.
However, the sad circumstances also highlighted areas where contingency
plans and medical attention could be strengthened. I am pleased to see that
the deputy governor and staff at Standford Hill recognised where gaps could
be filled and congratulate the management team for implementing changes so
speedily after the man’s death.
69. That said, my investigation has highlighted one further area where
performance could be improved and addresses the issues raised by the
man’s family. I deal with these below.
Clinical care
70. The man died as a result of a rare physical health condition. (I understand
that miliary tuberculosis represents just one to two per cent of all patients with
TB.) His medical records overwhelmingly concentrated on his mental health
and there was no evidence of him seeking medical attention for any physical
symptoms. During his interview with my investigator, the duty governor
confirmed that the man had been seen walking towards the healthcare unit on
the day he died. That said, the duty governor pointed out that the man did not
go into the building and was not booked in to see a member of healthcare
staff. The clinical reviewer has found no evidence that the man had sought
medical attention in the days leading up to his death.
71. The man had a long term history of drug misuse and had been under regular
psychiatric review both in the community and in prison. Approximately nine
years before he arrived at Standford Hill, he was identified as someone with
mental health needs. In 1998, whilst on remand at HMP Belmarsh, he was
diagnosed with paranoid schizophrenia. When released, he continued to
receive support from his local mental health service but did not always comply
with his treatment.
72. When he came into contact with the criminal justice system again, he was
supported by the mental health in-reach teams at HMP Brixton, HMP
Maidstone and HMP Standford Hill. When he transferred to Standford Hill, his
mental health was monitored by a CPN every four to six weeks. Throughout
his whole period of imprisonment, the man was also in touch with the CARAT
team.
73. In terms of his medication, the man was prescribed anti-psychotic drugs to
help control his mental health problems. When he first came into custody, he
was already being prescribed Piportil, via an injection, and Procyclidine, a
drug to control the side effects of the injection. Whilst in custody at
Maidstone, his medication was reviewed and he was prescribed another anti-
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psychotic drug, Amisulpride, twice daily which he took orally. The clinical
reviewer found that the man’s prison prescription charts did not provide
sufficient information for him to comment on whether he took his medication
reliably. (Administering medication orally instead of intravenously necessarily
increases the chances of patients not complying.) However, the man’s
medical records do not suggest that he was not taking his medication (and, in
any event, patients cannot be forced to comply with prescriptions whether
they are in the community or a prison environment).
74. The man was not diagnosed with miliary tuberculosis whilst in custody. The
clinical reviewer comments that this rare form of the disease is difficult to
diagnose without secondary medical interventions. He adds that the man did
not appear to display any of the mild symptoms: fever, coughing, weight loss
or swollen glands.
75. About a week before he died, the man told a CPN at his mental health review
that he was working as a cleaner and going to the gym regularly. He did not
seek medical help or raise concerns amongst staff about his physical health.
In the clinical reviewer’s experience, he would not expect a mental health
patient in either the community or prison to be the subject of regular physical
checks or routine blood tests or x-rays. In terms of diagnosing the condition,
ante mortem, the clinical reviewer suggests that a chest x-ray might have
revealed the pulmonary lesions on the man’s internal organs. (Lesions are
synonymous with miliary TB). In relation to diagnosis of the condition, the
Clinical reviewer concludes as follows (I have reworded his words slightly):
“It is my opinion that the man’s lifestyle, as a result of his drug habit
and his time in Nigeria, would have increased his risk of contracting the
disease, two fold. Miliary TB is a chronic disease and more common in
African countries. On the balance of probabilities, the man contracted
the disease long before he received a custodial sentence.”
76. As page 10 of my report notes, the building used by the healthcare unit has
been criticised by both the Chief Inspector of Prisons and the IMB. The duty
governor told my investigator that the healthcare unit aspired to better mirror a
community doctor’s practice and adopt chronic disease management
provision in future. The duty governor also said that a new, albeit portable,
building would be in use in 2008.
77. The clinical review makes no criticism of the primary care the man received.
That said, once the clinical reviewer received the post mortem results, the
following suggestion was added to the clinical review as a preventative
measure:
“It may be a matter for the Prison Health service to consider whether
those deemed to be at extra risk of tuberculosis, by virtue of lifestyle,
country of origin or countries visited, should have a routine x-ray”
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Medical records
78. The clinical review finds that the man’s prescription records were incomplete.
In addition, the clinical reviewer comments negatively on his medical records
in general. Review of the records was also hampered by frequent illegible
entries and a lack of continuity in some instances. Record keeping is
essential in order to maintain continuity of care for patients. I endorse the
clinical reviewer’s view and make the following recommendation,
The Head of Healthcare should ensure that medical records are clear,
concise and continuous, in accordance with the Nursing and Midwifery
Council’s guidelines.
Response to a medical emergency
79. When prisoner C and the officers first responded to the man’s collapse, they
thought he was having an epileptic fit. Police statements taken on the day,
and subsequent statements taken by my investigator, mention that his body
appeared to be in spasm and he was still breathing. Prisoner C did all he
could to make the man comfortable and to keep him conscious until officers
and healthcare staff took over. I commend Prisoner C for acting so
instinctively to help the man, and for continuing to help staff once CPR was
being administered.
