Individual at Swansea

Investigation into the death of a man in hospital in
November 2005, while a prisoner at HMP Swansea
REPORT BY THE PRISONS AND PROBATION
OMBUDSMAN FOR ENGLAND AND WALES
JULY 2006
This is the report of an investigation into the death of a man who died from
natural causes in a local hospital in November 2005, having being admitted
there from HMP Swansea. He was 51 years of age.
The loss of a loved one is always distressing. I would like to add my personal
condolences to the man’s family, to those already expressed by one of my
Family Liaison Officers.
The man had been received into custody at Swansea prison in October 2005,
having been charged with arson and carrying an offensive weapon. Following
his first reception healthscreen, he was admitted to the Healthcare Centre.
Later the same day, he was taken to a local hospital because of concerns
about his health. He had spent just a few hours in prison – his first and only
experience of imprisonment.
This investigation has been undertaken by one of my colleagues. I would
like to thank the Governor of Swansea Prison, and his staff for their
participation in the investigation. I am particularly grateful to the Head of
Residence, who acted as the liaison officer.
I make no recommendations in this report although I draw the attention of
Prison Health to my comments in para 42 and that of the Governor to my
comments in para 47.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2006
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CONTENTS
Summary
HMP Swansea
Conduct of the investigation
The man’s time in HMP Swansea
and in Hospital
Clinical review
Key findings
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Summary
1. The man was born in November 1954. He was 51 years old when he
died from natural causes in November 2005 at the local hospital,
Swansea, while a prisoner at HMP Swansea.
2. The cause of death was recorded as septicaemia and septic shock,
pneumonia, alcohol abuse and malnutrition.
3. In October 2005, the man had been arrested and charged with arson at
his home address. The house was owned by his mother, but he lived
there alone. Police records show that, while in police custody, officers
were initially more concerned about his mental health than his physical
health. The man’s sister telephoned from Canada on 12 October and
expressed concerns about her brother’s mental health. Later that day, a
doctor attended to assess his mental state. The doctor advised police
officers that, in his opinion, the man did not have mental health problems
but did need to go to hospital because of his heart condition. He was
promptly taken to the local hospital, and stayed there on the Coronary
Care Unit until 18 October. During that time, he escaped from police
custody for around 20 minutes when he hid in the hospital. He returned
to the police station from the hospital on 18 October, and subsequently
attended the Magistrates’ Court on 19 October.
4. On 19 October, the man was remanded into custody at HMP Swansea.
This was his first experience of prison life. Following his first reception
healthscreen, he was admitted to the Healthcare Centre. He was taken
to hospital later the same day because of concerns about his health.
5. The clinical review commissioned as part of this investigation concludes
that it was appropriate that the man went straight from the prison’s
reception to the Healthcare Centre for supervision and medical care. His
medication was dispensed without delay. The review also concludes
that he was dealt with promptly and effectively by staff when he was sent
to the local hospital by ambulance later that day.
6. On 25 November 2005, one of my Family Liaison Officers contacted the
man’s sister by letter. She expressed various concerns about the care
and treatment given to her brother from the time of his arrest. Specific
concerns about the care and treatment of the deceased by Swansea
prison are addressed in this report. It is not within my remit to comment
on the care the man did or did not receive whilst in police custody.
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HMP Swansea
7. HMP Swansea is a small category B local prison which holds adult male
prisoners, both those remanded into custody from the courts and those
convicted and sentenced. The prison was completed in 1861 and has
remained substantially un-changed since then. However, D wing has
benefited from additional accommodation and the reception, kitchen and
visits area have been re-built. Considerable refurbishment of existing
accommodation areas is currently underway, including a new pedestrian
gate, healthcare and the re-establishment of B wing as a residential unit.
Swansea has an operational capacity of 425.
8. The Healthcare Centre provides 24 hour primary care and has 12 in-
patient beds. Clinical care is provided by a team of doctors and nurses
employed by the Prison Service. There is also a specialist Mental Health
In-Reach Team (MHIT) which has connections to the local medium
secure unit in Bridgend.
