Individual at Swaleside

Investigation into the circumstances surrounding the
death of a man
at HMP Swaleside in June 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2010
This is the report of an investigation into the death of a man at HMP Swaleside on 3
June 2009. He died after being found collapsed on the floor of his cell. A post
mortem examination concluded that he had died as a result of ischaemic heart
disease.
I would like to extend my condolences to the man’s family and all those who knew
him on their loss. I apologise that my investigation has taken some time to complete
and for any additional distress this may have caused.
The investigation was led by an Investigator from my office. We are grateful to the
Governor of Swaleside and his staff for their assistance and cooperation. A clinical
review of the man’s care was commissioned from Eastern and Coastal Kent PCT,
and I am grateful for the Clinical Reviewers timely review.
The man came into prison already having had a heart attack, for which he had
received extensive hospital treatment. Although he told healthcare staff about the
heart attack, it seems that the information was not followed up. However, his blood
pressure was monitored regularly from 2006 and, in 2008, medication was
prescribed. Unfortunately, this medication caused side effects which meant that the
man only took it in small quantities.
A fellow prisoner found the man in his cell. Although an officer attended
immediately, he did not have a radio and had to shout for assistance. This meant
that the alarm bell was pressed instead of an emergency call being put over the
radio. As a result the emergency equipment did not arrive as soon as it could have
done. However, it is unlikely that this would have meant that the man would have
survived this heart attack. Nevertheless, like the clinical reviewer, I do not believe
that the care the man received at Swaleside was equivalent to what would have
been expected in the community.
I make three recommendations. One concerns the treatment of prisoners who have
already suffered a heart attack, and the others concern the provision and use of
radios at Swaleside.
Jane Webb
Acting Prison and Probation Ombudsman
March 2010
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CONTENTS
Summary 4
The Investigation Process 5
HMP Swaleside 6
Key Findings 8
Issues 13
Conclusion 15
Recommendations 16
3
SUMMARY
The man was remanded in custody in 2003 after being charged with the murder of
his estranged wife. He suffered a heart attack in 2000, and underwent heart surgery.
He was given medication, but stopped taking it as he suffered from side effects.
After being remanded, he was taken to HMP Wormwood Scrubs. During a health
screening, he explained that he had previously had a heart attack. Although it was
noted in his medical notes that his local hospital should be contacted to substantiate
his history, this was never done.
The man was convicted in January 2004. Shortly afterwards, he transferred to HMP
Belmarsh and subsequently, in 2005, to HMP Swaleside. Again, his medical history
was noted on reception, but no further action was taken.
From 2006, he regularly attended a blood pressure clinic, and his blood pressure
was found to be within normal limits. On 2 October 2008, he saw a smoking
cessation advisor and was also prescribed aspirin to thin the blood. However, his
blood pressure was raised the next month and he was prescribed
bendroflumethiazide, a diuretic which helps to lower the blood pressure.
The man next saw a doctor on 12 March 2009, when he reported that his gums were
bleeding and he had stopped taking his medication. His blood pressure at this time
was normal. The man started taking the medication again, but at a reduced level.
On 3 June 2009, the man collapsed in his cell and was found by a fellow prisoner
collapsed on the floor. Staff attended quickly, but attempts to resuscitate him were
unsuccessful and he was pronounced dead at the scene by paramedics.
I concur with the clinical reviewer that the standard of care the man received at
Swaleside fell short of what he would have expected in the community. I make three
recommendations as a result of this investigation. The first concerns the treatment
of prisoners who have previously had a heart attack. The other two concern the
provision of radios and the use of emergency codes at Swaleside.
4
THE INVESTIGATION PROCESS
1. After the Ombudsman’s office was notified of the man’s death, Investigator A
was appointed to conduct the investigation. Notices were issued to staff and
prisoners at Swaleside informing them of the investigation and providing
contact details should they wish to provide any information. In the event, no
other witnesses came forward.
2. The Eastern and Coastal Kent Primary Care Trust were commissioned to
provide a clinical review of the man’s medical care while he was at Swaleside.
