Individual at Wakefield

Investigation into the circumstances surrounding
the death of a man from HMP Wakefield,
who died in February 2010 at Leeds General Infirmary
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2010
A man was in his sixties when he died in February 2010, in Leeds General Infirmary.
He had been transferred to hospital from HMP Wakefield the previous day, after
being taken ill in his cell. A Senior Investigator, Family Liaison Officer and I offer our
sincere condolences to his family and friends for their sad loss.
I wish to thank the Governor of HMP Wakefield for making the necessary facilities
and information available to our investigator.
In the course of the investigation, I asked for a clinical review to be carried out into
the medical care and treatment the man received in custody. A Registered General
Nurse (RGN) was appointed by Wakefield District Primary Care Trust to undertake a
clinical review on my behalf. I am grateful for their assistance and her report.
Since taking over responsibility in April 2004 for the investigation of all deaths in
custody, there have been 25 deaths in custody at Wakefield, including that of the
man. Although the number appears high, it should be recognised that the prison
holds a number of elderly prisoners, which inevitably brings about a higher incidence
of deaths.
For the purpose of this report I concentrate in the main on events from when the man
became ill on 30 January 2010. However, I have included a brief chronology of his
custodial and medical history prior to that date.
This report makes seven recommendations, all of which relate to medical matters. I
also identify two areas of good practice.
Jane Webb
Acting Prisons and Probation Ombudsman August 2010
Final Report: August 2010 2
CONTENTS
Summary
The Investigation process
HMP Wakefield
Findings
Issues
Conclusion
Recommendations
Final Report: August 2010 3
SUMMARY
The man had a number of complex medical needs. He had previously had his right
leg amputated below the knee, was totally deaf in one ear and partially deaf in the
other. He had a prosthetic leg and wheelchair, although he was able to walk with the
aid of sticks. He experienced some discomfort with the residual limb and treatment
was ongoing.
On 30 January 2010, he became ill during the night and was assessed by a nurse on
duty in the prison. He told an officer and the nurse that he had a stomach problem
which caused him to produce too much acid and that his discomfort was of a similar
nature. The nurse prescribed an antacid medication and advised the man to see a
doctor in the morning.
The man’s condition did not improve and, following further examination by the duty
nurse later that morning, an electro cardiograph (ECG) reading was carried out and
the reading sent for analysis. The result of the analysis was that he had suffered a
heart attack and an emergency ambulance was required.
The man was initially taken to the Coronary Unit at Leeds General Infirmary (LGI),
but then transferred to a hospital in Dewsbury. He remained at Dewsbury for a short
time before returning to the LGI. (The reason why he was transferred is currently
under investigation by the management at the LGI.)
When the man returned to LGI and due the seriousness of his condition, a temporary
pump was inserted into his heart to help increase his heart output. (I explain this in
greater detail later.) About two hours after removing the pump, the man had a
further heart attack and, despite attempts by doctors to resuscitate him, he died.
The post mortem report states that the cause of death was a heart attack, with a
secondary cause of heart disease.
This report makes seven recommendations relating to medical care. It also identifies
two areas of good practice which also relate to medical care.
Final Report: August 2010 4
THE INVESTIGATION PROCESS
1. After receiving notification from the Prison Service on 3 February that the man
had died, the Ombudsman appointed a Senior Investigator to carry out the
investigation. The investigator contacted the prison and arranged to travel
there for the purpose of opening the investigation.
2. On 4 February, the investigator opened the investigation by meeting the
Deputy Governor. Also at that meeting was an officer representing the Prison
Officers Association, and Healthcare Principal Officer.
3. A clinical review into the care the man received while he was in Wakefield
was commissioned from NHS Wakefield District Primary Care Trust. The
Trust appointed an RGN to conduct the review.
4. The investigator returned to the prison on 17 February to continue the
investigation and, on this occasion, he was joined by the clinical reviewer.
They carried out a number of informal interviews with prison staff which were
not recorded. Before leaving the prison the investigator met a senior prison
manager to feedback what had been identified. He followed up the feedback
by writing to the Governor.
5. A family liaison officer wrote to three separate members of the man’s family to
inform them of the investigation and provide them with an opportunity to ask
any questions or raise any concerns about the care the man received. At the
time of issuing this report the man’s family have not raised any specific
issues. The draft report has been shared with those members of his family
who wished to receive it, and an additional comment added as a result. The
final version of the report will also be shared with the family. I hope this report
helps his family better understand the events leading to his death.
