Individual at Standford Hill

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING
THE
DEATH OF A MAN IN HOSPITAL IN JULY 2007 WHILST A
PRISONER AT HMP STANDFORD HILL
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2008
This is the report of an investigation into the death of a man in hospital in July
2007. He was a prisoner at HMP Standford Hill and died of natural causes.
He was aged 69.
The man had a history of ill-health related to various chest problems. He had
diagnoses for asthma, emphysema and, latterly, cardio obstructive pulmonary
disorder (COPD). These conditions were thought to be related in part to his
longstanding cigarette habit.
During the morning of his death, the man complained to prison staff that he
was feeling unwell. He was assessed in his room by a doctor and a nurse
who decided he needed to be admitted to hospital. An ambulance was
requested to arrange for him to be taken to hospital. This was done by way of
a direct call to the ambulance service rather than via the emergency services.
The deputy governor was asked to authorise the man’s absence from the
prison and queried whether an ambulance needed to be called more urgently.
She was told that the man had been assessed by a doctor. She went to see
him anyway and asked a member of wing staff to “keep an eye on him”. At
11.40am, a prison officer found the man unconscious. Emergency
resuscitation was started and 999 called. An ambulance arrived and took him
to hospital where he died later that evening.
The investigation was undertaken on my behalf by one of my colleagues. I
would like to express my thanks to the governor of Standford Hill for the help
my investigator received. Particular thanks go to the prison liaison officer for
making the arrangements to facilitate my investigator’s visits. A medical
practitioner conducted a review of the clinical care received by the man on
behalf of Eastern and Coastal Kent Teaching Primary Care Trust. I thank him
for his contribution and invaluable input.
I make four recommendations. In making these I have been guided by the
findings of the clinical reviewer who found the long term management of the
man’s chronic health problems fell below expected standards. Whilst the man
was at times a difficult patient to treat, there was no evidence that this was
challenged in a structured way. The way he was managed on the day of his
death is also a cause for concern. I am pleased to say that the Prison Service
have accepted the three recommendations which apply to them.
On a more positive note, I was pleased to learn that the prison arranged for
six prisoners to attend the man’s funeral to pay their respects. In addition, the
prison properly recognised the actions of two prisoners who helped staff in
attempting to revive the man after he was found unconscious.
Fatal incident investigations conducted by my office attempt, as far as
possible, to address the concerns of family members and anyone to whom the
person who died was close. Sadly, the man had lost contact with his family
over the course his lengthy prison sentence and it has not been possible to
trace any next of kin.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2008
CONTENTS
Summary
The Investigation Process
HMP Standford Hill
Key Findings
Clinical Issues
Other Issues
Recommendations and good practice
SUMMARY
The man was sentenced to life imprisonment in October 1985. He
progressed through the prison system before being released on life licence in
February 2000. He was recalled to prison in June 2001 after breaking the
terms of his licence. Upon his return to custody it was noted that he was in
poor health, and that he suffered with asthma and chronic emphysema.
In November 2003, the man secured a progressive move to HMP Standford
Hill. When he arrived it was once again recorded that he suffered from a
chest complaint related to his asthma and emphysema. In February 2004, the
man saw a specialist at outside hospital and was diagnosed with chronic
obstructive pulmonary disease (COPD) and prescribed recognised medication
to treat it. His chest problems and other ill health were treated as an ongoing
concern by the healthcare team throughout his time at Standford Hill.
However, the man failed to attend numerous appointments.
During the morning of his death, the man complained to prison staff that he
was feeling ill. Staff called their colleagues in the healthcare department and
a nurse and a doctor attended. They assessed him and found that he had
lost weight and was struggling to breathe. A fungal growth was also observed
on his tongue. The doctor concluded that the man was too poorly to be
treated at the prison and therefore contacted the hospital to arrange for him to
be admitted. He also organised an ambulance to transport the man to
hospital, although he did not say it was an emergency.
The nurse who assessed the man asked the deputy governor to authorise his
temporary release from the prison. The deputy governor enquired how long it
would take for the ambulance to arrive. She was told “anything up to four
hours”. She questioned whether the man would be alright for this long, and
was told that he would. However, she went to see the man anyway and
asked a member of wing staff to “keep an eye on him”. Whilst waiting for the
ambulance to arrive, the man was allowed to return to his room.