9. Her Majesty’s Chief Inspector of Prisons (HMCIP) carried out an
unannounced inspection of Swansea in April 2005. The inspection
report said Swansea is “a small, genuinely local, prison: 70% of its
prisoners live less than 50 miles away. One of its distinguishing features
is the good relationship between staff and prisoners, often based on
familiarity: many prisoners are repeat offenders. Most prisoners told us
they felt safe in Swansea; and most said they were well treated by staff
on arrival and while in the prison. Race relations were good, and
accommodation was clean, though overcrowded. Some of the drug
treatment work was excellent.”
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Conduct of the investigation
10. My investigator studied all relevant prison records relating to the
deceased. These included his main prison record and medical record.
She also examined the man’s police custody records. She spoke to two
members of staff at Swansea, and officer from Healthcare, and a
Principal Officer within the Security Department. She also spoke to the
man’s solicitor.
11. A nurse, who works for the Ombudsman’s office, undertook a review of
the man’s medical care in collaboration with the Investigations Manager
in the Healthcare Inspectorate Wales (HIW) and with the Director of
Investigations, HIW.
12. 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. The coroner explained that the hospital doctor issued a
medical certificate of cause of death. The coroner had discussed the
matter with the man’s family who felt strongly that they did not want a
post mortem. The coroner therefore decided it would be appropriate to
proceed on the strength of the medical certificate identifying the cause of
death alone, and not to conduct a post mortem examination. The cause
of death was recorded as septicaemia and septic shock, pneumonia,
alcohol abuse and malnutrition.
13. One of my Family Liaison Officers contacted the man’s family. His sister
raised some concerns about her brother’s treatment by police following
his arrest. She said that he was obviously ill, but it was his solicitor,
rather than the police, who first called a doctor for him. She also
questioned why, having been taken to hospital while in police custody,
he was discharged from the hospital ultimately to the Magistrates’ Court
to stand trial, when he was clearly very ill. She also expressed concerns
about the doctor at the hospital who advised her on 25 October that her
brother’s health had improved. Given my terms of reference, issues
about the man’s treatment while in the custody of the police are outside
the remit of my investigation.
14. The man’s sister also said she did not believe it was necessary for her
brother to be guarded by two prison officers while in hospital. She also
said that she overheard two prison officers say that they would have to
handcuff her brother, “but not with the chain across his chest,” when they
became aware of the doctor’s opinion that his condition had improved.
These issues are within my remit, and are addressed in this report, which
I hope answers some of the concerns expressed by the man’s sister.
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The man’s time in HMP Swansea and in the local hospital
15. The man was remanded into custody at HMP Swansea from the
Magistrates’ Court on 19 October 2005 to await trial. The First
Reception Health Screen, carried out by a Healthcare Officer (HCO)
highlighted concerns about his physical health. It was noted that he was
not very well, and had suffered a “dual heart attack” about a week
previously while in police custody and had been treated at the local
hospital. It was also noted that he had concerns about emphysema and
suffered from asthma and chest pains. The HCO noted that the man was
very emaciated.
16. The man was referred to a doctor for a secondary healthscreen. The
prison doctor examined him and he was immediately admitted to
healthcare as an inpatient. He later complained about chest pains and
was seen by the duty nurse. An Electrocardiogram (ECG) was
performed which showed that he had an abnormal heart rhythm (SVT).
On the advice of the doctor, the man was taken to hospital by ambulance
at 10pm that night. He went initially to the Accident and Emergency
Department (A&E), but he was later moved to the Coronary Care Unit. A
detailed bedwatch log was completed by various prison staff throughout
the time he was in hospital. There is a note in the bedwatch log by the
escorting officer that a consultant at the hospital had seen the man and
was planning to conduct a number of tests which would require him to
stay in hospital for approximately one week.
17. On 20 October, a staff nurse from HMP Swansea attempted to telephone
the man’s next of kin, his sister, but there was no reply. His sister lives in
Canada and their mother was visiting her at the time. The man’s
solicitors were then informed at 11.10am that the man had been
admitted to hospital. The solicitors phoned the prison back at 12.50pm,
and said they would visit the man in hospital and inform his uncle of his
whereabouts.
18. Hospital staff informed the prison that they considered that it was not
appropriate to handcuff him, due to his serious medical condition. A risk
assessment was undertaken and it was decided that no handcuffs
should be used. Two prison officers were detailed to watch him.