Final Report: August 2010 5
HMP WAKEFIELD
6. The prison is located in Wakefield very close to the city centre. There has
been a prison on the site since 1594. It is a high security prison and most of
the prisoners are serving life sentences or have been convicted of serious
offences.
7. There have been 24 previous deaths in custody at Wakefield since the
Ombudsman began investigating such cases in 2004. There are no
similarities between those cases and the circumstances of the man’s death,
although the clinical reviewer has pointed out that, in a report into a death in
2007, a similar recommendation was made about the importance of clinical
leads.
Her Majesty’s Chief Inspector of Prisons
8. Her Majesty’s Chief Inspector of Prisons reports on all Prison Service
establishments. The majority of inspections are pre-announced and allow the
prison being reported on to prepare for inspection. The most recent inspection
was carried out in December 2008.
9. In the introduction to her latest report, published in February 2009, Her
Majesty’s Chief Inspector of Prisons said the prison had improved
considerably over the previous five years and that she was pleased the
improvement had been sustained. She said there was still work to do in
aspects of safety and staff prisoner relationships and activities, including
engaging offenders in treatment programmes.
10. In the main body of the inspection report, it was noted that, despite provision
for five hospital visits per day, “too many” outside hospital appointments were
cancelled with no record kept of the reasons why. (The man missed a
hospital appointment because of staff shortages on 21 January 2010.) The
inspection team also noted that many “older prisoners and those with
disabilities were dissatisfied with the support they received”.
Independent Monitoring Board (IMB)
11. Each prison has an Independent Monitoring Board (IMB) which is made up of
members from the local community. Their role is to monitor the prison and
report any concerns that they have regarding the prison or how prisoners are
treated. In the first instance, the Board report to the Governor, or, if
necessary, can report directly to Parliament. Board members are able to visit
any area of the prison at any time and have direct access to any prisoner who
they wish to see, or who requests to see them. The Board holds regular
meetings in the prison, with the Governor attending for part of the meeting.
The Chairperson of the Board produces an annual report to the Secretary of
State for Justice.
12. In its most recent report, covering the period 1 May 2008 to 30 April 2009, the
Board said they were concerned at the available accommodation for elderly
Final Report: August 2010 6
prisoners. They added that many improvements had taken place in the
healthcare centre and made special mention of the quality of the good service
in the treatment clinics. The Board were positive about the provision of
healthcare, adding that patients appeared to be well cared for.
Final Report: August 2010 7
FINDINGS
13. The man had his leg amputated below the knee following an industrial
accident in 1992. Although he had a wheelchair he was able to walk with the
aid of walking sticks. In addition to that injury and as a result of a motorcycle
accident, he was totally deaf in his right ear and partially deaf in his left.
14. In January 1999, the man was sentenced to life imprisonment for a serious
offence. After receiving his sentence he was taken to HMP Hull where he
remained until November 2000, when he was transferred to HMP Wakefield.
15. His medical record shows that he attended a National Health Service
Prosthetic Clinic as and when necessary, but does appear to have had
ongoing pain in his residual limb. Additionally it appears that he occasionally
had difficulty obtaining the correct size residual limb socks. The man’s ex-
wife wrote to the prison twice offering to send a spare box of socks. This offer
was refused, however, for security reasons.
16. Initially he was prescribed ibuprofen (an anti-inflammatory tablet) on a regular
basis for pain in his residual limb, but this was discontinued in 2003 when he
began experiencing severe abdominal pain and heartburn. He was later
diagnosed as suffering from helicobacter pylori, a bacterial stomach condition,
and received treatment for this.
17. In January 2008, he was diagnosed with Carpal Tunnel Syndrome, which was
successfully operated on the following September. (Carpal Tunnel Syndrome
is a compression of the median nerve, which caused problems in his right
hand.) He received post operative physiotherapy within the prison. Two
months later, in November 2008, the man was diagnosed as having
hypertension (high blood pressure) and prescribed medication to treat his
symptoms.
18. According to his medical records, from August 2009 the man received
physiotherapy to his left shoulder although there is no information why it was
needed. Later that year he was given influenza and swine flu vaccinations
and, from the medical records, it appears he felt unwell with cold symptoms
afterwards.
