Individual at Stocken

Circumstances surrounding the death of
a man at HMP Stocken in July 2005
Prisons and Probation Ombudsman for England and Wales
September 2006
This is the report of an investigation into the circumstances of the death of a man at
HMP Stocken in July 2005. The man had been at Stocken since 31 May and was
found dead in his bed in a single cell at about 9.10am having died from natural causes.
He was only 47 years old but had not been in good health, suffering from diabetes and
heart disease complicated by obesity.
I would like to extend my condolences to the man’s wife and young family for their very
sad loss. I would also like to thank the then Governor, her secretary and the Head of
Residence for their co-operation and support during my investigation.
The investigation was carried out by a qualified nurse, who works in my office.
My family liaison officers made contact with the man’s family and provided them
with a copy of the draft report. Subsequently, the man’s wife raised some
concerns which we have endeavoured to address in this final report.
We would like to thank the Director of Public Health and the Prison Health Lead,
at Melton, Harborough and Rutland Primary Care Trust who provided a
thorough and timely clinical review of the man’s health care. The quality and
detail of their review enabled us to incorporate it as the main body of our report.
The clinical review found that the man had a strong family history of coronary
heart disease and also significant risk factors for further cardiac events. From
all the evidence available, the review concluded that appropriate actions were
taken and relevant policies were adhered to following the discovery of the man’s
body. I have endorsed the detailed recommendations made in the clinical
review as well as the good practice that was highlighted. I have also added one
further recommendation about clinical practice with regard to prisoners holding
their medication in their possession.
The man was found in his cell by an assistant estates manager who went there to
undertake a plumbing repair. This led me to question what guidance the Prison
Service gives to staff about checking that prisoners are alive and well at the start of
each day. The current guidance is contained in the National Security Framework. It
does not include the more detailed instruction contained in the former Security Manual
(Prison Service Order 1000). I have recommended that the Prison Service reviews its
guidance to staff on this matter.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN September 2006
2
Contents
Summary 4
The Investigation 6
HMP Stocken 6
Clinical Review 7
The Family’s Concerns 13
Key Findings and Conclusions 15
Recommendations 17
3
Summary
1. The man was 47 when he was received into custody on 3 May 2005 at HMP
Lincoln. He later transferred to Stocken on 31 May to serve a fourteen
month prison sentence. He died in July 2005.
2. A clinical review by the local NHS Primary Care Trust found that the man
had a strong family history of coronary heart disease (CHD) and also
significant risk factors for further cardiac events. The clinical reviewer
pointed out that good clinical practice would be the proactive management
of this condition. However, the man had failed to attend appointments and
there appeared to have been little action taken to follow-up his non-
attendance.
3. The man was found dead in his bed in a single cell at about 9.10am. From
all the evidence available, the clinical reviewer concluded that appropriate
actions were taken and relevant policies were adhered to following the
discovery of the man’s body.
4. The clinical reviewer found that the suspension of chronic disease clinics
had reduced the opportunity to provide proactive care to the man. Linked to
this, there were issues in relation to the man’s compliance with treatment. It
was clear from the medicines found in his cell after his death that he had
taken more doses of some medication than others. This may or may not
have been due to confusion on the man’s part. The reviewer suggested that
these issues could have been addressed if the man had had access to a
chronic disease management clinic or a medicines management clinic.
5. The clinical reviewer observed that circumstances surrounding the
suspension of nurse-led chronic disease management clinics suggested that
there was a lack of understanding among non-healthcare staff in the prison
of the roles and most appropriate deployment of nursing staff who are
professional practitioners.
6. Although not highlighted by the clinical reviewer, the man’s wife raised a
significant concern about the policy on in possession medication. There was
no evidence that the man was assessed for his suitability to hold his
medication in-possession nor of his compliance with his prescription.