At 11.40am, the wing officer was carrying out a roll check on C Wing. She
found the man unresponsive on his bed and summoned assistance using the
prison radio. With the help of a prisoner she moved the man onto the floor
and started cardio pulmonary resuscitation (CPR). Nursing and discipline
staff soon arrived en masse and 999 was called.
The ambulance arrived at 11.55am and paramedics continued CPR before
taking the man to hospital. Sadly, he never regained consciousness and died
later that evening.
THE INVESTIGATION PROCESS
1. My investigator opened the investigation into the man’s death on 1
August 2007. He met a governor appointed as the prison liaison officer,
who outlined the circumstances surrounding the man’s death and
provided the investigator with his prison records.
2. Prior to my investigator arriving at Standford Hill, notices had been
issued to staff and residents announcing the investigation and inviting
anyone who had information relevant to the man’s death to make
themselves known to the investigator. No one came forward. However,
my investigator returned to the establishment on 25 September to
interview a governor who had contact with the man on the morning he
died. He also spoke to the chair of the prison’s Independent Monitoring
Board (IMB). He returned again on 11 October to interview a doctor who
assessed the man in the hour before he was found collapsed in his
room. Another member of staff to whom my investigator wanted to speak
has retired and emigrated since the man’s death. As a consequence,
she has not been interviewed.
3. My investigator also contacted Her Majesty’s Coroner to inform him of
the nature and scope of the investigation and to request a copy of the
post mortem report. Another colleague has completed the report as the
lead investigator has now left my office. Upon completion, this report will
be sent to the Coroner to assist him in his enquiries.
4. A medical practitioner undertook a review of the clinical care received by
the man who died on the instructions of Eastern and Coastal Kent
Teaching Primary Care Trust.
HMP STANDFORD HILL
5. HMP Standford Hill is an open (category D) prison, part of the cluster of
three adjacent prisons (Elmley and Swaleside are the others) on the Isle
of Sheppey in Kent. It was originally opened in 1950 and became a
category D prison in 1985. It can hold up to 464 prisoners. Like all
category D prisons, the ethos at Standford Hill is one of preparing
prisoners to lead independent, crime-free lives in the community after
release.
6. Eastern and Coastal Kent Primary Care Trust is responsible for the
delivery of primary health services in the prison. There are no inpatient
facilities and prisoners requiring 24-hour healthcare are transferred to
HMP Elmley. Elmley is a category B prison, and therefore any Standford
Hill prisoner who is transferred experiences some reduction in their
freedom of movement. Some prisoners who need a transfer for medical
reasons are reluctant to go for this reason.
7. A daily ‘sick parade’ is held in the healthcare unit at Standford Hill for
prisoners wishing to access primary care services. A general practitioner
from a practice in Sheerness holds a clinic every weekday morning, from
8.00am until 10.30am. Out of hours medical cover is provided by
MEDOC, a local on-call service based at Sheppey Hospital. Healthcare
also provides dental, optical, psychiatric and chiropody services. As the
ethos governing healthcare services is one of ‘comparative care’,
Standford Hill does not have special resources allocated to elderly
prisoners.
8. Standford Hill was last inspected by Her Majesty’s Chief Inspector of
Prisons in December 2006. Her report was critical of the physical state
of the prison and the healthcare centre was described as suffering from a
lack of investment. However, she commented positively on prisoners’
access to health services, and noted that all prisoners received their
medication in possession as they would in the community. Overall,
Standford Hill was assessed as being a safe, respectful and purposeful
place for prisoners.
KEY FINDINGS
9. As noted above, the man arrived at Standford Hill in November 2003.
Upon reception he was interviewed by a Healthcare Officer (HCO) and
disclosed that he suffered from two serious illnesses, asthma and
emphysema. A comprehensive list of his current medication was
recorded in his medical notes. The HCO also wrote that the man
described himself as a social drinker when it came to alcohol
consumption. After being processed through reception, he was
transferred to one of the residential units.