3. Investigator A contacted HM Coroner to inform him of the nature and scope of
the investigation and to request a copy of the post mortem report. Upon
completion, this report will be sent to him to assist his enquiries into the man’s
death.
4. One of the Ombudsman’s Family Liaison officers, contacted the man’s family
to give them the opportunity to contribute to the investigation and raise any
concerns they may have had.
5. Investigator A visited Swaleside and interviewed 12 members of staff. She
also spoke informally to a prisoner who knew the man.
5
HMP SWALESIDE
6. Swaleside is one of three prisons on the Isle of Sheppey which make up the
Sheppey Cluster. The other prisons are HMP Elmley and HMP Standford Hill.
Swaleside is a Category B training prison, housing prisoners serving four
years or more or having at least 18 months left to serve on their sentence. It
has an operational capacity of 954.
7. Healthcare has been provided by the Eastern and Coastal Kent Primary Care
Trust since 2004. The prison also provides opportunities for work and
education, and a number of offending behaviour courses designed for
prisoners to progress to resettlement.
8. Swaleside has a high proportion of foreign national prisoners (meaning
prisoners who are not nationals of the United Kingdom). In 2009, the prison
had a population of between 30 and 40 per cent of foreign national prisoners,
compared to the national prison population figure of 14 per cent.
Performance rating
9. Prisons in England and Wales are assessed for performance by the National
Offender Management Service (NOMS). For public prisons, NOMS use a
combination of the Prison Performance Assessment Tool (PPAT, which looks
at 33 indicators) and the public prison weighted scorecard (which looks at a
set of 44 indicators). Each establishment is then given a rating between one
and four (one being “serious concerns” and four “exceptional performance”).
Swaleside is measured as part of the Sheppey Cluster of prisons, with Elmley
and Standford Hill. For the last four quarters, the Sheppey Cluster has been
given a rating of three, or “good performance”.
Her Majesty’s Inspectorate of Prisons
10. Each prison in England and Wales is subject to inspection by the HM Chief
Inspector of Prisons. The last inspection of Swaleside was an announced
inspection conducted in March and April 2008. The Chief Inspector, in her
foreword to the inspection report, found “… Swaleside to be a safe and
respectful prison, which was impressive given the many serious offenders
held”.
11. The inspection team also looked at the provision of healthcare at Swaleside.
The following judgement was made:
“Health services offered prisoners access to a broad range of clinical
specialisms in the prison and through external NHS sources. The
management of long-term illnesses was good, as was the GP service.
… Despite the positive aspects, prisoners were extremely dissatisfied
with perceived poor attitudes by healthcare staff, who they claimed
denied them access to some services.”
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12. Foreign national prisoners told the inspection team that they felt supported by
staff who understood their position. 91 per cent of foreign national prisoners
who responded to a survey said that they were treated with respect. The
inspection team also found that the prison library was well resourced, with
prisoners having good access to legal material.
Independent Monitoring Board (IMB) report
13. Every prison is monitored by and Independent Monitoring Board, members of
which are drawn from the local community. They have full access to
prisoners and every part of the establishment, and produce an annual report
for the Secretary of State for Justice. In their last published report, covering
the period from May 2008 to April 2009, the IMB described the prison as “a
well run prison … staff and prisoner relationships are excellent and the
personal officer scheme is effective”. Healthcare had improved following
refurbishment of accommodation, and the introduction of a consultative
committee with representatives from each wing.
Previous PPO investigations at Swaleside
14. This is the 14th death at Swaleside since the Ombudsman took responsibility
for investigating deaths in custody in 2004. Of these, nine have been the
result of natural causes. As a result of one of these investigations cases, a
recommendation was made which is of relevance to this report. This said:
“The prominent identification of individuals in custody at high risk of
medical problems must be urgently implemented, and appropriate Care
Plans prepared.”
Since the man’s death, there have been a further two deaths, both of which
were as a result of natural causes.