7. A post mortem took place on at Leicester Royal Infirmary. The pathologist stated
that the man had suffered at least one extensive heart attack previously,
consequent to severe narrowing of the arteries supplying blood to the heart. The
degree of narrowing was sufficient in the pathologist’s opinion to have caused
sudden and unexpected death. He concluded that the man died of natural causes:
ischaemic heart disease and atheromatous stenosis of the coronary artery.
8. The fact that the man was found dead by an assistant estates manager at 9.10am
has raised questions about the Prison Service guidance to staff on checking that
prisoners are in their cells. The current guidance contained in the National Security
Framework omits the more detailed instruction contained in the previous Security
4
Manual (Prison Service Order 1000). I have recommended that the Prison Service
reviews its guidance to staff on this matter.
9. I have also endorsed the detailed recommendations made by the clinical
reviewer and the good practice she highlighted.
5
The investigation
10. The investigation began when my investigator contacted the Governor of
Stocken. Notices were issued to staff and prisoners announcing the
investigation and inviting anyone with information relevant to the man’s
death to contact my investigator. The Governor arranged for a copy of The
man’s prison record and medical record to be posted to this office.
11. One of my family liaison officers (FLOs) tried to contact the man’s wife by
telephone. On 15 August, my FLO wrote explaining the role of my office
and offering the services of the FLO including a home visit if that was what
the man’s wife would wish.
12. Arrangements were made through Stocken’s Residential Manager for
interviews to take place when my investigator visited Stocken on 30 and 31
August. She familiarised herself with the prison, including the health care
centre and met staff and prisoners. She met with the Chair and Secretary of
the local branch of the Prison Officers’ Association (POA) who raised no
issues. She also spoke with a representative of the Independent Monitoring
Board (IMB). She interviewed three staff formally and three in a more
informal conversation. Records of the formal interviews and two of the
informal conversations were forwarded to Stocken for staff to check, amend
as necessary and sign.
13. My investigator liaised closely with the Prison Health Lead at Melton,
Harborough and Rutland Primary Care Trust who was acting on behalf of
the Director of Public Health, in respect of the clinical review. They provided
a thorough and timely clinical review of the man’s health care which forms
the body of this report
14. The investigation was completed on 20 October 2005. Unfortunately, due to a
number of eventualities, the man’s wife and children did not see the draft report
until May 2006. The man’s wife raised a number of questions about the report with
my FLO. These were addressed as far as was possible by my investigator and the
clinical review team from the PCT and included in this final report in June 2006.
HMP Stocken
15. Stocken prison was built in 1985 and has been expanded on four occasions. It now
accommodates over 600 convicted adult men. The emphasis is on training and
resettlement.
16. Stocken was last inspected by Her Majesty’s Chief Inspector of Prisons in October
2002 on a brief unannounced inspection. Given the pace of change, that report
was not relevant to this investigation. The Prison Service’s Standards Audit Team
was conducting an audit at the time of my investigator’s visit.
6
Clinical Review
17. The majority of the remainder of this report is the Clinical Review provided by the
Director of Public Health, Melton Rutland and Harborough Primary Care Trust, with
the assistance of the Prison Healthcare Development Manager at the Trust.
Review process
18. As part of the review process the following staff at Stocken were spoken with
or interviewed:
• the Clinical Nurse Manager
• three Staff Nurses
• the Head of Residence
• the governor with responsibility for health care∗
• the Practice Manager*
19. The following documentation has been examined:
• Prisoner Medical Record (PMR)
• Departmental Diary, Healthcare HMP Stocken
• GP Clinic Lists, Healthcare HMP Stocken
• Post-mortem examination report
Clinical care of the man
Background
20. The man was a 47-year-old man who was first received into custody on 3
May 2005 at HMP Lincoln. On reception, his medical problems were
recorded as diabetes (non insulin dependent) and left ventricular failure. He
had a strong family history of coronary heart disease (CHD) with both his
parents and his brother suffering myocardial infarctions (MI, heart attacks) at
relatively young ages. His brother died following an MI, aged 40. Previous
investigations had shown that the man had himself suffered an MI in the
past and was in heart failure. He had been referred to a cardiologist in
2004, but failed to attend. On arrival at HMP Lincoln he was taking the
following medication:
• Frusemide 80 mg daily
• Metformin 500 mg bd
• Aspirin 75 mg daily
• Ramipril 75 mg daily
• Simvastatin 40mg daily
• Paracetamol 1 gm daily
• Dihydrocodeine 60 mg daily
7
21. As a result of shortness of breath, the man spent his first night in the
healthcare inpatient unit. On the second day his BP was 150/95 and pulse
100 bpm. At that stage he was transferred to his cell with no documented
changes in treatment.