Instructions were that the prison was to be informed of any improvement
in the man’s condition for the Duty Governor to reassess the situation.
Police had advised the prison that the man had escaped their custody for
20 minutes when previously at the hospital. The man was never
restrained during his time in hospital following risk assessment by the
prison.
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19. Despite the fact that the man was clearly very ill, he would not have been
eligible for Release on Temporary Licence (ROTL) as he was on
remand.
20. On 22 October, there is an entry on the bedwatch log at 10.40am,
“Reported by nursing staff that the man had a confirmed MRSA blood
infection. All staff aware and advised no direct contact if possible.
Barrier nursing instigated immediately.” He was moved to the Intensive
Care Unit (ICU) at 6.45pm. At 9pm, the escorting officer noted that the
man was on a life support machine. At 11.50pm, he noted that hospital
staff were very concerned about the man’s condition and had contacted
his relatives.
21. On 23 October 2005, the staff nurse telephoned the hospital and was
updated about the man’s condition. The man was reported to be very ill
and on a ventilator. The man’s sister and mother had travelled from
Canada and were at the hospital. An escorting officer noted that nursing
staff indicated that the man had only a 50/50 chance of survival, as there
were problems with his blood pressure and heart beat. He remained
unconscious.
22. On 25 October, the man was still in the ICU and reported to be stable.
There is a note that the man’s solicitor told a bedwatch officer, that a
doctor had advised that the man was improving and could possibly be
discharged in a week or so. The officer noted on the bedwatch log that
he was told by a nurse that there was a chance of him being moved to a
lower dependency unit (LDU) or even an ordinary ward. The staff nurse
telephoned the hospital and was told that he was stable. This is when
his sister says she overheard two prison officers saying they would have
to handcuff her brother. There is no independent evidence to support
this. However, in view of the risk assessment, it is likely that the issue of
any improvement in the man’s condition would indeed have been
discussed as instructions were to report any such improvement to the
prison. In fact, the man was never moved from ICU.
23. The man’s solicitor explained to my investigator that the sister expressed
concerns to her that the man was being guarded by two prison officers.
She said that she explained to her that, as the man was on remand, the
only way to ensure that the prison officer escort was removed was to
apply for bail for him. She said that she did start that procedure, but as
the doctor had advised that he was improving she withdrew the bail
application as he had no home to return to and his mother could not look
after him.
24. On 26 October, the staff nurse telephoned the hospital again and was
told that the man remained in intensive care and was ventilated and
intubated and semi-conscious. The nurse passed that information on to
the man’s solicitors.
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25. On 3 November, the staff nurse and a principal officer (PO) visited the
man in hospital. The nurse reported that the man was seriously ill and
still ventilated. Furthermore, he could not speak and remained in
intensive care.
26. On 7 November, an officer had a telephone call from the man’s sister.
She told my investigator that during the call the man’s sister questioned
the need for prison officers to be in attendance at the hospital. She said
that she took advice from a Principal Officer within the Security
Department. The PO could not recall giving this advice to the officer.
The officer said that she then telephoned the man’s sister back, and told
her that there was no change to the risk assessment at that time. The
man passed away later in the day at 5.55pm.
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Clinical review
27. A nurse, who works for my office, undertook a clinical review of the
man’s medical care in collaboration with the Investigations Manager in
the Healthcare Inspectorate Wales (HIW) and with the Director of
Investigations (HIW).
28. The overall conclusion of the clinical review is that the man received
appropriate medical care when he arrived at Swansea prison.
Healthcare staff had acted swiftly in sending him to the local hospital to
by emergency ambulance shortly after he was located in the Healthcare
Centre.
29. The review also notes the regular contact which the prison, particularly
the Healthcare Centre, had with the nursing staff at the hospital for
updates on the man’s condition, and the visits that were made.
30. I refer to other findings from the clinical review in the following section of
this report.
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Key findings
31. From the time the man was admitted to hospital from Swansea on 19
October, the Healthcare Centre maintained regular contact with nursing
staff at the hospital and there was daily contact by the Security Manager.