80. With no emergency code system in place, the wing manager radioed for
emergency assistance in a timely fashion, but somewhat unclearly. The HCO
responded to the telephone call via a member of the communications staff,
thinking he was attending to a prisoner with epilepsy. He arrived at B wing’s
entrance without a full emergency medical bag and defibrillator, and sent
prisoner C back to the healthcare unit to pick up the equipment. I do not
believe that the delay in using an ambu bag and defibrillator would have
changed the outcome for the man. Indeed, staff continued to administer CPR
whilst they waited for the medical equipment. If the man had collapsed in the
street, it is unlikely that the same equipment would have been to hand until
the emergency services arrived.
81. Having said that, a code system, commonly used across the prison estate,
would have removed any confusion over the nature of the emergency.
Reflecting on the response to the emergency, both the wing manager and the
deputy governor mentioned that they were familiar with the system at other
establishments. The man’s death highlighted a gap in Standford Hill’s
contingency plans, and the need for further medical equipment to be made
available throughout the prison. This was raised at the hot debrief that
followed once the man was taken to hospital. The deputy governor confirmed
to my investigator that a Code Blue (unconscious/not breathing) and Code
Red (conscious/bleeding) system was implemented with immediate effect. In
practice, this means that healthcare staff now respond with the appropriate
equipment according to the Code given via radio. The duty governor
confirmed that across the Sheppey cluster of prisons, there are now nine
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defibrillators, of which three are held at Standford Hill. Protective face masks
have also been purchased and made available on the wings.
82. The response to the man’s collapse was generally managed well. In
particular, staff recognised the importance of taking it in turns to perform
mouth to mouth resuscitation and carry out chest compressions until the
paramedic arrived. I do not underestimate how stressful, tiring and, in some
instances, how emotionally draining it is for those who carry out CPR for any
length of time. I note that the SO from C wing did not hesitate to attend to the
man, initially without a protective face mask. The SO’s actions were not
necessarily good practice but they were instinctive and ensured that life
support commenced without delay. This would have been a particularly
unpleasant experience, and indeed it left the SO visibly unwell for a short time
afterwards. The likelihood of a member of staff finding themself in this
position in future has been significantly decreased now that face masks have
been made more accessible. I know that the deputy governor has already
commended the SO for his actions. I would like to offer my own
commendation for the way the SO responded so quickly and selflessly, and
would be grateful if the Governor could pass this on.
First Aid training and Family Liaison
83. When my investigator first visited Standford Hill, it became clear that the
prison had a shortage of first aid trained staff. Indeed, in a subsequent report
focussing on a later death at the prison, I mention that one of the prisoners
was specifically asked to respond to an emergency as a fully qualified first
aider. However, in the man’s case, the healthcare staff in attendance were
first aid trained and the second prison officer, who accompanied the man to
hospital, was also an experienced first aider and a firefighter prior to joining
the Prison Service.
84. All prison officers are first aid trained when first entering the Prison Service,
but many do not receive refresher courses once they qualify. The deputy
governor told my investigator that the issue of first aid was raised at the hot
debrief. The shortage of first aid trained staff came as a result of the
movement of qualified staff following the introduction of the prison cluster in
April 2006. The deputy governor said that the redistribution of staff to HMP
Elmley and Swaleside was an unforeseen circumstance of clustering the
three prisons.
85. Following the man’s death, the deputy governor and the management team at
Standford Hill conducted a risk assessment of first aid training, family liaison
officer (FLO) training and a review of the local contingency plans. They
suggested three improvements to training as a preventative measure. These
include heart start training for all members of staff, full first aid training for 20
volunteers and IDTS training. In addition, the deputy governor told my
investigator that two other members of the management team were on the
waiting list for family liaison officer training.
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86. I congratulate the deputy governor for her foresight in conducting a risk
assessment to ensure that as many lessons as possible were learnt from the
man’s death. I also commend her for acting as family liaison officer and
offering ongoing support to the man’s family after he died. As the deputy
governor, this was a substantial responsibility to take on. The deputy
governor demonstrated both professionalism and sensitivity as a FLO, in
addition to her other managerial responsibilities.
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RECOMMENDATION AND COMMENDATIONS
The Head of Healthcare should ensure that medical records are clear, concise
and continuous, in accordance with the Nursing and Midwifery Council’s
guidelines.
The prison service accepted this recommendation. In response they said:
All to be trained to use Emis System for Data Entries and the Healthcare
Manager to review patient notes to comply with NMC guidelines.
COMMENDATIONS
I commend the actions of all staff but especially those of the SO from C wing
and of the Deputy Governor. The Governor and Area Manager will wish to
consider if their actions should be further recognised
I commend the actions of prisoner C. The Governor will wish to consider if his
actions should be formally recognised too.
The prison service accepted the commendations.
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