22. On 24 May 2005 the man was transferred to HMP Nottingham via court and
then on 31 May 2005 to HMP Stocken. On assessment at reception at HMP
Stocken, the following were recorded:
• Diabetic with LVF (left ventricular failure)
• History of depression
• No history of smoking, drug or alcohol abuse
• Weight 137 kg, height 5’11”
23. At this stage, the man was referred to the nurse-led diabetic clinic but he did
not wish to see a doctor the following day so no appointment was made.
The medication which the man had ‘in-possession’ on arrival from HMP
Nottingham and his HMP Nottingham treatment chart were checked by
nursing staff. He kept the prescribed medication he had in his possession.
The staff nurse carrying out the reception assessment completed a new
prescription for the doctor to sign the following day. It is not common
practice for nurses to write out prescriptions for doctors.
24. Also on reception the man discussed his wish to lose weight and was given
advice and booklets providing relevant information to support him.
25. On 3 June 2005, results from the man’s blood samples taken in HMP
Nottingham arrived at HMP Stocken. It is documented that the doctor
checked the results and asked for tests to be repeated in July.
26. On 6 June, the man was seen in the nurse-led diabetic clinic where an initial
assessment of his disease was undertaken. Findings on examination were:
• Blood pressure (BP) 141/89
• Pulse 78 bpm
• Blood glucose 4.7 mmols/l
• Possible fungal infection on left big toe
27. The man was asked to attend to have blood samples taken for Hba1c1,
fasting lipids and glucose on 9 June. He did not attend for this appointment
but he was recalled on 10 June when a nurse did take a blood sample. The
man also had a GP clinic appointment on 10 June but he appears not to
have attended this. There is no documentation of any immediate actions
taken following his non-attendance and no follow-up was organised to attend
the diabetic clinic.
28. The results of blood tests, all within normal limits, were seen by the doctor
and it is recorded that no further action was required. It is not documented
1 A blood test relevant to the management of diabetes mellitus
8
whether the man was ever given the results of blood tests, nor is there an
audit trail to show whether prisoners actually get their nurse clinic
appointment slips.
29. On 20 June, the man had another appointment to see the doctor but again
did not appear for this appointment.
30. On 21 June, all nurse-led chronic disease management clinics at HMP
Stocken were suspended. As a result, the man could not be called for a
second diabetic clinic appointment. It had been proposed that nurses would
not be on duty in the evenings, thus freeing up capacity to provide a full
nursing service during the day, including the running of chronic disease
management clinics. In addition, this would have allowed nursing staff to
attend relevant clinical training sessions, essential to development of nurses’
skills and to improve standards of service delivery. However, it is
understood that both the Governor and the local POA branch took the view
that a nursing presence in the evening was essential. Since there was
insufficient nursing capacity to maintain this level of service, the governor
with responsibility for health care made the decision to suspend all nurse-led
clinics.
31. On 22 June, the man was seen by healthcare staff complaining of feeling
unwell. He stated that he was trying to lose weight. Nil of note was found
on examination, the nurse gave dietary advice and no follow up was
arranged.
32. On 23 June, the man attended the diabetic retinopathy clinic held in the
prison. Suspected eye disease was detected and an appointment for further
examination at Leicester Royal Infirmary was arranged.
