Individual at Sudbury

Investigation into the circumstances surrounding the
death of a man at HMP Sudbury in September 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2008
This is my report of an investigation into the death of a man in September
2007 at HMP Sudbury. He was aged 50. I offer my condolences to his family
and all those touched by his passing.
The man had been to see prison healthcare staff in July and August 2007
after experiencing tightness in his chest. He was prescribed medication and
was referred to the local hospital. Sadly, before the date of his appointment,
he suffered a fatal heart attack. The cause of death has been given as 1a)
myocardial infarction (heart attack), due to coronary thrombosis and severe
atherosclerosis (disease affecting arterial blood vessels).
This investigation was carried out on my behalf by one of my investigators. I
would like to thank the Governor of HMP Sudbury and his staff for their co-
operation.
I also commissioned a clinical review into the man’s medical care. This was
carried out by a review team led by the Deputy Director Clinical Quality and
Nursing on behalf of Derbyshire County Primary Care Trust (PCT). I am most
grateful to the clinical panel for their assistance. Unfortunately, the review
was delayed and I must apologise for the consequent late issuing of this
report.
Overall, the medical care the man received in prison was comparable to that
which he would have received in the community. However, the clinical review
has highlighted areas of learning for the prison. I include these findings in my
report and make five recommendations. The clinical review panel has also
identified two strategic recommendations for the PCT. I have not included
these in this report, but will forward them to the Chief Executive of the PCT to
consider.
Stephen Shaw CBE
Prisons and Probation Ombudsman May
2008
CONTENTS
Summary
The Investigation Process
HMP Sudbury
Key Findings
Issues
Recommendations
SUMMARY
The man received a three year custodial sentence in January 2007. It was his
first time in prison. His medical records show that he was a generally fit and
well man although he was considered to be overweight. During the prison
reception process, he reported a history of knee pain and depression prior to
receiving his sentence. He had been prescribed anti-depressants. No other
concerns were reported.
As a classroom assistant in the prison’s education department, followed by a
job in the staff mess, the man was keen to further his own education whilst in
custody and on his release. He was reported to be a hard worker and got on
well with his peers.
During his first seven months in prison, the man had many contacts with the
healthcare team. These predominately related to his knee pain, back pain
and pain in his calf. Medication was given when necessary and tests were
carried out where appropriate. During this time, he was also trying to lose
weight. He took medication to assist, as well as exercising and attending a
weight loss clinic. He had lost two stone by the time he died.
At the end July 2007, the man attended healthcare because he had
experienced tightness in his chest. He returned in the middle of August for
the same complaint. On the second occasion, on 14 August, he was referred
to the doctor. The doctor saw him on 17 August and referred him for an
urgent cardiology appointment at the local hospital. There is no time target for
this, but patients are seen within four weeks where possible.
An appointment was booked for 21 September, five weeks after referral, but
postponed by the hospital to 28 September. Sadly, two weeks before the
appointment, whilst at work in the staff mess, the man suffered a heart attack.
The catering manager, with the help of other prisoners, put the man into the
recovery position and called for assistance. Healthcare staff arrived and
commenced cardio pulmonary resuscitation (CPR), which paramedics took
over when they arrived.
CPR was continued on the way to hospital but was unsuccessful. The man
was pronounced dead on arrival at the hospital. His family were already en
route to the prison for a visit, as it was the birthday of one of his daughters.
They were told the news on arrival, and a member of staff escorted them to
the hospital.
INVESTIGATION PROCESS
1. My investigator requested all the relevant documentation including the
man’s medical records and core prison records. The lead investigator and
another of my investigators visited HMP Sudbury during the course of their
investigation.
2. Notices to staff and prisoners were sent to the prison to be displayed.
These invited anybody with information to talk to my investigators.
Following the publication of my draft report, the man’s wife told my
investigator that a fellow prisoner had written to my office. There is no
record of such a letter so my investigator arranged a telephone call with
the prison. He told my investigator that the man had been experiencing
chest pains for approximately three months. He confirmed that the man
was waiting for a hospital appointment which had been delayed and was
convinced there was something wrong with his heart. He saw the man the
night before he died and commented that he did not look unwell or
complain of any ill health.
3. Derbyshire Primary Care Trust (PCT) was asked to carry out a clinical
review and the Deputy Director Clinical Quality and Nursing led this on the
PCT’s behalf. The clinical review was received by my office on 5 March
2008.
4. HM Coroner for Staffordshire was informed of my investigation and
provided details of the man’s cause of death. He will receive a copy of this
report.
