Individual at Swaleside

Investigation into the circumstances surrounding the
death of a man, who was a prisoner at HMP Swaleside,
on 17 December 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
October 2006
This is the report of an investigation into the death of a man who died from
apparent natural causes on 17 December 2005 in outside hospital. He was
59 years old.
I would like to add my personal condolences to those already expressed to
the man’s family by my Family Liaison Officer.
This investigation has been undertaken by one of my investigators. I would
like to thank the Governor of HMP Swaleside and his staff for their
participation and willing assistance.
Swale Primary Care Trust was asked to conduct a clinical review of the man’s
care in line with my terms of reference. I am disappointed that the review did
not deal with the issues raised by the family and did not comment on the
medical care provided to the man. I draw this to the attention of Prison
Health. In addition, the Coroner may wish to consider calling someone from
Swale Primary Care Trust to the inquest on the man to comment on the
clinical care he received.
I make two recommendations in this report. One relates to the quality of the
clinical review. Much more positively, the other reflects the good, kind and
sensitive practice shown by Swaleside towards the man and his family.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman October
2006
CONTENTS
Summary 3
The investigation process 4
HMP Swaleside 5
Key findings 6
Issues raised by the family 8
Clinical review 9
Conclusion 10
Recommendations 11
Summary
1. The man was born in 1946. He was 59 years old when he died on 17
December 2005.
2. The man was received into custody after being sentenced to 18 years
imprisonment. He was initially held at HMP Belmarsh before being
transferred to HMP Swaleside on 21 September 2004.
3. At his first reception health screen, it was noted that the man suffered from
diabetes and Crohn’s disease (an inflammatory disease of the
gastrointestinal tract). As a result of his health problems, the man was
prescribed a range of medication which he was allowed to keep in his
possession.
4. On 10 December 2005, the man was taken to outside hospital. Whilst he
was an in patient at the hospital, a bedwatch was carried out by prison
officers. The security risk assessment identified that a closeting (escort)
chain was used. However, this was removed when the man’s condition
started to deteriorate, shortly before his death, on 17 December.
5. A doctor was identified by Swale Primary Care Trust, to carry out a clinical
review of the care provided to the man.
6. On 10 January 2006, one of my Family Liaison Officers contacted the
man’s family. Their concerns centred on the cause of the man’s death and
the clinical care provided by the outside hospital.
The investigation process
7. My investigator studied all relevant prison records relating to the man.
These included his main prison record, his medical records and
statements from prison staff.
8. My investigator contacted Swale Primary Care Trust who identified a
doctor to carry out a clinical review of the care the man received while in
prison. The review was completed but did not address issues raised by
the family and did not comment on the quality of medical care the man
received whilst in custody. I am disappointed that the review did not
address these issues.
9. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner to
assist him in his enquiries into the man’s death.
10. One of my Family Liaison Officers contacted the man’s family. The family
told her of their concerns, which are considered later in the report.
11. My investigator discussed aspects of the man’s treatment and the issues
raised by his family with both staff at Swaleside and the clinical reviewer.
HMP Swaleside
12. Swaleside opened in 1988 as a Category B Training Prison. It accepts
prisoners who are serving four years or more and who have at least 18
months left to serve. It is has a total of 460 places for life-sentenced
prisoners, being a main centre for prisoners in the first stage of their life
sentence and accepting prisoners in the second stage of their life
sentence. Swaleside has a high minority ethnic population of between 30
and 40 percent. It also has a high proportion of foreign national prisoners.
13. Swaleside has an active regime with a focus on resettlement. The prison
provides a range of accredited offending behaviour courses and other non-
accredited courses, including victim awareness and anger management.
14. From 1 April 2004, the provision of healthcare within the prison became
the responsibility of Swale Primary Care Trust. A medical officer provides
primary health care. Medication is administered on a weekly and/or
monthly basis to those prisoners who have been assessed as suitable to
manage their own administration. It is administered on a daily basis to
other prisoners, when either they are considered to be at risk or the
medication is unsuitable to be held in their cell.
15. The system for seeing the prison doctor changed during the summer of
2005. Prisoners now need to book an appointment in advance to see the
doctor, and specific days are allocated for each wing of the prison.
16. There were three deaths from apparent natural causes at Swaleside
during 2005.
Key Findings
17. The man arrived at Swaleside on 21 September 2004 and, after induction,
was allocated a cell on F wing. During his health screen interviews, it was
noted that the man had diabetes and Crohn’s disease. Due to his health
problems, the man was prescribed a range of medication which he kept in
his possession.
18. On 25 September 2005, the man was taken to outside hospital to attend a
consultation with a Consultant Physician and Gastroenterologist.
19. On 2 November, the man’s son moved onto F wing. He had been moved
from another prison to be closer to his father.
20. During the morning on 7 December, the man was found lying on the floor
of his cell. His son and officers helped him back onto his bed. The man
was asked if he wanted to go the Healthcare Centre, but he declined.
21. However, two days later on 9 December, the man was moved to the
Healthcare Centre. He was accompanied by his son who stayed with him
while he settled in.
22. At 3:40pm on 10 December, it was decided that the man needed to be
transferred to hospital for further assessment. He arrived at the outside
hospital at 4:30pm and was moved onto a ward at 10:20pm.
23. Once the man was settled on the ward, a closeting (escort) chain was
used instead of handcuffs. This was entirely appropriate and enabled the
nursing staff to have easier access when they carried out their duties.