10. Two weeks after his arrival, he was seen by a doctor after suffering from
acute shortness of breath. After carrying out an examination, the doctor
referred him to a chest specialist in the local hospital. The doctor
thought that he might be suffering from chronic obstructive pulmonary
disease (COPD), a disorder characterised by an impaired ability to expel
air from the lungs which makes breathing extremely painful and difficult.
11. On 18 February 2004, the man attended an outpatient appointment with
the specialist. His main problem was assessed as breathlessness on
exertion. It was noted that central heating made his breathing worse and
that he could walk 400-500 yards on flat ground before having to stop. A
history of hypertension and high cholesterol was identified, as was the
fact that the man had been a smoker since the age of 14. The
specialist’s diagnosis was that the man suffered from a moderate to
severe form of COPD, but considered that it could be controlled by
medication. The specialist made out a prescription for Serevent and
Atrovent, two widely used treatments for COPD, and set a review date
for three months.
12. As arranged, the man attended a further outpatient appointment with the
chest specialist on 2 June 2004. It was recorded that he had been stable
on his medication and his tolerance to exercise was unchanged. It was
further noted that he continued to smoke, although he told the consultant
that he had reduced his intake to three to four cigarettes a day from a
previous level of ten. The specialist advised him to stop smoking as this
would be likely to make the most difference to his ability to breathe. He
also issued him with an inhaler. As the man’s condition was assessed
as stable, no follow-up appointment was made.
13. On 20 July, the man attended an appointment with an optician who
noted that his eyesight was getting worse. From late 2004 and
throughout 2005, the man attended numerous outpatient appointments
at the local hospital in order to correct the problem.
14. In January 2006, the man was due to be released from prison on
temporary licence in order to stay at an Approved Premises (probation
hostel) for four nights. Unfortunately, this was cancelled at the last
minute when he came down with flu.
15. Six months later, on 16 June 2006, the man was seen by a member of
the healthcare team after complaining of feeling unwell. His blood
pressure was raised so he was referred to the prison’s General
Practitioner (GP). The prison doctor assessed him and noted that his
symptoms were related to his COPD. No further action was deemed
necessary.
16. In July 2006, the man was seen again in healthcare and it was recorded
in his notes that he was suffering from “severe COPD”. A random blood
sugar test was carried out and revealed that his blood sugars were at a
borderline diabetic level. A fasting blood sugar test was suggested,
although there is no evidence that this was followed up.
17. In order to prepare for their eventual release, many category D prisoners
are released for short periods on temporary licence order to stay at an
Approved Premises or another suitable address. As the man was one of
the longest serving lifers at Standford Hill, staff knew he felt settled in the
prison environment. He was described as a quiet, insular man, and as a
consequence preparations for his release had to be carefully managed.
Between 4 December and 8 December 2006, he was released on
temporary licence (ROTL) to a probation partnership hostel. His stay
was successful and he returned to the prison, as required, on 8
December.
18. On 30 January 2007, the man was seen again by the prison. It was
noted that he continued to smoke heavily, against the advice of the chest
specialist he had seen at the local hospital.
19. Between 5 February and 9 February, and again between 10 April and 13
April, the man was released on temporary licence to hostel. Both stays
apparently passed without incident and, on 1 May 2007, the hostel
offered him a permanent place if he was released from prison. (A Parole
Board Oral Hearing, which could have resulted in him being released,
was due to take place on 3 October 2007.)
20. Around 10.00am on 23 July, the man complained to staff that he was
feeling ill. A call was made to the healthcare department and the duty
HCO and the prison doctor attended. Unfortunately, the HCO has now
retired and it has not been possible to speak to her about what
happened. However, the prison doctor told my investigator that, when
he and the duty HCO arrived at the door to the man’s room, they
knocked and initially received no response. The doctor considered
breaking the door down just as the man was heard making his way
across the room. He opened the door and the doctor immediately
noticed that he looked “grey” and ill. The HCO and the doctor helped
him back to bed before he carried out an examination.
21. The prison doctor found that the man had lost a lot of weight and was
struggling to breathe. He examined his tongue and saw that it was
covered in a fungal growth. He concluded that the man was too ill to be
treated at the prison and phoned the hospital to arrange an admission.