5. The man’s wife is recorded as his next of kin. One of my Family Liaison
Officers contacted her to offer the opportunity of involvement in the
investigation. She raised the following matters:
(cid:127) That the investigation should consider all aspects of the healthcare her
husband received, including when he informed healthcare of the chest
pains, what action was taken, and whether this was adequate.
(cid:127) That the investigation consider whether he was waiting to be assessed
on a walking treadmill that monitors the heart. Did he wait a long time
for this and was it postponed? The investigation should consider
whether he was waiting an unreasonable length of time for necessary
and important tests.
(cid:127) For the investigation to look at the emergency response. This should
include whether there were staff capable of carrying out CPR close by,
and how quickly they were able to respond.
(cid:127) For the investigation to consider whether entries made in the man’s
food diary regarding his chest pain were picked up.
HMP SUDBURY
6. HMP Sudbury is an adult male open prison in the East Midlands. Initially
built as a hospital for the US Air Force, Sudbury was converted to a prison
in 1948. It has an operational capacity of 571 prisoners.
7. The healthcare centre at Sudbury operates throughout the day during the
week and in the mornings at weekend. Her Majesty’s Chief Inspector of
Prisons last inspected Sudbury on a full announced visit in January 2005,
and found that the majority of prisoners rated the quality of healthcare as
good or very good. There were good links with the local PCT but there
were also some poor practices. These were highlighted again in an
unannounced inspection in May 2007, and related in particular to
recording procedures, policies and general practitioner (GP) appointments
being too short.
8. The prison told my investigator that these areas have been tackled, with a
policy review and extended consultation times with the doctor. The issue
of recording practices was also being addressed by transferring all
prisoner medical notes onto a computerised system. However, the clinical
reviewer has found that some recording practices are still deficient.
Glyceryl Trinitrate (GTN)
9. Glyceryl Trinitrate is highly effective in controlling the pain of angina. It
opens up the coronary arteries, improving blood supply to the heart
muscle. It works quickly but the effect only lasts for a short time. GTN
comes as a spray or tablets. (Definition taken from www.nhs.co.uk.)
KEY FINDINGS
10. The man was convicted and sentenced to three years imprisonment in
January 2007. He was taken from court to HMP Shrewsbury. When he
arrived he was seen by a nurse as part of the reception process. The
nurse completed an assessment form to establish his previous and current
physical and mental health.
11. When asked if he had any medical problems such as asthma, diabetes or
chest pain, he answered “no”. (However, later in his sentence he told
healthcare staff that he had previously experienced chest pain which had
been investigated, but tests had showed nothing abnormal.) He told the
nurse of an old knee injury and also that he was taking prescribed anti-
depressant medication. The nurse referred him for a doctor’s
appointment.
12. The records do not give much more information about him over the
following three weeks except that he was categorised as a category D
prisoner, which meant that he could move to open conditions. He
transferred to HMP Sudbury on 20 January 2007. A further reception
health assessment was carried out. The man answered “no” to any health
problems including a heart condition or any history of heart problems.
13. On 22 January, the man was seen by a visiting doctor. The medical
record shows that he felt well and was not depressed, however it was
agreed that he would continue with the prescribed anti-depressants.
14. Two months later, on 15 March, the man saw the prison doctor about a
back problem which he said he had been experiencing for about ten years.
He had requested a better mattress and it was noted in the medical record
that his general practitioner (GP) should be consulted for confirmation.
The doctor has recorded that, if the mattress was not adequate, then it
should be replaced. The clinical reviewer has commented that the man
had previously requested a better mattress but not all of these requests
were recorded. There is no evidence to suggest that a new mattress was
acquired or that his GP was contacted for this information.
15. The record also shows that, during the consultation, the man told the
doctor he wished to reduce his anti-depressant medication, and this was
agreed. He also told the doctor that he had pain in his calf on exertion.
He had apparently been experiencing this for a couple of years so the
doctor requested a test to assess the blood flow in his legs.
16. It was noted in the medical record that on 3 April 2007 the pain in the
man’s calf “was easing”. The assessment to check the blood flow still
went ahead however, and was performed on 13 April. The results
indicated some restriction in the blood flow to the man’s leg.
17. At the beginning of May, the prison doctor discussed the issue with the
man again. Minor symptoms were continuing but the man did not want
any intervention. The medical record shows that his weight had dropped
to 104.3 kg and the doctor prescribed medication to help with continued
weight loss. The man was also attending a weight loss clinic at the prison,
which included keeping a food diary and taking exercise in the prison gym.
18. During May, the man experienced pain in his left knee. The medical
record shows that this may have been aggravated by the exercise he was
doing. He was prescribed painkillers and had a blood test. An x-ray was
recommended if the pain did not subside. The blood test results were
normal but an x-ray was requested at the end of May after the man
complained of more pain. This took place on 14 June and the results
showed that early osteo-arthritic changes were present in the left knee.