33. On 1 July, the man collected the medicines listed:
• Frusemide 40 mg od (daily)
• Metformin 500 mg bd
• Aspirin 75 mg od
• Ramipril 75 mg od
• Simvastatin 40 mg od
34. On 6 July, the man was due to attend the nurse phlebotomy clinic for repeat
blood tests but he failed to attend.
35. Following his death a significant amount of medication was found in the
man’s cell. This included varying amounts of the above drugs, as shown in
the following table. Additionally, 14 tablets of aspirin 300mg. There is no
record of him ever having been prescribed or given these aspirin tablets by
the approved ‘over the counter medication’ access route.
9
Medicines collected Medicines removed Number of
by the man on 1 from cell after the tablets missing
July 2005 man’s death
Frusemide 40 mg od 56 tablets 30 tablets 26
Metformin 500 mg bd 56 tablets 44 tablets 12
Aspirin 75 mg od 28 tablets 21 tablets 7
Ramipril 75 mg od 28 tablets 22 tablets 6
Simvastatin 40 mg od 28 tablets 24 tablets 4
Findings
36. In relation to the Prisoner Medical Records (PMRs), on some sheets of the
records dates are incorrect, signatures are illegible and the name and status
of individuals making entries is not recorded. In addition, some relevant
information, ascertained through interviews with staff, was not detailed in the
records.
37. Prescriptions were written, dispensed and administered from inadequately
completely prescription charts which omitted information required for safe
use of medicines. In addition, the staff nurse carrying out the reception
assessment completed a new prescription chart for the doctor to sign the
following day. It is not appropriate for nurses to write out prescriptions for
doctors.
38. The man had a strong family history of CHD and also significant risk factors
for further cardiac events. In such a case, proactive management of his
condition would have been good clinical practice. However, he regularly
failed to attend appointments and there appears to have been little action
taken to follow-up his non-attendance. The suspension of chronic disease
clinics further reduced the opportunity to provide proactive care to the man.
39. Linked to this, there were issues in relation to the man’s compliance with
treatment. It is clear from the medicines found in his cell after his death that
he had taken more doses of some of his medication than of others. In the
nine days before his death, it appears that he took far more frusemide and
half as much simvastatin as had been prescribed. This may or may not
have been due to confusion. These issues could have been addressed if
the man had received adequate care through a chronic disease
management clinic or had attended a medicines management clinic. There
is no record that he attended either despite the fact that he was taking a
number of different medicines.
40. The fact that unaccounted for tablets of aspirin were found in the man’s cell
after his death gives cause for concern. It is not clear from where the man
obtained the tablets.
41. Circumstances surrounding the suspension of nurse-led chronic disease
management clinics suggest that there is a lack of understanding among
non-healthcare staff in the prison of the roles and most appropriate
10
deployment of nursing staff, who are highly trained professionals. The
provision of quality healthcare services within the prison is a priority.
42. Areas of good practice include the use of pathology laboratory results action
forms to ensure that all investigation results are checked and acted upon as
necessary by healthcare staff. In addition, at reception at HMP Stocken, the
man expressed a wish to lose weight. He was given both verbal and written
advice and support.
Chronology
43. At weekends, cells are unlocked at approximately 8.00am. The man was
observed to be in bed at this time but it was not until 9.10am, when an
Assistant Estates Manager entered his unlocked cell to carry out a repair,
that anything untoward was noticed. The Assistant Estates Manager
thought initially that the man was asleep. He spoke to him in a raised voice
and put on the light but once he entered the cell he could see that the man
was dead. He did not touch him but raised the alarm with the wing staff.
They in turn looked at the man for themselves before raising the alarm. The
prison’s contingency plan instructs staff to initiate resuscitation unless rigor
mortis is present and defines rigor mortis.
44. An emergency call was immediately put out and the staff nurse on duty and
the duty governor responded. On their arrival, they found the man in bed.
He was clearly dead, with fixed dilated pupils, absent carotid pulses, no
response to painful stimuli and no visible breathing. No attempt was made
at cardio-pulmonary resuscitation (CPR) and there is no record in the
prisoner’s medical record (PMR) of any discussion.