7
KEY FINDINGS
15. The man was sentenced to life imprisonment at a local Criminal Court for the
murder of his wife. He was ordered to serve a minimum of 14 years. He had
previously been remanded in custody for this offence to HMP Wormwood
Scrubs on 27 January 2003. During the reception process, he was seen by a
member of healthcare staff (it is not clear from the notes who he met). He
said that he had an angioplasty (a procedure in which the coronary artery is
repaired) after suffering a heart attack in 2000. Although he was prescribed
medication, he had stopped taking it because of the side effects. It was
recorded that he showed no signs of any mental health problems.
16. After a visit to the triage clinic on 10 February as he had fallen off a chair, the
man next attended healthcare on 21 October as he was concerned about his
blood pressure. It was checked and found to be 129/82 (which the clinical
reviewer describes as being “within the normal range”). A plan was drawn up
to write to the Hospital where the angioplasty was performed in 2000 and ask
for further details, but there is no evidence that this was ever done.
17. Following his conviction, the man transferred to HMP Belmarsh on 29 March
2004. He was seen again in reception, and it was noted in his medical record
that he had “some history”. He was referred to the wing surgery. He chose,
however, not to wait for the doctor and instead signed a disclaimer saying he
did not need medication and knew how to make an appointment to see a
doctor if he needed to.
18. On 15 April, he attended healthcare as he felt something “hitting” on his chest
and he had a pain in his shoulder. There was no chest pain, and he did not
become breathless on exertion. He was examined, and the doctor recorded
that he was “clinically ok”. The doctor also recommended that an
electrocardiogram (ECG) be conducted, that is a procedure which monitors
the electrical activity of the heart, but there is no record to show whether it
took place.
19. The following year, on 4 March, the man transferred to HMP Swaleside. A
reception health screen was conducted by the senior medical officer. He
recorded the man’s medical history, including the heart attack, and stated that
he was fit for work and exercise. He did not take any observations or blood
pressure readings.
20. In July 2005, the man attended his appeal against his conviction. During this
time, he was held at HMP Pentonville for two days. After his appeal was
dismissed on 28 July, he returned to Swaleside where he declined to see the
doctor on arrival in reception.
21. During the summer of 2005, he experienced further pain in his shoulder. He
was offered physiotherapy, but did not attend his appointments. He was,
however, prescribed diclofenac, an anti-inflammatory drug.
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22. On 13 April 2006, the man went to a blood pressure clinic (he had missed an
earlier appointment on 23 March). He said that he was a smoker, and
nicotine replacement was offered to help him stop. Although he did not
exercise, the man said that he tried to eat healthily given the dietary
constraints of the prison catering. His blood pressure was recorded as
126/82, again within normal levels.
23. The man next attended healthcare on 4 August. He complained that he was
suffering from vitiligo, a loss of pigment in his skin, although was otherwise
physically well. Blood tests were taken, which showed a raised level of
haemoglobin (which the clinical reviewer suggests “could indicate a thickening
of the blood and is often related to smoking”), a normal thyroid function and
slightly raised level of glucose.
24. Over the next 18 months, he attended the blood pressure clinic on four
occasions. Each time, his blood pressure was recorded as within normal
limits. The only other entry in his medical record was for an appointment on
16 October 2007, when he complained of toothache. He was given an
antibiotic (amoxicillin) and a pain killer (co-codamol).
25. In the meantime, in June 2007, the man complained that he was being
restricted in the telephone numbers he was allowed to call. In his response,
the Deputy Head of Offender Management, said that the decision had been
made because of public protection issues resulting from a former offence.
The man rejected this response, taking the case to a judicial review at the end
of 2008 (this was outstanding at the time of his death).
26. The man applied for enhanced status under the Incentives and Earned
Privileges scheme (IEPS) on 14 November 2007. The application was
granted, with the assessor noting his continued good behaviour and attitude
towards staff.
27. On 22 July 2008, he attended healthcare as he was suffering from insomnia
and palpitations during the night. An ECG was taken, although no results
were recorded. His blood pressure remained within normal limits.
28. After being referred to a smoking cessation advisor on 13 August, the man
was seen in the healthcare clinic again on 2 October. He was concerned that
he still needed follow up care after the angioplasty, and asked whether he
needed an ECG. Observations were taken, and were found to be normal. He
was referred again to the smoking cessation advisor. The next day, he saw a
prison doctor, who prescribed aspirin to thin his blood.