The escort was supervised daily by managers from Swansea. The Staff
Nurse and the PO visited him on 3 November. A proper risk assessment
was undertaken by the prison based on all the available information and
was appropriately reviewed throughout. The man was never handcuffed
during his time in hospital. The overall standard of record keeping is
high.
32. The man was not eligible for Release on Temporary Licence (ROTL)
according to Prison Service Order (PSO) 6300 as he was on remand.
He was not eligible for release on compassionate grounds for the same
reason.
33. I agree with the findings of the clinical review that the man’s care while
he was in prison was appropriate. The initial health screening by the
health care officer and the doctor elicited all necessary information from
the man, and it was entirely correct that he went straight from reception
to the Healthcare Centre where his medication was dispensed without
delay.
34. Swansea prison staff acted promptly and effectively in sending him to the
local hospital by emergency ambulance on 19 October. I am also
pleased that the Healthcare Centre kept in regular contact with the
nursing staff in the hospital which was in addition to the daily contact by
the Security Department and management supervision of the escort.
35. Some of the concerns raised by the man’s family are outside the remit of
this investigation. The man’s sister was concerned about his treatment
by police following his arrest on 11 October. She said that he was
obviously ill, but it was his solicitor, rather than the police, who first called
a doctor for him. She also questioned why, having been taken to
hospital on 12 October while in police custody, he was discharged from
the hospital on 18 October when he was clearly very ill. This is
something which the NHS and Swansea police may wish to examine
further.
36. The man’s sister also expressed concerns about the doctor who advised
her on 25 October that her brother’s health had improved. Again, this is
outside the remit of this investigation, but the man’s sister might want to
pursue this within the NHS clinical complaints system.
37. In view of his failing health, the man was not handcuffed at any time in
hospital while in prison custody. It is possible that officers did discuss a
reported improvement in the man’s condition, as they had been
instructed to be alert to any such improvements. I appreciate that, if
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such a conversation took place and was overheard by the family, it would
have been distressing for them.
38. As already mentioned, I am satisfied that the prison authorities had all
the necessary information and undertook a proper risk assessment of the
man while he was in hospital. While it was clearly distressing for the
family that there were two prison officers in attendance at the hospital, I
believe that the risk assessment was appropriate in view of the nature of
the charges against the man, and the fact that he had escaped from
police custody previously. However, it was unfortunate, as the clinical
review says, “that it was not possible for the prison to at least reduce the
escort to one officer when the man was so seriously ill and so unlikely to
make any sort of escape attempt.”
39. I make no formal recommendations, but I suggest that the NHS and
Swansea Police may wish to pursue further the issues the man’s sister
raises about her brother’s treatment after his arrest and before his arrival
at Swansea prison. I trust that I may leave this matter in the hands of
Prison Health.
40. The Prison Service did not find any factual inaccuracies or request any
amendment of the draft report. However, the man’s sister had a number
of comments – some of which I reflect in the following paragraphs but
many of which I am afraid I cannot address as they concern matters
outside the remit of my investigation.
41. The man’s sister was distressed that her brother’s date of birth had been
wrongly recorded. I am sorry for this error that originated when the man
was remanded. This report now correctly records the man’s date of
birth. Paragraph 7 of the clinical review has also been amended as the
sister said that she did not telephone regarding the man’s mental state
but rather his physical condition.
42. I appreciate that the man’s solicitor told his sister that there was no
evidence against her brother and that the house fire was a tragic
accident. However, the man’s guilt or innocence would have been
established by a court. Until then, the Prison Service had a duty to
assess any risk or potential problems when transferring him to hospital
on the basis that he had been arrested and charged with the serious
offence of arson.
43. The man’s sister was also concerned that comments in sections of the
Hospital Risk Assessments indicated that she and her mother were
angry and might cause problems when they visited the hospital. She
found the comments offensive. The sister said they were unfounded and
the subsequent Visit Check List indicated there had been no problem.
44. Finally, the sister was offended that the bedwatch log stated that she
stormed out after her brother’s death, when she had just watched him die
and was extremely upset. I can appreciate that the presence of prison
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staff and their comments noted in the hospital risk assessment,
management check list and bedwatch log could have caused distress to
the family. In this respect, the Governor might wish to remind staff of the
need to ensure that all comments in prison records are carefully
considered and sensitively written.
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