45. At interview, the staff nurse concerned confirmed that she did not initiate
CPR because rigor mortis was present. She was confident that she was
responsible for the decision not to resuscitate and the duty governor present
agreed with her professional judgement. Having worked in medical wards,
she was familiar with death. The discipline staff took no active role in the
decision. The staff nurse in question had last received a CPR update in
October 2004.
46. The on-call doctor was called at 9.30am and certified the death at 10.45am.
He was recorded as attending at 10.20am in the incident log.
47. A post-mortem examination was carried out at Leicester Royal Infirmary.
The main findings of the examination were that the man had suffered from
ischaemic heart disease and the severe narrowing of the blood vessels that
supply oxygen to the heart was sufficient to have caused sudden and
unexpected death. Cause of death was reported as:
1a Ischaemic heart disease
1b Atheromatous stenosis of the coronary artery
11
Findings
48. From all the evidence available, it appears that appropriate actions were
taken and relevant policies were adhered to, following the discovery of the
man’s body.
Recommendations
49. Detailed, informative, contemporaneous and legible records are essential, to
support communication between staff and improve patient care. There is a
need to reiterate this to all healthcare staff and stress that the Prisoner
Medical Records are legal documents and all entries must be dated and
signed legibly and that all relevant information should be recorded.
50. Policies in relation to the writing of prescriptions and the dispensing and
administration of medicines, both prescription and non-prescription (‘over the
counter medicines’) need to be clear and adhered to by staff.
51. Chronic disease management nurse-led clinics need to be re-established.
These clinics, together with the maintenance of chronic disease registers are
essential elements of the National Service Frameworks (NSFs). On
reception screening, patients requiring chronic disease management should
be identified and referred to appropriate clinics and an appropriate audit trail
established.
52. Clinical Information Technology systems are essential to support the
effective implementation of NSFs, to facilitate organisation and management
of clinics, to identify patients on multiple medicines requiring regular
medication review or attendance at medicines management clinics and to
flag up non-attendance requiring follow-up.
53. Action is required to increase understanding of all staff in the prison,
including management staff, as to the importance of providing appropriate
standards of healthcare within the prison. This requires that healthcare staff
are deployed appropriately, maximising use of their professional clinical
skills. It may not be best use of nursing staff time to maintain a presence in
the evenings to the detriment of providing treatment and care to those who
require it. There needs to be discussion with prison staff as to what function
they feel a nursing presence in the evening fulfils. It may be that the
function can be fulfilled through alternative arrangements.
54. Within the healthcare service, there needs to be an audit trail in place to
demonstrate that prisoners receive information about their condition,
including results of investigations and that they receive information
concerning booked appointments.
55. Of particular relevance to the man, consider establishing a care pathway for
morbidly obese patients trying to lose weight. Recording the BMI, or other
obesity index, of prisoners on reception would aid with the monitoring of the
condition.
12
The Family’s Concerns
56. During the original investigation, my FLO received no formal response from the
man’s family. However when the man’s wife read the draft report she raised a
number of concerns. These are listed below and addressed where possible:
a) The man had a history of depression which had not been highlighted
in the report to her satisfaction.
When the man was assessed on reception at Stocken the nurse
noted that he had a history of depression. This was not elaborated
on and never followed up. There was no evidence from the man’s
various appointments with medical and nursing staff that he
expressed any concern about his state of mind nor were any relevant
signs or symptoms noted.
b) Why wasn't the man kept in the hospital wing?
The man spent his first night in custody at Lincoln in the health care
centre because he had been found to be short of breath when
examined in reception. The next morning he was discharged to a
residential wing with the same prescribed medication as he had
brought in from home. The doctor who discharged him did not
elaborate on the reason for discharging him. Stocken does not have
an inpatient unit.
c) What time did the man die and how long was it before he was found?