The doctor described the man’s symptoms to the specialist at the
Medical Assessment Unit and the specialist told him to “send him in
straightaway”.
22. The doctor then arranged for an ambulance to collect the man and take
him to hospital. He called the ambulance service directly rather than by
making a 999 call. He then wrote a memorandum to the specialist at the
Medical Assessment Unit, briefly describing the man’s medical history
and his current presentation. The doctor wrote:
“[l]ongstanding COPD and asthmatic. Today he has lost a lot of
weight. Tongue dry, coated & fungus. Unable to walk or
breathe properly. Looks greyish. Cyanosed+.”
After faxing this off to the hospital, the doctor says he left the man in the
care of the duty HCO.
23. Whilst waiting for the ambulance to arrive, the HCO completed the
Release On Temporary Licence (ROTL) paperwork so that the man
could leave the prison with proper authority. She went to the
administration block at the prison and asked the deputy governor, to sign
the documentation. The deputy governor asked the HCO why the man
needed to go to hospital and says she was told that he had deteriorated
quite badly. The deputy governor asked the duty HCO whether the man
could go to hospital in a taxi with an accompanying member of staff. The
duty HCO apparently replied that he was too poor for that. The deputy
governor asked whether 999 needed to be called if the man was too ill to
go by taxi. She says the HCO told her that the doctor had assessed him
and had arranged for an ambulance. The deputy governor asked how
long it would be before the ambulance arrived, and the HCO apparently
said “anything up to four hours”. The deputy governor thought this was a
long time and asked the HCO whether the man would be alright for four
hours. She was assured that he “should be”. Finally, she enquired
whether the man was going to hospital willingly, as she knew from
previous experience that he was a very reluctant patient. She told my
investigator that the duty HCO told her that she hoped he would get in
the ambulance when it arrived.
24. The deputy governor then made her way to the man’s wing to speak to
him. She observed that he sounded very chesty and asked him how he
was doing. He said he was quite bad. She enquired whether he was
going to go to hospital. He replied that he did not want to before
conceding that he would have no alternative. The deputy governor then
left his room, leaving the door open so that wing staff could keep an eye
on him. She also spoke to the officer on duty and said, “The man is quite
poorly, the ambulance is en route, can you keep an eye on him?”
25. Around 11.30am, the wing officer started carrying out the roll check on C
Wing. At 11.40am, she arrived at the man’s room, C1-16. She looked
into the room and observed that he appeared to be asleep on his bed.
Aware that he was unwell, and mindful of the deputy governor’s’
instruction to keep an eye on him, she spoke to him but got no reply.
She then approached the bed, continuing to speak. Arriving at the man’s
bedside, the officer touched his arm in order to rouse him. The man was
unresponsive and the officer immediately realised that there was a
problem. She sent a message over the prison’s radio network urging all
available staff to come to C Wing immediately.
26. At this point, prisoner A, came into the man’s room, followed shortly
afterwards by another prisoner, prisoner B. The latter quickly left to find
first aid trained staff whilst prisoner A helped the officer lift the man onto
the floor. The wing officer checked the man’s vital signs, could find no
pulse and started cardio pulmonary resuscitation (CPR).
27. A prison officer then arrived at room C1-16. He removed a face mask
and pair of surgical gloves from the first aid pouch issued to all frontline
staff, and then took over from the wing officer who is not CPR trained.
He also instructed the wing officer to send out a ‘code blue’ message
over the radio, which prompted the communications department to call
999 and request an emergency ambulance. The prison officer continued
to administer CPR for a number of minutes before being relieved by the
senior officer (SO). a second prison officer, a healthcare worker (HCW),
the duty HCO and the deputy governor subsequently arrived at C1-16,
and collectively they worked on the man until an ambulance arrived at
11.55am.
28. The paramedics assumed responsibility for administering CPR whilst
prison staff helped as best they could. The man was taken by
ambulance to hospital, situated 17 miles away. He was admitted as an
inpatient and received emergency treatment. However, he failed to
regain consciousness and died later that early evening. He was aged
69.