29. The man went to healthcare on 17 October, and was diagnosed with
pharyngitis (a sore throat). He was prescribed antibiotics for a week.
30. Further blood pressure readings were taken on 28 November and 16
December. On these occasions, his blood pressure was found to be raised.
On the second occasion, the man was prescribed bendroflumethiazide (a
9
thiazide diuretic used to treat high blood pressure). His blood pressure was
taken again on 21 December and 28 December and was found to be normal.
31. On 13 December, the man was notified by the UK Borders Agency that he
was liable to deportation as a result of his offence. He was asked to complete
a form detailing his immigration history, which he did.
32. The man next attended healthcare on 12 March 2009, when he saw Doctor A,
he said that he had stopped taking his medication as it was making his gums
bleed. His blood pressure was taken and remained normal, although a
cholesterol reading was also taken and was just above the normal range. A
further blood test was taken and he was found to have a slightly high level of
creatinine (a higher level of creatinine can be a sign of deterioration of kidney
function). He discussed the result with Doctor A on 16 April as he was
concerned about it. Doctor A said that a repeat test had been ordered and, if
the creatinine level continued to rise, the underlying issue would be
addressed. There is no evidence that the test was carried out.
33. An IEPS review was held on 9 May. As the man was not complying with his
sentence plan, he was warned the following day by Principal Officer A that he
would be downgraded to standard if he did not comply in the future. On 15
May, the man was interviewed by a prison psychologist to complete part of
the sex offender treatment plan. He said that he was appealing against his
conviction and did not want to participate in the programme.
34. On 29 May, the man went to healthcare again and demanded to see the
doctor about his blood pressure. He said that he had just taken his final
bendroflumethiazide tablet and needed some more. A Nurse took the man’s
blood pressure, which he found to be raised, and advised him to see the
doctor the following week. He also reminded the man that it was his
responsibility to reorder his medication. The man was given a fresh supply of
medication on 1 June.
35. The same day, an OASYS (an offender assessment system) board was
convened. It examined the man’s cooperation with his sentence plan and
found that he was still failing to engage with staff. As a result, and in line with
Principal Officer A’s warning on 10 May, the man’s IEP status was changed to
standard.
Events of 3 June
36. During the day, the man spoke with a friend and fellow prisoner. (Prisoner A)
Prisoner A recalled that the man had complained some days earlier about not
feeling right, and that he had gone to visit healthcare. Prisoner A did not
think, however, that the man looked unwell. They spoke shortly before they
were locked in their cells for dinner, and Prisoner A agreed that he would visit
the man later so that he could use his typewriter.
37. Shortly after being unlocked from his cell at around 6.10pm, Prisoner A went
to the man’s cell. He saw him lying face down on the floor and, as he often
10
practised yoga, thought he was playing a joke. He asked the man to get up
but soon realised that he was not getting a response. He then screamed for
assistance.
38. Officer A responded to Prisoner A’s call for help. He went into the cell and
found another prisoner there. (Prisoner B) Prisoner B told Officer A that he
thought that the man had had a fit. The man was lying face down, and Officer
A tried unsuccessfully to get a response from him. The officer rolled the man
into the recovery position and, as he did not have a radio, also shouted to
staff to get more assistance.
39. Almost immediately, Senior Officer A arrived at the cell. She checked to see if
the man was breathing and found that he was not. She also failed to find a
pulse.
40. In the meantime, Officer B also heard Officer A’s shout for help and pressed
the general alarm before going to the cell. She moved the other prisoners
and returned them to their cells.
41. As a result of the alarm, Nurse A (who was carrying the Hotel 1 radio and was
therefore the designated emergency response nurse on duty) went
immediately to the cell accompanied by a Healthcare Worker (HCW). Nurse
A could not obtain a response from the man either and she asked for an
emergency ambulance to be called. She took readings using a pulse
oximeter (a machine which measures the oxygen saturation of the blood and
the pulse), finding no pulse and an oxygen saturation rate of 63 per cent (a
normal reading would be around 97 to 99 per cent).