While the man was an in patient at the hospital, a bedwatch was carried
out by prison officers.
24. On 14 December, doctors at the hospital stated that the man had a chest
infection and pneumonia at the base of both of his lungs. The man was
visited by his family on 16 December.
25. On 17 December, the man slept most of the morning and missed his
lunch, but had some chocolates. He fell asleep again at 1:00pm. Officers
noted at 2:30pm in the bedwatch log that the man had been talkative and
fully co-operative whilst he had been awake. When a nurse checked on
the man at 3:20pm, she noted that he had stopped breathing. The man’s
restraints were removed and attempts were made to try to resuscitate him.
These were unsuccessful and he was pronounced dead at 3:40pm.
26. A Senior Nurse from the outside hospital immediately informed the man’s
family, by phone, of his death. The Principal Officer, who was on
bedwatch duty, informed the prison control room. The duty Governor and
Head of Residence, informed the wing where the man was located. The
manager on the wing informed the man’s son of the death and he was
allowed to make a phone call to his mother.
27. The Principal Officer met the man’s family when they arrived at the
hospital and offered his condolences and support. The man’s daughter
informed the officer that her husband was also located in Swaleside. The
officer notified the prison and the man’s son-in-law was informed of the
death. It was noted on the man’s son-in-law’s record that he was fine, as
he had expected the news.
28. The prison’s family liaison officer maintained contact with the family and
offered to assist with arranging the funeral and providing financial help.
The prison family liaison officer also invited the man’s wife to the prison
where she met with prisoners and staff and visited her husband’s cell.
29. The post mortem states that the cause of death was due to natural causes
as a consequence of bronchial pneumonia (inflammation of the lung),
chronic pulmonary (lung) disease and chronic pancreatic (intestinal)
disease.
Issues raised by the family
30. The man’s family told my Family Liaison Officer that their concerns were
mainly focussed on the clinical care provided during his time in the outside
hospital. Their concerns were:
I. The man’s insulin being changed by the hospital the day before
his death and the possible impact of this change of medication.
II. The sister at the hospital not having any information about the
shadow on the man’s lungs. This was a concern because both
the man and the doctor in the hospital were aware of this.
III. The way in which the hospital notified the family of the man’s
death.
IV. The fact that that the man’s son informed his mother that her
husband had been taken to hospital.
31. The prison was asked to comment about how the family was notified that
the man had been taken to hospital. Swaleside was unable to explain why
it was the man’s son who informed his mother that her husband had been
taken into hospital.
32. My Family Liaison Officer explained that the other issues concerning the
man’s treatment whilst in hospital were outside the remit of our
investigation. However, she agreed that they would be forwarded onto the
clinical reviewer.
33. The family also drew my Family Liaison Officer’s attention to some of the
positive practices employed by Swaleside. These included:
I. Moving the man’s son from another prison so that he could
spend more time with his father.
II. Giving permission for the man’s son to attend his father’s funeral
and allowing him to sit next to his mother.
III. Handing back the man’s belongings in a timely manner.
IV. The excellent support they received from the prison family
liaison officer, where he kept in regular contact with the family.
V. The sensitive way in which the man’s wife’s visit to the prison
was handled including the prison flag being at half mast during
their visit.
34. The family were also grateful that the officers who escorted the man’s son
to the funeral were sensitive and unobtrusive.
Clinical Review
35. The clinical review of the care provided to the man whilst in prison has
now been completed. However, the reviewer did not look at the care
given to the man whilst he was in outside hospital, which the family had
raised as an area of concern. The review also did not give any opinion on
the quality of care provided to the man whilst he was in custody. My
investigator has therefore not been able to consider any of the clinical
issues about the way the man was cared for by the prison and it has not
been possible to provide the family with answers to the question they
have raised.
The Head of Prison Health should ask the Chief Executive of the
Swale Primary Care Trust to arrange an urgent review into the
clinical care received by the man. The review should specifically
consider the issues raised by the man’s family.
Conclusion
36. The man died from natural causes. It was not relevant that he was a
prisoner at the time of his death.
37. From comments made by staff and prisoners at Swaleside it seems that
the man was a respected and well liked man. His popularity was further
demonstrated by the prisoners on his wing who spoke to the man’s wife
when she visited the prison after his death.
38. In reviewing the bedwatch log, it is clear that the staff involved with the
man’s care behaved with sensitivity. The security arrangements at the
hospital seem to have been appropriate, and struck a good balance
between public protection and sensitivity to the needs of someone in the
last stages of life.
39. The comments from the family relating to Swaleside’s treatment of the
man (paras 33-34 above) reflect well upon individuals, their place of work,
and the Service they represent. I draw attention to the good practice of
allowing the man’s son to be allowed to move to Swaleside so that he
could be closer to his father and spend more time with him. I also
commend the sensitivity employed by the prison in allowing the man’s son
to sit with his mother at his father’s funeral, and the compassion shown to
the family when they visited the prison after the man’s death.
The Governor should draw the attention of all staff to the findings of
this report at paras 33, 34 and 39.
Recommendations
The Head of Prison Health should ask the Chief Executive of the
Swale Primary Care Trust to arrange an urgent review into the
clinical care received by the man. The review should specifically
consider the issues raised by the man’s family.
The Governor should draw the attention of all staff to the findings
of this report at paras 33, 34 and 39.