The man continued to lose weight and remained on the medication to
assist with this. At the end of June he weighed 100.3kg.
19. Also in June, the man resigned from his role as a classroom assistant in
education. He wished to undertake an assessor’s qualification, and this
required him to carry out relevant assessments on others. He felt unable
to do this in education and, therefore, secured a new job in the staff mess.
It was reported that he worked hard and got on well with his peers and the
catering manager.
20. The following month, on 29 July, the man visited the healthcare centre
complaining of tightness in his chest after exertion. His medical
observations were taken. He was not experiencing pain at the time and no
further action was taken. Two weeks later (on 14 August), he went to
healthcare again. He had had tightness in his chest but, as before, was
not experiencing pain at the time. Blood tests were taken and an
appointment made for him to see the doctor.
21. The man saw a prison doctor three days later on 17 August. The clinical
reviewer received a statement from the doctor in which she recorded that
the man had been concerned that the pain was anginal and had tried to
exercise vigorously to see if this reproduced the symptoms. He reportedly
found that this was not the case. The doctor wrote in her statement that
the man had had similar episodes before arriving in prison which had been
investigated, and nothing abnormal had been found. It is not known why
he had not given this information on his reception into prison.
22. The doctor requested an urgent cardiology referral at the local hospital and
prescribed him with a GTN spray. The aim was to test if the spray would
alleviate the pain and help to diagnose if he had angina. The referral form
was sent that day. An appointment was given for 21 September but was
subsequently postponed by the hospital until 28 September. The hospital
operates a Rapid Access Chest Pain Clinic (RACPC), where patients are
seen within two weeks, but this was not known to the doctors at the prison.
Since receiving my draft report, the doctors have commented that they
were aware of a RACPC at another hospital and the prison doctor would
have referred him there if she felt it necessary. However, because she
deemed the man’s chest pain to be atypical, the doctor felt an urgent
referral to the local hospital to see a consultant was appropriate.
23. Between 18 August and 10 September, the man was seen by healthcare
staff on several occasions, predominately for painkillers and medical
observations. On 4 September, he was given a repeat prescription of his
GTN spray by a healthcare nurse. Although, the prescription is
documented in the notes, the dosage previously used is not noted. The
following day, the man saw the doctor. My investigator has spoken to the
prison GP who confirms that he asked the man to tell him about all his
episodes of angina. The man told him of three occasions and it was noted
in the medical record that he might have had a recent new episode of
angina but found quick relief when using the GTN spray. The doctor
advised him about calling for assistance if he experienced pain and there
was no relief within 15 minutes. The GP told my investigator that at the
time he was unaware of the new GTN prescription and could not
understand why, when the man told him he had only had three suspected
episodes, he would have used the full dose.
24. On 10 September, the man was seen by a nurse and asked her if he could
try the medication Omeprazole. He had been speaking to another
prisoner who was taking this for what he perceived as similar symptoms.
(It appears from the records that the person the man referred to was taking
Omeprazole for indigestion.) The nurse explained the signs and
symptoms of angina and indigestion and agreed to give him a two week
trial on Omeprazole.
25. Also on 10 September, the man wrote to one of the prison governors
regarding a forthcoming legal visit. The man attached a second letter,
addressed to the Regional Director. In the letter, he praised the
compassion and understanding of the staff with whom he had contact and
their assistance in trying to re-integrate those under their care back into
society. The man had particular praise for the education staff who had
helped him plan a teaching career upon his release.
26. On the morning of 12 September, he started work as usual at
approximately 8.00am. The statements given by staff after his collapse
give different timings, but on balance it appears that between 10.15am and
10.20am, he and the other prisoners had a break for some tea and toast.
The man sat in the chair. As he did so, he slumped forward. One of the
prisoners called the catering manager who immediately came from the
kitchen area. They could not get a response from the man.
27. The manager knew that the man carried a spray for angina, which she
took from his pocket and tried, unsuccessfully, to administer. She and two
of the other prisoners put him into the recovery position. The catering
manager then made a direct call to the healthcare centre. The healthcare
manager sent two nurses to the mess and advised the catering manager
to call the central emergency number.
28. Within a few minutes, the nurses from healthcare arrived at the staff mess.
The man was initially found to be ”breathing noisily” but then stopped. The
nurses did not have a defibrillator with them, but had other emergency
equipment including oxygen and oxygen masks. When the man stopped
breathing they immediately commenced CPR. The nurses also asked for
a defibrillator to be brought to them.