42. Nurse A asked for a defibrillator (a machine which can deliver electrical pulses
to try and restart the heart) to be brought to the cell. Senior Officer B who had
also attended following the alarm, ran to healthcare to collect it, returning
within three or four minutes. In the meantime, Senior Officer A and the
healthcare staff began administering cardio-pulmonary resuscitation (CPR) to
the man.
43. When Senior Officer B returned, Nurse A removed the man’s shirt and applied
the defibrillator pads. The defibrillator advised that there was no shockable
rhythm, and that CPR should continue. An ambu-bag (a mechanical device
used to administer oxygen) was also used. Nurse A continued to try the
defibrillator to see whether she should administer a shock.
44. The paramedics arrived at the man’s cell at 6.41pm, after being escorted
through the prison by Senior Officer B. Nurse A gave them a verbal
handover, and the paramedics changed the oxygen cylinder and used their
own defibrillator. Again, this advised not to shock but to continue CPR. The
paramedics tried to insert an airway using a laryngoscope (a medical
instrument which can be used to insert a tube into the throat), but were unable
to do so because there was fluid in his airway. They did manage to insert a
liner into one of his veins, and gave two doses of epinephrine (also known as
adrenaline, a drug used to treat the effects of a heart attack).
11
45. At 6.55pm, the paramedics and Nurse A agreed that there was no more they
could do for him, and they pronounced his death. Senior Officer B arranged
for the cell to be sealed and kept a log of events. The coroner arranged for
the man’s body to be removed to the mortuary.
46. Staff ensured that Prisoner A was cared for, and he was offered the chance to
speak to a Listener (who are prisoners trained by the Samaritans to provide a
confidential listening service to fellow prisoners). Other prisoners were
checked, although there were no prisoners on the wing who were subject to
monitoring procedures at that time.
47. A hot debrief was held at 8.30pm, where staff had the opportunity to discuss
what had happened, and statements were given to the police. Staff were also
given details of the Care Team, should they need further support.
Following the man’s death
48. A post mortem examination was carried out at a local hospital, on 8 June.
The pathologist who conducted the examination, concluded that the man died
from ischaemic heart disease. A toxicology report was also requested, with
no positive results returned.
49. Following an invitation from the prison the man’s brother visited on 10 June.
He was shown to the man’s cell and allowed to take a few photographs and a
pair of glasses. He later met both the Governor and Deputy Governor.
50. The man’s funeral took place at the local Mosque. It was attended by the
Imam from the prison. The man was then buried in a traditional Muslim
ceremony at the local cemetery. The Imam met the man’s family, and
answered some of their questions about what had happened to him in prison,
and arranged for his property to be returned. He also passed on the
condolences of the prison managers and staff.
12
ISSUES
Clinical care
51. The clinical reviewer comments that, in her opinion, the standard of care the
man received at Swaleside “fell short of that which would have been expected
in the community”. In particular, the Clinical Reviewer criticises the failure to
address any of the risk factors of a further heart attack that he presented
when he came into prison and when he transferred to Swaleside.
52. In particular, the Clinical Reviewer notes that the man’s medical records were
not obtained when he was first remanded in custody in 2003 (even though it
was recorded in his medical notes, on 21 March 2003, that they should be
requested from his local hospital. There was a further opportunity to address
these issues when the man transferred to Swaleside in 2005 which was also
missed. As the reception process at all three prisons took place more than
five years ago, and with the advent of electronic medical records, it may be
that this issue has been addressed in the meantime. I therefore do not make
a recommendation on this point, although the Head of Healthcare will wish to
assure himself that previous medical records are being received when
appropriate. I will also arrange for a copy of my report to be sent to the Head
of Healthcare at Wormwood Scrubs and Belmarsh.
53. The Clinical Reviewer suggests that the risk factors associated with the man’s
previous heart attack should have been examined at a cardiac clinic.
Although he did attend a clinic on 2 October 2008, when he was prescribed
aspirin and spoke to a smoking cessation advisor, and subsequently had his
blood pressure and cholesterol checked, I believe that this should have
occurred much earlier.