19. Access to a physiotherapist within the prison enabled the man to receive the
correct follow up following his operation for Carpal Tunnel Syndrome. The
clinical reviewer adds the assessment also included treatment for a shoulder
problem which, had it not been treated, could have impacted on his mobility
as a wheelchair user.
20. On 17 December, he saw the prison doctor, and complained that the foot on
his prosthesis was loose. The doctor referred him to Prosthesis Clinic so that
the foot could be repaired or replaced. In addition he complained of cold
symptoms and right sided chest pain following his swine flu vaccination. The
medical record shows that when examined, his chest was clear and that his
“air exchange” (the process in the alveoli in the lungs where oxygen is
Final Report: August 2010 8
absorbed into the body as carbon dioxide is expelled) was good. However
the doctor was unable to check his blood pressure because a
sphygmomanometer (blood pressure monitor) was not available. (I
understand the reason was that another investigation concerning healthcare
was ongoing and it had not been replaced.) It was noted in the man’s medical
record that he was at high risk of cardio-vascular disease and had been given
smoking cessation advice.
21. Later that month, on 31 December, he was seen by a nurse at the prison
complaining of cold symptoms, sore throat and a cough. The nurse carried
out an examination and recorded his temperature as normal. Although his
throat appeared normal, he had a slight inflammation in his left ear.
2010
22. On 21 January, the man was due to attend an appointment at the Prosthetic
Clinic but, due to staff shortages within the prison, he was unable to go. It is
not clear whether an alternative appointment date was scheduled.
23. At about 1.30am on 30 January, he pressed his in cell emergency button to
alert staff that he required assistance. A prison officer told the investigator
that he went to the cell and looked in through the door observation panel. He
saw the man sitting up on his bed. The officer said the man told him he had
pain across his chest and that he had a medical condition which caused him
to produce too much acid. He also told the officer that the pain was stomach
cramp.
24. The officer told the investigator that it was unusual for the man to press his
cell call button and so he decided to contact the healthcare centre to speak to
the night nurse. The nurse went into the cell and carried out her own checks,
after which she gave the man Gaviscon (a medication for indigestion) and told
him to see a doctor that morning.
25. The nurse told the investigator that before going to see the man she had
looked at his medical notes. She said there were no significant issues other
than he had only one leg. When she arrived at the cell the man was sitting in
a chair. She said he was talking and breathing normally and told her that he
had indigestion. The nurse noted that his skin colour was normal, but that he
was “anxious”. She did not know why he was anxious but explained that the
man said he had had indigestion for about two weeks.
26. The man confirmed to the nurse that he did not have any pain in his left arm.
The nurse said his blood pressure was slightly raised, but that it was within
normal range for him. She said she did not suspect from his symptoms that
he had any cardiac problems.
27. After leaving the cell, the officer when carrying out his routine wing patrol,
looked in the man’s cell from time to time to ensure his wellbeing. The officer
said he spoke to him to ask how he was and he replied that he was okay.
Final Report: August 2010 9
28. At about 6.00am, the officer completed his morning roll check. He said he
spoke again to the man and reminded him to see a doctor. Before leaving the
prison for the day, the officer told the wing staff coming on duty what had
happened during the night. In the meantime the nurse had arranged for the
man to be seen by a nurse and, if necessary, a doctor.
29. Later that morning a Registered General Nurse was on duty. She had been
told that the man had been ill during the night and said she had been asked to
follow up and check his condition. The nurse told our investigator that her
plan was to see the man after she had completed her morning treatment
work.
30. At about 10.10am, the RGN was contacted by a member of the wing staff who
asked her to see the man. She said the officer told her the man was
complaining of chest pain. The nurse said that, although the request was not
urgent, she went straight away as she was aware that he had been ill during
the night.
31. The RGN told the investigator that when she went into the cell the man was
sitting up and complaining of pain which he said was due to a duodenal ulcer.
She said he coughed and that it was a chesty cough. He also told her he had
pain down his left arm.