29. An ambulance had been requested by the communications room at
10.22am. However, when the communications room staff were asked
about the priority they had to radio the nurses to check. The first response
paramedic arrived at approximately 10.37am and began Advanced Life
Support (ALS) which involved intubating him. The ambulance crew arrived
and took over the situation. The man was then taken to the local hospital
by ambulance. The ambulance crew continued CPR and advanced
resuscitation (defibrillation and drug administration).
30. Sadly, the resuscitation attempts were not successful and the man was
pronounced dead on arrival at the hospital at 11.16am.
Events after the man’s death
31. My investigators asked the prisoners who worked with him if they thought
that the man had looked visibly unwell that day, or if he had mentioned
feeling unwell. They were told that he looked fine and did not complain of
any ill health.
32. One of the prisoners who lived on the same unit had seen the man on the
morning of 12 September. He had heard him singing ‘Happy birthday’,
and assumed he was on the telephone to his daughter whose birthday it
was that day.
33. I have already explained that the man’s wife and children were due to visit
him that afternoon. The prison tried to contact the family, but they had
already left home to travel to the prison. When they arrived, they were
taken aside and told of his death. A member of staff then accompanied
them to the hospital.
34. Staff and prisoners in the mess were distressed by the man’s death. They
told my investigators that they were given appropriate support, and staff
were given the opportunity to discuss matters with the care team. The
healthcare team held their own debriefing meeting to provide support as a
team and reflect on the events surrounding the man’s death.
35. A memorial service for him was held in the prison on 9 October 2007. My
investigators were told that over 40 staff and prisoners attended.
ISSUES
36. The man posed no problems to staff in terms of his behaviour or work
within the prison. He was a well liked individual who worked hard and tried
to further his education. My investigation has raised no issues or concerns
on those matters. The following issues considered are a result of the
clinical review into the man’s medical care.
Recordkeeping
37. As did the inspection report by HM Chief Inspector of Prisons, the clinical
review has highlighted the need for a single recordkeeping format to be
adopted. Although the majority of the man’s healthcare consultations were
entered onto a computerised system, some remained in the paper record
alone. Several of these entries are unsigned and use abbreviations
unfamiliar to the clinical reviewer however, she was able to have these
clarified.
38. After the man was taken to hospital, the record of healthcare staff’s
attempts to resuscitate him was below the standard expected. The man’s
medical record was secured after his death was pronounced, as per
policy, however staff should have been able to have made an accurate
record of the care provided prior to it being secured.
The Healthcare Manager should arrange a date for the transition to
the computerised records system and establish audits to ensure the
records conform to professional guidelines. This should also
include accurate records of any serious incidents.
Referrals for Secondary Care
39. The man was urgently referred for a cardiology opinion by one of the
prison doctors. The referral was dictated and sent the same day that the
doctor saw him. The prison doctors were unaware that the local hospital
operated a Rapid Access Chest Pain Clinic and therefore did not refer him
through this. The clinical reviewer has found that systems for sharing
information between clinical practitioners are not robust. Information on
service changes is passed on via a mixture of mailshots and briefings.
The prison healthcare centre had not been routinely included on such lists,
but since the clinical review was undertaken, this has been addressed.
40. This is an issue that the PCT should consider and I draw it to their
attention. I would also ask the healthcare manager at Sudbury, in
conjunction with the PCT, to ensure that staff are up to date about
available services, as well as the waiting times.
41. My investigator asked the clinical reviewer if a referral via the Rapid
Access Chest Pain Clinic would have had an impact on the man’s life
expectancy. Although the panel was unable to give a definitive answer,
the likelihood would have been that, even if a diagnosis of ischaemic heart
disease had been confirmed, it would not have prevented his sudden
death. It would have been very unlikely that he would have had
interventional procedures, for example, angioplasty or coronary artery
bypass within the likely timescale. These interventions also only reduce
mortality in a few specific situations.
42. The man’s wife asked about an exercise test that the man was waiting for.
This test was not something that could be carried out in the prison setting,
and there would have been a waiting time at the hospital. In terms of any
intervention that would have been triggered if the test was positive and a
definite diagnosis reached. Under some circumstances a statin would be
prescribed, however the man had had a recent abnormal liver test and
compromised circulation in his calf. He would not therefore, have been
prescribed this. The panel has commented that even if he had been able
to take other medication, none would have significantly reduced the short
term risk of sudden cardiac death if he had stable angina. There is no
definite evidence of unstable angina, for example pain at rest, rapid
increase of frequency of attacks or a poor response to the GTN spray, so
on balance the panel felt that it was unlikely that the alternative
medications would have prevented his sudden death.
