Individual at Wakefield

Investigation into the circumstances surrounding the
death in May 2007 of a man in hospital, whilst a prisoner at
HMP Wakefield
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2008
This is the report of an investigation into the circumstances surrounding the death of
a man in May 2007 in hospital. The man was a prisoner at HMP Wakefield.
The man had been exercising in the prison gymnasium when he collapsed onto the
floor. Healthcare staff attended to him, paramedics arrived and he was transferred
to hospital. The man died shortly after being admitted to the Accident and
Emergency Department. A post mortem was held at the request of the Wakefield
Coroner and it revealed that his death was due to apparent natural causes. The
cause of death was given as a severe heart attack and his death was considered
unavoidable.
I extend my sincere condolences to the man’s family and friends. I would like to
thank the Governor of Wakefield and his staff for their help and assistance in this
investigation. I am especially grateful to a member of staff, who acted as prison
liaison officer with my office.
I commissioned a clinical review of the care afforded to the man whilst he was in
Wakefield from Wakefield and District Primary Care Trust. At the time of writing this
report, I have still not received the clinical review and I am therefore unable to
comment on the medical care afforded to him.
I have made three recommendations. One requested Wakefield and District PCT to
complete a clinical review. The others are in respect of the prompt care offered by a
prisoner after the man collapsed, and the support his bereaved family received from
two members of staff. I also make one housekeeping point.
In this version of the final report I acknowledge a draft clinical review has now been
received from Wakefield and District PCT and is annexed to this report. I note the
recommendations from that review. The man’s sister has viewed the draft report and
commented that she wished to see the clinical review to find out whether her brother
had had a previous heart attack whilst at Wakefield, and if this was the case, did he
receive appropriate medical intervention.
This version of my report, published on my website, has been amended to remove
the name of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2008
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CONTENTS
Summary
The Investigation Process
HMP Wakefield
Key Findings
Issues
Recommendations
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SUMMARY
The man had been sentenced to life imprisonment in 1996 for murder. He
transferred to Wakefield in April that year. The man made two unsuccessful appeals
to the High Court and was considering making a third appeal. He had always denied
his offence.
The man was a popular prisoner with both prison staff and prisoners. He was
described as a polite and respectful man, with a good sense of humour. The man
had a good relationship with all staff.
In May, the man was attending remedial exercise classes in the weights room. After
completing his exercises he moved upstairs to the large gymnasium. He
acknowledged a member of the gym staff, a Physical Exercise Instructor (PEI) who
was leading a power walking group. A few minutes later the man seemed to trip and
fell onto the floor in front of the PEI. The PEI believed the man was play acting and
continued with his class.
Less than a minute later, a prisoner went over to where the man was lying on the
floor. He was then joined by the PEI. The man was unresponsive and his breathing
was abnormal. The prisoner and PEI moved the man upright, then into the recovery
position. The PEI called for assistance and healthcare staff were asked to attend.
Two nurses arrived at the gym. The man was drifting in and out of consciousness.
His heart stopped and one of the nurses carried out Cardio Pulmonary Resuscitation
(CPR). Paramedics then arrived and took over the care of the man. He was
transferred by emergency ambulance to hospital, and died shortly after arriving in the
accident and emergency department.
When the man first fell to the floor, it was believed that he was having a joke. When
it became obvious he was very unwell, he received prompt and appropriate care and
support. The post mortem report indicates that the man had suffered a severe heart
attack and that his death was unavoidable.
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THE INVESTIGATION PROCESS
The man’s medical records and prison file were sent to the Ombudsman’s office
shortly after his death.
The investigation was opened by one of my investigators in May 2007 when she
visited HMP Wakefield. My investigator met with the Deputy Governor, the Family
Liaison Manager, the Healthcare Clinical Manager, a Physical Exercise Instructor, a
representative of the Prison Officers’ Association (POA), and the Chair of the
Independent Monitoring Board (IMB). Notices of the investigation and terms of
reference had been sent to the prison in advance of my investigator’s visit for display
around the prison.