32. An ECG (electrocardiogram, a measure of electrical activity in the heart) was
carried out and the results sent by telephone line to Bromwell Health Watch
for analysis. (Bromwell Health Watch analyse the ECG readings and advise
on the appropriate course of action.) The RGN said that the assessor told her
the man had suffered a heart attack and an emergency ambulance should be
called. Due to the level of pain he was experiencing, the nurse gave him
glyceril trinitrate (used to treat angina).
33. In the meantime, an ambulance was called and, when it arrived, the
paramedics carried out their own checks. After attaching a 12 lead ECG
machine to the man’s they were able to say that he had “right bundle branch
block [a defect in the heart’s electrical activity], acute myocardial infarction
[heart attack] and a history of myocardial infarction”. The man was
transferred by emergency ambulance to the Coronary Care Unit at Leeds
General Infirmary (LGI).
34. The clinical review shows that, after being examined at LGI he was taken to
the Cardiac Unit at Dewsbury District Hospital. He remained there for a short
period and was then taken back to the LGI. (It is not clear why the transfer
took place, and the matter is being investigated separately by LGI and does
not form part of this report or the clinical review.)
35. When the man returned to the LGI, and because of the serious nature of his
condition, a “balloon pump” was inserted into his heart. (The pump is a
mechanical device used to reduce the demand on the heart and increase
cardiac output.) The intention was to leave the pump in place for about 24
hours and then review the situation. A registrar at the hospital told the man’s
Final Report: August 2010 10
family that the pump could not remain for longer than 24 hours and there was
a risk that his heart could not manage without it and he would die. (The man’s
ex-wife and stepdaughter had been contacted by Wakefield at 11.40am.
Although they were surprised to be named as next of kin by the man, they
visited him in hospital.)
36. The following morning at about 3.00am, the pump was removed. About two
hours later he collapsed without regaining consciousness and despite
emergency resuscitation attempts he died. His family, who were not with him
at the time, were informed by the hospital at around 9.00am. The family
liaison officer from Wakefield, visited the family at the same time as they
wished to break the news in person.
Final Report: August 2010 11
ISSUES
Clinical Care
37. The clinical reviewer said that the man’s overall health care appears to have
been adequate, although for someone with complex and chronic health needs
there was no identified clinician to co-ordinate his care. She adds that this is
an observation that has been made in relation to a previous death in custody
at Wakefield.
Hypertension
38. The clinical reviewer said the man’s initial diagnosis of hypertension in
November 2008 appears to have been made on a single reading, which she
explained is not in line with National Institute for Clinical Excellence (NICE)
guidelines. She said the guidelines suggest that two further readings should
be made at monthly intervals before a diagnosis is made and treatment
begins. The treatment should then be reviewed annually.
39. Additionally the clinical reviewer said the man was reviewed after 13 months,
but that it appeared to have been more by chance than design. She went on
to say that although protocols and guidelines are available to healthcare staff,
not all staff appeared to be aware where they are located.
The Head of Healthcare should review the protocols for the management
of hypertension and conduct an audit of clinical staff awareness of the
protocols and guidance.
Sphygmomanometer
40. In December 2009, the prison doctor was unable to use the
sphygmomanometer to record the man’s blood pressure as there was another
ongoing investigation. It is not clear why another one was not available to
use. The clinical reviewer also recorded in her review that the
sphygmomanometers were not regularly calibrated or maintained, which could
limit their usefulness in future tests.
The Head of Healthcare should ensure that a sphygmomanometer is
always available for use, and that there is a protocol for the routine
maintenance and calibration of sphygmomanometers.
Health records
41. SystmOne is the electronic health record in use at Wakefield. As well as
recording details of interactions between healthcare staff and patients, it
enables clinicians to record health problems and consultations, using a range
of clinical templates, some of which have been specifically designed to
support management of long term conditions. Information can be stored in
different ways, with different template options. Providing the correct template
is used, it can alert the user when reviews are due and assess specific health
Final Report: August 2010 12
risks, for example cardio-vascular risk. The clinical reviewer said there
appears to be no agreed approach to the use of SystmOne within the prison
and not all of the clinicians fully understand the functions available.
42. SystmOne has the potential to support clinicians in the management of patient
care. It would appear that an agreement has not yet been reached in relation
to which templates to use to record information. Additionally the clinical
reviewer identifies significant training issues for staff. This too is also an area
that has been identified in a previous clinical report.