This investigation was unable to establish the answers to these
questions but the Coroner’s inquest may be able to offer some more
information.
d) Why were there not more regular checks made upon the man?
The clinical review report found a lack of proactive management of
the man’s heart condition. The reviewer commented further that the
man failed to attend some appointments. However there was little or
no action taken to follow-up his non-attendance. The suspension of
chronic disease clinics further reduced the opportunity to provide
proactive care to the man.
e) When was the decision taken not to resuscitate the man, by whom
and on what grounds?
The staff nurse on duty and the duty governor found the man in bed
with fixed dilated pupils, absent carotid pulses, no response to painful
stimuli and no visible breathing. At interview, the staff nurse
concerned confirmed that she did not attempt resuscitation because
rigor mortis was present. Having worked in medical wards, she was
familiar with death and had last received a resuscitation update in
October 2004.. She was confident that she was responsible for the
decision not to resuscitate and the duty governor present agreed with
her professional judgement. The prison’s contingency plan instructs
staff to initiate resuscitation unless rigor mortis is present and defines
rigor mortis.
13
f) Why was the man allowed to have his own medication given his
history of depression?
Prison Service and Department of Health policies on medication are
built on a presumption of the prisoner having personal responsibility
to hold his or her medication in possession2. Stocken is a training
prison, preparing prisoners to return to life in the community where
managing one’s own medication would be the norm. However the
duty of care on an institution such as a prison can be best
implemented by routinely undertaking a risk assessment of all
prisoners before allowing medication in possession.
g) The man was never prescribed Aspirin so where did the Aspirin found
in the cell come from?
Investigations before he came into prison had shown that the man
had suffered a heart attack in the past and had been in heart failure.
He also had a strong family history of coronary heart disease (CHD)
and significant risk of further heart problems, such as obesity. A low
dose of aspirin is used as an antiplatelet drug3 for the secondary
prevention of brain and heart disease caused by blood clots. The
treatment is aspirin 75mg daily which is what was prescribed for the
man. The Aspirin tablets found in the cell were 300mg each. This
form of the drug is used in the treatment of pain. The investigation
was unable to establish how the man had come by these tablets.
h) Did the post mortem show any abnormal amounts of any substances
that might have led to the man's death?
Nothing untoward was reported to my investigator. However this
matter may be further explored at the Coroner’s inquest.
i) Do we know when the heart attack that was identified in post mortem
occurred?
No, that has not been established during the investigation. Again
however this matter may be further explored at the Coroner’s inquest.
j) What are the rules about prisoners being allowed to keep medication
in their cells?
The answer to this is similar to that given to concern (f) above.
k) The prison did not really seem to bother about the man’s welfare.
Was this the view of the investigator.
The investigator and clinical reviewer’s conclusions are set out in the
next section and recommendations for changes in practice follow with
the intention of improving the prevention of similar events in future.
2 ‘A Pharmacy Service for Prisoners’ published Department of Health 2003
3
Antiplatelet drugs decrease platelet aggregation and may inhibit thrombus formation in the
arterial circulation, where anticoagulants have little effect.
14
Key Findings and Conclusions
57. The post mortem concluded that the man died of natural causes: ischaemic heart
disease and atheromatous stenosis of the coronary artery. The pathologist found
that the man had suffered at least one extensive attack previously, consequent to
severe narrowing of the arteries supplying blood to the heart. The degree of
narrowing was sufficient in the pathologist’s opinion to have caused sudden and
unexpected death.
58. The man had a strong family history of coronary heart disease and also
significant risk factors for further cardiac events. The clinical reviewer
pointed out that proactive management of his condition would have been
good clinical practice. She noted however, that he had failed to attend
appointments and there appeared to have been little action taken to follow-
up his non-attendance.
59. The clinical reviewer found that the suspension of chronic disease clinics had
reduced the opportunity to provide proactive care to the man. There was other
evidence of the man’s unpredictable compliance with treatment. For example, the
medicines found in his cell after his death indicated that for whatever reason he had
taken more doses of some medication than others. The reviewer suggested that
these issues could have been addressed if the man had had access to a chronic
disease management clinic or a medicines management clinic.