43. The clinical reviewer could not find any information about the man’s food
diary in the prison. From information received by the man’s wife, he
started keeping it at the end of July. The man’s wife was concerned about
notes in the diary referring to her husband’s chest pain and whether or not
these were picked up. The medical records show that it was around this
time that the man saw healthcare staff about the tightness in his chest, so
they were aware of his condition. He received medication and was
referred for a hospital appointment for a full diagnosis.
44. Although he did not let healthcare staff know initially that he had had
previous tests for chest pains or that he suffered from back pain, both
issues came to light later in his sentence. A prison doctor recommended
seeking information from his GP regarding his back pain, but there is no
evidence that this was followed up. Similarly, there is no evidence to show
that the previous chest pain test results were requested.
The Healthcare Manager should ensure a process for requesting
previous medical records is implemented and audited quarterly.
Medicine Management
45. The man was prescribed a GTN spray as a treatment for possible angina.
Two and a half weeks later he had a repeat prescription. The clinical
reviewer has noted that the spray contained approximately 200 doses and
would have expected this to be reviewed. There is no documented
evidence to suggest that an assessment or review took place.
Additionally, whilst he saw the doctor the day after the repeat prescription,
there is no indication that the doctor was informed about the GTN usage.
46. On 10 September, a nurse prescribed Omeprazole after the man told her
about another prisoner who was taking it for similar symptoms. The
clinical reviewer has commented that, whilst this was within the nurse’s
authority, there did not appear to be any clinical indication to prescribe this
particular medication. However, there would have been no serious
adverse effect to his health.
47. Although not related to the man’s death, the clinical reviewer has noted
that it was acknowledged by the nurse prescriber that the process for
monitoring medication needed to be more robust. She has also noted that
the prison does not have an up-to-date medicines code for use by nursing
staff.
The healthcare team should review the policies used by the nurse
prescriber and ensure ongoing clinical supervision needs are met.
Managing emergency call outs
48. The catering manager called for healthcare assistance when the man
collapsed in the mess, but she telephoned them directly and was then
advised to call the central emergency number. The healthcare centre is
approximately 345 metres from the staff mess and the nurses were able to
respond quickly. They took an emergency bag and oxygen, but not the
defibrillator. This was requested once they had assessed the situation.
When a call was made for the ambulance, the communication room did
not know the priority and had to radio the nurses to check.
49. It is common practice across the Prison Service to use a code system,
whether this be a numerical or colour code. For instance a ‘code blue’ is
sometimes used for someone having breathing difficulties, and a ‘code
red’ when somebody is bleeding. By using this system, healthcare staff
have a better idea what equipment they need to bring in an emergency.
By using a radio or the emergency phone number, all relevant parties can
be called quickly from wherever they may be in the prison.
50. Although the response by healthcare in this instance was quick, I
recommend that Sudbury adopts a single code system that is easy to use
by all staff.
The Governor and Healthcare Manager should agree a system for
medical emergency responses and ensure that all staff are aware of
the new procedure.
51. The clinical reviewer reviewed the emergency equipment and found it all to
be in good working order. She did find that access to CPR training was
limited, although all staff were trained and the training updated.
The Healthcare Manager should review the access to CPR training
and ensure skills are maintained by annual updates. An auditable
updated training record should be established within the next two
months.
RECOMMENDATIONS
1. The Healthcare Manager should arrange a date for the transition to
the computerised records system and establish audits to ensure the
records conform to professional guidelines. This should also
include accurate records of any serious incidents.
HMP Sudbury has accepted this recommendation. Computerised
records are now kept.
2. The Healthcare Manager should ensure a process for requesting
previous medical records is implemented and audited quarterly.
HMP Sudbury has accepted this recommendation. All requests for
medical records are now logged in a central record, including dates
requested, chased and received.
3. The healthcare team should review the policies used by the nurse
prescriber and ensure ongoing clinical supervision needs are met.
HMP Sudbury has accepted this recommendation. Policies relating
to the nurse prescriber and non medical prescribing have been
reviewed. Appropriate clinical supervision is being sought.
4. The Governor and Healthcare Manager should agree a system for
medical emergency responses and ensure that all staff are aware of
the new procedure.
HMP Sudbury has accepted this recommendation. A system for
emergency responses is being implemented.
5. The Healthcare Manager should review the access to CPR training
and ensure skills are maintained by annual updates. An auditable
updated training record should be established within the next two
months.
HMP Sudbury has accepted this recommendation. All healthcare
staff are trained. Some non healthcare staff have received
defibrillator training and First Aid. Records are in place and
planned refresher training documented.