43. Whilst I acknowledge the difficulties attached to using two different electronic
systems (SystmOne and the pharmacy record) and hard copy, for prescribing,
dispensing and administering medication, I am aware that steps have been
taken to reduce the risk.
The Head of Healthcare should review the templates available to
clinicians to support care management and agree how they should be
used.
Drug sensitivities
44. The man’s medical record shows that, on several occasions, he had a
reaction to a number of drugs and food which usually took the form of a skin
rash. There appears to have been some discussion regarding potential drug
allergies and sensitivities but they do not appear to have been definitively
addressed. Informal interviews with clinical staff suggest that not all clinicians
felt confident about finding clinical information stored on SystmOne, or how to
use the various templates.
45. The clinical reviewer said it is important to include self reports from patients of
previous health problems and drug sensitivities. However there does not
appear to have been any clarification as to the exact nature of all the man’s
gastric problems.
The Head of Healthcare should conduct an audit of staff awareness and
understanding of SystmOne and develop a programme to meet
individual training needs
Issuing drugs
46. The clinical reviewer said that the man had been allowed to hold his own
medication which meant that after the first issue, any subsequent supplies
would only be dispensed at his request. She said his pharmacy record shows
one issue of bendroflumethiazide (a diuretic used to treat high blood pressure)
for 28 days, which was given to him in November 2008. However the
SystmOne report shows the prescription was for 84 days prescribed in
November 2008 and discontinued until September 2009. The clinical
reviewer said there is no reason documented for the bendroflumethiazide
being discontinued. However, there had been an audit of repeat prescriptions
Final Report: August 2010 13
and as the man’s medication had not been dispensed for ten months, this
may be the reason for it being discontinued.
47. The clinical reviewer notes the disparity between the medication recorded
information held on SystmOne and the pharmacy record. She said the prison
and NHS Wakefield District had taken action to minimise the risks.
48. Additionally she said that when prisoners attend for planned health
appointments, pharmacy records provide a list of the medication they were
currently prescribed. However, in emergency situations and out of hours, this
service is not available. The clinical reviewer said that it means that clinicians
do not have access to the patient’s current medication record, as was the
case with the man.
49. The man appears to have made choices about whether or not to take the
medication prescribed for his hypertension. The clinical reviewer said it is
unlikely that better maintenance of his hypertension over a 12 month period
would have prevented his myocardial infarction.
The Head of Healthcare should review the current system for providing
access to the patient’s medication record in emergency situations and
out of hours.
Gastric ulcer
50. The man appears to have told medical staff that since having an ‘ulcer’ he
often suffered from heartburn. The clinical reviewer said he was quite
convinced that the ulcer was the cause of his pain on 30 January. She adds
that there is no information to support any history of a duodenal ulcer,
although he had been diagnosed with, and treated for, helicobacter pylori (a
stomach condition). The clinical reviewer goes on to say that the man’s
medical record does not show that he ever asked for medication for gastric
pain. It is important that staff accurately record when patients report health
problems and also then confirm that the information they have been given is
correct.
The Head of Healthcare should develop a protocol for confirming that all
self reported health problems and ensuring information is recorded in
the medical record.
51. Despite the man’s complex health needs, the clinical reviewer comments that
a multi-disciplinary approach to the management of his care does not appear
to have been taken. There were no management plans evident for his
ongoing problems and no identified clinician to oversee or co-ordinate his
care.
The Head of Healthcare should review clinical leadership within the
Primary Health Care setting, and conduct an audit of current roles,
responsibilities and working practices and that a structured case
management approach is taken for prisoners with complex long term
conditions.
Final Report: August 2010 14
Events on 30 January 2010
52. The clinical reviewer said that, based on the information the man gave to
medical staff on 30 January, the assessment of his medical condition appears
to have been satisfactory. She said that appropriate action was taken,
including a request for follow up assessment, although it was not regarded as
urgent.
53. At about 10.00am, when a full assessment was undertaken, an emergency
ambulance was requested. The clinical reviewer said the RGN demonstrated
an excellent understanding of the man’s health status and requirements. The
ECG report from Bromwell Health Watch confirmed that he was suffering from
an acute myocardial infarction and the RGN asked for the man to be taken to
hospital.