60. The clinical reviewer observed that circumstances surrounding the
suspension of nurse-led chronic disease management clinics suggested that
there was a lack of understanding among non-healthcare staff in the prison
of the roles and most appropriate deployment of nursing staff. My
investigator learned from the Head of Regimes that there was tension over
the interpretation in practice of the first aid requirement within the Health and
Safety at Work Act. For example, plans for nurses’ development and
training had been restricted because of a requirement to provide ‘first aid’
cover in the evenings for which the nursing team was not resourced.
61. Although not highlighted by the clinical reviewer, this case raises a
significant concern about the policy on in possession medication. There was
no evidence that the man was assessed for his suitability to hold his
medication in possession nor of his compliance with his prescription.
62. The man was found dead by an Assistant Estates Manager at 9.10am and
that has raised questions about the Prison Service guidance to staff on
checking that prisoners are safe and well in their cells. The new National
Security Framework (NSF) makes no mention at all of what staff should look
for when counting the roll. In contrast, the Security Manual (Prison Service
Order 1000) stated in the section on ‘Checking the roll’:
15
“Para 26.9 Prison management must issue written instructions to
staff to ensure roll checks at least four times every 24 hours as
follows:
i. before morning unlock
ii. at lunch time:
iii. at tea time:
iv. after lock up at night”
“Para 26.10 When checking the roll, staff must assure themselves
that prisoners are in cells, dormitories or cubicles by obtaining a clear
view of their face, if necessary by waking them.”
63. The Governor of Stocken confirmed that, as she understood it, the NSF had
superseded PSO 1000. And in terms of respect and decency, historic
practices whereby prisoners were woken, perhaps by banging on the cell
door, are no longer acceptable. Likewise, offering respect and decency
means that adult male prisoners are not checked whether they have got up
for, or eaten, their breakfast. However, once the core day of the prison is in
progress, it is not appropriate for the whereabouts or well being of prisoners
to be unknown. It was quite by chance that a member of staff entered the
man’s cell in order to carry out a repair to his sink at 9.10am. If this had not
happened, the man could have remained unfound for another couple of
hours, probably until lunchtime. The issue raises questions about what
guidance, if any, is currently given on this aspect of prison officers’ work. It
is a matter that requires further consideration by the Prison Service.
16
Recommendations
I recommend that the Governor works with the Melton Harborough and Rutland
Primary Care Trust to implement all the recommendations made in the clinical review.
I recommend that the Melton Harborough and Rutland Primary Care Trust works with
the pharmacy and health care managers at Stocken to improve the management of
medication, undertaking a routine risk assessment of prisoners for holding their
medication in possession and monitoring compliance.
I recommend that the Prison Service reviews the instruction it gives to governors and
staff regarding the checking of prisoners in their cells. The guidance must ensure there
is an acceptable balance between obtaining assurance that prisoners are safe and well
in their cells, dormitories or cubicles and the requirement to treat prisoners with
decency and respect.
Good practice
I endorse the good practice identified in the clinical review. Namely:
♦ the use of pathology laboratory results action forms to ensure that all
investigation results are checked and acted upon as necessary by healthcare
staff;
♦ the practice of giving both verbal and written advice and support to prisoners
who express a wish to lose weight to improve their health, as in the man’s case.
The prison’s response
Stocken’s management has produced a response to the recommendations in this
report in the form of an action plan. They welcomed the identification of two examples
of good practice. The response can be summarised as follows:
1. I recommend that the Governor works with the Melton Harborough and Rutland
Primary Care Trust to implement all the recommendations made in the clinical
review.
Accepted subject to the comments made against paragraphs 2 – 8 below.
2. Detailed, informative, contemporaneous and legible records are essential, to
support communication between staff and improve patient care. There is a
need to reiterate this to all healthcare staff and stress that the Prisoner
Medical Records are legal documents and all entries must be dated and
signed legibly and that all relevant information should be recorded.