54. Although the man was prescribed medication to treat his blood pressure, the
Clinical Reviewer believes the wrong medicine was prescribed. In particular,
he was prescribed bendroflumethiazide, but the Clinical Reviewer says there
is no evidence to suggest that it prolongs life after a heart attack. After the
man stopped taking the medication, there is no evidence that anything else
was offered as an alternative. The man continued to take
bendroflumethiazide, but irregularly.
55. The Clinical Reviewer believes that the man’s medical needs should have
been properly identified when he entered prison, and that the National
Institute of Clinical Excellence (NICE) guidelines were not followed. Had they
been followed, an antihypertensive would have been prescribed much earlier.
Although the Clinical Reviewer identifies that the prison doctor should keep up
to date with the latest guidelines for secondary prevention, I believe that the
Head of Healthcare should be responsible for ensuring that healthcare staff
comply with national guidelines, and thus I make the following
recommendation.
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The Head of Healthcare should ensure that all relevant staff are aware
of, and implement appropriately, the latest NICE guidelines on
secondary prevention for patients who have had a heart attack.
56. The Clinical Reviewer also comments that the reception screening form at
Swaleside does not allow sufficient information to be recorded. She
recommends that it is redesigned to ensure that health assessments can be
expanded, referrals for further health care noted and responsibility for these
referrals attributed to individual member of staff. I do not repeat the
recommendation in full, but would draw the attention of the Head of
Healthcare to this section of the clinical review.
Use of radios and emergency codes
57. Although it is unlikely that the outcome for the man would have been different,
I am concerned about the communication that took place after Prisoner A
found the man in his cell. Officer A had to shout for assistance from his
colleagues, and it is fortunate that Senior Officer A and Officer B were able to
hear him and respond. At interview, Officer A explained that there would
usually be two members of staff on the landing, both of whom would have
radios. He was there as an extra member of staff, but there was no additional
radio for him to draw. Had Officer A had access to a radio, it is possible that
the confusion described below would not have occurred, as he would have
been able to alert all staff to the emergency that was taking place.
The Governor should review whether radio provision is adequate.
58. Officer B pressed the general alarm before proceeding to the man’s cell,
which ensured that Nurse A attended quickly with a Healthcare Worker.
However, she did not have the equipment she required as she was unaware
of the type of emergency she would be presented with. While there was only
a small delay whilst Senior Officer B fetched the equipment, this could have
been avoided with better communication.
59. Swaleside operates a system of “codes” for alerting staff (and in particular
healthcare staff) to emergencies. In line with many other prisons, the codes in
use are blue for an incident involving breathing difficulties, and red for those
involving blood issues. Staff then respond to the emergency with the correct
equipment. In this case, Officer B pressed the alarm rather than using the
radio, which led to equipment having to be collected after the healthcare staff
had arrived at the scene.
The Governor should ensure that all staff are aware of the importance of
the correct use of emergency codes.
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CONCLUSION
60. The man had already suffered a heart attack before committing the offence
which resulted in his imprisonment. He had also stopped taking his
medication because of the side effects. When first remanded in custody,
these details were noted in his medical record, although it seems that no
further information was sought from the hospital that had previously treated
him.
61. The clinical reviewer has identified that the man was not prescribed
medication for high blood pressure for some time after his arrival at
Swaleside. When he was, he again found that the medication caused side
effects but was not offered an alternative. As a result, he did not take the
medication as prescribed, but took it less often. It is impossible to be sure
whether this contributed to the heart attack which eventually killed him.
62. Although the response to the man being found in his cell was not helped by
problems in communication, staff made every effort to resuscitate him. They
worked well together, but sadly were unable to revive him.
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RECOMMENDATIONS
1. The Head of Healthcare should ensure that all relevant staff are aware of, and
implement appropriately, the latest NICE guidelines on secondary prevention
for patients who have had a heart attack.
Recommendation accepted by prison
2. The Governor should review whether radio provision is adequate.
Recommendation accepted by prison
3. The Governor should ensure that all staff are aware of the importance of the
correct use of emergency codes
Recommendation accepted by prison
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