My investigator visited D wing where the man was located and spoke to two
prisoners. My investigator also spoke to an officer who was the man’s personal
officer.
A review of the man’s medical care was commissioned from Wakefield and District
Primary Care Trust in accordance with my terms of reference. At the time of
circulation of the draft report, no clinical review into his healthcare had been
received. A draft clinical review was received in time to be incorporated into this final
report.
My investigator returned to Wakefield in June to carry out interviews with prison staff.
She also interviewed prisoners who had responded following the display of notices.
One of my Family Liaison Officers made contact with the man’s sister. The man’s
sister did not raise any specific issues into her brother’s care.
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HMP WAKEFIELD
Wakefield is a male prison for those serving four years or over (including many life
sentence prisoners). It forms part of the high security estate holding prisoners who
potentially pose the greatest risk the public. It specialises in the treatment of serious
sex offenders.
The prison provides workshops and an education department offering both full and
part time education. The programmes department offers a range of offending
behaviour courses including FOCUS (a drug programme), Sex Offender Treatment
Programme (SOTP) and the Enhanced Thinking Skills (ETS) programme.
The gymnasium is a popular area of the prison. A well-equipped weights room and
large gymnasium is used on a daily basis. Remedial exercise is prescribed for
prisoners to improve their life style and manage medical conditions. Following a
referral for remedial exercise, a member of the gym staff will interview the prisoner.
An exercise programme will then be developed focusing on the prisoner’s individual
needs.
The most recent report by HM Chief Inspector of Prisons in April 2005 followed an
unannounced follow up inspection. The report said of healthcare:
“There had been little change in healthcare facilities since the last report.
Wakefield provided 24 hour care for prisoners and had a 20 bed inpatient
facility. Staff were enthusiastic and committed to improving services but there
appeared to be a lack of strong clinical leadership particularly in primary care
area.”
The annual report by the prison’s Independent Monitoring Board in August 2004
praised the jail’s healthcare department, responsibility for which was about to pass to
the local Primary Care Trust.
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KEY FINDINGS
The man was received into HMP Wakefield in April 1996. A first reception health
screen indicated no specific health problems. He reported sick on a number of
occasions with minor ailments, for which he was prescribed appropriate medication
and treatment.
In February 2001, the man saw the medical officer and was referred to the gym for
remedial exercise to help with pain in his lower back. In September, he went to the
healthcare unit complaining of chest tightening and sweating after running for one
mile. The man told the medical officer that the tightness was severe and he had
experienced two episodes of chest pain during the run. The medical officer advised
the man to stop smoking, and to take gentle exercise, and arranged for blood tests.
The doctor wrote a letter of referral to hospital requesting an investigation. However,
the prison’s primary care manager and security manager are unable to find any
record of the doctor sending this referral or any evidence of a letter being received
by the hospital.
In October 2001, the man was prescribed Simvastatin as his cholesterol was noted
to be 7.4 (this well above the average reading). It was also noted that he had a
family history of angina. In August 2004, the man was prescribed aspirin of 75mgs
daily to help with his blood circulation.
In May 2006, the man attended healthcare with a dental infection. He was referred
to the dentist and given amoxicillin, an antibiotic. Later in May, the man was seen
again by the medical officer as his dental infection had returned. The man was
prescribed more antibiotics and a mouth wash. In September, the man was seen
again in the healthcare unit. One of his teeth had broken and an infection was
present. He was again prescribed antibiotics and mouth wash.
On a morning in mid May 2007, the man attended the gym for a remedial exercise
class. These classes took place in the weights room. Near to the end of the
session, the man was approached by one of his friends. The friend was also using
the gym. The man was kneeling, with his head down, on the floor close to his friend.
The friend asked him if he was okay. The man said he would be alright in a minute.
He then left the weights room.