29. A hot debrief subsequently took place and the staff who were involved in
trying to resuscitate the man were informed of the support available to
them. The governor and prison liaison officer wrote to prisoner A and
prisoner B to commend them for helping the staff in their efforts to save
the man’s life.
30. The man had lost contact with his family many years previously, and he
had named his solicitor as his next of kin. His funeral took place at a
crematorium and was attended by six prisoners, one former prisoner, his
solicitor, three prison officers and the governor appointed as the prison
liaison officer. I commend Standford Hill for arranging for six prisoners to
be released on ROTL to attend the funeral and to pay their respects.
CLINICAL ISSUES
Management of the man’s chronic ill health
31. The clinical review prepared by the clinical reviewer details of the man’s
history of COPD, hypertension (high blood pressure) and
hypercholesterolaemia (high cholesterol). From the man’s ‘in
possession’ prescription charts there is evidence that all these conditions
were treated with prescribed medication. He received aspirin for his high
blood pressure and Lipostat for his high cholesterol, recognised
treatments for these conditions, right up until his death. However, there
is no evidence in the man’s medical records that his blood pressure or
cholesterol levels were checked after he was discharged by the hospital
on 2 June 2004. It is not therefore possible to say whether the
medication was still having the desired effect. This is poor practice.
32. In interview, the prison doctor and medical lead ultimately responsible for
the man’s care, suggested that these levels would have been monitored
as a matter of course. However, failing to document the results in the
man’s notes seriously diminishes the value of doing this. I therefore
recommend:
Healthcare staff should be reminded of the importance of record
keeping. The results of examinations and tests should be routinely
documented and all entries should be signed and dated.
33. The clinical reviewer’s report is also critical of the fact that no coherent
care plan was put in place for the man after he arrived at Standford Hill.
The prison doctor said that the man would have been told when he
arrived at the prison that he could access GP services every day. He
also said that this is no different to how things are for ordinary members
of the community. However, it was known that the man was not a
particularly cooperative patient and that he seemed indifferent to his
deteriorating health. (One example being the fact he continued to smoke
against medical advice.) It was also known that he frequently failed to
attend pre-arranged appointments, so it is doubtful that he would have
referred himself to the GP. The clinical reviewer comments that there
seems to have been no proactive attempt to improve the man’s health
and that he became a victim of his own indifference. A comprehensive
care plan would have provided the healthcare team with a structured way
of engaging with the man, and would have ensured that missed
appointments were followed up more effectively.
Prisoners with complex/chronic health problems should be
managed by a care planning system. Care plans should be tailored
to individual prisoner’s needs and should adopt a multi-disciplinary
approach.
Failures to attend healthcare appointments should be recorded in
the clinical records and audited regularly. If prisoners with chronic
diseases are regularly missing appointments, strategies should be
developed to engage with them.
The man’s care on 23 July
34. About an hour and a half before he was found collapsed in his cell, the
man was jointly assessed by a healthcare officer (HCO) and by the
prison doctor. It was immediately obvious to the doctor that the man was
“in a bad state”. A brief examination revealed he had lost a lot of weight
and was struggling to breathe. His tongue was also covered in a fungal
growth. The doctor concluded that the man was too ill to be treated at
the prison and phoned the hospital to arrange an admission. After
describing the man’s symptoms to the specialist, the specialist
apparently told the prison doctor to “send him in straightaway”.
35. Given this, I was surprised to learn that instead of calling 999 the doctor
contacted the ambulance service directly to arrange for the man to be
transported to hospital. My investigator has learned that ‘routine’
ambulance transports of this type can take up to four hours. This was
known by the HCO who spoke to the deputy governor who was asked to
authorise the man’s temporary release from the prison. When the
deputy governor asked the HCO whether the man would be okay for four
hours, she was told that the doctor had assessed him and he “should be”
alright.
36. Whilst it is not possible to say whether the man’s life would have been
prolonged by an earlier hospital admission, it is manifestly the case that
a hospital is a more suitable environment for treating an ill patient than a
category D prison. To my mind, being asked to send a patient to hospital
“straightaway” should prompt a more dynamic response than merely
requesting an ambulance transport.