Accepted – The requirement will be incorporated in all staff performance and
development records and be an agenda item at healthcare meetings.
17
3. Policies in relation to the writing of prescriptions and the dispensing and
administration of medicines, both prescription and non-prescription (over the
counter medicines) need to be clear and adhered to by staff.
Accepted – All relevant policies will now be reviewed to ensure that
procedures are clear and understandable. All staff will sign that they have
read and understood the requirements. New staff will do this as part of their
induction.
4. Chronic disease management nurse-led clinics need to be re-established.
These clinics, together with the maintenance of chronic disease registers are
essential elements of the National Service Frameworks (NSFs). On
reception screening, patients requiring chronic disease management should
be identified and referred to appropriate clinics and an appropriate audit trail
established.
Accepted locally – Clinics will be re-established. Reception screening will be
reviewed to ensure compliance.
5. Clinical Information Technology systems are essential to support the
effective implementation of NSFs, to facilitate organisation and management
of clinics, to identify patients on multiple medicines requiring regular
medication review or attendance at medicines management clinics and to
flag up non-attendance requiring follow-up.
Not accepted by the prison because it falls under the remit of the PCT
6. Action is required to increase understanding of all staff in the prison,
including management staff, as to the importance of providing appropriate
standards of healthcare within the prison. This requires that healthcare staff
are deployed appropriately, maximising use of their professional clinical
skills. It may not be best use of nursing staff time to maintain a presence in
the evenings to the detriment of providing treatment and care to those who
require it. There needs to be discussion with prison staff as to what function
they feel a nursing presence in the evening fulfils. It may be that the
function can be fulfilled through alternative arrangements.
Accepted – Full review/consultation to take place.
7. Within the healthcare service, there needs to be an audit trail in place to
demonstrate that prisoners receive information about their condition,
including results of investigations and that they receive information
concerning booked appointments.
Accepted for review – A full review will take place taking account of the
recommendations made.
8. Of particular relevance to the man, consider establishing a care pathway for
morbidly obese patients trying to lose weight. Recording the BMI, or other
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obesity index, of prisoners on reception would aid with the monitoring of the
condition.
Partially accepted locally – In order to implement this it will be necessary to
identify additional nurse time. A full review will be undertaken to establish
feasibility. See also recommendation 5.
9. I recommend that the Melton Harborough and Rutland Primary Care Trust works
with the pharmacy and health care managers at Stocken to improve the
management of medication, undertaking a routine risk assessment of prisoners for
holding their medication in possession and monitoring compliance.
The prison is engaged in a tendering process for a new pharmacy provider and will
seek to introduce revised risk assessments with the new provider. Monitoring
checks are carried out on prisoners with in-possession medication to ensure
compliance.
10. I recommend that the Prison Service reviews the instruction it gives to governors
and staff regarding the checking of prisoners in their cells. The guidance must
ensure there is an acceptable balance between obtaining assurance that prisoners
are safe and well in their cells, dormitories or cubicles and the requirement to treat
prisoners with decency and respect.
Accepted for review – This recommendation has now been reviewed by the
Security Policy Group of the Prison Service. Previous historical practices involving
the frequent disturbance of sleeping prisoners whilst checking the roll have been
discontinued on decency grounds. The previous policy was amended with the
introduction of the National Security Framework to allow individual establishments
to develop practises and procedures that firstly met the mandatory outcomes of the
National Security Framework (i.e. 4 roll checks within any 24 hour period), and,
secondly allowed a degree of local discretion as to how and when these checks
would be made. It would be physically impossible for staff to individually check all
prisoners on normal allocation without some degree of disturbance, entering
individual cells and/or potential physical contact. To do so regularly would
undoubtedly cause unrest and resentment amongst prisoners. We believe that the
current risk assessed based discretional policy is a proportionate response to the
number of deaths through natural causes currently experienced across the prison
estate.
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