About 9.50am, a physical education instructor (PEI) was leading the power walking
session in the gym. The PEI was in front of a group of prisoners in the gym who
were in the ‘cooling down’ part of the session. The PEI noticed the man who had
come into the gym from the weights room. He was standing behind the barrier
boards on the right hand side of the gym. The PEI acknowledged the man, with
whom he had a good relationship. The man acknowledged him back.
The PEI continued to lead his class around the gym floor. Several minutes later he
saw the man walk onto the gym floor. He crossed in front of the PEI. The man then
seemed to stumble as if he was tripping over. He fell onto the floor near to the
barrier boards and in front of the gym office. The PEI had to side-step the man to
avoid falling over him. The PEI first thought that the man was having a “joke”, as the
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manner in which he had fallen seemed to be “play acting”. The PEI continued with
the class and it ended less than a minute later.
A fellow prisoner had been participating in the power walking class and had
observed the man stumble and fall to the floor in front of the class. The prisoner also
initially assumed that the man was “messing around” or had tripped and stayed down
because he “felt silly”. The prisoner went to the man’s side. The prisoner tried to
talk to the man but he was unresponsive and rigid. The prisoner noted that the
man’s breathing was coarse and rasping. The prisoner was then joined by the PEI.
The PEI saw the man was lying on his front, his eyes were open and he was
breathing. At this point the PEI still believed that the man was play acting. The PEI
said to the man, “Come on, that’s enough”. He repeated himself twice. When the
PEI got no response from the man, he bent down to him on the floor and saw his
eyes were open, but his breathing was heavy. There was still no verbal response
from the man.
The prisoner checked the man’s pulse. (the prisoner had completed a first aid
course for prisoners.) The prisoner noticed a nasty bump on the man’s head which
had appeared consistent with his fall to the floor. The man appeared to show signs
of consciousness, and started to wriggle around trying to get up. The PEI and the
prisoner moved the man to a sitting position against the barrier board. The man was
going in and out of consciousness and his body became floppy. The PEI and the
prisoner then moved the man onto his side into the recovery position. The PEI had
alerted other gym staff and requested the attendance of healthcare staff. He then
fetched a towel to go under the man’s head, whilst the prisoner stayed with the man
talking to him and monitoring his pulse.
Two members of healthcare staff arrived at the gym within several minutes. They
attached a heart monitor to the man and an oxygen mask. He began to struggle and
tried to remove the oxygen mask from his face. He also said his stomach was
hurting and cried out in pain. The nurses immediately requested that an emergency
ambulance be called. The man’s heart stopped and one of the nurses commenced
Cardio Pulmonary Resuscitation (CPR). The prisoner assisted the nurses in opening
the man’s mouth so he could be intubated.
At 10.07am, the paramedics arrived at the gym and took over the man’s care. The
man was escorted from the prison at 10.08, with a three officer escort, the Imam and
a nurse. A nurse assisted the paramedics with CPR in the ambulance. The man
was given adrenaline on the journey to the hospital by one of the paramedics.
On arrival at the hospital, the man was taken to the Accident and Emergency
Department. Despite the efforts of all concerned, they were unable to resuscitate
him and he was pronounced dead at 10.40am. The Imam was able to carry out the
appropriate religious rituals once the man’s death was confirmed.
The Imam returned to the prison, and with the prison’s family liaison officer, went to
the man’s nominated next of kin (his sister). On arrival at the man’s sister’s address,
they were told that the man’s wife lived nearby. The man’s wife came to her sister-
in-law’s house and the governor informed them of his death. The Imam
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accompanied the man’s sister, along with other family members, to the hospital to
see her brother’s body. Along with the Assistant Imam, the Imam attended the
man’s funeral service two days later at a mosque.
The man’s relatives accepted an invitation to visit HMP Wakefield to meet their
brother’s friends and prison staff. The family has told my office that they greatly
appreciated the assistance from the prison towards funeral expenses.