37. The decision only to request an ambulance for transport purposes could
be considered a defensible one in one set of circumstances. If the man
had been given basic medical treatment (the clinical reviewer has
suggested that oxygen, intravenous steroids and a nebulised
bronchodilator may have been appropriate) whilst waiting for the
ambulance to arrive, it is possible that his condition could have been
stabilised. As it was, he was allowed to return to his room
unaccompanied, his condition deteriorated and he lost consciousness.
The only element of direct supervision was requested by the deputy
governor who asked staff on the man’s wing to “keep an eye on him”. As
she had already been told that the man should be alright until the
ambulance arrived, I think she did all that could reasonably have been
expected (indeed, she emerges well). Certainly, I cannot criticise her not
asking the officer to watch the man constantly. Likewise, the officer
concerned cannot be criticised. Nevertheless, there are self-evident
concerns about the management of the man on the day of his death.
Eastern and Coastal Kent Teaching Primary Care Trust should
conduct a critical incident review into the care received by the man
on 23 July.
OTHER ISSUES
Preparing the man for release
38. Prisoners in category D establishments are expected to be proactive in
planning for their own release. Usually this requires them to make efforts
to obtain purposeful employment and suitable accommodation, and to
show that they are capable of leading independent, law-abiding lives.
39. Due to his age, infirmity and the length of time he had spent in prison
(over 20 years at the time of his death), the man was probably less
proactive in planning for his release than most prisoners in category Ds.
Indeed, according to the deputy governor, he seemed quite content to
spend the rest of his life in prison. By almost anyone’s measure, the
man was ‘institutionalised’.
40. For that reason, I was pleased to learn that, whilst taking on board the
man’s need to take things slowly, Standford Hill continued to engage with
him in a way that ensured he did not stagnate in prison. At the time of
his death he was three months away from a Parole Board hearing that
would decide whether he would be released. Whilst there is no merit in
speculating on what the outcome would have been, the man’s successful
stays at the hostel (facilitated by Standford Hill) would have helped his
case.
Recognising the actions of prisoner A and prisoner B
41. I welcome the fact that the two prisoners who helped staff after the man
was found unconscious were thanked in writing by the governor acting
as the prison liaison officer. This was good practice.
RECOMMENDATIONS
1. Healthcare staff should be reminded of the importance of record keeping.
The results of examinations and tests should be routinely documented
and all entries should be signed and dated.
The Prison Service have accepted this recommendation. Extra staff
have been drafted into HMP Standford Hill since July 2007. This
includes a full time Administrative Officer from January 2008. The extra
staff will ensure a better standard of practice regarding documentation in
the Healthcare Department. The use of the EMIS IT system is due to be
in place by February/March 2008. This will further enhance the
efficiency of documentation.
2. Prisoners with complex/chronic health problems should be managed by
a care planning system. Care plans should be tailored to individual
prisoner’s needs and should adopt a multi-disciplinary approach.
The Prison Service have accepted this recommendation. As noted
above, extra staff have been brought in. Long Term Condition clinics
have commenced in HMP Standford Hill and care planning is an
inevitable part of this. Further clinical staff are required for HMP
Standford Hill. This will be established as part of a re-profiling exercise.
3. Failures to attend healthcare appointments should be recorded in the
clinical records and audited regularly. If prisoners with chronic diseases
are regularly missing appointments, strategies should be developed to
engage with them.
The Prison Service have accepted this recommendation. Staff have
been requested to follow up appointment failures for all prisoners who
have made appointments or who have had appointments made for them.
This will be part of Clinical Audit for the Department. Failure to attend
will be entered in paper records and later on EMIS with the reason for
failure to attend fully documented.
4. Eastern and Coastal Kent Teaching Primary Care Trust should conduct a
critical incident review into the care received by the man on 23 July.
GOOD PRACTICE
1. Arranging for six prisoners to be released on temporary licence to attend
the man’s funeral is an example of good practice.
2. I welcome the fact that the two prisoners who helped staff after the man
was found unconscious were thanked in writing by the governor acting
as the prison liaison officer. This was good practice.