54. The clinical reviewer said the RGN should be commended for her knowledge
and understanding of the true cause of the man’s chest pain despite his
obvious suggestion that it was ‘gastric’ pain. She ensured that a thorough
examination was made, provided appropriate care and requested the
paramedics to take him to the LGI. Whilst I make no formal recommendation,
the Governor may wish to share the comments with the RGN and her
employer.
55. Since carrying out a clinical review, the reviewer has learned that after an
initial assessment at LGI the man was transferred to the Cardiac Unit at
Dewsbury District Hospital. He was later taken back to LGI.
Final Report: August 2010 15
CONCLUSION
56. This case has highlighted a number of issues relating to medical care. That
said, I am satisfied that the man believed that his symptoms were of a gastric
nature and something he had experienced previously. Additionally I am
satisfied that the nurse who attended him during the night made satisfactory
arrangements for him to be followed up by the doctor the next morning.
57. Once the ECG report had been sent for analysis, the situation was found to
be far worse than expected. Arrangements were made very quickly to
transfer him to hospital as an emergency patient.
58. However, it does concern me that after being taken to the LGI he was then
taken to Dewsbury before returning to Leeds. Whilst I do not want to
speculate on what the outcome might have been had he received emergency
treatment sooner, it is worrying that there may have been delays in his
treatment. I am satisfied that the matter is under investigation by managers at
the LGI and I encourage them to share their findings with me.
Final Report: August 2010 16
RECOMMENDATIONS
1. The Head of Healthcare should review the protocols for the management of
hypertension and conduct an audit of clinical staff awareness of the protocols
and guidance.
Accepted – “Practice Development Facilitator working with GP’s via the GP
Clinical meeting to implement a protocol and framework for the management
of those Offenders with Hypertension in line with NICE Guidance.”
2. The Head of Healthcare should ensure that a sphygmomanometer is always
available for use, and that there is a protocol for the routine maintenance and
calibration of sphygmomanometers.
Partially accepted – “A Sphygmomanometer is always available for Clinical
Staff, however, on the day in question, the HCC was “locked down” to
facilitate a search of all clinical areas, therefore staff were prevented from
accessing clinical equipment.
“Wakefield do accept that there should be a protocol in place for the routine
maintenance and calibration of equipment. This will be taken forward by the
Practice Development Facilitator.”
3. The Head of Healthcare should review the templates available to clinicians to
support care management and agree how they should be used.
Accepted – “Funding through the PCT / Prison SLA has now been agreed for
2010/11. One day per month has been allocated for SystmOne Training for
healthcare staff. This will concentrate on up-skilling staff as well as record
keeping information. Training for staff in respect of SystmOne has now
commenced on a monthly basis, and will continue throughout 2010/11.”
4. The Head of Healthcare should conduct an audit of staff awareness and
understanding of SystmOne and develop a programme to meet individual
training needs.
Accepted – “Funding through the PCT / Prison SLA has now been agreed for
2010/11. One day per month has been allocated for SystmOne Training for
healthcare staff. This will concentrate on up-skilling staff as well as record
keeping information. Training for staff in respect of SystmOne has now
commenced on a monthly basis, and will continue throughout 2010/11.”
5. The Head of Healthcare should review the current system for providing
access to the patient’s medication record in emergency situations and out of
hours.
Accepted – “A review of processes has been conducted, and in line with
SystmOne developments, Electronic prescribing initiatives will be taken
forward which will improve access to medication records.”
Final Report: August 2010 17
6. The Head of Healthcare should develop a protocol for confirming that all self
reported health problems and ensuring information is recorded in the medical
record.
Accepted – “Protocol for self reported problems being developed around initial
health screening on Reception. The secondary Health screen will explore
further the issues of self reported health problems.”
7. The Head of Healthcare should review clinical leadership within the Primary
Health Care setting, and conduct an audit of current roles, responsibilities and
working practices and ensure that a structured case management approach is
taken for prisoners with complex long term conditions.
Accepted – “A review was undertaken of clinical leadership within HMP
Wakefield and two posts were successfully filled in late 2009. One post
concentrates on Clinical Leadership and the other being Clinical Governance
and practice improvement issues.
“Band 5 nurse training in respiratory care. Diabetic services to be improved
with the Integrated Diabetic services coming into the prison. Coronary Heart
Disease management being reviewed with a view to commission a
Community Model into the Prison.”
Final Report: August 2010 18