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ISSUES
Clinical
In June 2007, Wakefield and District Primary Care Trust was requested to undertake
a clinical review into the care the man received whilst at HMP Wakefield. This was
in accordance with the standard procedures set out in my terms of reference. At the
time of completing the draft report, I had not received the clinical review from the
PCT. I was therefore unable to comment on the clinical care the man received.
I recommended that a copy of the draft report should sent to the Chief
Executive of Wakefield and District PCT with a further request that he should
commission and complete an urgent clinical review into the standard of care
received by the man at HMP Wakefield.
A draft clinical review was finally received before the issue of this final report. I
understand that enquires are still being made with Yorkshire Ambulance Service.
The draft clinical review noted that the man appeared to have been well cared for in
the vast majority of his medical needs. There is no criticism of the assessment made
prior to his referral for exercise. The man’s condition was monitored and his
cholesterol level treated. He was advised to increase the Simvastatin dose when the
level went over 5, and he was repeatedly advised about smoking. The man should
have had an exercise Electrocardiogram (ECG), to monitor his heart rate, in 2001.
This would have given indication about his fitness to exercise. However, exercise
within limits is probably beneficial in heart disease and staff should not be concerned
that his death followed a period of exercise.
The most obvious failing is that the man did not attend the hospital physician after
the clinical diagnosis of angina. It is not possible to determine whether this was due
to administrative error either in prison or in hospital, or a possibility that the man
refused to attend. There is one entry on the medical record in October 2001 that
may mean that he did not accept the diagnosis of heart disease. It is a further failing
that there is no record of any conversation about this referral, or any action that was
taken to ensure the man attended.
The entries on the medical notes around this time are illegible and seem to be
written by different doctors. There may be a lack of continuity of care, and the notes
may not have been read following entries by locum doctors. Many of the prison
doctor’s notes are of limited use due to the poor legibility.
The medical notes do not say whether the man was being treated for primary
prevention on the basis of his raised cholesterol, or for secondary prevention. There
is a ‘heart’ symbol entered in his record on a few occasions by one doctor, though
the significance of this is unclear. Had the man had the ECG that was requested, it
is possible this would have shown evidence of ischaemic heart disease, although
this is not always the case in patients with angina. This would have placed him in a
different risk category.
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The clinical reviewer noted that having made this criticism, it is possible that the
eventual outcome might have been the same had he received a diagnosis of heart
disease. The man’s management might have included additional medications such
as a beta blocker or ACE inhibitor, but he did receive Simvastatin and aspirin, which
are important in secondary prevention as well as primary. However, the man may
have been more motivated to stop smoking if he had the diagnosis confirmed.
The man’s sister read the draft report and told my family liaison officer that she
wanted to see the clinical review. The man’s sister wanted to know if her brother
had a previous heart attack or heart problems, several years ago. There is a family
history of heart disease and she had spoken to her brother about maintaining good
health, which he supported following their mother’s bypass operation in 2004.
The clinical review said that the man had angina, and was seen by the doctor in
September 2001, after becoming unwell following exercise. As previously noted
there is no record regarding a referral to hospital and there was no firm diagnosis of
heart disease. The man was treated appropriately after blood rests confirmed he
had high cholesterol.
The man’s collapse in the gymnasium
The man was well known by gym staff. He had a very good relationship with the
staff, enjoying a joke and friendly banter. On the day he collapsed in the gym, the
PEI at first believed that the man was joking and play acting. Once it became
obvious that he was not play acting, the PEI went to his aid and raised the alarm.
In response to the Ombudsman’s notice to prisoners following the man’s death,
several prisoners wrote to my investigator. My investigator also received two formal
complaint forms from the prison in relation to his death.
Two of the prisoners interviewed raised concerns not relating to the man’s death.
Three prisoners raised issues about what was described as the lack of response
from gym staff to the man’s collapse and the length of time before healthcare arrived
at the gym. The prisoners’ main points were based on the fact that, following the
man’s fall to the floor, there was not an instant response. One of the three prisoners
said during interview that they thought, “He was larking around.” A second prisoner
was not in the gym at the actual moment the man fell to the floor, arriving a few
minutes later when the prisoner was at the man’s side.
All the prisoners interviewed described the man as a likable and nice man. He had a
great sense of humour and got on well with fellow prisoners and prison staff.
Whilst acknowledging the points the raised by the three prisoners, it is the prisoner
who assisted the PEI on the day the man collapsed, who has given a full account of
what occurred. The prisoner indicated that the gym staff, in particular the PEI
responded to the man with dignity and respect once it was realised he was not play
acting. The prisoner praised the professionalism of the healthcare nurses and the
PEI.
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The PEI was distressed and upset that he had not reacted to the man’s fall
immediately. The PEI told my investigator that the man did not show the ‘text book’
signs of having a heart attack. He did not clutch his chest or complain of tingling in
his arms. The PEI believed that the man was having a joke with him.
The post mortem clearly indicated that the man had a massive heart attack, and that
his death was unavoidable.
The care shown by the prisoner was exemplary. He offered compassion and
kindness to the man and was shocked by his death. They had been friends for many
years. The prisoner was dismissive of rumours circulating amongst prisoners
criticising the gym staff. He told my investigator he thought that some of the
prisoners were using the man’s death to further their own agendas and found this
contemptible.
I am content that the man was treated in an appropriate and timely manner. The
relationship between the man and gym staff was friendly, with mutual respect shown
on both sides. The PEI reacted with professionalism once he realised that the man
was unwell. He should not attach any blame to himself for not responding
immediately to his fall.
Healthcare staff arrived at the gym within a few minutes of being called to attend and
gave appropriate care to the man in an attempt to resuscitate him. Sadly, despite
their best efforts he could not be revived.
For the prisoner who assisted the man when he collapsed, his prison file
should record the help, assistance and care he gave to the man.
Support to Prison Staff
The man’s personal officer was shocked by his death. The officer was off duty on
the day he died. She was contacted at home by a colleague and friend who told her
what had happened. This colleague was aware the officer was the man’s personal
officer.
Returning on duty two days later, the officer was not informed by line management of
the man’s death or offered any staff care and welfare service. The officer was aware
of those services, but I understand she would have appreciated a more personal
touch. Whilst I make no formal recommendation, staff should be informed at the
commencement of their shift about the sudden death of a prisoner. In addition,
Personal Officers of a deceased prisoner should be spoken to personally and offered
support as required.
Family Liaison
It was fortunate that the Imam was in the prison on the day the man collapsed. He
responded to the message for him to go to the gym. On arrival at the gym he
accompanied the man to the hospital. Following his death, the Imam carried out
religious rituals appropriate to the man’s faith.
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The Imam and the family liaison officer broke the sad news of the man’s death to his
family with compassion and respect. This was followed by much appreciated
support to the man’s family. His family have been extremely grateful to the Imam
and the governor for their help, kindness and assistance.
As with the involvement of the prisoner, the family liaison officer will wish to
acknowledge the work of the Imam and the governor in meeting the needs of the
man’s family following their bereavement.
The Governor should formally commend the Imam and the family liaison
officer for the support and compassion shown to the family of the man.
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RECOMMENDATIONS
1. I recommended that a copy of the draft report should sent to the Chief
Executive of Wakefield and District PCT with a further request that he
should commission and complete an urgent clinical review into the
standard of care received by the man at HMP Wakefield.
A draft clinical review was received from Wakefield and District PCT following the
issue of the draft report. I have therefore been able to include this is this final report.
2. For the prisoner who assisted when the man collapsed, his prison file
should record the help, assistance and care he gave to the man.
3. The Governor should formally commend the Imam and family liaison
officer for the support and compassion shown to the family of the man.
Housekeeping Point
On the sudden death of a prisoner, staff should be informed at the
commencement of their shift. Personal Officers of a deceased prisoner
should be spoken to personally and offered support as required.
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ANNEXES
1. Documents considered during the investigation
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